Every finding on record at Trinidad Rehabilitation and Healthcare Center

Based on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for six (#3, #1, #7, #2, #5 and #6 ) of 9 residents reviewed for abuse out of nine sample residents.Specifically, the facility failed to: -Protect Resident #3 from physical abuse by Resident #4;-Protect Resident #1 from physical abuse by Resident #2;-Protect Resident #7 and Resident #2 from physical abuse by each other; and,-Protect Resident #5 and Resident #6 from physical abuse by each other.Findings include:I. Facility policy and procedureThe Abuse Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/18/26 at 2:04 p.m. It read in pertinent part: All reports of resident abuse shall be reported and investigated by facility management.II. Incident of physical abuse of Resident #3 by Resident #4 on 9/25/25A. Facility investigationThe 9/25/25 facility investigation revealed that an altercation occurred between Resident #3 and Resident #4. The investigation revealed Resident #4 positioned his wheelchair next to Resident #3. Resident #3 asked Resident #4 not to run into her with his wheelchair. Resident #4 responded and struck Resident #3 on the face, and Resident #3's eyeglasses were bent, causing a laceration on the bridge of her nose. Resident #4 was placed on monitoring with observations every 15 minutes and moved to a room in another hallway. Resident #4 was prescribed sertraline (selective serotonin reuptake inhibitor) once a day for physical aggression.The investigation substantiated the incident of physical abuse. B. Resident #3 (victim)1. Resident statusResident #3, age greater than 65, was admitted on [DATE] and discharged home on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia, anxiety and depression.The 9/1/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15.The assessment revealed Resident #3 required substantial to maximum assistance from staff for bed mobility and transfers, and was dependent on staff for walking. Resident #3 used a manual wheelchair for mobility.The assessment documented Resident #3 had no physical or verbal behaviors towards others. 2. Record reviewThe communication care plan, initiated 9/3/25, revealed Resident #3 had impaired communication. Pertinent interventions included allowing ample time for Resident #3 to comprehend what was said, allowing time for response and using simple and direct communication to promote understanding.The 9/25/25 nurse progress note revealed Resident #3 had an incident with another resident (Resident #4). Resident #3 sustained a 0.5 centimeter (cm) by 0.5 cm laceration on the right side of her nose and a 1.5 cm by 2.0 cm laceration on the left side of her nose. The progress note documented Resident #3 was transferred to the emergency department for evaluation and had no additional injuries. The lacerations were treated by the nurse with first aid.The 10/2/25 nurse progress note revealed the resident's lacerations were healing and Resident #3 denied pain from the lacerations.The 10/8/25 progress note revealed Resident #3 discharged home with her responsible party.C. Resident #4 (assailant)1. Resident statusResident #4, age less than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia, anxiety, a history of traumatic brain injury and epilepsy. The 12/2/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. The assessment revealed Resident #4 was dependent on staff for bed mobility and transfers. dressing. Resident #4 used a manual wheelchair for mobility.The assessment documented Resident #4 had no physical or verbal behaviors towards others.2. Record reviewThe physical aggression care plan, initiated 9/29/25, revealed Resident #4 had aggressive behavior by striking out towards another person. Pertinent interventions included educating about negative behavior, encouraging talking when frustrated or anxious, redirecting from others if behaviors were present, monitoring for signs of frustration, and escalating behaviors.The 9/29/25 nurse progress note revealed that a staff member observed Resident #4 raise his open hand towards Resident #3, but Resident #4 did not make contact with Resident #3. The progress note revealed the physician was contacted and gave a new order for sertraline 25 milligrams (mg), one time a day for physical aggression for eight days.III. Incident of physical abuse of Resident #1 by Resident #2 on 11/15/25 A. Facility investigationThe 11/15/25 facility investigation revealed Resident #1 exited her room as Resident #2 walked past her in the hallway. Resident #1 approached Resident #2 in an attempt to hold his arm and walk in the hallway. Resident #2 responded by pushing Resident #1, and Resident #1 lost her balance and fell to the ground. The investigation revealed staff intervened and separated Resident #1 and Resident #2. The nurse completed an assessment on Resident #1, who had a skin tear that was treated with first aid. Resident #2 had no injuries.The investigation revealed after the altercation, the staff separated the residents, and the staff monitored both residents every 15 minutes.The investigation substantiated the incident of physical abuse. B. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia and difficulty walking. The 2/12/26 MDS assessment revealed Resident #1 was unable to complete the BIMS assessment. Per the staff assessment for mental status, Resident #1 had severe cognitive impairment with daily decision making and had continuous inattention and disorganized thinking. The assessment indicated Resident #1 had no physical or verbal behavior symptoms during the assessment look-back period. 2. Record reviewThe wandering care plan, initiated 4/3/25, revealed Resident #1 wandered on the secured unit. Pertinent interventions included keeping Resident #1 safe during episodes of behaviors and monitoring and documenting episodes of inappropriate behaviors. The 11/15/25 nurse progress note revealed a staff member found Resident #1 on the floor. The nurse completed an assessment of a 6.0 cm by 1.5 cm skin tear on Resident #1's right forearm. C. Resident #2 (assailant)1. Resident statusResident #2, age greater than 65, was admitted on [DATE]. Diagnoses included Alzheimer's disease and dementia with behavioral disturbance.The 12/23/25 MDS assessment revealed Resident #2 was unable to complete the BIMS assessment. Per the staff assessment for mental status, Resident #2 was moderately cognitively impaired with daily decision-making. Resident #2 required supervision from staff for dressing, bed mobility, transfers, and walking.The assessment indicated Resident #2 had physical behaviors directed toward others for one to three days of the assessment look-back period.2. Record reviewThe dementia care plan, initiated 6/12/25, revealed Resident #2 lived in the secured unit for a therapeutic environment. Pertinent interventions included encouraging Resident #2 to avoid doorways to avoid injury when others entered and exited the secured unit The physical aggression care plan, initiated 12/1/24, revealed Resident #2 attempted to strike another resident when he felt threatened. Pertinent interventions included administering medications as ordered (12/1/24), redirecting when exhibiting behaviors (1/2/25), approaching Resident #2 in a calm manner (1/2/25) and providing a calm and safe environment (1/23/25).Review of Resident #2's electronic medical record (EMR) revealed there were no corresponding progress notes regarding the altercation with Resident #1 on 11/15/25.IV. Incident of physical abuse between Resident #7 and Resident #2 toward each other on 11/18/25A. Facility investigationThe 11/18/25 facility investigation revealed Resident #2 and Resident #7 were in the common area. Resident #2 lifted and swung his feet over the armrest of the chair. Resident #2's foot bumped Resident #7. Resident #7 pushed Resident #2's foot away, Resident #2 kicked Resident #7 in the leg and Resident #7 slapped Resident #2. The investigation revealed staff separated the residents immediately and Resident #2 was placed on one-to-one care for safety monitoring. The facility investigation revealed Resident #2 had a history of pushing others away if they touched him. The nurse assessed Resident #7 and found no injuries.The investigation substantiated the incident of physical abuse. B. Resident #2 (victim and assailant) 1. Record reviewReview of Resident #2's EMR revealed there were no corresponding nurse progress notes regarding the altercation with Resident #7 on 11/18/25.The 11/18/25 physician progress note revealed Resident #2 had refused medications. The physician and the interdisciplinary team (IDT) reviewed the resident's non-pharmacological and pharmacological interventions for physical aggression. The physician gave a new order for aripiprazole (antipsychotic) two milliliters (ml), every morning for dementia with behaviors. C. Resident #7 (victim and assailant) 1. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included schizoaffective disorder and depression.The 11/4/25 MDS assessment revealed Resident #7 had mild cognitive impairment with a BIMS score of 13 out of 15. Resident #7 required supervision or touching assistance from staff for bed mobility, transfers, dressing, and walking.The assessment indicated Resident #7 had no behavioral symptoms directed at others during the assessment look-back period. 2. Record reviewThe behavioral care plan, initiated 10/22/25, identified Resident #7 had an incident of misconduct with another resident. Interventions included providing one-to-one social services for decreased stimuli, discussing feelings and providing non-judgmental support, increasing sessions with the mental health provider and monitoring for mood and/or behavioral changes.Review of Resident #7's EMR revealed there were no corresponding progress notes regarding the altercation with Resident #2 on 11/18/25.V. Incident of physical abuse between Resident #5 and Resident #6 toward each other on 12/7/25A. Facility investigationThe 12/7/25 facility investigation revealed a staff member heard a male and a female resident yelling in the common area. Staff responded and observed Resident #5 and Resident #6 rolling away from each other in their wheelchairs.The investigation revealed staff separated the residents and monitored both residents every 15 minutes. The nurse completed assessments on both residents and determined Resident #6 had an abrasion above his right eye.The investigation substantiated the incident of physical abuse.B. Resident # 5 (victim and assailant) 1. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia and Wernicke's encephalopathy (a neurological condition caused by a vitamin deficiency). The 1/1/26 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 13 out of 15. Resident #5 required supervision and/or touching assistance for bed mobility, transfers, dressing, walking, and using a manual wheelchair for mobility.The assessment indicated Resident #5 had no behavioral symptoms directed at others during the assessment look-back period.2. Record reviewThe physical altercation care plan, initiated 12/7/25, included pertinent interventions for monitoring at 15-minute intervals (initiated 12/8/25), educating staff on protocol to report resident altercations (initiated 12/8/25) and redirecting from Resident #6 while in the smoking area (initiated 12/8/25).Review of Resident #5's EMR revealed there were no corresponding progress notes regarding the altercation with Resident #6 on 12/7/25.C. Resident #6 (victim and assailant) 1. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included stroke, difficulty walking, and dementia.The 2/16/26 MDS assessment revealed Resident #6 had severe cognitive impairments with a BIMS score of six out of 15. Resident #6 required setup to maximum assistance from staff for dressing and bed mobility. Resident #6 was dependent on staff for transfers, was non-ambulatory, and required supervision/touching assistance for using a manual wheelchair.The assessment documented Resident #6 had verbal symptoms directed toward others for four to six days during the assessment look-back period.2. Record reviewThe behavior care plan, initiated 12/7/25, included pertinent interventions for monitoring at 15-minute intervals (initiated 12/8/25), educating staff on protocol to report resident altercations (initiated 12/8/25), redirecting from Resident #5 while in the smoking area (initiated 12/8/25), and monitoring the abrasion above the right eye (initiated 12/9/25). The wheelchair safety care plan, initiated 6/25/24, revealed Resident #6 was at risk for abuse from other residents due to running into others with his wheelchair. Pertinent interventions included intervening to avoid confrontations with others, redirecting to a safe area when agitated and administering medications as ordered.The 12/7/25 nurse progress note revealed staff heard Resident #6 and a female resident arguing in the lobby. Staff investigated and observed Resident #5 and Resident #6 self-propelling their wheelchairs away from each other. The 12/7/25 facility investigation revealed Resident #6 sustained an abrasion above his right eye during the altercation with Resident #5. The 12/8/25 nurse progress note revealed no concerns regarding the abrasion above the right eyebrow. The resident had no complaints of pain. The 12/8/25 progress note revealed the physician gave a new order to start Risperdal 0.5 mg, every day at bedtime for aggression. VI. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/18/26 at approximately 2:30 p.m. RN #1 said she had worked at the facility for one year. RN #1 said after she was hired, the facility provided abuse prevention training. RN#1 said staff training included monitoring all residents for potential for altercations. RN #1 said when residents had increased risk for altercations, behavior monitoring needs were documented in residents' care plans and also at each change of shift report. RN #1 said if residents were involved in altercations, it was facility policy to separate all the residents and to complete nursing assessments for any changes in conditions. RN #1 said it was the facility policy to place residents involved in altercations on close monitoring, every 15 minutes. The NHA, the director of nursing (DON) and the social services director (SSD) were interviewed together on 2/18/26 at 4:45 p.m. The NHA said after resident altercations, residents involved in altercations were separated and monitored closely, every 15 minutes, or sometimes one-to-one assignments were necessary if residents had increased agitation.The DON said after the altercation between Resident #3 and Resident #4, Resident #4 was transferred to another unit in the facility. The DON said the new room assignment was on a unit that had less stimuli, to avoid increased anxiety or agitation for Resident #4. The NHA said Resident #4 had no behavioral altercations towards others after he moved to his new room and after the physician adjusted his medications. The SSD said Resident #3 had no changes in her mood or behaviors after the altercation. The NHA said Resident #1 had behaviors of approaching other residents to walk with them. The NHA said Resident #1 had one-to-one monitoring when she was out of her room to prevent her from approaching and reaching out towards other residents. The DON said staff involved Resident #1 with their tasks to keep Resident #1 on one-to-one monitoring. The SSD said the physician adjusted medications for Resident #2 after he pushed Resident #1. The SSD said after Resident #2 had his medications adjusted, he had not had altercations with other residents.The NHA said after the altercation between Resident #6 and Resident #5, the common area furniture was rearranged to allow a greater passing area for residents in wheelchairs. The NHA said Resident #6 had updates to his care plan for staff to closely monitor him when he was in the common areas and outside in the smoking area. The SSD said Resident #6 had not had altercations with other residents after the physician prescribed the Risperdal. THe NHA said Resident #5 had no previous behavioral concerns. The NHA said Resident #5 was was observed striking Resident #6 in response to Resident #6's attempt to hit Resident #5 after their wheelchairs collided. The NHA said Resident #2 sat in the common area and swung his feet over the arm of the chair. The NHA said when Resident #7 walked passed Resident #2 he came into contact with Resident #2's foot. The NHA said Resident #7 pushed Resident #2's foot away in an attempt to continue walking. He said Resident #2 responded by kicking Resident #7 and then Resident #2 slapped Resident #2. The NHA said after the furniture was rearranged in the common areas and after Resident #2 had aripiprazole prescribed, there were no further occurrences between Resident #2 and Resident #7.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of five residents reviewed for failure to transcribe and initiate the physician's orders out of nine sample residents.Specifically, the facility failed to ensure Resident #'1 post hospitalization orders for hematoma care were entered into the electronic medical record (EMR) and followed. Findings include:I. Facility policy and procedureThe Hematoma Aftercare procedure, undated, was received from the nursing home administrator (NHA) on [DATE] at 2:36 p.m. It read in pertinent part, Aftercare for a hematoma involves monitoring vital signs and neurological status, applying cold compresses, and promoting elevation of the affected area. Nurses should also assess for signs of complications like worsening pain or infection, carefully manage any anticoagulant medications as ordered by the physician. and educate the patient and family when to seek further medical attention. Monitoring and assessing:-Vital signs;-Neurological status;-Signs of deterioration ; and,-Skin integrity. Treatment and care:-Rest;-Elevation;-Cold compresses; and,-Medication management. Patient and family education-Activity restrictions;-Signs of complications; and,-Wound care. Work closely with the physician to manage the hematoma and any complications; and consult with a certified wound nurse if the hematoma is complex or failing to heal properly.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and expired in the facility on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included stage four kidney disease, diabetes mellitus, unsteadiness of feet, difficulty walking, abnormal gait, depression, atrial fibrillation, dementia, macular degeneration and a history of falling.The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #1 required substantial to maximum assistance from staff for sitting to lying in bed and partial to moderate assistance from staff for bed mobility, for sitting to standing, and transfers. Resident #1 was non-ambulatory and used a manual wheelchair for mobility. The MDS assessment documented that Resident #1 was prescribed anticoagulant, Eliquis 2.5 milligrams (mg) twice daily.B. Record review-Review of Resident #1's comprehensive plan of care did not reveal documentation regarding the resident's abrasion and hematoma treatments or monitoring.The [DATE] fall occurrence progress note revealed Resident #1 fell from his wheelchair during a transfer. The progress note read that Resident #1 fell onto his left knee and then fell and hit his head. The nurse completed an assessment and documented vital signs: blood pressure 94/52 millimeters of mercury (mmHg), temperature 97.4 degrees Fahrenheit, heart rate 49 beats per minute, and respirations 16 per minute. The progress note revealed Resident #1 had a large knot on his left forehead with a small open area oozing blood. Resident #1 was transferred to the emergency department for evaluation. The [DATE] nurse progress note revealed the facility nurse spoke with the hospital nurse, who reported Resident #1 had a head computerized topography (CT) scan and determined the findings were negative (no active bleeding in or around the brain) and Resident #10 was doing well and would return to the facility.The [DATE] hospital discharge instructions revealed Resident #1 was evaluated for a same-level fall and had an abrasion and hematoma on his head. Resident #1 was diagnosed with an abrasion and a hematoma. The special notes of the discharge instructions read in pertinent part, the CT scan did not show any sign of internal bleeding or fracture. Please follow up with your primary care provider in two to three days. Return to the emergency department with symptoms worsening. Occasionally, hematomas can calcify. Recommend placing ice on the immediate face to help with inflammation. In two to three days, switch over to heat to help the body reabsorb the blood. The [DATE] hospital discharge instructions included wound care instructions and read in pertinent part: Abrasion care:-Your abrasion will be cleaned with water and mild soap;-An antibiotic ointment may be applied to your abrasion to prevent infection; and,-A bandage may be placed on your abrasion to keep it clean;-Clean your wound one to two times a day with soap and water;-Keep your dressing clean and dry;-Check your wound every day for signs of infection;-If directed, put ice on the injured area; and-If possible, raise the injured area above the level of your heart while you are sitting or lying down. Hematoma care:-If directed, to put ice on the injured area and leave the ice on for 20 minutes, two to three times a day for the first couple of days;-If directed, apply heat to the affected area as often as told by your provider with a heat source recommended. Leave the heat on for 20 to 30 minutes; and-Raise the injured area above the level of your heart while you are sitting or lying down.-However, Record review revealed the facility failed to review and reconcile medications when Resident #1 returned to the facility. The medication reconciliation form, dated [DATE], was blank and unsigned.-Further review of Resident #1's EMR revealed the facility nursing staff did not transcribe or enter the new treatment orders into Resident #1's EMR. As a result, nursing care was not provided for the abrasion and hematoma. III. Staff interviewsThe DON was interviewed on [DATE] at 2:00 p.m. The DON said when residents returned to the facility from the emergency department, the admitting or charge nurse was responsible for reviewing the documents for new physician's orders or changes to existing orders. The DON said the [DATE] emergency department discharge instructions were not reviewed, noted, or entered into Resident #1's EMR. The DON said when physician's orders were not entered into the EMR, nursing staff would be unaware of specific resident needs because nurses refer to physician orders for required medications and treatments. The DON said staff monitored Resident #10 after he returned from the hospital on [DATE] and said she was unable to find documentation that nursing care was provided for the abrasion and hematoma. The DON said on [DATE], Resident #1 had a change in condition and was transferred to the emergency department. The DON said while Resident #1 was at the hospital, his family, friends, and power of attorney opted to place Resident #1 on hospice care, and Resident #10 expired on [DATE].

Based on observations, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of five residents reviewed for maintaining resident health records out of nine sample residents.Specifically, the facility failed to ensure physicians' progress notes for Resident #1 were available in the electronic medical record (EMR). Findings include:I. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included history of stroke, left-sided paralysis, atrial fibrillation, epilepsy, diabetes mellitus, high blood pressure, depression, chronic pain and mild intellectual disabilities.The 8/28/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #1 was dependent on staff for her activities of daily living. B. Record reviewThe record review revealed there were no physicians' progress notes in Resident #3's EMR for the period of 1/1/25 to 10/7/25. II. Staff interviewsThe director of nursing (DON) was interviewed on 10/7/25 at 2:00 p.m. The DON said the Resident #3's physician documented the physician evaluations and progress notes in a health record system that the facility did not maintain. The DON said if physician records were required by nursing or other health care providers, the physician records were not immediately available. The DON said the current process to obtain physician progress notes was that she contacted the physicians' office staff with the records request, and the records were forwarded the same day or the next day by secure email messaging. The DON said the facility would review the health record requirements with the physician and develop a process to ensure physicians' evaluations and progress notes were available in the facility's EMR system.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the facility's kitchen and dining room. Specifically, the facility failed to: -Ensure nourishment beverages in the main dining room and unit refrigerators were dated and labeled; -Ensure cooking utensils were dried appropriately; -Ensure food preparation area vents were free from hanging dust and lint; -Ensure the main dining room refrigerator maintained a safe operating temperature; and, -Ensure dented food cans were not used. Findings include: I. Ensure nourishment beverages in the main dining room and unit refrigerators were dated and labeled. A. Professional reference The Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, were retrieved on 6/13/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, Time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. A date marking system may include using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine, marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded and/or marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. B. Observations On 6/2/24 at 2:15 p.m. the following was observed at the main dining room nourishment refrigerators during the initial kitchen tour: -In the dining room refrigerator, there were two opened gallons of milk. Both of the gallons of milk were not labeled with the date they were opened or the date they were to be used by. -Additionally, one of the gallons of milk did not have a lid on it. On 6/3/24 at 2:30 p.m. the south side unit refrigerator was observed to have a half-used bottle of mango juice which was not dated with the date it was opened or a use by date. C. Staff interviews Dietary aide (DA) #1 was interviewed on 6/4/24 at 2:40 p.m. DA #1 said opened beverages were to be dated and labeled to ensure every staff member knew when the beverage should be discarded. He said one of the gallons of milk in the dining room refrigerator had no lid and needed to be thrown away. He said residents could become sick from drinking milk products that had been left open without the lid or were past the date they should be discarded. II. Ensure cooking utensils were dried appropriately. A. Professional reference The Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, were retrieved on 6/13/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, Equipment and Utensils, Air-drying required. After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food and may not be cloth dried. B. Facility policy The nursing home administrator (NHA) provided the Dishwashing policy, with no revision date, on 6/11/24. The policy read in pertinent part, The dishwashing procedures and techniques are well developed, understood, and carried out in compliance with the state and local health codes to assure the safety of the residents. C. Observation On 6/4/24 at 3:30 p.m. a volunteer and an unidentified staff member were observed using paper towels to dry eating and cooking utensils, such as silverware, plates, pots and pans, before placing them on the dish rack. D. Staff interview The dietary manager (DM) was interviewed on 6/4/24 at 4:00 p.m. The DM said the staff used paper towels to dry clean dishes to hurry the drying process so they could use the utensils again. The DM said she was unsure if utensils should be dried with paper towels and said she would verify the process with her supervisor. III. Ensure food preparation area vents were free from hanging dust and lint. A. Professional reference According to The Food and Drug Administration (FDA) Food Code (2019) p. 441, retrieved on 6/8/24 from https://www.fda.gov/media/164194/download?attachment, Surface Characteristics: Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible. Heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents. B. Facility policy and procedures The Sanitation policy, undated, was provided by the NHA on 6/11/24 at 12:01 p.m. It read in pertinent part, Sanitation conditions are maintained at all times in the dietary department. Effective procedures for cleaning all equipment are well developed and are followed consistently. C. Observations On 6/2/24 at 3:30 p.m., during the initial kitchen tour, two vents in the food preparation area were observed to have hanging dust and cobwebs. On 6/4/24 at 3:00 p.m. the two vents in the food preparation area continued to have lint and dust around them. The cook was observed preparing mechanical and pureed food directly underneath the area where the vents were located. D. Staff interviews The DM was interviewed on 6/4/24 at 4:00 p.m. The DM said there was a daily, weekly and monthly cleaning schedule for maintaining the kitchen in a sanitary condition. The DM said the hanging dust and cobwebs around the vents in the food preparation area was unsanitary.The DM said the maintenance department were responsible for cleaning the high sky ceiling vents. She said a work order had been submitted. The DM said the hanging dust would be cleaned after hours by the maintenance department once the kitchen had completed all food services for the day. The maintenance supervisor (MS) was interviewed on 6/5/24. The MS said he was a new employee and was still being trained. The MS said he had received a work request for the cleaning of the kitchen vents but had not cleaned them yet. IV. Ensure the main dining room refrigerator maintains a safe operating temperature A. Professional reference The Food and Drug Administration (FDA) Food Code (2022), reviewed 1/18/23, was retrieved on 6/8/24 from https://www.fda.gov/food/retail-food-protection/fda-food-code. It read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safe food remains in the temperature 'danger zone' of 41 degrees Fahrenheit (F) to 135 degrees F for too long. B. Facility policy The Refrigerators and Freezers policy, undated, was provided by the NHA on 6/11/24 at 12:01 p.m. It read in pertinent part, All refrigerated foods are stored in such a manner to keep them safe and free from contamination. The temperature of each refrigerated unit will be maintained below 40 degrees Fahrenheit (F) C. Observations On 6/2/24 at 3:30 p.m. during the initial kitchen tour, the refrigerator in the main dining room, which contained beverages and snack foods, was observed with a temperature of 51 degrees F. On 6/4/24 at 4:00 p.m. the dining room refrigerator continued to have a temperature of 51 degrees F. D. Staff interview The DM was interviewed on 6/4/24 at 4:00 p.m. The DM said all nourishment refrigerators should maintain an operating temperature of 40 degrees F and below. She said it was unsafe for beverages and food items to remain too long in the food danger zone. The DM said all beverages and food items in the dining room refrigerator would be discarded and she would request maintenance to check the refrigerator. The DM was interviewed again on 6/5/24 at 11:30 am. The DM said the beverages and snack foods in the dining room refrigerator had been removed and the refrigerator would not be in use again until maintenance ensured that it was operating at a proper temperature. V. Ensure dented food cans were not used. A. Professional reference According to the United States Department of Agriculture (USDA), retrieved on 6/13/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous. It read in pertinent part, Never use food from cans that are leaking, bulging, or badly dented, cracked jars or jars with loose or bulging lids, canned food with a foul odor or any container that spurts liquid when opening. Such cans could contain clostridium botulinum. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam. While extremely rare, a toxin produced by it is the worst danger in canned goods. Don't taste such foods. Even a minuscule amount of botulinum toxin can be deadly. Recommended storage times are as follows: two to five years for low-acid foods (such as meat, poultry, fish, and vegetables; 12-18 months for high-acid foods (such as juices, fruit, pickles, tomato soup, and sauerkraut). B. Observations On 6/2/24 at 3:30 p.m., during the initial kitchen tour, one dented can of crushed pineapple and two dented cans of fancy shredded sauerkraut were observed on the canned food rack in the pantry. On 6/4/24 at 4:20 p.m. there was one dented crushed orange can observed on the canned food rack in the pantry. C. Staff interview The DM was interviewed on 6/5/24 at 11:30 am. She said she had previously removed the dented food cans from the rack but they somehow got put back on the food rack. The DM said staff were educated and were aware not to place dented food cans on the rack to be used. The DM said she had removed the dented can and would offer education to the kitchen staff immediately to avoid staff using any dented food cans. VI. Additional interviews The regional registered dietitian (RRD) was interviewed on 6/5/24 at 11:35 a.m. The RRD said dented food cans could allow bacteria growth which could be detrimental to the health of the residents. The RRD said kitchen utensils should be air dried according to facility policy and staff should avoid the use of paper towels to dry plates and silverware. She said drying utensils with paper towels could cause cross contamination leading to illnesses. The RRD said all opened beverages should be dated and labeled when opened. The NHA was interviewed on 6/5/24 at 11:50 a.m. The NHA said she had initiated training for the DM to complete and would ensure that all kitchen staff were appropriately retrained immediately to maintain proper refrigerator temperatures, air dry eating and cooking utensils and to ensure all opened items in the unit's refrigerators were dated and labeled. She said all dented food cans would be separated and returned to the vendor for credit or replacement.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #5 and CNA #6. Findings include: I. Record review CNA #2 (hired on 2/1/11), CNA #3 (hired on 7/26/11), CNA #5 (hired on 4/5/23) and CNA #6 (hired on 1/26/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 6/4/24 at 12:30 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of the reviews. She said going forward she would ensure the performance reviews were completed annually to ensure the best care was being delivered to the residents.

