Every finding on record at VI at Highlands Ranch Skilled Nursing

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure: -Foods were palatable in temperature; and, -Always available alternative menus were available for residents. Findings include: I. Facility policy and procedure The Food and Beverage Operation Guide, dated 2024, was received from the nursing home administrator (NHA) on 9/19/24 at 8:00 a.m. It documented in pertinent part, All food and display units maintain proper temperature to avoid contamination and deterioration. Appropriate times/temperature include: hot food display units must maintain food above 135 degrees Fahrenheit (F). Harmful microbes grow best in the temperature danger zone at 41 to 135 degrees Fahrenheit. II. Individual resident interviews Resident #16 was interviewed on 9/16/24 at 11:26 a.m. She said the food was always served cold when it was served to her in her room. She said she always ate toast for breakfast, and it was served cold and rock hard. She said she did not enjoy the toast when it was served hard. She said she enjoyed chocolate ice cream with her meals and it often was served melted. She said it took a while to get her meals and they never came at the same time each day. Resident #17 was interviewed on 9/16/24 at 12:04 p.m. He said the food tasted terrible, there was no flavor in the food served and there was no variety. He said he was served chicken frequently and the facility did not mix it up. He said the food could be served hotter. He said he did not know how to get another option if he did not want what they were serving and there was no always available menu in his room. Resident #7 was interviewed on 9/16/24 at 2:43 p.m. He said he did not have access to the weekly menu. He said he did not have an always available menu. He said the food was served cold and did not taste right. He said the quality of food started changing when they changed to a new chef. Resident #13 was interviewed on 9/16/24 at 3:12 p.m. He said he generally did not eat lunch, however his main meals were breakfast and dinner. He said for the past several weeks the food was served cold. He said he complained to the staff about it but nothing so far had been done. He said he did not know there was an always available menu. He said when he did not like the food that was served, the staff told him to order a sandwich. Resident #13 was interviewed on 9/16/24 at 3:15 p.m. He said the food was served cold. Resident #4 was interviewed on 9/16/24 at 3:22 p.m. He said he usually would eat everything that was served. He said he ate his meals in his room and were sometimes served cold, but he did not ask the staff to heat it up. He said when the food was bad, it was bad at every meal that day. He said he was not aware he could order food from an always available menu because he did not know there was an always available menu. He said he was the resident council president and the residents had complained about the food quality and temperature during recent meetings. Resident #7 was interviewed again on 9/17/24 at 4:30 p.m. She said her lunch meal was served cold and did not taste right. She said she complained about the food at the resident council meeting a while back. She said the food quality changed when they hired a new chef. Resident #16 was interviewed