Based on record review and interviews, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for one (#2) of one resident out of 37 sample residents. Specifically, the facility failed to invite Resident #2's representative to participate in the care conferences to review the resident's plan of care. Findings include: I. Facility policy The Care Planning - Interdisciplinary Team policy, revised March 2022, was provided by the nursing home administrator (NHA) on 6/5/24 at 12:00 p.m. It read in pertinent part, The interdisciplinary team is responsible for the development of resident care plans. The resident, the resident's family and/or the resident's legal representative or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. II. Resident #2 A. Resident status Resident #2, age 79, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, severe dementia with mood disturbances, sleep apnea, hearing loss and insomnia (difficulty sleeping). The 5/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He was dependent on staff for toileting, showering, personal hygiene, and dressing. He required supervision for eating and substantial assistance with oral hygiene. B. Resident representative interview The resident's representative was interviewed on 6/3/24 at 9:42 a.m. She said the facility did not invite her or the other resident's representatives to the care conferences. She said she was frustrated because the only time she was updated on the resident's care was when the facility wanted to change his risperdal (antipsychotic medication). She said the facility did not communicate with her and it took a long time to get the resident enrolled in hospice care. C. Record review The 1/23/24 multidisciplinary care conference note revealed the Resident #2's representative did not attend the care conference. The 4/30/24 multidisciplinary care conference note revealed the resident's representative did not attend the care conference. The 5/7/24 multidisciplinary care conference note revealed the residen'ts representative did not attend the care conference. The 5/16/24 multidisciplinary care conference note revealed the resident's representative did not attend the care conference. A review of the Resident #2's electronic medical record (EMR) on 6/5/24 at 9:00 a.m. revealed there was no documentation that the resident's representative was contacted to attend the care conferences on 1/23/24, 4/30/24, 5/7/24 and 5/16/24. III. Staff interviews The social services director (SSD) was interviewed on 6/5/24 at 10:40 a.m. The SSD said the MDS coordinator was responsible for coordinating care conferences. The SSD said care conferences were completed at least quarterly. The SSD said a care conference was held more frequently if the resident had a change in condition. The SSD said the social services department, the MDS coordinator, the dietary manager, the activities department and restorative services attended the care conferences. The SSD said the social services department was responsible for inviting the resident's representative. The SSD said a card was sent, by mail, 45 days before the care conference date. The SSD said the resident's representative called to confirm if they could or could not attend the conference. The SSD said if the representative did not call, social services was responsible for calling the representative the day before the care conference and when the care conference started. The SSD said the social services department documented in a progress note that a card was sent and if the resident's representative was contacted. The SSD said the social services department did not invite Resident #2's representative to any care conferences because she thought the representative did not want to be a part of the resident's care plan. The SSD said she should have called the representative to allow them to accept or decline. The SSD said she would contact the Resident #2's representative for future care conferences. The SSD said she would document in a progress note if the representative wanted to attend the care conferences. The director of nursing (DON) was interviewed on 6/5/24 at 11:11 a.m. The DON said Resident #2's representative should have been invited to the care conferences that took place. The DON said the social services department was responsible for inviting the resident or resident's representative to care planning conferences.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#87) of three residents reviewed for accidents/hazards out of 37 sample residents. Specifically, the facility failed to ensure Resident #87 had an order for a medication (Aleve) found at his bedside or a self medication assessment. Findings include: I. Resident status Resident #87, age 69, was admitted on [DATE]. According to the June 2024 computerized physician's order (CPO), diagnoses included difficulty walking, muscle weakness and abnormality of gait. The 5/15/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. II. Record review The care plan, initiated 5/7/24 and updated 5/14/24, identified the resident had activities of daily living (ADL) self care performance deficits. Interventions included supervising and assisting the resident with ADLs. A review of Resident #87's electronic medical record (EMR) did not reveal the resident had a physician's order for Aleve (pain medication). A review of Resident #87's EMR did not reveal a self medication assessment. III. Observations and interview There was a bottle of Aleve was on a television tray in Resident #87's room on 6/2/24 at 11:15 a.m. There was a bottle of Aleve was on a television tray in Resident #87's room on 6/3/24 at 2:05 p.m. There was a bottle of Aleve was on a television tray in Resident #87's room on 6/4/24 at 10:41 a.m. Licensed practical nurse (LPN) #2 retrieved the bottle of Aleve. She said Resident #87 did not have a physician's order for Aleve. Resident #87 said he only had it for when he had a headache. He said he did not need to tell a doctor about a headache. He said he had purchased the bottle while out of the facility. LPN #2 said she would let the provider know and ask for an as needed (PRN) medication for headaches. She removed the bottle from the resident's room. IV. Staff interview The director of nursing (DON) was interviewed on 6/4/24 at 11:30 a.m. The DON said the facility did not have any residents who were allowed to self administer medications. She said staff should have seen the bottle of Aleve and removed it from the resident's room She said if Resident #87 needed medication for headaches, the facility could ask the provider for a PRN medication order.

Based on interviews and record review, the facility failed to ensure two (#18 and #19) of four residents investigated for abuse out of 37 sample residents were kept free from physical abuse. Specifically, the facility failed to: -Prevent a physical altercation between Resident #93 and Resident #19, and, -Prevent a physical altercation between Resident #71 and Resident #18. Findings include: I. Facility policy The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, reviewed September 2022, was provided by the nursing home administrator (NHA) on 6/2/24 at 3:36 p.m. The policy read in pertinent part, Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are thoroughly investigated. The administrator initiates investigations. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. II. Altercation on 3/21/24 between Resident #93 and Resident #19 A. Facility investigation of the altercation on 3/21/24 The witness statement dated 3/21/24 by certified nurse aide (CNA) #7, noted she heard some yelling and saw Resident #19 on the floor being kicked by Resident #93. The victim statement dated 3/21/24 documented Resident #19 said he saw Resident #93 leaving his room with his belongings. Resident #19 told Resident #93 to give the items back. Resident #93 then slammed Resident #19 to the ground and started kicking Resident #19. Resident #19 stated he was afraid of Resident #93. A progress note dated 3/21/24 at 11:30 a.m. identified Resident #93 was in Resident #19's room. Resident #19 confronted Resident #93 for taking his belongings. Resident #93 pushed Resident #19 into the wall then threw Resident #19 to the floor and kicked Resident #19. Resident #93 admitted to pushing Resident #19. B. Resident #19 1. Resident status Resident #19, age 69, was admitted on [DATE], and readmitted on [DATE]. According to the June 2024 computerized physician's orders (CPO), diagnoses included paranoid schizophrenia (mental illness that affects a person's thoughts and behaviors), type II diabetes and chronic obstructive pulmonary disease (COPD). The 4/20/24 minimum data set (MDS) assessment documented the resident was moderately cognitively intact with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment did not identify behaviors during the assessment period. 2. Record review The care plan, initiated 6/29/23, identified Resident #19 had the inability to problem solve. Interventions included the staff were to remind Resident #19 to ask for help. The care plan, initiated 6/29/23, identified the diagnosis of schizophrenia to include paranoid ideation. Interventions included the target behaviors of paranoia and people persecuting him. Staff were to monitor for the behaviors. The progress note, dated 3/21/24 at 10:50 a.m. identified the following injuries to Resident #19 from the altercation with Resident #93: -A scalp contusion to the forehead, -An abrasion to the right arm measuring 0.5 centimeters (cm) by 0.3 cm; -An abrasion to the left hand measuring 0.1 cm by 0.5 cm; -An abrasion to the right arm measuring 1.2 cm by 0.5 cm; and, -A contusion to the right side of the forehead measuring 4.3 cm by 4 cm. The progress note dated 3/21/24 at 3:21 p.m. noted the resident had returned from the hospital with a contusion on the right side of the forehead that had been cleansed with normal saline (NS) and Bacitracin (topical antibiotic ointment) was applied. There were abrasions to his left and right arms also. C. Resident #93 1. Resident status Resident #93, age 72, was admitted on [DATE] and discharged to the hospital on 3/21/24. According to the March 2024 CPO, diagnoses included Alzheimer's disease, dementia and amnesia (memory loss). The 3/20/24 MDS assessment documented the resident had moderate cognitive impairments with a BIMS score of eight out of 15. The MDS assessment did not identify any behaviors during the look back period. 2. Record review The care plan, initiated 3/11/24, identified the resident had a diagnosis of dementia which made it hard for him to know time or place. Interventions included if he became upset, try to find out the cause and address it or resolve it. The care plan, initiated 3/13/24, identified Resident #93 was at risk for impaired psychiatric/mood status secondary to amnesia, dementia, anxiety, and Alzheimer's disease. Interventions included providing a calm and safe environment when the patient was emotional or frustrated and allowing time to voice his feelings. The multidisciplinary care conference form dated 3/19/24, identified Resident #93 would get confused regarding which room was his and he needed redirection to find his room. Interventions included potentially placing a sign on his door as a visual cue. -The facility failed to update Resident #93's care plan with the intervention discussed in the care conference on 3/19/24. The progress noted dated 3/21/24 at 11:30 a.m. identified the provider gave a verbal order to send Resident #93 to the hospital for an evaluation after the altercation. Resident #93 did not return to the facility following his discharge to the hospital. D. Staff interviews CNA #3 was interviewed on 6/4/23 at 1:55 p.m. CNA #3 said Resident #93 had a habit of wandering into other resident's rooms and saying items he found were his. She said when the altercation on 3/21/24 occurred, she saw Resident #19 on the floor getting kicked. She said she helped separate both the residents and called the administrative staff. She said Resident #19 had a scrape on his knees and a rug burn on his head. She said the other residents were afraid of Resident #93. The NHA was interviewed on 6/5/24 at 12:30 p.m. The NHA said the facility immediately separated the residents and each resident was placed on one on one staff monitoring until they were both sent to the hospital to see if they had suffered any injuries beyond the noted ones by the staff. She said the facility worked hard to prevent abuse in any form. III. Altercation on 5/28/24 between Resident #18 and Resident #71 A. Facility investigation Housekeeper (HSK) #1's statement, dated 5/28/24, indicated Resident #71 yelled at Resident #18, then got up and went over and slapped Resident #18 in the face. She said she could not hear what they were saying to each other. The investigation documented that during the investigation, Resident #71 continued to deny slapping Resident #18 even after showing him the video evidence. A progress note, dated 5/28/24 at 3:42 p.m., noted Resident #18 went outside to smoke and Resident #71 slapped him. Resident #18 was taken back inside the facility by staff. Resident #18 was noted to have a red mark on his left cheek. B. Resident #18 1. Resident status Resident #18, age 69, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included cerebral infarction (stroke), aphasia (difficulty talking) and left side weakness. The 3/20/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment identified one episode of verbal behaviors during the assessment period. 2. Record review The care plan, revised 2/20/24, identified Resident #18 would display behaviors that included knocking people down. Interventions included allowing Resident #18 to express his feelings in appropriate ways, analyzing the behavior for a possible cause and effect relationship and explaining his behavior was not acceptable. C. Resident #71 1. Resident status Resident #71, age less than 65, was admitted on [DATE] and discharged home on 5/28/24. According to the May 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), heart disease and respiratory failure. The 3/20/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment identified one episode of verbal behaviors during the assessment period. 2. Record review The care plan, initiated 10/16/23, identified Resident #71 had impaired psychiatric/mood status related to depression. Interventions included providing him with quality listening time and encouraging expressions of feelings. -The facility failed to identify and care plan that Resident #71 displayed verbal behaviors towards others (see MDS assessment above). The progress note, dated 5/28/24 at 3:21 p.m. documented Resident #71 began yelling at Resident #18. Resident #71 stood up and slapped Resident #18 on the left cheek. A nurse in the building heard a commotion, went outside to see what was going on. The nurse took Resident #18 into the facility. When Resident #71 was questioned, he denied he hit Resident #18. Resident #71 was shown the video of him hitting Resident #18 on the left cheek. Resident #71 was put on a one on one staff monitoring. IV. Staff interviews The social services assistant (SSA) was interviewed on 6/4/24 at 2:30 p.m. The SSA said Resident #71 was planning to leave the facility at the end of May 2024. She said he had not displayed any kind of aggressive behavior toward another resident before. She said he denied the assault even after he watched the video. She said Resident #18 had a reddened cheek after the incident. The NHA was interviewed on 6/5/24 at 12:30 p.m. The NHA said Resident #71 had not displayed aggressive behaviors previous to the altercation. She said after the one on one was started, Resident #71 signed out of the facility against medical advice (AMA) shortly after the altercation. She said everyone who lived at the facility had the right to be free from any form of abuse to include physical abuse.

Based on observations, record review and interviews, the facility failed to ensure one (#80) of three residents with skin conditions of 37 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to identify, assess, monitor and care plan a large growth on Resident #80's face. Findings include: I. Resident status Resident #80, age over 65, was admitted on [DATE]. According to the June 2024 computerized physician's order (CPO), diagnoses included atrial fibrillation (irregular heart beat), dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD). The 4/20/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. II. Observation On 6/2/24 at 1:15 p.m. Resident #80 was observed to have a large growth that was approximately the size of a pear on the right side of his face in front of his right ear. III. Record review A 11/1/23 physician's note identified a mass on the right side of Resident #80's face by the mandible (jaw). A 12/20/23 physician's note identified the mass on the right side of the resident's face near the mandible. A 2/21/24 physician's note identified a large mass on the right side of the resident's face. A 4/16/24 physician's note identified a large growth on the right side of the resident's face by the mandible. -Resident #80's care plan did not address the growth on the right side of the resident's face. -The resident's admission assessment did not identify the resident had a growth on the right side of his face. -The facility did not have any assessments or monitoring of the growth on the right side of his face. IV. Interviews Certified nurse aide (CNA) #8 was interviewed on 6/4/24 at 10:10 a.m. CNA #8 said Resident #80 had always had the growth on his face. She said she did not think there were any special treatments for the growth. She said the family did not want any procedures done to the growth. She said if staff saw any changes to the growth she would report the changes to the nurse. Registered nurse (RN) #1 was interviewed on 6/5/24 at 9:00 a.m. RN #1 said the growth on Resident #80's face had always been there. She said she did not have an order to monitor the area. She said if she saw a change in the area she would have notified the director of nursing (DON). She said the family did not want any treatment to the area. The DON was interviewed on 6/5/24 at 11:15 a.m. The DON said the facility should have identified the growth upon initial assessment when the resident was admitted to the facility. She said she did not know why the growth was not being monitored by the facility staff. She said she did not know why there was not a care plan identifying the growth and indicating that the family wished to not remove the growth. She said the provider would see the resident later that day (6/5/24) and she would provide education to have the staff start monitoring the area. She said she would have a care plan started to identify the growth and the wishes of the family for non-treatment.

Based on observations, record review, and interviews the facility failed to use a person-centered approach when determining the use of bed rails for four (#27, #36, #40, and #70) of ten residents reviewed for bed rails out of 37 sample residents. Specifically, for Resident #27, #36, #40 and #70, the facility failed to: -Assess the resident for risk of entrapment prior to installing the bed rails; -Obtain consent, which included the risks versus benefits of bed rails, from the resident and/or the resident's representative prior to bed rail installation; and, -Conduct quarterly assessments of the bed rails to evaluate the safety and/or continued need for bed rails. Findings include: I. Professional reference The U.S. (United States) Food and Drug Administration (FDA) Recommendations for Health Care Providers Using Adult Portable Bed Rails (2/27/23), was retrieved on 6/8/24 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health- care-providers-using-adult-portable-bed-rails. It read in pertinent part, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. II. Facility policy and procedure The Bed Safety and Bed Rails policy and procedure, revised August 2022, was provided by the nursing home administration (NHA) on 6/8/24 at 12:00 p.m It read in pertinent part, Residents' beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bedrails are prohibited unless the criteria for use have been met. Consideration is given to the residents' safety, medical conditions, comfort and freedom of movement, as well as input from residents and resident families regarding previous sleeping habits and bed environment. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspections to the administrator and reports results to the Quality Assurance and Performance Improvement (QAPI) committee for appropriate action. III. Resident #27 A. Resident status Resident #27, over the age of 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia, heart failure, chronic pain syndrome, and arthritis of the right shoulder. The 3/20/24 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 required supervision with transfers, toileting, personal hygiene, eating, and bed mobility. -The assessment documented Resident #27 did not use bed rails. B. Observations On 6/3/24 at 9:40 a.m., Resident #27 was sitting in her wheelchair in her room with one metal half bed rail attached to the resident's bed. On 6/4/24 at 1:15 p.m., Resident #27 was lying in bed with one metal half bed rail attached to her bed. C. Resident interview Resident #27 was interviewed on 6/4/24 at 9:17 a.m. Resident #27 said the side rail helped her with transfers. She said the bed rail had been attached to the bed since she arrived in the room. D. Record review -The June 2024 CPO revealed Resident #27 had no physician's order for a bed rail on one side of the resident's bed to help with mobility. The comprehensive care plan, initiated and revised on 6/11/23, revealed Resident #27 had impaired mobility, poor range of motion and was at risk for falls. -The care plan failed to include an intervention for the use of a bed rail for Resident #27. -A comprehensive review of the resident's electronic medical record (EMR) failed to reveal a bed rail evaluation and consent prior to the initiation of the one bed rail as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. IV. Resident #36 A. Resident status Resident #36, under the age of 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included paraplegia, type 2 diabetes mellitus, bipolar disorder and difficulty in walking. The 5/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision assistance with toileting, showering, dressing, personal hygiene and mobility. -The assessment documented Resident #36 did not use bed rails. B. Observation On 6/3/24 at 9:50 a.m. and 6/4/24 at 3:02 p.m., one bed rail was observed on the left side of Resident #36's bed. On 6/5/24 at 9:05 a.m. Resident #36 was lying down in bed with a bed rail attached to her bed on the left side. C. Resident interview Resident #36 was interviewed on 6/5/24 at 9:06 a.m. Resident #36 said she was offered a new bed by the facility and the new bed arrived with one side rail. The resident said she used the side rail to assist her with transfers and positioning during incontinence care. She said the bed rail prevented her from falling out of bed. D. Record review The care plan, revised on 4/11/24, revealed Resident #36 was at risk for falls due to impaired mobility related to the diagnosis of paraplegia. Interventions included to assess the need for assistive/supportive devices. -The care plan failed to include an intervention for the use of a bed rail for Resident #36. -A review of Resident #36's June 2024 CPO revealed there was no physician's order for the resident's bed rail. -The resident's EMR revealed Resident #36 was not evaluated for the use of a bed rail, there was no consent for bed rails, and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. V. Resident #40 A. Resident status Resident #40, over the age of 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included muscle weakness, anemia, abnormality of gait and movement and pain. The 4/5/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance for mobility and maximum assistance with showers, personal hygiene, and toilet transfers. -The assessment documented Resident #40 did not use bed rails. B. Observation On 6/3/24 at 10:00 a.m. and 6/4/24 at 2:15 p.m., Resident #40 was sitting in her wheelchair in her room. A bed rail was observed attached to the right side of the resident's bed. C. Resident interview Resident #40 was interviewed on 6/3/24 at 11:04 a.m. Resident #36 said the bed rail was for her to hold on to to assist her with turning herself during incontinence care at night. D. Record review The resident's care plan, revised on 2/11/24, revealed Resident #40 had potential for skin integrity impairment due to immobility. The care plan documented the use of a right-sided grab bar (bed rail) attached to the resident's bed for assistance in repositioning. -A review of Resident #40's June 2024 CPO revealed there was no physician's order for the resident's bed with the bed rail. -The resident's EMR revealed Resident #40 was not evaluated to use a bed rail. There was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. VI. Resident #70 A. Resident status Resident #70, age greater than 65, was admitted on [DATE]. According to the June 2024 computerized CPO, diagnoses included heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), muscle weakness, chronic pain and rheumatoid arthritis. The 4/30/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required supervision assistance with showers, toileting and personal hygiene. -The assessment documented Resident #70 did not use bed rails. B. Observation On 6/3/24 at 10:30 a.m. and 6/4/24 at 1:57 p.m. bed rails were observed on both sides of Resident #70's bed. C. Record review The care plan, revised on 10/30/23, revealed Resident #70 was at risk for falls related to obesity, muscle weakness, pain and rheumatoid arthritis. -It indicated the use of a grab bar (bed rail) for assistance with bed mobility. -A review of Resident #70's June 2024 CPO revealed there was no physician's order for the resident's bed rails. -The resident's EMR revealed Resident #70 was not evaluated to use a bed rail, there was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rails. -The maintenance department had no routine inspections for the resident's bed rails. VII. Staff interviews The physical therapy assistant (PTA) was interviewed on 6/5/24 at 11:00 a.m. The PTA said the bed rails were handles added to the sides of the bed to assist residents during transfers and repositioning. The PTA said. if used appropriately, bed rails could help residents become independent. She said she had noticed several resident's beds with the bed rails and would assume all of the residents had physician's orders and assessments completed for the bed rails. She said the maintenance department should be monitoring the functioning of the bed rails. The maintenance supervisor (MS) was interviewed on 6/5/24 at 11:15 a.m. The MS said he installed the bed rails of the residents' beds when he received a maintenance order from nursing staff. He said he thought, before an order was placed for a bed rail, the nursing staff would ensure the proper assessment for the bed rails had been completed. The MS said there was no ongoing monitoring of the bed rails once he initially installed them. The director of nursing (DON) was interviewed on 6/5/24 at 12:42 p.m. The DON said it was the policy of the facility to complete a bed rail assessment prior to attaching bed rails to a bed. She said the therapy department was responsible for completing bed rail assessments. She said once the decision was made to attach bed rails to a resident's bed frame, it was the responsibility of nursing staff to obtain informed consent from the resident or resident's representative. The DON said it was the responsibility of the nursing unit nurse manager to update a resident's care plan to identify the bed rail use as an intervention. The DON said when bed rails were attached to residents' bed frames there should be ongoing routine maintenance checks for functioning. The DON said routine maintenance checks were not being done and she would immediately ensure consent, assessment, and routine monitoring of all bed rails.

Based on record review and interviews, the facility failed to ensure three (#2, #21, #54) of five residents reviewed for unnecessary medications out of 37 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #2, Resident #21 and Resident #54 had appropriate non-pharmacological interventions for behaviors initiated; and, -Ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained from the resident or resident's representative before the resident's use of a psychotropic medication for Resident #2, Resident #21 and Resident #54. Findings include: I. Facility policy The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 6/5/24 at 12:00 p.m. It read in pertinent part, Non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for the discontinuation of medications when possible. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes the indication for use, dose, duration, adequate monitoring for efficacy and adverse consequences and preventing, identifying and responding to adverse consequences. Residents and representatives have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident and representative the risks related to not taking the medication as well as appropriate alternatives. II. Resident #2 A. Resident status Resident #2, [AGE] years old, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, severe dementia with mood disturbances, sleep apnea, hearing loss and insomnia (difficulty sleeping). The 5/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of zero out of 15. He was dependent on staff for toileting, showering, personal hygiene, and dressing. He required supervision for eating and substantial assistance with oral hygiene. The resident exhibited verbal and other behavioral symptoms not directed towards others one to three days. The resident took antipsychotic, antidepressant and hypnotic medications on a routine basis. B. Resident representative interview The resident's representative was interviewed on 6/3/24 at 9:42 a.m. She said the resident had a terrible time when he was admitted to the facility. She said she was frustrated because the facility tried a couple of times to decrease his Risperdal (medication used to treat mood disorders). She said it was difficult for him with the constant changes in the strength of the Risperdal because his behaviors like spitting and kicking were managed. She said when the facility tried to lower the strength his behaviors were not managed. She said she wished they kept him at the dose where his behaviors were managed. She said she did not know if the facility tried non-pharmacological interventions in addition to the antipsychotic medications he was prescribed. C. Record review The dementia and Alzheimer's care plan, revised on 2/2/24, revealed the resident had impaired cognitive function related to dementia with delusions and Alzheimer's disease. Interventions included monitoring for side effects of medication and disease conditions that could affect his cognition and orientation, redirecting as needed and notifying hospice and the primary care physician of any significant changes in resident's baseline cognitive status. The psychiatric and mood status care plan, revised on 2/2/24, revealed the resident was at risk for impaired mood status related to dementia, Alzheimer's disease and depression. Interventions included monitoring and reporting to hospice of any signs or symptoms of acute psychosis or changes from resident's baseline and monitoring sleep pattern changes The psychotropic medication care plan, revised on 1/29/24, revealed the resident took psychotropic medications related to insomnia, dementia and depression. Interventions included monitoring for adverse effects of antidepressant medication and antipsychotic medication, monitoring for effectiveness and completing a quarterly review for gradual dose reduction if appropriate. -A review of the comprehensive care plan revealed there was not an intervention that identified person-centered non-pharmacological interventions. The June 2024 CPO revealed the following physician orders: Lexapro (medication used to treat depression) 5 milligrams (mg). Administer one tablet by mouth one time a day related to dementia with mood disturbance, ordered 5/2/24. Trazodone (antidepressant medication) 100 mg. Administer one tablet by mouth at bedtime for insomnia, ordered 4/18/24. Risperdal 1 mg. Administer one tablet by mouth two times a day for hospice related to dementia with severe mood disturbance, ordered 5/11/24. Lorazepam (anti-anxiety medication) 2mg/ml (milliliters). Administer 0.5 ml by mouth every four hours as needed for anxiety, agitation and for hospice, ordered 6/4/24. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include a calm approach, positive reassurance, one on one, quiet environment, offering fluids or snacks, diversion activities, re-orientation and redirection. Document Y for interventions were attempted and N for no interventions were attempted, ordered 1/20/24. -The January 2024 MAR revealed non-pharmacological interventions were not offered on 24 of 31 days. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 18 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 30 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 30 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's electronic medical record (EMR) revealed there was no documentation to indicate person centered non-pharmacological behavioral interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read Consent to use and one box read Refuse the use. The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent form for Resident #2's Lorazepam revealed the resident's representative had signed the form, however, neither of the boxes on the consent form was marked to indicate whether or not the representative gave consent to use or refused the use of the medication for Resident #2. III. Resident #21 A. Resident status Resident #21, [AGE] years old, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included paranoid schizophrenia (psychosis that affects thoughts and behavior), extrapyramidal and movement disorder (a drug-induced disorder that causes uncontrollable movement), hallucinations, insomnia and anxiety. The 2/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required partial assistance with oral hygiene, personal hygiene and showering. He required substantial assistance with toileting and dressing. B. Record review The anxiety care plan, revised on 7/16/23, revealed the resident had an anxiety disorder that caused continuous pacing. Interventions included eliminating or correcting underlying causes of problems, offering drink or food, sitting with him, and promoting relaxation exercises. The aggressive behavior care plan, revised on 7/16/23, revealed the resident had a history of aggressive behaviors towards staff and peers. Interventions included offering the resident to listen to classical music, providing deep breathing exercises, going on short walks, and providing him with his teddy bear. The antipsychotic medication care plan, revised on 7/16/23, revealed the resident was at risk for adverse side effects. Interventions included monitoring for target behaviors of pacing, yelling and hallucinating. The June 2024 CPO revealed the following physician orders: Clozapine (antipsychotic medication) 100 mg. Administer one tablet by mouth one time a day at 8:00 a.m. and administer three tablets by mouth one time a day at 8:00 p.m. for paranoid schizophrenia, ordered 2/1/23. Clonazepam 0.5 mg. Administer one tablet by mouth one time a day for anxiety, ordered 2/1/23. Trazodone 50 mg. Administer one tablet by mouth at bedtime for insomnia, ordered 2/1/23. Risperidone 1 mg. Administer one tablet by mouth two times a day for paranoid schizophrenia, ordered 2/1/23. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include repositioning, pillows for support, cold compress and massage. Document Y for interventions were attempted and N for no interventions were attempted, ordered on 2/12/24. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 23 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's EMR revealed there was no documentation to indicate person centered non-pharmacological behavior interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read Consent to use and one box read Refuse the use. The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent forms for Resident #21's clozapine, clonazepam, trazodone and risperidone revealed the resident's representative had signed the consent forms for each psychotropic medication, however, neither of the boxes on the consent forms was marked to indicate whether or not the representative gave consent to use or refused the use of the medications for Resident #21. IV. Resident #54 A. Resident status Resident #54, age greater than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included severe dementia with agitation, insomnia and muscle weakness. The 2/15/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. She required partial assistance with oral hygiene, toileting, dressing and personal hygiene. She required substantial assistance with showering. B. Record review The antipsychotic drug use care plan, revised on 2/2/24, revealed the resident was at risk for side effects and falls. Interventions included assessing the resident for adverse side effects, completing quarterly psychotropic medication review and administering medications as ordered. The sleep care plan, revised on 6/23/23, revealed the resident had difficulty with insomnia. Interventions included monitoring sleep patterns, providing a pharmacy consultant review of medication and side effects. The June 2024 CPO revealed the following physician orders: Donepezil (medication used for Alzheimer's disease) 5 mg. Administer one tablet by mouth at bedtime for dementia with severe agitation, ordered 9/25/23. Risperdal 0.25 mg. Administer one tablet by mouth at bedtime for agitation for dementia with agitation, ordered 6/3/24. Trazodone 50 mg. Administer 1.5 tablets by mouth at bedtime for insomnia, ordered 5/18/24. Memantine 10 mg. Administer one tablet by mouth two times a day for severe dementia with agitation, ordered 3/19/24. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include calm approach, positive reassurance, one on one, quiet environment, fluids/snacks, diversion activities, re-orientation and redirection. Document Y for interventions were attempted and N for no interventions were attempted, ordered 12/29/23. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include repositioning, pillows for support, cold compress and massage. Document Y for interventions were attempted and N for no interventions were attempted, ordered 12/29/23. -The January 2024 (1/1/24 to 1/31/24) MAR revealed non-pharmacological interventions were not offered on 14 of 31 days. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 18 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 24 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's EMR revealed there was no documentation to indicate person centered non-pharmacological behavior interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read Consent to use and one box read Refuse the use. The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent forms for Resident #54's Risperdal, trazodone, donepezil and memantine revealed the resident's representative had signed the consent forms for each psychotropic medication, however, neither of the boxes on the forms was marked to indicate whether or not the representative gave consent to use or refused the use of the medications for Resident #54. V. Staff Interviews Licensed practical nurse (LPN) #2 was interviewed on 6/5/24 at 9:46 a.m. LPN #2 said she tried non-pharmacological interventions when a resident was anxious or had facial grimacing. She said interventions included playing music, playing a video or porch time. She said she documented non-pharmacological interventions in progress notes as a behavior note. LPN #2 said said Resident #2's effective non-pharmacological interventions included repositioning, lying down in the recliner or in his bed, playing music and playing an action movie. LPN #2 said Resident #21's effective non-pharmacological interventions included offering him to read a book, complete a puzzle and word searches. LPN #2 said Resident #54's effective non-pharmacological interventions included to keep her near staff, provide one on one care, talk to the resident and read the newspaper. LPN #2 said consent for psychotropic medications was obtained at the time of admission by the admissions department. She said once a resident was admitted , social services was responsible for obtaining consent when a resident was prescribed a new psychotropic medication. She said she checked the resident's EMR to ensure a consent form was on file for each psychotropic medication. The social services director (SSD) was interviewed on 6/5/24 at 10:40 a.m. The SSD said the social services department and the nursing staff determined behaviors that needed to be monitored. The SSD said she completed a demographics form upon a resident's admission to the facility. She said she wrote any behaviors that needed to be monitored in the comment section. The SSD said she wrote non-pharmacological interventions in the same area. She said nursing staff were responsible to offer and to document the non-pharmacological interventions that were attempted. She said the nurse documented the behavior and interventions in a behavior progress note. The SSD said she was familiar with Resident #2, Resident #21 and Resident #54. The SSD said Resident #2 found Native American music was helpful when he had behaviors. The SSD said Resident #21 found if staff walked with him or talked to him about different topics was helpful when he had behaviors. The SSD said Resident #54 found reading flower and family magazines was helpful when she had behaviors. The SSD said informed consents should be signed before a psychotropic medication was administered. She said the admissions department was responsible for obtaining consent for any medications the resident took at the time of admission. She said the psychotropic medication consent form was part of the admissions paperwork the resident or representative reviewed and signed. She said the consent forms contained a section for each type of psychotropic medication, what side effects would be monitored and what the risks and benefits were for each type of psychotropic medication. The SSD said the resident or the resident's representative authorized the facility that psychotropic medications may or may not be administered by an initial next to the phrase Consent to use or the phrase Refuse the use on the consent form. The initials were to be obtained on the form in addition to a resident or resident representative's signature. The SSD said she was not sure what the nurses did when a resident was prescribed a new psychotropic medication. She said she thought the nurses called the resident's representative to review the medication, why it was prescribed, the side effects and the risks versus benefits of the medication. She said she thought the nurses obtained verbal consent and documented the conversation in a progress note. The SSD said she mailed a two page consent form to the resident's representative. She said once the consent was mailed back, she added the informed consent form to the resident's EMR. The SSD said she did not check the progress notes to see if the nurses documented their phone call to the resident's representative. She said she should start checking the nurses progress note. The SSD confirmed Resident #2, Resident #21 and Resident #54 were administered psychotropic medications without a signed informed consent. The director of nursing (DON) was interviewed on 6/5/24 at 11:11 a.m. The DON said the nurses did not consistently offer and did not document if non-pharmacological interventions were offered. She said non-pharmacological interventions should be documented in the resident's MAR. She said the type of non-pharmacological interventions offered and used should be documented in the resident's MAR. The DON said when an existing resident was prescribed a new psychotropic medication the nurse called to notify the resident's representative. The DON said the nurse only contacted the resident's representative to inform them the resident had started a new medication. The DON said the resident's representative did not review why it was prescribed, the side effects, and the risks versus benefits. She said informed consents should be obtained before the nurse administered a new psychotropic medication to a resident. The DON said she would change the process so nursing staff was responsible for obtaining informed consents on psychotropic medications. The DON confirmed Resident #2, Resident #21 and Resident #54 were administered psychotropic medications without a signed informed consent.

Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#89) of five residents receiving hospice services out of 37 sample residents. Specifically, the facility failed to orient hospice aides to the facility, including the policies and procedures. Findings include: I. Facility policy The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 6/5/24. It read in pertinent part, Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. II. Resident status Resident #89, age 78, was admitted on [DATE]. According to the June 2024 computerized physician's orders (CPO), diagnoses included neoplasm of the prostate, chronic kidney disease and malignant neoplasm of bone. The 5/5/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment identified the resident received hospice services during the assessment period. III. Staff interviews Certified nurse aide (CNA) #1, who worked for a hospice agency, was interviewed on 6/3/24 at 4:25 p.m. He said he had been providing hospice services at the facility for about a year and a half. He said he was familiar with the facility, having worked there previously. He said he had not received an orientation to the facility to include the facility policy and procedures since providing care as a hospice aide. The director of nursing (DON) was interviewed on 6/4/24 at 12:30 p.m. The DON said she was not aware the facility needed to provide an orientation to the facility and the facility policy and procedures to the hospice aides. She said going forward she would provide orientation to the hospice aides prior to providing care in the facility.

Based on resident record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for one (#1) of three residents out of eight sample residents. On 11/18/21 a pressure injury was found on Resident #1 sacrum which measured 2.5 cm (centimeters) long by 1 cm wide. At that time, the facility only implemented repositioning for the resident every two hours; no additional interventions or treatments were ordered for the resident. According to the documentation in Resident #1's medical record, the pressure injury was not assessed until 11/23/21, which was five days later. The 11/23/21 wound assessment documented that the sacrum wound increased to 3 cm long by 1.50 cm wide and .10 cm deep and was a stage 3 pressure injury. The resident's primary care physician was notified on 11/23/21 of the wound, and ordered treatments for the wound. Due to the facility's failure evaluating preventive measures with the resident being at risk for pressure injuries (per minimum data assessment 6/24/21), implementing interventions when the wound was discovered on 11/18/21, and failure to notify the resident's physician, the resident developed an avoidable facility acquired Stage 3 pressure injury. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 1/24/22, pressure ulcer classification is as follows: Category/Stage I: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage II: Partial Thickness Skin Loss Partial thickness loss of (the) dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. *Bruising indicates suspected deep tissue injury. Category/Stage III: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover ' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (1/24/22), Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. Interventions for Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nutrition for Pressure Ulcer Prevention and Treatment Multivariable analyses of epidemiological data indicate that a poor nutritional status, indicated by low body weight or poor dietary intake among other signs, is a factor that impacts upon pressure ulcer risk. All individuals at risk of pressure ulcers should have their nutritional status screened. A comprehensive assessment should be conducted where risk of malnutrition is identified, and in individuals with existing pressure ulcers. Repositioning and Early Mobilization Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at-risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. II. Facility policy and procedure The Skin Condition Stage I (one) through Stage IV (four) policy and procedure, undated, was provided by the nursing home administrator (NHA) on 1/19/22 at 6:15 p.m. It read in pertinent part: Policy: -The responsibility of all caregivers is to prevent, care for, and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . -Nursing judgement may be used to determine what preventive measures [NAME] (sic) used for each resident. These measures are included in the individualized comprehensive care plan. The licensed nurse under the direction of the physician and Medical Director, will document the treatments as ordered for Stage I through Stage IV skin conditions. -The physician must be notified of any skin condition Stage II and above. -If a skin condition State I - Stage IV is not responding to a treatment in a 2-4 week period, a licensed nurse will discuss with the physician and alternative treatments may be put into place. Procedures: Stage III is defined as a full thickness skin loss involving damage to, or necrosis of (the)subcutaneous tissue that may extend down to, but not through (the) underlying fascia. The ulcer presents clinically as a deep crater with or without undermining or adjacent tissue. a. Notify Director of Nursing and/or charge nurse and physician of change in resident condition. b. Continue preventative measures. c. Obtain (an) order from physician for wound care order. d. If infection is suspected, notify the physician. e. Monitor (the) condition of the wound daily and document. f. Place (the) resident on an alternating pressure mattress or speciality bed. g. Notify (the) resident or responsible party of status and plan. III. Resident #1 A. Resident status Resident #1, age 80, was admitted on [DATE] and discharged to the hospital on 11/25/21. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/24/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident required extensive assistance of two staff members for bed mobility, transfers, personal hygiene, and bathing. She required extensive assistance of one staff member for locomotion, dressing, and eating. The 6/24/21 MDS documented the resident did not have a pressure injury but had the following interventions in place to reduce the risk of obtaining a pressure injury; device in her wheelchair and bed, as well as turning and repositioning, and nutritional and hydration interventions. The 12/1/21 discharge MDS revealed the resident had one Stage 3 pressure injury upon discharge. -The resident did not return to the facility. B. Record review The pressure ulcer care plan, last revised 12/21/21 (the resident was discharged on [DATE]) revealed the resident was at risk for pressure ulcers due to immobility and incontinence. The pertinent interventions included the following: -Repositioning frequently in bed and wheelchair; -Good peri care after incontinent episodes; and, -Encourage good nutritional intake. -A review of the resident's electronic medical record revealed there was no care plan for the pressure ulcer discovered on the resident on 11/18/21. A 11/18/21 nursing progress note documented the following: CNA (certified nurse aide) reported (the) resident had an open area on (her) coccyx. Charge nurse informed and assessed (her) coccyx. Measured by (the) charge nurse. 2.5 cm (centimeters) L (length) by 1 cm W (width). Repositioning q (every) two hours. DON (director of nursing) informed by (the) charge nurse. Completed by licensed practical nurse (LPN) #4. -There were no additional progress notes or skin assessments regarding Resident #1's pressure injury in her electronic medical record until 12/1/21 when a late entry nursing note was documented for 11/23/21. -The facility implemented repositioning for the resident every two hours, however there was no documentation of CNAs providing repositioning or turning for Resident #1 from 11/18/21 (discovery of the wound) to 11/25/21 when the resident was discharged to the hospital. A 12/1/21 late entry nursing note (completed after the resident had been sent to the hospital) documented the following: Late entry 11/23/21: It was reported by RN (registered nurse) #1 resident noted to have a new wound to her coccyx. Measurements obtained and treatment provided by RN (#1) was hyrdogel to wound bed and [MEDICATION(S)]-island dressing on 11/18/21, PCP (primary care physician) made aware of (the) wound by charge nurse on this day via charge nurse phone .Charge nurse on this day was able to obtain new treatment orders d/t (due to) wound worsening. Completed by the director of nursing. The 11/23/21 wound assessment report documented the following: Wound type: pressure ulcer Location: sacrum Date wound identified: 11/18/21 Assessment occasion: new wound Stage: 3 Drainage: serosanguineous (leakage of fresh blood product produced by an open wound), moderate Measurements: length - 3.00 cm (centimeters), width - 1.50 cm, depth 0.10 cm Infection: no Pain with treatment: no Wound bed: granulation tissue 100 percent Wound edges: border definition - distinct, outline clearly visible Surrounding skin: red, indurated (hardened) Physician notified: yes Date of physician notification: 11/23/21 Responsible party notified: yes (sic) Date responsible party notified: 11/23/21 Notes: Entire affected area of discoloration measures 5 cm by 6 cm with an open area of 3 cm by 1.5 cm by 0.1 cm. Periwound (tissue surrounding the wound) is purple in color and denuded (loss of skin). Her appetite has been very poor. Her MSContin (pain medication) was decreased to qd (everyday) today for increased sedation. Treatments: 11/23/21 Sacral wound: 1. Cleanse with wound cleanser 2. Apply xeroform gauze to wound bed 3. Cover with dry dressing (no bordered gauze) 4. Change everyday. Review of the November 2021 CPO revealed the following physician orders: Sacral wound (ordered 11/23/21) 1. Cleanse wound with wound cleanser; 2. Apply xeroform gauze; 3. Cover with dressing (no bordered gauze); and 4. Change every day. -The orders were initiated five days after the discovery of the sacrum wound on 11/18/21. C. Interviews The director of nursing (DON) was interviewed on 1/19/22 at 3:45 p.m. She said the pressure injury had been identified on Resident #1 on 11/18/21. She said she was notified of the wound, and looked at the wound but did not complete any assessment or orders for the wound. The DON said it was the responsibility of either the charge nurse or the resident's nurse to complete a wound assessment, notify the physician, notify the family and get treatment orders. She said she became aware on 11/24/21 that a wound assessment, physician notification and treatment orders had not been obtained for Resident #1. The DON said she reviewed Resident #1 medical record, and was unable to find treatment orders for the wound from 11/18/21 to 11/24/21, although staff were providing treatments which she was unsure of, and had implemented interventions such as repositioning every two hours. Licensed practical nurse (LPN) #4 was interviewed on 1/20/22 at 9:05 a.m. She said she was Resident #1's nurse on 11/18/21, and a certified nurse aide (CNA) had been providing incontinence assistance to the resident and noticed the open area on the resident's coccyx. The LPN said she immediately notified the charge nurse (registered nurse, RN, #1) of the wound. She said RN#1 looked at the wound and took measurements, and she thought RN #1 was going to complete the wound assessment, physician and family notification, and get treatment orders. The LPN said she placed hydrogel on the wound and covered it with an island dressing, although she was unsure if there was an order to do so. The LPN said she worked with Resident #1 again on 11/24/21 and a CNA had notified her the wound looked worse so she informed the charge nurse working that day ( LPN #3). She said LPN #3 called the physician and got treatment orders, as well as completed the wound assessment with the physician. The LPN said a meeting was held following Resident #1's hospitalization regarding timely completion of wound assessment, physician notification, family notification and getting treatment orders. Registered nurse (RN) #1 was interviewed on 1/20/22 at 9:15 a.m. She said LPN #4 notified her of the open area on Resident #1 on 11/18/21. The RN said she had taken measurements of the wound, but had not completed a wound assessment or an incident report. The RN said she did place an island dressing on the wound to protect it from BM (bowel movement), and did not recall if she had done anything to the pressure injury. The RN said she texted the resident's primary care physician (PCP) but did not receive a call back, so she left the information on the 24 hour report for the other nurses to follow-up on. The RN said the floor nurse should have completed the wound man which was a paper that showed the location and measurements of the wound, and the floor nurse should have followed up with resident PCP as well as notified the family. The RN said the breakdown came from all of the nurses thinking the other nurses were going to follow-up with the PCP and get orders and that was why nothing happened until 11/24/21. The RN said she did not receive any education or training after the incident. LPN #3 was interviewed on 1/20/22 at 10:20 a.m. He said he was a charge nurse in the facility, and was also responsible for overseeing the wounds in the facility. He said he worked closely with the wound care physician to provide wound treatments in the facility. He said he was notified of Resident #1 pressure injury on 11/23/21. He said Resident #1 pressure injury looked bad and he immediately notified her PCP who classified the pressure injury as a Stage 3 pressure injury, and obtained treatment orders which he began immediately. -LPN #3 did not notify the wound care physician of the pressure injury in addition to the PCP. Resident #1's primary care physician (PCP) was interviewed on 1/20/22 at 7:45 a.m. She said she was never informed of the residents pressure injury until LPN #3 called her on 11/24/21 at which time she gave treatment orders. The PCP said Resident #1 had been having an overall decline, but treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was interviewed a second time on 1/20/22 at 11:08 a.m. She said either RN #1 or LPN #4 should have completed the skin assessment on 11/18/21 when the wound was first discovered. The DON said treatment orders should have also been in place, and the family provided notification. The DON said moving forward she would be responsible for assessing the pressure injuries in the facility since she was the registered nurse. She said staff would be provided with education regarding the new change to wound assessments, as well as timely physician and family notification, and getting timely treatment orders.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to prevent the spread of infection during wound care for two (#6 and #7) of three residents of eight sample residents. Specifically, the facility failed to implement appropriate hand hygiene practices and glove use while providing wound care for Residents #6 and #7. Findings include: I. Professional standard According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/8/21, retrieved on 1/25/22 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. II. Facility policy and procedure The Handwashing Procedure policy, undated, was provided by the nursing home administrator (NHA) on 1/20/22 at 10:05 a.m., and included the following guidance: Proper handwashing techniques were used for the prevention of transmission of infectious diseases. All personnel working in the facility were required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing nose, after using the restroom, and when hands became obviously soiled. III. Wound care observations and interviews A. Resident #6 The coccyx wound dressing change was observed on 1/20/22 at 8:26 a.m. with the director of nurses (DON) and licensed practical nurse (LPN) #1. The following was observed: At 8:26 a.m., the DON reviewed the dressing change orders in the electronic medical record, retrieved dressing supplies from the supply cart, and then entered the resident's room. Resident #6 was lying in bed on her left side and the DON touched the pillow behind her back, and then donned clean gloves without performing hand hygiene. The DON adjusted the level of the bed using the remote control, closed the window curtain, and then doffed her gloves. She performed hand hygiene with alcohol-based hand rub (ABHR). At 8:29 a.m., the DON pulled back the resident's incontinence brief and then removed the coccyx dressing. She removed her gloves and donned a clean pair without performing hand hygiene. She placed the clean dressing supplies (wound cleanser, wound gel, bordered gauze) directly on the resident's bed linens rather than on a clean field. At 8:32 a.m., the DON cleansed the wound with wound cleanser, dabbed it dry with gauze, and then measured the wound. At 8:37 a.m., without changing her gloves or performing hand hygiene, the DON applied skin prep to the area around the wound, placed wound gel to the wound bed, and then applied the clean dressing. At 8:43 a.m., the DON was interviewed and she said she usually placed a clean surface down on the bed or bedside table to create a clean field for dressing supplies, but explained there was nothing in the room to use at the time of the dressing change. She said she should have performed hand hygiene before she donned clean gloves each time, and should have changed her gloves and sanitized her hands after measuring the wound, before applying the clean dressing. She was not able to provide a reason for not doing so. B. Resident #7 The ankle wound dressing change was observed on 1/20/22 at 8:56 a.m. with LPN #1, who was the charge nurse. The following was observed: At 8:56 a.m., LPN #1 donned clean gloves, wiped her writing pens down with a sanitizing wipe, and then doffed her gloves. At 8:57 a.m., LPN #1 entered Resident #7's room, placed her writing pen directly on the bedside table, without cleaning the surface off. She performed hand hygiene with ABHR. She donned clean gloves and went to the closet and retrieved a package of pads, removed one and placed it on the bedside table. She removed the resident's multi podus boot and [CONDITION(S)]-[CONDITION(S)] deterrent (TED) hose from her left leg, and placed the pad underneath her ankle. The LPN removed the current dressing, then doffed her gloves and sanitized her hands with ABHR. At 8:59 a.m., LPN #1 donned clean gloves then picked up her writing pen and dated the new bordered gauze dressing. She placed it back down directly on the bedside table and began to clean the wound with wound cleanser, then measured the wound without performing hand hygiene after touching her pen. At 9:01 a.m., using the same gloved hands, LPN #1 applied skin prep to the area surrounding the wound, then fanned her hands back and forth directly above the wound to encourage it to dry faster. -However, fanning above the resident's wound could increase potential infected air particles moving around and potentially cause cross-contamination to the wound (see DON interview below). At 9:03 a.m., LPN #1 applied [MEDICATION(S)] to the wound bed using swabs, and then placed the bordered gauze dressing over the wound wearing the same gloves. At 9:04 a.m., LPN #1 was interviewed and she said she did not clean off the resident's bedside table or create a clean field for the dressing supplies or her pen because they were all of the resident's own germs, and there was less risk of cross contamination because she did not have a roommate. She said she did not remember what initially caused the resident's wound, but it was approximately two years old, and historically would heal and then re-open from time to time. LPN #1 said she should have performed hand hygiene and changed her gloves after she touched her pen, before measuring the wound and applying the new clean dressing. IV. Record Review The Dressing-Clean Technique policy and procedure, undated, was provided by the NHA on 1/20/22 at 10:05 a.m. The procedures in the policy were not up to date with the current CDC guidance and instructed licensed nurses to do the following during treatments: Remove soiled dressing and discard into a designated receptacle, bag, barrel, or container. Remove gloves. Place new gloves on. Cleanse wound with normal saline or as directed by physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Place new gloves on, place dressing on as ordered by physician, and touch only the outer part of the dressing. -The policy and procedure did not provide the instruction to perform hand hygiene each time gloves were removed. V. Staff interviews The DON was interviewed on 1/20/22 at 11:08 a.m., and said she had been the facility's DON for approximately eight months. She was also the facility's infection control nurse and was currently working on her infection control certification. She said she was not aware of any outside resources she could use to refer to when she had questions about clinical nursing practices or wound care, and was not wound care certified. She said she had been a nurse in long-term care for [AGE] years, and relied on her experience rather than formal training for pressure ulcer and wound care. She said the charge nurses on each shift usually provided wound care in the facility, and she was not aware of any formal training they had received on wound care treatment. The facility had not provided the charge nurses with any formal wound care training and stated, It would be nice to have because wound care is a specialty. The DON said a clean surface should be created during wound care in order to keep the treatment supplies as clean as possible to prevent the spread of bacteria or infection. She said it was not appropriate to fan a wound to help it dry faster because that would increase potential infected air particles moving around and potentially cause cross-contamination to the wound. She said she had observed LPN #1 fan the wound during the dressing change, but did not say anything to correct her at the time. The DON said hands should be sanitized each time gloves were removed, before new gloves were applied. She said they could use either hand washing with soap and water or ABHR. She said she had already implemented one-on-one education with nursing staff present in the facility to explain the importance of hand hygiene and how it should be completed each time gloves were removed. She said she would continue with the nursing education until all nurses had received it and were aware of the importance of performing hand hygiene prior to donning a clean pair of gloves. The NHA was interviewed on 1/20/22 at 11:03 a.m., and she said there were professional resources available to the facility and DON to provide them with formal training and assistance with how to perform proper wound care. She said she would reach out to a local physician immediately to arrange for education and assistance for the nurses that included proper hand hygiene and glove use.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#1) resident out of three sample residents. Specifically, the facility failed to notify and ask Resident #1 to be present during his room search. Findings include: I. Resident #1 Resident #1, age 56, was admitted on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. The 9/21/2020 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. He required setup assistance with most activities of daily living (ADLs), including meals. II. Resident interview Resident was interviewed on 1/16/21 around 4:30 p.m. He said he was very upset that staff searched his room without his permission. He said he had alcohol in his room [ROOM NUMBER]/16/21, and staff entered his room when he was not there, went through all of his belongings and took alcohol away. He said he wanted to live in a less restrictive environment where he can make his personal choices about everyday life. III. Record review The care plan for depression initiated on 9/9/2020 revealed that when Resident #1 starts getting depressed he would turn to drinking. The goal was to maintain a positive outlook. Interventions included to offer services from (behavioral health company), provide the resident with the right information, and offer to talk about concerns. According to the nurse admission note on 9/20/2020 Resident #1 had a history of [REDACTED]. The nurses note dated 1/20/21 (marked as a late entry for 1/16/21) revealed the resident was noted acting weird and maybe drunk, medical tech was sent to the residents room to see if there was any alcohol. A large empty bottle 1.75 liters was found with a receipt dated 1/16/21. Prior to that resident was seen at the vehicle in the parking lot. The admission contract signed by the resident on admission, revealed that the resident did not want to be offered alcoholic beverages during happy hour in the facility. The facility policy on resident's room search was requested from the nursing home administrator (NHA) on 2/11/21. She provided verbal/written consent to clean resident drawers and closets. The verbal/written consent to clean resident drawers and closet, signed by Resident #1 on 9/2/2020 revealed that the resident was accepting that his closet and drawers will be cleaned on the condition that he will be present during the cleaning process. The physician order [REDACTED]. IV. Staff interviews The director of nursing (DON) was interviewed on 2/11/21 around 4:00 p.m. She said the resident was alert and oriented, able to make needs known. He liked to be independent and refused offers for help from staff. She said he generally did not have any behaviors except for a couple of occasions when the facility suspected he was drinking. She said she was aware his room was searched. She said it was done due to his safety because the physician said he should not have any alcohol. The social services director (SSD) was interviewed on 2/11/21 around 4:00 p.m. She said the resident's room was searched because it was a safety issue. In instances when safety of the resident or other residents were compromised, the search of the room completed without the resident's permission or presence. The NHA was interviewed 2/11/21 around 4:00 p.m. She said upon admission, the resident signed a form that allowed the facility staff to search the room (see above under record review). She said the resident's room was searched because it was a safety issue. In instances when safety of the resident or other residents were compromised, the search of the room completed without the resident's permission or presence. -However, she acknowledged that the resident's room was searched without him being present according to the verbal/written consent signed by Resident #1.

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19 in two of three neighborhoods. Specifically, the facility: -Failed to ensure residents had face coverings while staff were in their rooms; and, -Failed to ensure correct face masks were worn in a presumptive positive COVID isolation room. Findings include: I. CDC recommended guidelines 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 (Update April 13, 2020), retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, 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. Healthcare Personnel As part of source control efforts, HCP should wear a facemask at all times while they are in the healthcare facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. If there are anticipated shortages of facemasks, facemasks should be prioritized for HCP and then for patients with symptoms of COVID-19 (as supply allows). Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required. HCP should have received job-specific training on PPE and demonstrated competency with selection and proper use (e.g., putting on and removing without self-contamination). 2. Adhere to Standard and Transmission-Based Precautions: HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. When available, respirators (instead of facemasks) are preferred; they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions (e.g., [MEDICAL CONDITION], [DIAGNOSES REDACTED], [MEDICATION NAME]). II. Facility training Facility handout dated 4/8/2020, CDC Use personal protective equipment (PPE) when caring for patients with confirmed or suspected COVID- 19, Preferred PPE use: N95 or higher respirator. Acceptable Alternative PPE use: Facemask N95 or higher are preferred III. Lack of using necessary PPE A. Observations and interviews On 5/14/2020 at 10:11 a.m., during a walk through of Cokedale neighborhood, there were no hand sanitizers in each room. On 5/14/2020 at 10:24 a.m. on the Beshor neighborhood, housekeeping (HSKG) #1 was observed entering room [ROOM NUMBER]. She did not ask the resident to cover her face when she entered the room or while she was cleaning her room. She said residents are encouraged to wear a mask when out of their rooms. She said staff were to ask residents to cover their face when staff entered the room. She said she had forgotten to ask the resident when she entered the room. On 5/14/2020 at 11:38 a.m. on the Beshor neighborhood, certified nurse aide (CNA) #1 was observed in isolation room [ROOM NUMBER] assisting the resident with lunch. room [ROOM NUMBER] was on droplet precautions. CNA #1 was wearing a gown, goggles, a surgical mask, and gloves. When the aide was finished assisting the resident, they removed the gown, gloves, and goggles, sanitized according to standards. The aide removed the surgical mask, sanitized hands, and went to the isolation supply cart. The cart did not have a replacement mask. Another staff member retrieved a new surgical mask. The aide was not wearing a N95 or higher respirator while in a presumptive positive COVID isolation room. On 5/14/2020 at 11:43 a.m. activities assistant (AA) #1 was observed entering room [ROOM NUMBER]. She did not ask the resident to cover her face when she entered. She handed the resident mail. She said residents were asked to keep a mask on all the time. She said if residents left their room, they were asked to wear a mask. She said residents did not have to wear a mask if they were in their room. She said staff did not have to ask a resident to wear a face covering when going into a residents room. On 5/14/2020 at 12:04 p.m. licensed practical nurse (LPN) #1 was observed outside of room [ROOM NUMBER] (a presumptive positive COVID isolation room). She sanitized her hands, put on a gown, did not tie the gown closed, put on goggles, and put on gloves. The gloves did not cover the end of the gown sleeve, the gown had short sleeves. She entered the room, adjusted the nasal cannula for the resident and took the residents vital signs. While she was assessing the resident she had to adjust her gown over her right shoulder three times. She completed her assessment, took off the goggles in the room, took off the gown, and removed the gloves. She saitized her hands. She said she did not have to change her mask unless the patient was COVID positive. She said due to the pandemic she did not have to throw away the mask she was wearing until it had become torn or soiled. She said the resident did not have to wear a face covering while in their room. She said she would make sure the gown would be tied in the future. B. Administrative Interviews The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 5/14/2020 at 2:41 p.m. The NHA said staff had been trained to ask the residents to cover their faces when staff entered. The DON said the facility had provided staff with their own personal bottle of hand sanitizer to use when going in and out of resident rooms. The DON said the resident in room [ROOM NUMBER] had taken a COVID-19 test and the results were pending due to her having a temperature and new respiratory difficulties. She said the facility had placed her in isolation pending the results of the test. The DON was interviewed a second time on 5/15/2020 at 2:18 p.m. She said the facility had N95 masks. She said she would make sure the staff used the masks until the results came back.

Based on observation, record review and interviews, the facility failed to ensure freedom from abuse for six (#14, #19, #29, #36, #37 and #66) of six residents reviewed out of 52 sample residents. Specifically, the facility failed to protect Residents #29, #37 and #66 from physical abuse by Resident #36 who was physically aggressive toward others and protect Resident #14 from physical abuse by Resident #19. Cross reference F609 failure to report abuse allegations. Findings include: I. Facility policy and procedure The abuse policy entitled Resident safety dated 5/31/19 was sent via email by the nursing home administrator (NHA) on 2/12/2020. It read, in pertinent part; It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property; -Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Physical abuse includes but is not limited to hitting, slapping, pinching and kicking . II. Resident to resident abuse A. Resident #36, perpetrator 1. Resident status Resident #36, age 76, was admitted [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 12/3/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview of mental status( BIMs) score of nine out of 15. There were no physical and verbal behavior symptoms toward others documented. She had no rejection of care and received antipsychotic daily. She was supervision with bed mobility and transfers. Resident #36's care plan was reviewed. It failed to identify aggressive behaviors (e.g., kicking, hitting, and slapping) with appropriate interventions to prevent further resident to resident altercation as identified in the interviews below. B. Staff knowledge the Resident #36 had aggressive behaviors The nurse aide (NA) #2 was interviewed on 1/29/2020 at 3:48 p.m. NA #2 said Resident #36 displayed aggressive behaviors towards other residents and staff members. She said the resident did not like to be around people. She said the resident would get agitated and aggressive when other residents came too close to her. The NA said the resident would say if anyone got close to her she would either hit, kick or slap that person. NA #2 said the staff tried to keep other residents from going around the resident; however, the staff were unable to ensure Resident #36 was not around other residents. She said she asked Resident #36 why she hit Resident #37 in his stomach. She said, Resident #36 said, He was in her face and was bothering her. NA #2 said Resident #37 walked all day in the unit and would not sit down to participate in activities. Licensed practical nurse (LPN) #3 was interviewed on 1/29/2020 at 4:00 p.m. LPN #3 said Resident #36 displayed aggressive behaviors towards others. She said Resident #36 liked to be alone. She said when anybody got close to Resident #36, the resident would get agitated and strike out at the person. She said the staff tried to keep other residents from being close to Resident #36, but sometimes it was impossible to do so. Review of Resident #36's record revealed at least five incidents of Resident #36 hitting, kicking and slapping other residents in the secured unit. -A nursing note, dated 12/2/19 documented a CNA reported that while Resident #29 was walking in the hallway, Resident #36 slapped her on her right arm. It further documented when Resident #36 was asked why she slapped Resident #29, she said I slapped her because she is (a different race than Resident #36). -A nursing note, dated 12/5/19 documented the activity staff witnessed Resident #36 grab and squeeze Resident #66's arm. -A nursing note, dated 12/14/19 documented, Resident #66 was sitting in the common area near Resident #36. It documented Resident #36 kicked Resident #66 on the left leg. It documented no bruising, swelling or redness noted. The follow-up investigation documented Resident #36 was sitting in the common area and Resident #66 got close to Resident #36. It documented Resident #36 kicked Resident #66 on her left leg. It documented no injuries. It further documented Resident #36 denied kicking her. -A nursing note, dated 12/17/19 documented a kitchen staff witnessed Resident #36 hit Resident #37 in his chest. It documented no mark was noted on Resident #37's chest. Intervention was to keep Resident#36 in line of sight; however, this was not documented in Resident #36's care plan. -A nursing note, dated 1/29/2020 documented, Resident #37 was in the common area and was standing in front of Resident #36. It documented Resident #36 hit Resident #37 across his lower stomach and upper groin area. C. Failure to develop a comprehensive plan with effective interventions to protect Residents #37, #29, and #66 and the other 14 residents on the secured for abuse. 1. Observation Observations, revealed throughout the survey, Resident #36 was not in the line of sight of staff (see planned intervention above). Resident #36 was left alone sitting in the common area alone with other residents including Resident #66 (see incident above). On 1/29/2020 at 3:44 p.m., Resident #37 was observed standing in front of Resident #36. Resident #36 was sitting in a chair in the common area by the nurse station. Certified nurse aide (CNA) #2 and nurse aide (NA) #2 were present in the common area. Resident #36 said to Resident #37, get away from here. Resident #37 did not move and Resident #36 proceeded to hit him in his stomach. Both staff present in the area said to Resident #36, oh why did you hit him? Resident #36 said because he was in front of me and was bothering me. CNA #2 removed Resident #37 from the area and Resident #36 remained sitting in the common area around other residents. 2. Record review revealed no evidence of an interdisciplinary team meeting to discuss Resident #36's physically aggressive behaviors, no care plan to address the abusive behavior, and no plan to supervise the resident when she was around others in the secured unit. D. Residents abused by Resident #36 1. Resident #37 Resident status Resident #37, age 69, was admitted [DATE]. According to the January 2020 computerized physician orders [REDACTED]. The 12/4/19 (MDS) assessment revealed the resident had severe cognitive impairment with a BIMs score of zero out of 15. There were no physical and verbal behavior symptoms toward others documented. He had no rejection of care and received antipsychotic daily. He required limited assistance with bed mobility and transfers. The resident resided on the secured unit. Record review -A nursing note, dated 12/17/19 documented a kitchen staff witnessed Resident #36 hit Resident #37 in his chest. It documented no mark was noted on his chest. The follow up incident reported documented Resident #37 was leaning forward near Resident #36 and Resident #36 hit him in his chest. -A nursing note, dated 1/29/2020 documented, Resident #37 was in the common area and was standing in front of Resident #36. It documented Resident #36 hit Resident #37 across his lower stomach and upper groin area. It further documented Resident #36 stated get your stuff out of my face. Staff went to assist and removed Resident #37 out of the area. No bruising was noted. The record failed to show an intervention was put into place to prevent recurrence of similar incidents between Residents #37 and #36. Same as the staff did not put interventions in place to keep Resident #36 from abusing other residents. The follow-up investigation documented the resident was walking into the dining room and bent over when Resident #36 hit him with an open fist. It documented staff immediately separated both residents. It documented Resident #37 said he was not afraid of anyone. It further documented it was not a reportable incident. 2. Resident #29 Resident status Resident #29, age 64, was admitted [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. The 11/20/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. There were no physical and verbal behavior symptoms toward others documented. She required limited assistance with bed mobility and supervision with transfer Record review Resident to resident altercation The 12/2/19 nurse's note documented a CNA reported that while Resident #29 was walking in the hallway, Resident #36 slapped her on her right arm. It further documented when Resident #36 was asked why she slapped Resident #29, she said I slapped her because she is (a different race than Resident #36). The follow-up investigation dated 12/3/19 documented staff and residents were interviewed. It documented the incident was witnessed by staff. Resident #36 had no recollection of what happened. The planned intervention was for staff to monitor Resident #36 where abouts. 3. Resident #66 Resident status Resident #66, age 79, was admitted [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. The 12/31/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMs score of zero out of 15. There were no physical and verbal behavior symptoms toward others documented. She required limited assistance with bed mobility and transfer. Record review -A 12/5/19 nursing note documented the activity staff witnessed Resident #36 grab and squeeze Resident #66's arm. It documented no bruising, redness and no swelling. It further documented charge nurse, director of nursing (DON) and NHA were notified. The investigation documented staff and Resident #36 were interviewed. It documented Resident #66 was in her wheelchair close by Resident #36 and Resident #36 grabbed Resident #66's arm. Staff separated both residents. Resident #36 denied she grabbed Resident #66's arm. It documented the social worker interviewed both residents and both were not afraid of each other. There was no intervention put in place to prevent further altercations. - A nursing note, dated 12/14/19 documented, Resident #66 was sitting in the common area near Resident #36. It documented Resident #36 kicked Resident #66 on the left leg. No bruising, swelling or redness was noted. III. Other resident to resident altercations on the secured unit. A. Resident #19 Resident Status Resident #19, age 76, was admitted [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. There were no physical and verbal behavior symptoms toward others documented. He required supervision with bed mobility and transfer. Record review -A nurse's note, dated 12/4/19 documented Resident #14 was in her wheelchair in the hallway and Resident #19 came from behind and pushed her out of the way which resulted in Resident #14 hitting both knees against the wall. It further documented no bruising, or redness and no complaint of pain Staff were instructed to keep Residents #14 and #19 apart. Resident #19's care plan was reviewed. It failed to identify Resident #19 displayed aggressive behaviors (pushing) toward other residents and failed to identify appropriate interventions to prevent further resident-to-resident altercation. B. Resident #14 Resident #14, age above 90, was admitted on [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. The 11/4/19 MDS assessment revealed the resident had severe cognitive impairments with a BIMs score of four out of 15. She had delusions and no behaviors documented. She required extensive assistance with bed mobility and total dependence with transfer. Record review A nurse's note, dated 12/4/19 documented Resident #14 was in her wheelchair in the hallway and Resident #19 came from behind and pushed her out of the way which resulted in Resident #14 hitting both of her knees against the wall. It further documented no bruising, or redness and no complaint of pain. It documented Resident #14's son was notified. Staff interview The NHA and the director of nursing (DON) were interviewed on 2/4/2020 at 12:21 p.m. The NHA said the above incidents were not abuse. She said because the residents did not have intent, it was not considered abuse. Additionally, because there were no injuries, and no fear it was not abuse, and therefore she did not report the incidents to the health department or other agencies. She said an investigation was completed, in order to put interventions in place, or to know more of what happened. The DON agreed the above incidents were not abuse allegations. The DON confirmed there had been resident-to-resident altercations on the unit and she said her intervention was an activity assistant (AA) who was primarily on the secured unit was added in December 2019. She said the AA could also assist with hydration and eating. She said the incidents had decreased significantly in the last 30 days since the activity staff was on the unit.

Based on record review and interviews the facility failed to report to the state survey and certification agency, in accordance with state law, five of five incidents of physical abuse stemming from resident-to-resident altercations in the memory care unit. The facility failure to report alleged abuse involved six (#14, #19, #29, #36, #37 and #66) of six residents reviewed for abuse reporting out of 52 sample residents. Cross-reference F600 Free from Abuse Findings include: I. Facility policy and procedure The abuse policy entitled Resident safety dated 2/1/11 was sent via email by the nursing home administrator (NHA) on 2/12/ . It read, in pertinent part; any suspected, observed or reported violation of this resident safety policy will be reported to the supervisor on duty. The supervisor on duty shall report any suspected violations of this resident safety policy immediately to the administrator and to the director of nursing (DON) or their designee(s) as soon as practicable. The state Department of Health, Health facilities division will be notified by no later than the next business day. II. Failure to report resident to resident physical allegations of abuse A. Resident #36 Resident #36, age 76, was admitted [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 12/3/19 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. There were no physical and verbal behavior symptoms toward others documented. She had no rejection of care and received antipsychotic daily. She was supervision with bed mobility and transfers. B. Record review Review of Resident #36's record revealed multiple incidents of Resident #36 hitting, kicking and slapping other residents in the secured unit. -A nursing note, dated 12/2/19 documented a CNA reported that while Resident #29 was walking in the hallway, Resident #36 slapped her on her right arm. It further documented when Resident #36 was asked why she slapped Resident #29, she said I slapped her because she is (a different race than Resident #36). -A nursing note, dated 12/5/19 documented the activity staff witnessed Resident #36 grabbed and squeezed Resident #66's arm. -A nursing note, dated 12/14/19 documented, Resident #66 was sitting in the common area near Resident #36. It documented Resident #36 kicked her on her left leg. It documented no bruising, swelling or redness noted. The follow-up investigation documented Resident #36 was sitting in the common area and Resident #66 got close to her. It documented resident #36 kicked Resident #66 on her left leg. It documented no injuries. It further documented Resident #36 denied kicking her. -A nursing note, dated 12/17/19 documented a kitchen staff witnessed Resident #36 hit Resident #37 in his chest. It documented no mark was noted on his chest. B. Resident #19 Resident #19, age 76, was admitted [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. The 11/11/19 MDS assessment revealed the resident had a BIMS of 7 out of 15 which indicated moderate cognitive impairment. He understood others.There were no physical and verbal behavior symptoms toward others documented. He required supervision with bed mobility and transfer. Record review -A nurse's note, dated 12/4/19 documented Resident #14 was in her wheelchair in the hallway and Resident #19 came from behind and pushed her out of the way which resulted in the resident hitting both knees against the wall. III. Failure to report allegations of abuse None of the above resident to resident altercations were reported as physical abuse to the state survey certification agency. The DON and the NHA were interviewed on 2/4/2020 at 12:21 p.m. The NHA confirmed the above allegations of abuse were not reported to the state survey certification agency. She said the resident to resident altercations were not abuse and therefore not reported. She said if there was bodily injury and intent, then she would report it. The DON and NHA said they felt all the altercations were not willful, intent and there were no bodily injuries. They said after the incidents the residents had no recollection of what had happened. The NHA said the residents had not reported that they had been abused. Later on that day, the NHA acknowledged the incidents should have been reported to the state. She said she read the regulations and she understood now.

Based on record review and interviews, the facility failed to provide written notice of the bed hold policy before transfer to the hospital to the residents or their representatives in a sample of four ( #248, #63, #80 and #60) of four out of 52 total sample residents reviewed. Specifically the facility failed to ensure: Resident #248, #63, #80 and # 60 were informed,in writing of the bed hold policy, when they were transferred to the hospital from the facility. Findings include I. Policy The bed hold policy read, residents who were discharged or transferred from the facility to a hospital or other facility upon physician's orders [REDACTED]. The policy shall be included in the admissions contract, and must additionally be furnished to the resident at the time of transfer or discharge. II. Resident #248 A. Resident #248, age 99, was admitted on [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 1/8/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of 8 out of 15. She required limited assistance and cuing with activities of daily living. B. Record review The hospital transfer form for resident # 248 documented the resident was transferred to the hospital on [DATE]. The medical record failed to show that a bed hold policy form was given to the resident or her representative. The facility provided a signed bed reserve policy form for Resident #248 upon admission to the facility on [DATE]. The policy must be additionally furnished to the resident at the time of transfer or discharge. This paperwork should accompany the resident upon admission to the hospital.The social service paperwork (policy No:3-5.2) about the bed hold policy includes residents that were discharged or transferred from the facility for any reason should be offered a reservation of their bed at the facility. III. Resident # 60 A. Resident #60, age 73, was admitted on [DATE]. According to the February 2020 CPO [DIAGNOSES REDACTED]. The 12/28/19 MDS assessement revealed the resident was cognitivly intact with a brief interview for mental status (BIMS) of 15 out of 15. Record review The hospital transfer form for resident #60 documented the resident was transferred to the hospital on [DATE]. The medical record failed to show that a bed hold policy form was given to the resident. Resident #60 was interviewed on 1/27/2020 at 1:27 p.m. The resident said he was transferred to the hospital in the past six months. He said he was not provided a written bed hold policy when he was transferred to the hospital. IV. Resident #80 A. Resident status Resident #80, age 81, was admitted on [DATE]. According to the January 2020 computerized physician orders [REDACTED]. The 12/1/19 minimum data set (MDS) assessment documented the brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with transfers, and personal hygiene. She required limited assistance with activities of daily living and locomotion on unit. B. Record review The hospital transfer form for resident #60 documented the resident was transferred to the hospital on [DATE]. The medical record failed to show that a bed hold policy form was given to the resident C. Interviews The social service director (SSD) was interviewed on 2/4/19 at 10:20 a.m. The SSD said she was not aware that a bed hold policy should be provided to residents when they were transferred from the facility to the hospital. She stated that she would do so in the future. She did the bed hold policy when the residents were admitted to the facility. V. Resident #63 A. Resident #63, age 78, was admitted on [DATE]. According to the January 2020 computerized physician orders [REDACTED]. The 1/21/2020 minimum data assessments (MDS) did not document the cognitive status. It documented zero for daily decision making skills. She required extensive assistance with bed mobility and transfer. Record review The transfer form dated 1/21/2020 was reviewed. It documented the resident was sent to the emergency room for emesis (vomiting) positive for blood. There was no evidence that the resident returned to the facility from the hospital. The progress note written by activity staff on 1/25/2020(four days after the resident was sent to the emergency room ) was reviewed. It documented the resident's granddaughter went to the facility to get the resident belongings while she was in the hospital. It further documented that the resident representative was called. It documented the resident's representative gave permission for granddaughter to take resident's belongings. A review of progress notes and the transfer paper work failed to reveal the resident/resident representative was given a bed hold notice when she was transferred to the hospital on [DATE]. Interview The nursing administrator (NHA) was interviewed on 2/03/2020 at 3:11p.m. She said when a resident was admitted , the bed hold policy was given to the resident in the admission packet. She said she was not sure whether bed hold notice was given to residents at the time of transfer. The social service director (SSD) was interviewed on 2/3/2020 at 4:40p.m. She said she gave the residents bed hold policy on admission. She said the bed hold policy was a part of the admission package paperwork. She said she gave Resident #63 the bed hold policy and she signed it at the time of admission however, the resident was not provided a bed hold notice at the time she was transferred to the hospital. She said she was not aware that a bed hold notice should be given to residents/residents representative at the time of transfer to the hospital. She said since she was aware now she would give bed hold notices to residents at the time of transfer from the facility to the hospital.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation procedures. Specifically, the facility failed to ensure: -Holding temperatures were at appropriate level; -Adequate hand washing occured; -Moisture was not between stacked pans; and, -Health shakes were appropriately dated. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Main kitchen The evening meal began to be served at 3:30 on 1/29/2020. The tray line was observed beginning at 4:15 p.m. The dining room consistently had residents continue to come to the dining room to be served. During observations of the tray line the following food temperatures were obtained from the steam table with the staff member present: -The tuna salad was at 50 degrees F. The tuna was in a deep full size pan. Although the tuna salad was on ice, the ice did not encase the tuna salad to ensure it was kept at the appropriate holding temperature. -The garlic pasta was 130 degrees F after the server gave a good stir to the pasta. The pasta was in a large deep pan with the lid off. C. Secured unit The evening meal on the secured unit was observed at 4:30 p.m., on 1/29/2020. During observations of the tray line the following food temperatures were obtained from the steam table prior to serving with the dietary staff member present: -The pureed tuna was 50 degrees F. The tuna was in a smaller pan, and in ice, however it was not encased around the tuna salad. -The regular texture tuna was 58 degrees F. The tuna was in a large pan and the ice was not encased around the tuna salad. -The puree tortellini (pasta) was 124 degrees F. -The toss green salad was 50 degrees F. -The mechanical soft green salad was 50 degrees F. -The puree green salad was 50 degrees F. The dietary aide #1 was interviewed on 1/29/2020 at approx 4:45 p.m. The DA #1 said the holding temperatures for the cold foods should be about what they are or lower. She said the hot foods should be held at 170 degrees F. The DM was interviewed on 1/30/2020 12:26 p.m. The DM said the food temps needed to be held at below 40 degrees. He said the hot foods need to be held between 160 and165 degrees F. The DM said they are all trained on proper holding temperatures. The DM said the lids should be on the hot foods at the tray line II. Handwashing A. Policy The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf. It read in pertinent part; Food employees shall clean their hands and exposed portions of their arms for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, area between the fingers, hands and arms for at least 15 seconds, followed by; thorough rinsing under clean, running, warm water; and immediately follow the cleaning procedure with thorough drying of cleaned hands and arms .Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles .after handling soiled equipment or utensils . B.Observations 1. Main kitchen Dietary aide (DA)#2 was observed to serve the evening meal on 1/29/2020 beginning at 4:15 p.m. The DA #2 had gloved hands. He touched the meal tickets, his shirt, and various other items, he then proceeded to reach into the hamburger bun bag, and retrieved a bun (ready-to-eat food) and placed tuna salad on the bun. He then used his other gloved hand to put the top bun onto the tuna salad. He did not use utensils when touching ready-to-eat foods. This process happened through several other meals. When he did change his gloves, he did not wash his hands prior to putting a new set of gloves on. 2. Secured unit Dietary aide #1 was observed to serve the evening meal on 1/29/2020 beginning at 4:30 p.m. The DA #2 was observed to have gloved hands. She was observed to use a pen while taking the food temperatures, touched the meal tickets, and the refrigerator handle. She then began to serve the meal, and touched the hamburger buns with the same gloved hands. She then placed the tuna salad onto the bun and used her other hand to place the top bun onto the tuna salad. She did not use utensils when touching ready to eat foods. This process happened throughout the meal service in the secured unit. The DM was interviewed on 2/5/2020 at approximately 5:00 p.m. The DM said ready to eat foods should not be touched by gloved hands. He said utensils should be used. The DM said he would provide additional training. The DM said hands should be washed in between tasks and also prior to putting on new gloves. III. Health shakes A. Directions The health shakes contained directions on the box which documented, the health shake needed to be used 14 days after being thawed. B. Observations On 1/27/2020 at 9:26 a.m. nine thawed 4 oz. (ounces)vanilla and strawberry health-shakes were observed in the north hall refrigerator without any thaw dates posted or written on the container. On 1/29/2020 at 5:00 p.m., the secured unit refrigerator had three 4 oz. health-shakes were without any thaw dates posted or written on the container. On 1/30/2020 at 12:00 p.m., the north hall refrigerator had approximately 20 health-shakes without any thaw dates posted or written on the container. The DM was interviewed on 1/30/2020 at 12:30 p.m. The DM was not aware the health shakes needed to be used within 14 days of being thawed. He said a lot of times the health shakes are delivered thawed. He said he would put dates on each individual health shake indicating a use by date. IV. Moisture in pans A. Policy The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf. It read in pertinent part; . Unless used immediately after sanitization, all equipment and utensils shall be air-dried. B. Observations -During the initial tour of the kitchen on 1/27/2020 at approximately 9:45 a.m., there were two stacks of six pans each which were stacked and stored as ready to use. In between the pans were trapped moisture, as the pans were not completely dried before stacking or stacked in a way that would allow the pans to fully dry. -On 2/5/2020 at 4:30 p.m., with the DM, the stacked pans were observed. there were a stack of six high large pans, and four stacked half pans. The pans had moisture between them, same as the above observation. The DM was interviewed on 2/5/2020 at 4:30 p.m. The DM said the pans needed to be completely air dried prior to stacking. He said the staff had been trained, however, he would provide additional training.

Based on observations, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure residents were free from the hazard of entering the level A east and west stairwells. The findings include: A. Immediate Jeopardy Record review revealed resident #1, who had a history of [REDACTED]. According to the incident report, dated [DATE], resident #1 was still belted into his wheelchair with injuries to his left side and a laceration to his head. Emergency medical services were called and the resident was transferred to the emergency room then admitted to the hospital for treatment of [REDACTED].#1 subsequently was discharged to a different long term care facility where he expired on [DATE]. Record review and interviews revealed that prior to resident #1 falling down the stairs the facility had unlocked the stairway doors to comply with fire safety codes. According to an in-service signed by the nursing home administrator (NHA), staff had been informed on [DATE] of the (fire safety code) violations of federal and state regulations. However, no interventions for resident safety were indicated on the in-service. The in-service content included, "Stairwells on A level locked." The in-service did not indicate that the resolution to the issue would be to unlock the stairwell doors, and it did not indicate any increased monitoring of residents or other action would be needed from the staff. The in-service was signed only by the NHA and dated [DATE]; however, the sign in log provided separately, was titled, "Checks," and dated ,[DATE]-26. Following resident #1's fall, the facility failed to implement interventions that would prevent other residents from accessing the egress and stairwell. During a tour of the facility with the maintenance director (MD), on [DATE] at 12:45 p.m., the stairwells on the A floor, both east and west were observed. The nursing station was in the middle of the unit with resident rooms to the east and west along the hall. The stairwells were at opposite ends of the hall in the middle section of the unit which had utility rooms and nursing stations: each stairwell had two doors (on each side of the hall). Each door to the stairwell had a Velcro stop sign affixed approximately four feet high, and one door on each end of the hall had a motion activated chime. The MD stated that the stop signs and chimes were the interventions put in place to prevent residents from entering the stairwells. He stated, however, that the height of the stop signs seemed high and that a resident in a wheelchair could roll under the signs without them being removed. The chimes were only on two of the four doors (southeast and southwest doors) because the facility did not have enough chimes though they had been ordered. He stated that due to the height of the stop sign and the ability of most residents to remove the Velcro, along with the lack of chimes or additional monitoring, there was nothing stopping residents from accessing the stairwells. Once in the stairwell, there was nothing in place to prevent a resident from falling over the railing or down the stairs. During an interview with the NHA, on [DATE] at 2:21 p.m., she stated they had not implemented interventions to prevent residents from accessing the stairwells, prior to resident #1 falling, because the doors were heavy and hard to open. However, they proved not to be safe. She stated the current interventions of the stop sign and chimes would prevent residents from accessing the stairwell because a red stop sign was universal for stop. She added the fact that the doors had been unlocked since April was reassurance that residents would not try to access the stairwells. An interview with a certified nurse aide (CNA) on the A level, on [DATE] at 3:33 p.m., revealed until that day she was not aware of how to reset the chimes on the south stairwell doors. She stated that she did not know about the doors being unlocked when resident #1 fell and she did not know what they could have done to stop the resident from going down the stairs. She said she did not think the stop sign or chimes could stop a resident from entering the stairwell. An interview with the medication aide on the A level, on [DATE] at 3:35 p.m., revealed that she had been working the day the resident fell down the stairwell. She stated she was informed that she had received an in-service on the doors being unlocked; however, she could not remember receiving any notification or training regarding doors being unlocked, until after the resident fell . There had been no increase in staffing or other interventions offered to keep the residents from accessing the stairwell. There were residents on the hall that walked independently and had the dexterity to remove the Velcro stop sign. She stated that residents from other floors passed through their floor to access activities at the front of the building. She did not feel there were interventions in place to keep the residents safe. The facility's failure to take steps to ensure the safety of the residents created a situation of immediate jeopardy for serious harm. On [DATE] at 4:05 p.m., the NHA and director of nursing (DON) were informed that as of 3:29 p.m. (the time of confirmation of the immediacy) the facility's failure to ensure the safety of the residents created the situation of immediate jeopardy for serious harm. B. Plan to Remove Immediate Jeopardy On [DATE] at 10:00 a.m., the fifth draft of the facility's plan to remove immediate jeopardy was presented, reviewed and accepted, following observation of an independent contractor starting the process of installing delayed egress to the A level stairwells. The plan documented in its entirety: Abatement for immediate jeopardy - [DATE] - A level stairwells will be monitored with one staff member inside each stairwell. This involves two staff members on duty at all times to monitor the area. They will be relieved for bathroom breaks and meals by a staff member designated by the DON/Designee. This will continue until delayed egress is installed by (local security system company) by [DATE]. A 50% deposit of (amount of deposit) has been issued to (a local security system company). All staff members assigned to this duty will receive orientation of the process of monitoring these areas. It was signed by the NHA with attachments of a detailed schedule of coverage for monitoring of the stairwells through [DATE] and a receipt of deposit from the security company. On [DATE] at 10:00 a.m., the immediate jeopardy was removed; however, deficient practice remained at a G level (actual negative outcome). C. Failure to Ensure Residents' Environment was Free from Accidents and Hazards Residents in the facility had the potential of being affected by the hazard of access to the stairwell as it was the fire evacuation route for the A level. Some residents on the lower level were seen being brought through the A level to participate in activities, outings, and transportation, and there was no restriction of movement for residents on the north or south units giving them free access to the A level unit. Resident #1 was an [AGE] year old male admitted to the facility initially on [DATE], and his most recent readmission was [DATE]. He was discharged emergently to the hospital on [DATE] after a fall down a flight of stairs while in his wheelchair. On his discharge from the hospital on [DATE] he went to a different long term care facility, where he expired within 24 hours. According to the face sheet, his [DIAGNOSES REDACTED]. According to his most recent quarterly minimum data set (MDS), the resident could not participate in his brief interview for mental status (BIMS) as he was rarely or never understood. He did not exhibit wandering, was limited assist for locomotion on and off the unit, and he had no restraints other than his chair prevented rising (please see identification of wandering noted before and after MDS below). The resident was identified as a wander risk and at a higher risk than non-wandering residents for accessing the stairwell. An interview with the NHA on [DATE] at 2:21 p.m., regarding resident #1 being a higher risk for injury from unsecured doors due to his wandering, revealed the following: The NHA stated that when they unlocked the doors to the stairwells on the A-level unit they contacted the families of residents who wandered and asked the families if they were afraid of the resident(s) accessing the stairwells. She stated that no families were afraid of such an incident; however, they were asked if they felt comfortable with the doors being unlocked, or if they wanted to consent to the resident being moved to the secured unit. There was no other alternative for families, when asked, than accepting the risk of the doors being opened, or consenting to the residents being moved to another room in the secure unit. If the family did not feel comfortable with either situation they would be asked to move the resident to another facility. All families did not consent to having their loved one moved to the secure unit. However, there was no documentation of the conversations with families when requested, on [DATE] through [DATE], on exit from the facility. The NHA stated the intervention implemented to keep residents safe from accessing the stairwell was calling the families. However, she could not describe how that would prevent a resident from accessing the stairwells. Record review revealed resident #1 had been identified as a wander risk. A chemical and physical restraint review, dated [DATE], revealed the resident was attempting a trial off the secured unit. Secured unit consents, dated ,[DATE] and ,[DATE], revealed the resident had previously been on the secured unit due to wandering behaviors and exit seeking. Review of the resident's care plan revealed there were no added interventions or monitoring at the stairwell doors provided for the resident; however, he did have a wander system alert bracelet on which alerted staff if he exited exterior facility doors. An interview with the resident's physician, on [DATE] at 1:32 p.m., revealed that he was not made aware of the added risk of being on a unit with unlocked doors for resident #1. He stated that although he was not aware of the issue, in retrospect, it was a clear hazard. He indicated that when resident #1 was trailed on the A-level unit, the expectation was not that he would cease exit seeking behavior; however, the expectation was that the resident and family would be happier on the A-level, as they had requested it. He stated that if the resident were to be readmitted his recommendation would be to the secure unit. He added that the stairwell doors being unlocked was a serious risk for any residents with mobility and a lack of judgment. D. Harm Resulting from Failure to Ensure Resident Environment was Free from Hazards An incident report, dated [DATE], included the following in pertinent part: "Resident (#1) opened the A level south east door that goes down stairs, wheeled himself into stairwell. He was found at the bottom of the first flight of steps lying on his right side, sitting in his wheelchair with the lap belt fastened. His chair alarmed and he was found by a CNA from (lower floor). There was fresh blood under his head and had a 3 cm (centimeter) deep laceration above right eye brow. Cervical spine maintained until c-collar was placed by EMS (emergency medical service). (Resident) complained of pain to left lateral ribs. He was palpated: Left eye brow laceration, Left lateral chest and rib pain, (and) Contusion to left shin. These were the obvious injuries found, without removing all his clothing. Called EMS, stopped bleeding, maintained airway and cervical spine, checked vital signs, head to toe assessment and explained what they would do in the emergency room for him." The investigation included that the resident was agitated and looking for his car prior to the fall. The nurse had re-directed the resident and let staff know to keep an eye on the doors to the outside, since he was exit seeking. Review of the hospital records, dated [DATE], documented in pertinent part: Physician's Notes "The patient was placed in a room and examined. The patient was maintained in full spinal precautions with a cervical collar in place. 2 large-bore intravenous catheters had been established and cardiac monitoring was initiated. The patient was examined, and with log roll precautions and C spine precautions, fully examined. To review the records from the prior facility, I reviewed the CT findings. He has a repaired laceration of the left eyebrow. He also has rib fractures on ribs 2 through 8 with anterior and posterior fractures of ribs 2 through 7. There is a small hemothorax or effusion present. He is not anticoagulated according to his records." During observations of the facility, on [DATE] at 5:45 a.m., there were two exit doors of egress (south/west and south/ east) on the A level, leading to a public way, equipped with motion sensors and "stop" strips attached to the frame of the door. The motion sensors, when activated, sounded to alert staff that someone was approaching the doors. However, the observation revealed when the chime was turned off on one of the doors the staff members did not promptly respond when the chime sounded on the other door. At 6:10 a.m., the chime on the exit door located across from room #20 was observed in the off position. The CNA who was responsible to monitor the exit doors was unable to demonstrate to the surveyors the proper setup of the motion detectors or the chime system. During an interview, on [DATE] at approximately 6:20 a.m., the CNA stated that she had received instruction from other staff members and the Maintenance Director (MD) prior to her duty on [DATE]. Instructions included how to monitor the doors, and how to disable the alarm and properly aim the motion sensor. However, she was unable to demonstrate this. On [DATE] at 2:50 p.m., the MD was interviewed and stated the staff members were in-serviced on [DATE] at approximately 6:00 p.m., on how to monitor the doorways, disable/reset the chimes and how to properly aim the motion detectors.

Based on record review and interviews, the facility failed to ensure five of six sample residents (#2, #3, #4, #5, and #6) received the care and services necessary to attain and/or maintain their highest practicable level of well-being. Specifically, the facility: -Failed to ensure physician orders for anticoagulants and monitoring were followed and clarified for resident #6. The resident's [MEDICATION NAME] dosage was substantially increased; staff failed to clarify the order with the physician and the resident required hospital intervention for repeat nosebleeds. -Failed to ensure physician's orders were clarified and followed for residents #2, #3, #4. -Failed to monitor to ensure placement of ordered [MEDICATION NAME] for resident #5. The finding include: A. Anticoagulants 1. Expectations a. References "2010 Mosby's Nursing Drug Reference," 23th edition, on page 10, provides in pertinent part: "-Action: Anticoagulants interfere with blood clotting by preventing clot formation. -Uses: Anticoagulants are used for deep vein [MEDICAL CONDITIONS] emboli, [MEDICAL CONDITION] infarction, open-heart surgery, disseminated intravascular clotting syndrome; [MEDICAL CONDITION] with embolization, transfusion, and [MEDICAL TREATMENT]. -Side effects: The most serious adverse reactions are hemorrhage, agranulocytosis, [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], and [MEDICAL CONDITION], depending on the specific product. The most common side effects are diarrhea, rash, and fever. . . -Precautions: anticoagulant should be used with caution in alcoholism, geriatric patients, and pregnancy. . . -Nursing Considerations: Blood studies (Hct, platelets, all cold blood in stools) Q3 months; Partial PT, which should be 1 1/2-2X control PPT daily, also A PTT, ACT. . ." - The web site www.labtestsonline.org/understanding/analytes/pt/test.html Lab Tests Online ?2001 - 2011 by American Association for Clinical Chemistry (page was last modified on March 22, 2011) "The test result for PT depends on the method used, with results measured in seconds and compared to the average value in healthy people. Most laboratories report PT results that have been adjusted to the International Normalized Ratio (INR) for patients on anti-coagulant <javascript:%20optionsdisplay('../../../glossary/anticoagulant.html')> drugs. These patients should have an INR of 2.0 to 3.0 for basic "blood-thinning" needs. For some patients who have a high risk of clot formation, the INR needs to be higher - about 2.5 to 3.5. . . " b. Facility Policy The facility policy for anticoagulation therapy was requested from the Director of Nursing (DON) on 4/13/11 and received by fax on 4/17/11. The policy, "Anticoagulation Therapy," reads in pertinent part: Recipients of anticoagulation therapy will have a documented need for the medication and ordered by the Physician. Shall be carefully monitored for therapeutic regimens, and the medication will be administered accurately by the licensed nurse and/or Medication Aids in states that allow Medication Aids. Labs will be drawn per Physician's order. Facility can obtain PT/INR using PT/INR machine, in-house per Physician's order. Procedure: 1. Anticoagulants shall be administered per Physician orders. 2. PT/INR shall be done per Physician orders. 3. Results shall be documented (current dosages, date/time, results, next date of INR/PT is due) and placed in charge under labs and faxed to Physicians. 4. In nurses notes document site of draw, sticks and how lab was obtained. (In-house, venipuncture/test tubes sent to laboratories.) 5. Monitor for side effects of anticoagulation therapy and document in nurses notes. Be alert to complaints of abdominal/back pain, severe headache, decrease in B/P (blood pressure). Increase in pulse rate may be sign of hemorrhage. 6. Monitor area of [MEDICAL CONDITION] for color, temperature. Peripheral pulses; skin for ecchymoses, petechiae. Monitor for excessive bleeding from minor cuts, scratches. Monitor gums for [DIAGNOSES REDACTED] and gingival bleeding, monitor urine output hematuria. 7. Care plan in place to identify risk factors and appropriate interventions." 2. Resident #6 a. Resident Status on Admission Medical record review revealed [AGE] year-old resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission assessment dated [DATE] indicated the resident weighed 175.5 pounds. According to the assessment, the resident was alert, anxious, withdrawn and agitated due to anxiety. The resident had bilateral hearing aids and wore glasses. Review of the comprehensive care plan, last updated on 1/26/11, revealed the resident was care planned for being above ideal weight, self-care deficit requiring assistance with activities of daily living to be sure hygiene and grooming were done well, alteration in elimination (constipation), at risk for bleeding related to [MEDICATION NAME], having the potential for dehydration/fluid maintenance related to the use of the diuretic [MEDICATION NAME] and an alteration in comfort, generalized pain - states moderate pain on verbal descriptive scale. Review of the physician's admission orders [REDACTED] -[MEDICATION NAME] 1.5 mg orally daily scheduled to be given at 4 p.m. - [MEDICATION NAME] 400 mg orally three times a day for pain, -PT/INR every two weeks. (There was no documentation of the INR parameters for this resident.) b. Status 1/11 and Failure to follow orders for [MEDICATION NAME] Administration and Laboratory Testing Review of the 1/11 Medication Administration Record (MAR) revealed: -[MEDICATION NAME] 400 mg was given at 7 a.m., 12 p.m., and 4 p.m. beginning on 1/17/11 through 1/31. -[MEDICATION NAME] 1.5 mg was given at 4 p.m. beginning on 1/17/11 through 1/31/11, with the exception of 1/26/11, where initials were circled; however, no explanation was given on the MAR or in the nurses' notes. On 1/24/11 the PT was high at 19.8 (reference range 10.3-14.9). The INR was high at 2.3 (reference range 1.0-1.5). A CBC (complete blood count) was completed on 1/24/11 and the resident's hemoglobin was critically low at 7.8 (reference range 12-16 g/dL.) and the hematocrit was low at 24.3 (reference range 36-47%). On 1/24/11 at 7:30 p.m. a telephone order was written to [MEDICATION NAME] stools three times. There was no documentation on the 1/14/11 - 1/31/11 handwritten Treatment Administration Record (TAR) that this was completed. On 1/25/11 at 9 p.m. a telephone order was written to type and cross match for two units packed red blood cells. [MEDICATION NAME] 20 mg IV was to be given in between the two units. A CBC was ordered to be done in a week. There was no documented evidence that the 1/25/11 CBC was completed as ordered on or on approximately 2/1/11. A CBC completed on 1/26/11 (no physician's order was found for this lab test in the medical record) was faxed from the facility on 4/17/11. The hemoglobin was low at 9.9 g/dL and the hematocrit was low at 30.2% c. Status 2/11 - Decline in Condition ([MEDICAL CONDITION], suspected bleed, and chest pain) Review of the 2/11 Medication Administration Record (MAR) revealed: -[MEDICATION NAME] 400 mg was given at 7 a.m., 12 p.m., and 4 p.m. beginning on 2/1/11 through 2/27/11 with the exception of at 4 p.m. on 2/15/11. -[MEDICATION NAME] 1.5 mg was given at 4 p.m. beginning on 2/1/11 through 2/27/11. There was no documentation that a PT/INR was completed on 2/7 and on 2/21/11 as ordered on [DATE] to be done every two weeks (every two weeks after the last PT/INR (1/24/11) would have been on 2/7 and 2/21/11). Review of the physician's progress notes included a note dated 2/22/11 and one dated 2/25/11. -The 2/22/11 physician progress notes [REDACTED].I. on [MEDICATION NAME] will consider dcing (discontinuing) if there is another bleeding episode." -The 2/25/11 physician progress notes [REDACTED].I. 2 U PRBC (units of packed red blood cells) ordered and PT (patient) to receive, to monitor H&H monthly." On 2/27/11 the resident was transferred to the emergency room for evaluation of chest pain. d. Status 3/11 - Readmission orders [REDACTED] The resident returned to the facility 2/28/11. New physician orders read: -[MEDICATION NAME] 7 1/2 mg daily, -CBC with the differential to be done on 3/1/11 and the PT/INR to be done on 3/1/11. A CBC had been completed on 2/27/11 and the hemoglobin was low at 11.8 g/dL and the hematocrit was low at 35.1%. A PT/INR was completed on 3/2/11 and the results were: 16.4 and 1.6. At the bottom of the laboratory results sheet was information that the lab results have been faxed to the physician on 3/4/11, and the physician had written on the bottom of the fax sheet that she needed (from the facility) the dose of the medication ([MEDICATION NAME]). This was requested a second time on 3/4/11 on the bottom of the faxed laboratory results. There was undated and unsigned documentation of a facility response on the fax sheet of "[MEDICATION NAME] 7.5 mg q (every) day." On 3/2/11 a CBC was completed and the hemoglobin was 12.3 g/dL (in the reference range) and the hematocrit was 37.0% (in the reference range). Review of the 3/11 Medication Administration Record (MAR) revealed [MEDICATION NAME] 7.5 mg was given at 4 p.m. beginning on 3/1/11 through 3/17/11 with the exception of 3/14 when the [MEDICATION NAME] was not available per nurse's notes on the MAR. On 3/15/11 a "[MEDICATION NAME] Notification Physician Orders" dated 3/15/11 indicated the PT with 16.4 and the INR was 1.6. The current dose [MEDICATION NAME] was documented as 7.5 mg every day. However, the physician had written on this sheet that [MEDICATION NAME] had been discontinued. There was no clarification of the physician's directives regarding the administration of [MEDICATION NAME] until 3/17/11. On 3/17/11 at 5:45 p.m. a physician telephone order was written and read: -[MEDICATION NAME] 10 mg PO on Monday, Wednesday and Friday, -[MEDICATION NAME] 7.5 mg PO remaining days, Saturday, Sunday, Tuesday, and Thursday -Recheck in one week-Friday. On 3/17/11 the INR was documented as 1.6, the current [MEDICATION NAME] dosage was 7.5 mg PO daily, the physician had been notified, the new [MEDICATION NAME] dosage was documented as 10 mg on Monday, Wednesday, and Friday and 7.5 mg (milligrams) on Tuesday, Thursday, Saturday, and Sunday. The next scheduled INR was documented as 3/23/11. According to the 3/11, MAR, [MEDICATION NAME] 7.5 mg was given daily 3/1 through 3/17 (with the exception of 3/13) and then again on 3/28/11 when the [MEDICATION NAME] was ordered on hold. The 3/11 MAR indicated 10 mg of [MEDICATION NAME] was given on 3/18/11. According to the nurses' notes and emergency room (ER) records, the resident was sent to the emergency roiagnom on ,[DATE], 3/22, and 3/23/11 for nosebleeds; however, the complete ER reports were not copied. In addition, the ER report dated 3/21/11, did not have resident #6's name as the patient name on the ER report. 3/21/11: -On 3/21/11 at 11:30 a.m. a nurse documented the resident had a bloody nose since 7 a.m. and was sent to the emergency room at 11:35 a.m. The nurse had documented 2 mg vitamin K were given at 4 p.m. -On 3/21/11 at 1 p.m. the physician had ordered: --"Vitamin K. 2 milligrams PO x one dose-INR 8.9/bloody nose --CBC/PT/INR in a.m.-HTN (hypertension) -- Hold [MEDICATION NAME] until further notice." 3/22/11: -A PT/INR completed on 3/22/11 at 6 a.m. was a high PT of 7.2 and critically high INR of 15 .4. On the bottom of the laboratory sheet was handwritten to repeat INR, DC [MEDICATION NAME], and check hematocrit and hemoglobin. -A CBC was completed on 3/22/11 at 6:00 a.m. and the hemoglobin was low at 10.7 g/dL and the hematocrit was low at 32.3%. On the bottom of this laboratory's role was handwritten PT 56.2 and INR 14.9. -On 3/22/11 at 6:30 a.m. a physician's telephone order documented the following: --"DC (discontinue) [MEDICATION NAME], --Call H&H (hemoglobin and hematocrit) results when available, --Send to emergency RM (room) if bloody nose con't (continues)" -On 3/22/11 at 8:30 am a nurse documented the resident "nose cont. (continued) to bleed-INR 15.4." The physician was called and a repeat PT/INR was drawn and sent to the lab. The nose continued to bleed and the resident was sent to the emergency room and returned (per nurse's notes) at 5:30 p.m. The 3/22/11 ER report contained, among the [DIAGNOSES REDACTED]." -On 3/22/11 at 9:14 a.m. the PT/INR laboratory results were a high PT of 56.2 and a critical high INR of 14.9. -On 3/22/11 at 4:25 p.m. the physician [MEDICATION NAME] spray to be given twice a day for three days when the nasal packing was removed. 3/23/11: -On 3/23/11 at 9 a.m. a physician's telephone order was written to send the resident to the emergency room for acute right epistaxis. A stat INR was ordered and if it was over 8 the resident was to be admitted to the hospital. -On 3/23/11 a nurse documented at 9:10 a.m. that the resident was sent to the emergency room . The nurse documented the bleeding had been noted off and on all morning from 6 a.m. till the resident was sent out. The nurse documented the resident was crying and stated, "this hurts already, I wish it would stop already." The resident returned to the facility at 12:45 p.m. The 3/23/11 ER report contained, among the [DIAGNOSES REDACTED]." -On 3/23/11 at 11:17 a.m. the partial [MEDICATION NAME] time (PTT) was critically high at 53.3 (reference range 23.3-37.8 seconds), the PT was high at 29.0, and the INR was high at 4.6. Review of the nurses' notes documented on 3/21, 3/22, and 3/23/11 contained no vital signs. e. Interview Several attempts to interview resident #6 were made on 4/12 and 4/13/11; however, the resident appeared to be sleeping. On 4/12/11 at 2 p.m. the Director of Nursing (DON), the nursing home administrator in training and the day nursing supervisor were interviewed. -They were queried about the [MEDICATION NAME] dose being increased from 1.5 mg daily to alternating days of 7.5 and 10 mg of [MEDICATION NAME] when the order PT/INR's were not being completed/or recorded. They were also questioned about if anyone had clarified with the physician: 1) the increase in the [MEDICATION NAME] dosage, 2) the physician's hand written statements on 3/4/11, requesting twice what the [MEDICATION NAME] dose being administered at that time was, and 3) the physician's hand written comments on 3/15 that the [MEDICATION NAME] was discontinued. -They were questioned if and where the results of the [MEDICATION NAME] stools the physician ordered on1/24/11 could be found. The DON stated the [MEDICATION NAME] results should be on the TAR. On 4/15/11, a [MEDICATION NAME] Flow Sheet was faxed to the surveyor (after exit of the facility on 4/13/11). The [MEDICATION NAME] flow sheet contained only three entries as follows: -On 1/24/11 the INR was 2.3, the current [MEDICATION NAME] dosage was documented as 7.5 mg PO daily, the physician had been notified, there was no change in the new [MEDICATION NAME] dosage, and the next scheduled INR was documented as 3/1/11. -On 3/2/11 the INR was documented as 1.6, there was no documentation of the current [MEDICATION NAME] dosage, the M.D. was notified on 3/2/11, there was no documentation for the new [MEDICATION NAME] dosage, and there was no documentation for the next scheduled INR date. -On 3/17/11 The INR was documented as 1.6, the current dose was documented as 7.5 po daily, the physician was notified and the new dose was documented as 10 mg of [MEDICATION NAME] on Monday, Wednesday and Friday and 7.5 mg on Tuesday, Thursday Saturday, and Sunday. The next scheduled INR was documented to be done on 3/23/11. -On 4/15/11 a copy of the 1/14/11 through 1/31/11 hand written TAR was faxed from the facility. This copy was identical to the copy received from the facility on 4/13/11 other than the [MEDICATION NAME] were documented on this faxed copy as a (-) negative on 1/25, a negative on 1/27, and a negative on 1/28/11. f. Facility record of events -On 4/15/11 a copy of the day RN supervisor's time line of events per her investigation was sent and signed by the RN. It read as follows: "(name of resident)-PT/INR was done on 1-24-11 -type and cross match 1-26-11 -[MEDICATION NAME] given on 3-18-11-communication error to physician regarding prior dosage. -Med error report done on communication of dosage being taken prior to notification. -[MEDICATION NAME] held on 3-21-11 and discontinued on 3-22-11. -Stools were [MEDICATION NAME] -see TAR (the word negative was handwritten in). -Labs done on patients-CBC 2-27, CBC 1-26, CBC 3-2, CBC 3-21, CBC 3-22, CBC 3-23. emergency room reported that the Physician's Name is in the patient name heading on the hospital forms and his nick name is (Nick name) and it is a misprint." g. Physician Interview On 4/25/11 at 3:38 p.m. a telephone interview was attempted with resident #6's primary care physician. According to the clinic (the physician's phone number) that was called, the physician was no longer associated with the clinic and the clinic was unaware of a current telephone number to reach the physician. B. Other Medication Orders 1. Professional References -According to "Fundamentals of Nursing, The Art & Science of Nursing Care", 4th edition, Lippincott, 2001, pages 109, 290, 583-586, and 637-629, in pertinent part, physician initiated interventions, or dependent nursing actions, involve carrying out physician prescribed orders. -According to Perry & Potter, Fundamentals of Nursing, 7th Edition (2009) page 687: "Because medication administration and evaluation are essential to nursing practice, nurses need to have knowledge about the actions and effects of the medications their clients' take. Administering medications safely requires an understanding of legal aspects of health care, pharmacology, pharmacokinetics, the life sciences, human anatomy and mathematics." -According to Fundamentals of Nursing, The Art and Science of Nursing Care, by Taylor, Lillis and LeMone, on page 343, "The client record is the only legal document that provides a comprehensive picture of the nursing care given to the client. Documentation should be consistent with professional standards; complete, accurate, relevant, factual, and timely." 2. Resident Failures a. Resident #2 Medical record review revealed [AGE] year-old resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated the resident's mental status was cognitively intact. The resident was coded as being dependent upon a staff member for bed mobility, transferring, dressing, toilet use, and personal hygiene. Facility Failures: Review of the 4/11 Computerized Physician Orders (CPO) included: -[MEDICATION NAME] ER. (Extended release) 50 mg tablet. A 50 mg tablet by mouth every day. Hold if systolic less than 100, diastolic less than 60 or heart rate less than 50 (4/22/10). -[MEDICATION NAME] 12.5 mg tablet. Give one tablet by mouth every day (however, scheduled at 8 a.m. and 4 p.m.) Hold if systolic is less than 100, diastolic less than 60 or heart rate less than 50 (4/22/10). -[MEDICATION NAME] 5 mg tablet. Give one tablet by mouth twice daily. (Scheduled at 8 a.m. and 4 p.m.) Hold if systolic is less than 100, diastolic less than 60 or heart rate less than 50 (10/15/10). Antihypertensives' Parameters not clarified: The 3/11 Medication Administration Record (MAR) revealed that [MEDICATION NAME] Succ. ER and [MEDICATION NAME] were given every day beginning with 3/1 through 3/31; however, there was no documented evidence of a blood pressure reading on the afternoon shifts on 3/1, 3/9, and 3/11, 3/28/11. In addition, it was unclear whether the blood pressure medication should have been held when both the systolic blood pressure was less than 100 and diastolic was less than 60 or only when the systolic blood pressure was less than 100 or the diastolic was less than 60 or when the pulse was less than 50. For example, on 3/4/11 the a.m. blood pressure was documented as 128/48 and the pulse was documented as 70; however, the medications were administered. On 4/12/11 at 2 p.m. the Director of Nursing (DON), the nursing home administrator in training and the day nursing supervisor were interviewed and told of the above concerns. The DON stated the facility had initiated the parameters (date unknown) to ensure the resident's blood pressure and pulse would be taken. The DON went on to say that she could see according to the examples given, that the parameters needed to be clarified. b. Resident #4 Medical record review revealed [AGE] year-old resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated resident #4's mental status was moderately impaired. The resident was coded as needing the limited assistance of a staff member with bed mobility, transferring, and toilet use and needed extensive assistance of a staff member with dressing. The MDS indicated the resident was depended upon a staff member for personal hygiene. Facility Failures: The 4/11 Computerized Physician Orders were reviewed on 4/7/11 and included: -[MEDICATION NAME] 10 to 20 mg capsule. Give one capsule orally every day. Hold if systolic blood pressure is less than 100, diastolic less than 60 or heart rate less than 50 (8/10/10). -[MEDICATION NAME] HCl 0.1 mg tablet. One tablet orally every day. Hold if systolic blood pressure is less than 100, diastolic less than 60 or heart rate less than 50 (8/10/10). -[MEDICATION NAME] 0.2 mg/hour patch. Apply one patch [MEDICATION NAME] every day. Alternate locations. Antihypertensives' Parameters not clarified: The 3/11 Medication Administration Record (MAR) revealed [MEDICATION NAME] and [MEDICATION NAME] were given every day beginning with 3/1 through 3/31; however, there was no documented evidence of a blood pressure reading on 3/22, 3/23, 3/27, and 3/28/11. In addition, it was unclear whether the blood pressure medication should have been held when both a systolic blood pressure was less than 100 and diastolic was less than 60 or only when the systolic blood pressure was less than 100 or the diastolic was less than 60. For example, on 4/2/11, the blood pressure reading was documented as 139/53 and the pulse was documented as 71 and the medications were held. On 3/21/11, the blood pressure was documented as 120/48 and the pulse was documented as 68; however, the medications were administered. Failure of Patch Removal: According to the 23rd edition of 2010 Mosby's Nursing Drug Reference on pages 787 and 788, in regard to [MEDICATION NAME] (TD) patches, "Dosage and Routes," Apply a pad daily to a site free of hair; remove at bedtime to provide 10-12 hr [MEDICATION NAME] -free interval to avoid tolerance. Under "Nursing Considerations" read, in part, "Apply a new TD patch daily and remove after 12-14 hours to prevent tolerance. Review of the 3/11 MAR revealed no documented evidence that the [MEDICATION NAME] was removed nightly with the exception of 3/31/11. On 4/12/11 at 2 p.m. the DON, the nursing home administrator in training and the day nursing supervisor were interviewed and told of the above concerns. The DON stated the facility had initiated the parameters (unknown date) to ensure the resident's blood pressure and pulse would be taken. The DON went on to say that she could see, according to the examples given, that the parameters needed to be clarified. The DON stated that after the new owners had taken possession of the facility on 2/1/11, she personally verified all residents' physicians' orders were correct, including requested documentation of parameters, insulin injection sites, and removal of the [MEDICATION NAME] in the evening. However, she continued, some of this information evidently had not been transcribed onto the 4/11 MARs and TARs. c. Resident #3 Medical record review revealed [AGE] year-old resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated resident #3's mental status was coded as severe impairment. The MDS coded the resident as needing extensive assistance of a staff member with bed mobility, transferring, dressing, and personal hygiene and with toilet use. Facility Failures: The 2/11 Computerized Physician Orders were reviewed on 4/7/11 and included: -[MEDICATION NAME] 10 mg. One tablet daily (1/3/11). -[MEDICATION NAME] 25 mg. One tablet twice daily (1/3/11). -[MEDICATION NAME] 100 mg. One tablet in the morning (1/3/11). (1) Failure to clarify blood pressure parameters. A MAR entry read: Hold if systolic blood pressure is less than 100 diastolic less than 60 heart rate less than 50. Review of the 2/11 MAR and the Blood Pressure and Pulse sheet revealed in part: -On 2/2 the a.m. blood pressure was 99/43 and the pulse was 86, all three of the above antihypertensives were given. -On 2/3 the a.m. blood pressure was 99/53 and the pulse was 68, all three of the above antihypertensives were given. -On 2/6 the a.m. blood pressure was 90/35 and the pulse was 74, all three of the above antihypertensives were held. The p.m. blood pressure was 87/69 and the pulse was 73 and the [MEDICATION NAME] was given. -On 2/9 the a.m. blood pressure was 100/48 and the pulse was 80, all three of the above antihypertensives were held. -On 2/12 the a.m. blood pressure was 108/46 and the pulse was 84, all three of the above antihypertensives were given. -On 2/14 the a.m. blood pressure was 117/47 and the pulse was 80, all three of the above antihypertensives were given. (2) Failures related to blood sugars Facility Policy: The facility policy regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED] was requested on 4/13 from the DON and received by fax on 4/17/11. "[MEDICAL CONDITION] and [DIAGNOSES REDACTED] Policy: Appropriate medical and nursing care are provided to residents with diabetes mellitus who require insulin or oral hypoglycemic agents to minimize the risk and ensure prompt recognition of [MEDICAL CONDITION] and [DIAGNOSES REDACTED], especially insulin shock, hyperosmolar nonketotic coma and ketoacidosis. *Physician is immediately notified when any resident who receives insulin exhibits altered behavior, or mental or (physical) state consistent with [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. *If attending physician cannot be reached promptly, notify the medical director. *If the diabetic resident experience as an acute or subacute change in consciousness, the nursing staff is authorized to taking STAT blood glucose by finger stick if physician is not immediately available. Procedure: 1. All diabetic residents receive insulin and diet according to the physician order. a. Notify the physician of blood sugar reading outside of normal range, or guidelines as ordered by the physician. 2. When a resident with diabetes mellitus on insulin or oral medications exhibits tremors, [MEDICAL CONDITION] anxiety, dizziness, headache, clouding of vision, [MEDICATION NAME] mental acuity, confusion, abnormal behavior or tachypnea, orange juice with sugar is given, and a finger stick is performed. 3. Obtains vital signs 4. Give glucose, insulin, and intravenous fluids as ordered by a physician for emergency administration. 5. Notify Physician and family of any changes in condition. 6. Update Resident Care Plan and Resident Profile as needed. 7. Document in clinical Notes. 8. Sign Medication Administration Record for all medication given. Monitor V.S. (vital signs) and follow up with additional blood glucose monitoring as ordered by physician or until resident is stable." Record Review: The 4/11 Computerized Physician Orders were reviewed on 4/7/11 and included: -Blood sugars - There were no times designated for Blood sugars other than with the sliding scale [MEDICATION NAME] ordered below. - [MEDICATION NAME] 100 units/ml Inject 20 units early a.m. daily (3/12/11). -[MEDICATION NAME] 100 units/ml Inject 40 units at bedtime in abdomen (3/3/11). -[MEDICATION NAME] 100 units/ml sliding scale before breakfast and at bedtime as follows: 70-139 = 0 units 140-200 = 1 unit 201-250 = 2 units 251-300 = 3 units 310-350 = 4 units 351-400 = 5 units Over 400 = call MD -[MEDICATION NAME] 100 units/ml. Inject 10 units with meals. Document sites. Review of the 3/11 MAR and Daily Diabetic Sheet revealed some of the following: -Inconsistent documentation of injection sites for the sliding scale insulin given. -No documentation of a blood sugar completed on 3/4/11 at 4 p.m. -No documentation of a before lunch blood sugar completed on 3/6/11. The blood sugar at 4 p.m. was documented as 489 and the physician was called. -On 3/8/11 the documented 5 a.m. blood sugar was 169 and 2 units of insulin were given. One unit of insulin should have been given. -No documentation of a blood sugar taken at bedtime on 3/13/11. -No documentation of a blood sugar completed before lunch on 3/20/11. Review of the 4/11 MAR and Daily Diabetic Sheet revealed in part: The bedtime [MEDICATION NAME] was decreased from 40 units to 20 units on 4/4/11. -No documentation of any blood sugars taken on 4/1/11. -Inconsistent documentation of injection sites for the sliding scale insulin given. -No documentation of blood sugars taken lunch and dinner on 4/3/11. On 4/12/11 at 2 p.m. the DON, the nursing home administrator in training and the day nursing supervisor were interviewed and told of the above concerns. The DON stated the facility had initiated the parameters (unknown date) to ensure the resident's blood pressure, and pulse would be taken. The DON went on to say that she could see, according to the examples given, that the parameters needed to be clarified. The DON also stated that the facility would return to using some of the prior forms regarding to diabetic and monitoring. d. Resident #5 Medical record review revealed [AGE] year-old resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE], revealed the resident had severe impairment when interviewed for mental status. The resident was usually understood; however, rarely or never understood others. -The resident was coded as needing extensive assistance of a staff member in all activities of daily living except personal hygiene with which she was dependent upon a staff member. -The resident's mobility device was a wheelchair. -The resident was frequently incontinent of urine and always continent of bowel; however, the resident was on neither a urinary nor bowel toileting program. Facility Failures: Review of the 4/11 Computerized physician orders revealed a 3/26/11 order for [MEDICATION NAME] on in the a.m. and off in the night. Observations made of resident #5 on 4/12/11 at 10:55 a.m. and at 4:47 p.m. revealed no [MEDICATION NAME] on. However, review of the 4/11 MAR on 4/13 revealed initials in the dated square for 4/12/11 a.m. shift indicating that [MEDICATION NAME] were on resident #5. On 4/12/11 at 2 p.m. the DON, the nursing home administrator in training and the day nursing supervisor were interviewed and told of the above concerns. No comment was made.

Based on observation, record review, and staff interviews, the facility failed to ensure one (#1) of six sample residents received adequate assistive devices to prevent accidents. Specifically, resident #1, who was assessed at high risks for falls, continued to fall from her bed without sufficient interventions in place to prevent further falls. The resident fell on [DATE], resulting in the right tibia and fibula non displaced fractures. The findings include: A. Facility Policy The facility policy entitled "Preventing Falls" was requested and received on 3/16/11 from the director of nursing (DON). The policy read in pertinent part: "Policy: Did you know that falls are the second leading cause of accidental death in the United States and that 75% of falls involved older adults? The death rate from all falls increases significantly with age. Minor falls often lead to periods of bed rest or reduced activity. Those that result in greater injury usually lead to hospitalization . These accidents also cause loss of confidence and fear of future falls. Why does the risk of falls increase with age? The incident of falls increases for variety of reasons, including: 1. Slowed reaction time which makes it difficult to regain balance once balance is lost. 2. Changes in balance caused by: 3. Tilting head back to look up 4. Posture changes that shift the center of gravity 5. Dizziness caused by medications such as tranquilizers, sedatives, diuretics and antihypertensives 6. Joint pain or stiffness 7. Muscle weakness 8. "Drop Attacks" (sudden loss of muscle tone) 9. Foot problems and improper shoes 10. Fractures that caused falls 11. Sensory changes 12. Low blood pressure 13. Hazards in the environment a. Slipping b. Tripping c. Faulty equipment, such as worn tips on canes, walkers 14. Improper use of wheelchairs, walker, canes (including locks) Who is at highest risk for falls? 1. Those that are experiencing high stress and anxiety, e .g. new residents 2. Those that are weak or unsteady . . . 6. Those with arthritis or painful joints 7. Those with visual losses 8. Those with a change in health status 9.*Those with a history of falls *Special Note: Those who have had limited activity or bed rest, e. g., those who have been in the hospital or who have had the flu. How can the risk for falls be reduced? The potential for falls can be lowered by: *Identifying residents at high risk and planning appropriate care with the resident *Keeping residents active and ambulating . . . *Teaching residents to: -Ask for help when needed -Rise slowly -Stay awake -Use wheelchairs, canes and walkers properly -Wear shoes when walking -Use handrails if needed *Keeping necessary items within reach . . . *Removing slipping or tripping hazards immediately *Allowing residents to proceed at their own pace instead of hurrying *Assisting residents to cope with stress and anxiety Observations of falls Research indicates: . . . 2. Most falls occurred near the resident's bed 3. Falls may be a symptom of a developing illness . . . Whose responsibility is it to prevent falls? Preventing falls is a responsibility of all staff members and the resident. The staff must be sure the environment is safe, health needs are met, and the residents had the necessary information to promote their own safety. Residents have the responsibility to use appropriate caution, report hazards, and take part in planning for their own safety. Residents sometimes choose not to follow our advice and therefore may increase their risk of falls. Though it is difficult, we must allow residents to take informed risks. Older persons often have a great fear of falls. Sometimes they are too cautious, limiting their mobility unnecessarily. This fear needs to be addressed directly with the resident and the mutual plans and goals related to the problems need to be made. Find out why the resident is fearful and plan your care based on those reasons. If a resident is mentally incapable of proper awareness of risks, the family should be involved in planning appropriate care." B. Resident #1 Resident #1, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was re-admitted on [DATE] with additional [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], indicated the resident was moderately impaired with a summary score of 12 in the interview for mental status, had moderate difficulty in hearing, wore glasses, and had no behaviors. -The resident was coded as needing limited assistance of a staff member with bed mobility and locomotion on and off the unit, was totally dependent upon a staff member for transferring and with toilet use, and needed extensive assistance of a staff member in dressing and with personal hygiene. The resident needed supervision only with eating. -The resident was frequently incontinent of urine and occasionally incontinent of bowel and the MDS indicated there had not been a trial of a toileting program. The resident was 62 inches tall and weighed 89 pounds. 1. Record Review - history of falls - facility response Review of the comprehensive care plan, last updated on 2/1/11, revealed the resident had self-care deficits requiring assistance with activities of daily living (ADLs), had limited mobility related to weakness and vertigo, had the potential for impaired skin integrity, had alteration in comfort related to back pain and muscle spasms, had some short-term memory loss and some unrealistic fears with regard to her health, and was at nutritional risk due to the [DIAGNOSES REDACTED]. -Some of the approaches listed for the limited mobility related to weakness and vertigo initiated on 7/27/10 included: --Ambulation program 3-5 times weekly with two staff and gait belt. --Resident has own wheelchair with a back gel cushion with regular foot rests. --Receives physical therapy and occupational therapy from the hospital. --Resident transfers independently with supervision of one staff to and from the bed to wheelchair. --Explain call light and encouraged to use. -Hi low bed with special lipped mattress and mat on floor next to bed and transfer bar used and enabler bed is adjusted to resident height due to doing transfers independently with supervision of staff. -Nonskid strips added to floor next to bed (8/10/10) -Family to bring in different shoes (2/4/11) -Bed replaced with facility bed high low alarm on bed (2/8/11) The Fall Risk Assessment, initially completed on 7/21/10, indicated the resident was at a high risk for falls scoring 18. According to the instructions on the assessment, a resident who scores a 10 or higher is at risk. Fall 8/9/10: Review of the nurse's notes dated 8/9/10 at 9:45 p.m. revealed the resident was found sitting on the floor with her back up against the bed. The nurse documented the resident had socks on with no shoes and the call light was not on. Neuro(logical) checks were initiated and completed. On 8/12/10 at 5 p.m., a nurse documented that the resident had no injuries from the fall and slip strips were added on the floor at the bedside. The nurse also documented the resident was reminded to use the call light for assistance. Fall 12/17/10: On 12/17/10 at 7:30 p.m., a nurse documented the certified nurse aide (CNA) found the resident sitting on the floor against the bed. The resident stated she had slid very slowly to the floor going to her wheelchair. "Slippers ... are still very slick." Neuro checks were reinitiated and completed. No injuries were noted. According to be Post-Fall Investigation Form, dated 12/17/10, the call light was not on. The Post-Fall Investigation Form asked various questions under sections entitled Falls History, Functional Status, Device/Restraints, Medications, Underlying Illnesses and Problems, and Environmental to which the staff circle either "Yes" or "No." The facility had circled "Yes" and handwrote "Sometimes" to the question "Does the resident have any cognitive impairments which could lead to poor judgement?" This summary of the fall was documented as "Slippers are still too slippery, does have nonslip tape on floor." The resident's orthostatic blood-pressure was checked with the results as 124/78 when lying down, 125/76 when sitting and 95/51 when standing. No new interventions were put into place. Fall 2/4/11: A nurse documented on 2/4/11 at 12:50 a.m., resident #1 was found sitting on the floor in her room propped up against the wall. The resident had stated she tried to stand up and pulled her shirt down and slipped. "These slippers are slippery." The resident did complain of hitting her head on the floor; however, no injuries were observed. Neuro checks were initiated and completed. Review of the Adverse Occurrence & Investigation Report included a summary of the investigation. This summary indicated the resident "had been transferring self at times. Requests assistance. Call light within reach. Call light was not on." Recommendations/new interventions listed were slippers were removed and resident and daughter are aware that the resident needs a better pair of shoes or slippers. Although the facility was aware the resident self-transferred and was aware she did not use the call light, there was no documentation in the report that the facility implemented interventions to minimize transfers without assistance - such as increasing supervision or applying a bed/chair alarm - or that the facility implemented interventions to prevent injury from falls - such as hipsters or low bed. The resident was encouraged to use the call light; however, review of the resident's fall history revealed this intervention was not effective. Fall 2/8/11: On 2/8/11 at 7:45 a.m., the resident was found lying on her stomach on the floor next to the bed. The resident had stated she was trying to pick up her phone. The resident was assessed for injuries and neuro checks were initiated and completed. According to the fall investigation report, dated 2/8/11, the summary of the fall indicated the resident did not use the call light which was within reach. The summary also indicated a high low bed would be given to the resident. Past interventions attempted were listed as physical therapy, transfer bars on the bed, commode in the room, and call light within reach. Recommendations/new interventions listed were: a high low bed with mat next to the bed, a bed alarm, a chair alarm, and a special lipped mattress. According to the report, the resident had been using her own bed, which had a transfer bar. Also the report indicated a family member refused physical therapy at this time. There was no documentation that the facility considered increasing supervision of the resident. Fall 3/1/11: Further review of the nurse's notes indicated on 3/1/11 at 2:05 a.m., the resident was found lying on her mat in her room. The resident stated she had slipped from the bed onto the mat. The nurse documented the resident had her call light in her hand but had not pressed it. The resident was reminded again to use the call light and the importance of it even to sit up in bed. The resident was assessed for injuries and none were apparent. The neuro checks were initiated. The resident was sent to the emergency room at 2:40 p.m. on 3/1/11 because of right leg/knee pain and was diagnosed with [REDACTED]. Review of the Adverse Occurrence & Investigation Report indicated the resident was wearing socks and no shoes. Documentation written in response to the question on the report that stated "Any other concerns that may have caused occurrence," read "made sure to remind resident to put call light on before she tries to sit up." Documentation in response to the question "What was done by the floor staff to keep this from happening again, read "orientate to the call light and offer the commode with every round." The summary of the investigation indicated the resident attempted to get up alone, was weak and having difficulty with balance and independent transfers. The summary included that the resident's family member had refused physical therapy on 2/22/11, stating the resident could not tolerate physical therapy at that time. There was no evidence on the fall investigation or in the nurse's notes that the bed alarm had been sounding as the resident attempted to sit up and fell out of bed. Past interventions attempted in the investigation report were listed as: a high low bed with a mat next to bed, bed alarm, chair alarm, call light within reach, and a special lipped mattress on the bed. New recommendations/interventions indicated a mattress next to the bed would be placed instead of a mat. Review of the physician's orders [REDACTED]. -On 3/1/11 at 6:30 p.m., a physician's orders [REDACTED]. -On 3/24/11, a telephone order was written at 3:15 p.m. documenting (1) Bed alarm to alert staff of movement, [DIAGNOSES REDACTED]. 2. Observations Resident #1 was observed lying on her back in bed with her eyes closed on 4/12/11 at 7:56 a.m. The bed had a lip mattress and there was a mattress observed on the floor beside the bed. There was a glass of water with a straw on the table by the bed out of reach of the resident. At 9:48 a.m., the resident was observed still lying in her bed on her back with the top cover off of the right lower leg. A cast was observed on the right lower leg. The resident remained on her back in bed at 10:55 a.m. At 12:40 a.m., the resident was observed seated in a wheelchair in the assisted dining area with a family member. No chair alarm was observed on the resident's wheelchair as expected per documentation on the post-fall investigation reports. 3. Interviews On 4/6/11 at 4:07 p.m., the Director of Nurses (DON) was interviewed about the resident's falls and interventions put into place. The DON stated she thought the bed alarm was put into place after the 2/8 fall. She also stated she thought that the alarm was sounding on the 3/1 fall on the fall investigation report. However, there was no documentation that the bed alarm was sounding on the 3/1 fall and review of the reports and orders revealed the bed/chair alarm was not ordered until 3/1/11. (See above.) A family member was interviewed per telephone on 4/7/11 at approximately 9:15 a.m. and again per phone at 7:05 a.m. on 4/13/11. -The family member stated the resident began to decline at the end of January and into February with poor fluid and oral food intake. Cross-reference F325 (nutrition) and F327 (hydration) documenting resident declines in nutrition and hydration. The family member also stated that she felt the facility had not adequately supervised the resident during this period when the resident was weaker than her normal baseline and could not transfer independently safely. -The family member stated she had recommended the mattress beside the bed instead of the mat the facility had placed. -When a family member was questioned about a chair alarm, she stated she was not informed that the resident had a chair alarm; however, she was aware of the bed pressure alarm. On 4/13/11 at approximately 3:30 p.m., a meeting was held with the DON, the nursing home administrator in training, the food service manager, nursing supervisor, social worker, and other staff members. Fall interventions for resident #1 were discussed. -When questioned about documentation on the fall investigation reports, the DON was unsure a chair alarm was being utilized for resident #1. The DON stated all of the facility's alarms were of the pressure alarm type in order that an alarm did not need to be attached directly to the resident. -The DON also stated the resident had her own low bed when admitted ; however, a facility high low bed was initiated after the first several falls.

Based on observation, interview and record review, the facility failed to provide an environment free from accident hazards over which the facility had control and failed to provide supervision/assistive devices to prevent avoidable accidents for three of 18 sample residents (#4, #12 and #13), other residents on the Silver (secure unit) including four supplemental sample residents (#23, #24, #25, #26), as well as residents who ate in the main dining room. Specifically, the facility failed to: -Ensure adequate supervision of residents on the Silver unit (secure unit) when resident #4 became agitated and physically aggressive. Record review and staff interviews revealed resident #4 struck out at other residents, yelled, screamed and threw things. The lack of staff supervision and intervention to address #4's aggressive behavior created the potential for immediate jeopardy and serious harm. -Provide resident #13 adequate supervision and assistance during dining. -Provide adequate supervision of the 25 residents in the main dining room during meals. The findings include: I. IMPOSITION AND REMOVAL OF IMMEDIATE JEOPARDY A. Imposition of Immediate Jeopardy (IJ) On 5/5/10 at 11:25 a.m., the facility was notified by the Health Facilities and Emergency Medical Services Division (HFEMSD) of the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to ensure facility residents residing on the Silver unit (secure unit) were provided adequate supervision to prevent identified resident-to-resident altercations involving resident #4 and the failure to identify interventions to try to prevent these altercations posed a situation of immediate jeopardy for serious harm. B. Facility Response - Plan for Removal of IJ In response to the imposition of immediate jeopardy, the facility submitted a final plan to remove the immediate jeopardy and to ensure the safety of residents on the Silver unit from resident #4. This plan was faxed to the HFEMSD at 5:00 p.m. on 5/6/10. The plan read as follows: A. Immediately: "1. Immediate Corrective action taken for resident in immediate jeopardy. - Fifteen minute observations were initiated at 10 p.m. on May 4 during the night until resident #4 woke up and was assisted to the wheelchair. 1:1 is being counted as beginning at 5/5/10 at 6:30 p.m. - 1:1 with patient is occurring until discharge, at all times. - 1:1 monitoring means the resident will be within arm's length of the staff member and no less than an arm's length from another resident. 1:1 monitoring also means eyes on the resident at all times. - The staff member assigned to the resident will document 15 minute checks. Documentation will cover time, observation, initials. The nurse supervisor will review 15-minute checks and sign off on the form hourly with the same documentation requirements of time, observation and initials. When a staff member needs to be relieved for a meal or break, report will be given and expectations of the 1:1 monitoring and documentation will continue by the relieving staff member. When the staff member needs to be relieved, they will radio their relief staff member. - Staff members monitoring are as follows: For 5/5/10: names of two staff members For 5/6/10: names of two staff members -Behaviors will be monitored during the 1:1 staffing. If the escalation of behavior occurs, the patient will have non-pharmacological approaches such as positioning, hydration, toilet, and/or offer snack. If those approaches are ineffective, the patient will be evaluated for prn medications. Should prn medications be unsuccessful at managing behaviors, the nurse will notify the attending physician and/or medical director (name of physician and name of medical director) for further orders. - (Name of the mental health facility) was contacted on May 5, 2010 to assess patient for MI status. (Name of the mental health facility) Emergency Mental Health Care Worker III assessed patient and the patient met the criteria for a MI hold and was deemed to be "gravely disabled." The patient is currently on an MI hold and awaiting hospitalization at the (name of the facility) in (name of the city), approved or May 6, 2010 at 8 a.m. transfer station has been arranged local ambulance service at the earliest sign of 9 a.m. in the facility social worker assigned to this case will accompany the patient to the hospital. - 1:1 monitoring and documentation will continue until the resident is transported from the facility. - On May 6, 2010 at 9:11 a.m. patient left facility by non-emergent care van accompanied by social worker to (name of facility) of (name of city) for admission to geriatric psychiatric unit." B. Ongoing: "2. Identifying other residents having the potential to be affected by the same alleged deficient practice. - All unit charts will be audited to determine if any other resident-to-resident interactions were documented in chart. - Social Worker and Clinical Supervisor will interview all residents or abuse (Completed 5/5/10). - All residents on unit will receive skin assessments to identify any possible injuries or signs of abuse. (Completed 5/5/10) - Behavior monitoring form has been modified to more easily identify targeted behaviors associated with particular medications of supporting diagnoses. Education for staff will be done by In-service on May 6, 2010 by (name of facility consultant social worker) and (name of) Director of Nursing (DON) and videotaped for staff viewing by May 10, 2010. New form has been initiated on May 6, 2010. Behavior monitoring will continue for policy. This means behaviors are documented when they occur. Documentation will include date, time, description of behavior, interventions provided, out come the intervention and signature. - Behavior monitoring form will be monitored daily by social workers, with DON or designee. - All behaviors exhibited will be taken to the Secure Unit Committee immediately and on a daily basis. The Secured Unit Committee consists of: the social workers, Nursing Administration team, DON, ADONS (assistant DONs), SDC (staff development coordinator), RN Supervisor on duty, staff from unit on duty, and outside facility team member. - The Secure Unit Committee will review and evaluate behavior, current medication regimen, identify revisions in care plan, and evaluate implemented approaches for effectiveness. - Individuals exhibiting behaviors will also be brought into the Psychiatric Committee Meeting each time the committee meets until behaviors are stabilized or cease to exist. - 1:1 changes in staffing will be implemented per Policy and Procedure if deemed necessary by the DON/Designee for Social Workers. A new 1:1 Policy and Procedure was developed by 5/5/10. - All residents on the Secure Unit will be considered at risk for abuse/neglect and those residents who have a history of assaults will be identified as potential for abuse. The Secured Unit Team (SCU committee) members to include: Social worker(s), DON, ADON, and NHA (nursing home administrator). Review each patient of the secure unit for appropriateness of placement by end of day 5/6/10. - Patients who may no longer need secured unit will be identified. Those patients and/or their responsible party will be notified of the teams' finding and afforded an opportunity to move from the secured area to another portion of the facility. This task will be completed by 5/7/10 (completed 5/6/10). The SCU committee members will utilize Chapter V (state regulations) criteria for assessing each patient. - From the above unit assessment, a list of residents will be developed who have had any history of assault by end of day May 6, 2010. The SCU committee review of all residents with behaviors of assault will include: Behavior review, behavior care plan review, evaluation of interventions needed and evaluation of effectiveness of interventions by end of day May 7, 2010. - Any changes in behavior of any SCU patient will warrant Secure Team review of the resident to determine safety and any necessary intervention changes. Significant behavior changes will result in the resident being reviewed at the next Psychopharmacological behavior review meeting. - Psychopharmacological Review Process (PAC) (the next psychopharmacological review meeting will be held on May 26, 2010). The team members include: Social Workers, DON, ADON, RN Supervisor, and Pharmacy Consultant. - The process for evaluation will include behavior review, medication review, care plan review, non-pharmacological intervention reviews and any other pertinent information relative to the patient being discussed. - Committee minutes will be kept in a more in-depth fashion to include all of the above-mentioned information. The DON or designee will assign duties for documentation during the psychopharmacological review process at the beginning of each meeting. Minutes will be kept in a separate binder and individual patient psychopharmacological forms will be kept current with the above-mentioned pertinent information. - The DON, ADON and House Supervisor will evaluate the staffing pattern daily on the Secured Unit and adjust the staffing pattern to reflect the needs of the unit according to the behaviors being exhibited. The DON will develop a form for documenting daily evaluation of staffing patterns and keep in the DON office. The form will be developed by end of day May 7, 2010. - 1:1 Staffing Policy and Procedure will be developed and implemented May 6, 2010. All staff will be in-serviced by Sat. May 8, 2010. 3. Systems measures/changes taken to ensure the alleged deficient practice do not occur. Communication Policy and Procedure has been developed to ensure all staff are communicating through the chain of command. Staff are educated on the Policy and Procedure May 6, 2010 and videotaped for staff in-services and required to be completed by May 10, 2010. Behavior Communicating Tool has been developed to ensure staff follows the chain of command for reporting unusual behaviors to include intimidation, kicking, hitting, biting, and altercations with others. Policy for Procedure 1:1 monitoring was developed and reviewed with staff on in-service on May 6, 2010 and videotaped for staff to complete by May 10, 2010. Compliance of Policy and Procedures for Abuse/Neglect internal investigation and occurrence reports will be monitored by DON and/or designee and Administrator. - Compliance will be monitored through the following measures: Nursing Administration will spend 2-4 hours each day at least five times weekly on the unit monitoring for compliance with policies and procedures regarding behavior monitoring, incident reporting, medication management, and observing for appropriate interventions for managing behaviors. When Nursing Administration staff are not on the unit, the RN supervisor will also observe for compliance of policies and procedures, behavior monitoring, incident reporting, medication management, and observing staff for appropriate interventions for managing behaviors. - Chart audits will be done weekly on unit by Nursing Administration/Designee looking for unusual documentation or documentation that states "Social Worker" or "RN Aware," follow-up will be monitored by appropriate discipline. Behavior monitoring forms will be monitored daily by social workers, reviewed with DON. Any behaviors exhibited will be taken to be Secure Unit Committee daily. The Secure Unit Committee consists of the Social Workers, Nursing Administration Team, DON, ADONs, SDC, RN Supervisor on duty, staff from the unit on duty. The Secure Unit Committee will review and evaluate behaviors with current medication regimen, identify revisions care plan, and evaluate implemented approaches. Individuals exhibiting behaviors will also be brought into the Psychoactive Committee Meeting (PAC) each time the committee meets until behaviors are stabilized. 1:1 Staffing will be implemented per Policy and Procedure if necessary by the DON/Designee or Social Workers. - A Staff training calendar for the following areas will be developed by the end of day 5/6/10. Staff training will include: Abuse/Neglect and documentation-given by (name of staff member) RN Staff Development Coordinator-completed by end of day of May 6, 2010. Policy and Procedure or incident/occurrence reports will be reviewed with staff and monitored by nursing administration. Behavior Monitoring, Behavior Management, Behavior documentation and Identifying Escalating Behaviors and appropriate interventions by (name of staff) consultant social worker on May 6, 2010. Videotape for all staff review by Monday 10, 2010. Communication between departments, chain of command, and documenting of reported behaviors by (name of staff) RN DON. Videotaped live on May 6, 2010 and for all staff review by Monday, May 10, 2010. Policy and Procedure for incident/occurrence reports will be reviewed with staff and monitored by nursing administration. Behavior Documentation Requirements for nursing by (name of staff) MSN RN CNS-vice president of (name of Corporation) management services. Additional in services to include: Managing Difficult People, Communicating with families, And Managing Stress. Staff will have competencies on the Policies and Procedures were the Secured Unit and on interventions for managing behaviors in July 2010. - Residents experiencing aggressive behaviors will be reviewed daily by the Social Workers and reviewed by the DON. The Secure Unit Committee will review those patients having behaviors, care plans will be revised as needed and medication regimen will be evaluated for effectiveness. Changes in regimen will be done with input of psychiatrists, physicians, pharmacists, social workers, nursing staff, and consultants as appropriate. Staff on unit will have communication through care notes regarding revisions in care plan or medication regimen. 4. Monitoring for changes or sustained compliance. A QA/QI (quality assurance/quality improvement) problem will be opened to assure that all incidents of resident-to-resident altercations will be documented and investigation will occur with each incident. - Residents with behaviors will be monitored and interventions in care plan to revise. - A QA/QI problem will be opened to assure that all residents are kept safe and will have appropriate treatment. - Monthly reports will be done to be (done by) QI Committee x6 months and if in compliance then quarterly. The Medical Director will determine if the frequency will be changed. The NHA and DON will be responsible for compliance. - Nursing consulting hours will be increased 16 hours per month. - Social Work consulting hours will be increased to 8 hours per month. Upon this next month's visit, Social Work consultant will determine if additional hours are needed. Social Work and Nursing Consultants will provide monthly and services to (name of facility) staff as directed by the DON. These in-services will include any and all of the above listed in services and further topics as deemed necessary." C. Removal of IJ On 5/6/10 at 5:05 p.m. two surveyors verified that in-services on identifying, documenting, and reporting any allegations of abuse/neglect were being conducted and, through interviews, were understood by staff. On 5/6/10 at 5:15 p.m., immediate jeopardy was removed based on the facility's final plan and with the discharge of resident #4. However, deficient practice remained at an E level - potential for more than minimal harm at a pattern. II. RESIDENT FAILURES A. Supervision on Silver Unit 1. Silver unit characteristics The initial tour on 4/20/10 beginning at 11:05 a.m., revealed the Silver unit, also known as the secure unit, was located in the basement of the building, accessed by an elevator with a key system. -The unit was rectangular in shape, had 24 resident rooms, two long hallways and three separate main/common areas. The main areas included a dining area at one end, a back day room and middle/main day room. The main day room had several seating areas and a TV. The seating area in the main day room with U-shaped seating, faced a TV. A windowless nursing station/chart room was located off this day room. Three ambulatory residents sat on the chairs and/or sofa in the main day room. Other residents in wheelchairs or geri chairs were on the periphery of the main seating area. The back day room had several tables and chairs where activities were held and contained a small kitchenette, music area and a small TV. The dining room held several tables, a piano and music area. -Review of a nursing instruction sheet disclosed 24 residents listed on the sheet by bed number who resided on the Silver unit. The sheet revealed there were 9 residents requiring total care assistance from staff, including resident #4. -On 4/20/10 at approximately 2:00 p.m., a licensed nurse said there was one nurse and two certified nurse aides (CNAs) scheduled for the unit on the evening shift. -On 4/21/10 at 3:30 p.m., the Director of Nursing (DON) revealed the facility accepted residents from the mental health hospital and some resided on the Silver unit. She disclosed these residents were followed by mental health including a psychiatrist. -On 5/4/10 at 4:55 p.m., a licensed nurse (LN3) revealed a resident, resident #4, had been screaming for the last couple of days and other residents were nervous around her. On 5/5/10 at 10:50 a.m., a licensed nurse revealed resident #4's behaviors included throwing things in the dining room, yelling, threatening staff and striking out at staff. 2. Resident #4 - Failure to provide adequate supervision for residents on the Silver unit when resident #4 became agitated and physically aggressive. Review of resident #4's record revealed she was admitted on [DATE], with [DIAGNOSES REDACTED]. a. Resident status The resident's most recent minimum data set (MDS) assessment dated [DATE], disclosed she had problems with short-term memory and moderate difficulty with decision-making. Indicators of delirium, disordered thinking/awareness were assessed as easily distracted, episodes of disorganized speech. Indicators of depression, anxiety and sad mood were assessed as repetitive anxious complaints/concerns, sad, pained worried facial expression, crying/tearfulness and these indicators were easily altered. She needed supervision with eating, required extensive assistance with bed mobility, transfers, hygiene, bathing and was dependent on staff for dressing. Review of a nursing instruction sheet disclosed resident #4 required "total care, in gerichair for meals then in w/c (wheelchair) between meals, lay down after lunch, float heels, turn and reposition every 2 hours, weight shift every 1 hour when in chair." Physician orders [REDACTED]. aggressive behavior: -9/9/08 trazodone 50 mg by mouth at bedtime prn for insomnia, -9/9/08 Risperdal 2 mg by mouth three times daily for bipolar disorder, -8/16/09 Lithobid sustained release 150 mg by mouth twice daily for bipolar disorder, -11/10/09 clonazepam 1 mg by mouth three times daily for bipolar disorder, -11/23/09 Thorazine 50 mg by mouth every 4 hours prn special symptoms/ syndromes NEC/NOS, -3/19/10 haldol 2.5 mg IM x 1 prn and 5 mg IM x1 for agitation -3/20/10 haldol 5 mg IM now for agitation -3/23/10 haldol decanoate 25 mg IM x 1 dose agitation -4/7/10 haldol 2.5 mg to 5 mg every 12 hours prn agitation with aggressive behavior. -4/7/10 haldol 5 mg IM (intramuscular) x 1 now for agitation with aggressive behavior -5/3/10 haldol decanoate 100 mg IM on day 1, 3, and 5, then 100 mg once every 4 weeks. Review of resident #4's medication administration records (MARs) disclosed: -She received Thorazine 50 mg orally prn and the medication was documented as effective, with relief or some relief 54 of 71 times. - She received haldol 2.5 mg IM prn on 0 of 44 days. - She received haldol 5 mg IM prn and the medication was documented as effective or helpful on 8 of 13 times. Review of updated PASRR (preadmission screening) level 1 documentation disclosed the following: -1/10 previous dosage 1/2 Klonopin at 7 a.m. current dosage 1 mg three times daily. Increase per psych visit on 11/10/09 at mental health due to increase in agitation, aggression, and increased psychotic signs and symptoms. -8/17/09 previous dosage Klonopin 1 mg three times daily. Current dosage 1/2 mg at 7 a.m., and 1 mg twice daily. Decrease per psych visit on 8/17/09 at mental health due to sedation per psychologist. Review of physician notes revealed: -4/30/10 (MD2 - current attending physician) reported to be eating and sleeping well. Having some issues with her psych medications. Not verbal, awake, alert, does not speak clearly, schizoaffective disorder, bipolar disorder-per psych, -4/30/10 (MD2) stamped noted "patient evaluated, renew medication, diet, treatment and activities, continue stay for skilled care 30 days". -4/13/10 (MD4 - psychiatrist) needs inpatient hospitalization to evaluate meds and restart medications and prevent violence. Hold haldol decanoate. use prn as possible needed. violent. rule out increased dementia. -4/7/10 (MD1- former attending) fairly stable, is now on long acting haldol per psychiatrist. Has continued her compliance past the short acting haldol that we gave her for a few days. Has been more compliant taking her medications. She is a little bit sluggish but it seems to be either that or aggressive behavior. There is not much in between so we will continue the current program. -3/23/10 (MD4) reason for consult-agitation, probable manic episode, diagnosis-bipolar type, start haldol decanoate 25 mg IM x 1 dose then see me in two weeks. Report any reaction. -3/21/10 (MD3 - medical director of facility) [DIAGNOSES REDACTED]. -3/30/10 (MD1) stamped noted "patient evaluated, renew medication, diet, treatment and activities, continue stay for skilled care 30 days". -2/23/10 (MD1) stable, slowly improving from having her medications changed several months ago but is taking a long time. No change in program today. -1/12/10 (MD4) reason for consult-med eval. improved mood and behavior. [DIAGNOSES REDACTED]. next appointment 3 months. -11/10/09 (MD4) reason for consult-increased agitation, aggression with staff, increased psychotic symptoms, aggressive. [DIAGNOSES REDACTED]. increase Klonopin, continue Risperdal, Thorazine and Lithobid. Need labs to consult. -8/11/09 (MD4) med review, sedation. [DIAGNOSES REDACTED]. change Klonopin, if no increased agitation in two months, change. Call clinic if problem. next appointment in 2 months. Additional records by the MD4 were requested from the DON on 5/5/10 around 1 p.m. and not provided prior to end of the survey. Review of care plans revealed: -1/26/09: difficulty sleeping at night revealed approaches including encourage to be up in chair and out of room for each meal, encourage to be active during the day and participate in activities of choice. Sleep hygiene protocol-offer warm milk or chamomile tea at bedtime, lotion massage at bedtime, encourage to be active during the day, to stay up later in the evening, document in MAR. Medication as ordered, monitor sleep during the day and evening hours and monitor for adverse side effects. -12/17/08: prefers independent activities, if becomes overstimulated-she will yell and become upset. A quiet place (her room) help her to relax and become calm. Approaches included staff will be watchful when she becomes overstimulated so she can have a quiet place to collect herself. -12/18/08: tendency to cry out loud or have loud outburst by yelling for what she needs or may want when she becomes overstimulated with noises and people. Approaches included take the time to remove from the area and give her time to calm down and/or regroup, comfort when she begins to cry out loud and sing or talk to her in calm gentle voice. Responds well to 1:1 attention after she has an outburst or crying episode. Remind staff to take her for a walk away from the situation and talk to her while walking with her down the hall. Episodes do not last long if someone is able to respond to her and redirect her in a positive manner. -12/18/08: short term memory loss, is able to recall her past well and tends to repeat events that have happened in her life. Able to make her needs known at all times, aware of her room location and that she is in a nursing home. Approaches included communicate and reinforce directions, repeating prn, avoiding overstimulation by not giving multiple choices. Responds very well to consistency with approaches, speak in clear simple sentences, maintain eye contact, keep voice slow and calm. Staff need to talk to resident during care, explain procedures prior to initiation, encouraging cooperation and expression of needs. Redirection is needed as she becomes agitated or overstimulated, provide simple answers to questions. -12/18/08: does identify herself with past roles very often. Approaches included allow her to express herself freely when speaking to her, talk with her during her time of distress and redirect her in a positive manner. Allow her to collect her thoughts when speaking to her, able to make her needs known at all times and seems to calm down when someone is present to redirect her in a positive manner if she is speaking negatively about herself. Seems to respond well to singing, laughing and talking about her interests. Take the time to sit and visit with her during a time of negative thoughts. -12/17/08: resides on secure unit - will have structured environment that supports cognitive impairment and provides room accommodations per resident and family needs. Approaches included evaluated by IDT (interdisciplinary team) per secured unit policies and procedures and is a candidate for other side of unit when room availability occurs. b. Recent history of escalation of resident's aggressive behaviors (hitting, slugging, grabbing) - facility response (1) Nurse's notes Review of nurse's notes 2/9/10 - 4/21/10 revealed the resident began grabbing, hitting, slugging other residents on 3/22/10. She was refusing medication and talking to unseen others. Review of nurse's notes disclosed the following: -5/3/10 MD2 gave the ok to write orders per MHI (mental health institute) psychiatrist recommendations -4/30/10 MD2 here, evaluation done, see new orders. -4/21/10 received Thorazine x2. She rested fairly well with 2 episodes of hollering out briefly. She did some singing during the night. During evening in common area, she was throwing then dropping magazines and swatting people's backsides whenever opportunity was found and giggling after. Cooperative with care but not redirection. Use of DVD calmed her. -4/17/10 continues to hit people and throw articles of clothing, books and drinks on the floor. Haldol IM given without much effect. -4/12/10 continues to throw things on the floor, strike out at residents and staff. -4/7/10 behavior issues continue throughout day, hitting other resident in dining room. All medications given in soda with effectiveness intermittently. Participating in activity, laughing then struck out at other resident. social worker and supervisor made aware. Haldol orders received. -4/7/10 social worker attempted to get placement for resident secondary to aggressive behavior and refusing meds-unable to place at this time. -4/7/10 restless and slightly agitated after dinner. prn Thorazine given and prn trazodone given. Slept well most of the night. Nurse's notes continued: -4/6/10 spit out medications at breakfast. -4/5/10 hitting staff and other residents, throwing bed covers, breathing machine on floor in room, breaking plates. -4/5/10 up throughout the night, tearing bed apart, throwing things on floor, hitting and kicking staff. Hit another resident (#26) while sitting on the couch. taken away to prevent further violent behavior. -4/4/10 did not eat, threw food all over, grabbed several residents by arm then hitting. Grabbed one resident (#23) from behind around neck. Thorazine given without effect. Medication given in soda after several attempts. Thorazine given again at lunch with effect. Ate calm in afternoon, no longer hollering, hitting or throwing things. currently lethargic and slumped over in w/c. redirected earlier to room when physically aggressive with other residents for safety. -4/2/10 continues to hit at staff, grab staff then cries with her head down. Also has hollered and wandered into other residents' rooms and thrown cups on floor. -4/2/10 continues to grab at people and hit staff. Spit out meds this AM, is screaming and yelling and throwing things. Will cry and scream and the next instant is laughing. Nurse's notes continued: -4/1/10 continues to hit and grab at people all evening. No yelling but talking and mumbling, most of the time without sense and at times to unseen others. -4/1/10 continues yelling, slurring her words, eyes red swollen, taking anything she can grab and putting it on the floor in her room and the hall. -4/1/10 in w/c in halls, yelling, cursing out loud, resistive to care. no sleeping, Ate 25% of breakfast then started throwing it on the floor. Took po med well with water. Keeping resident away from common area or too close to other residents as she is reaching at them, hitting and grabbing at them. -3/31/10 very verbal and verbally abusive this PM, throwing stuffed animals, cursing at times, hollering at times, calmed down after medication -3/29/10 hollering out, hitting residents and staff on numerous occasions throughout day. Throwing food and beverages in halls and dining room. Thorazine given x 2 with little effect. Refused AM medication. -3/29/10 continues to hit staff and at other residents. Generally calmer, no yelling this shift. Not always cooperative with care. Continues to talk to unseen others about unrelated subjects, sings, curses and answers with unrelated information. Gave a 2nd dose of Thorazine due to restlessness and arguing with unseen people and striking at staff. Nurse's notes continued: -3/28/10 spit out 7 am medications. Hitting staff, other residents, and visitors, hollering and cursing. Threw sheets and blanket on floor. -3/28/10 Hitting staff member in face while staff member was picking up magazine from floor resident threw on floor. Continued to throw personal items out of drawers and off dresser onto floor. Unable to sleep, trazodone given with no relief. restless all night. Took po meds good without complications. -3/27/10 hitting staff, other residents, visitors. Throwing belongings on floor of room. Hollering, cussing at staff and other residents. -3/26 and 3/27/10 continued to yell and hit at people during the evening. emptied all drawers and closet in her room, "I have to find stuff that didn't burn up" talking to people unseen, often unable to control yelling when redirected. Gave Lithium, Risperdal and Klonopin at 8 p.m. due to spit out doses during the day. She took them without problems then tried to hit. Approached talking very quietly and when in her reach, hauled off hitting. Grabbed and squeezed CNA's arm very hard and tried to hit several times. After 10 p.m. dose of Thorazine, did sleep for 3 1/2 hours then yelling at people she sees in her room. Gave Thorazine a third time and she quieted again. Upon awakening this AM, no yelling but talking with unseen persons, scattered unrelated thoughts often in a sentence of confusion. -3/26/10 resistant, still hitting staff, cursing, hollering. Threw can of soda across dining room during supper. - 3/26/10 still cursing and swinging, hitting staff, screaming as loud as possible, scaring other residents. Nurses notes continued: -3/25/10 up in w/c, hollering through halls, refused breakfast, drank fluids well. po medications spit on floor. Hit a resident (#12) on left arm, then hi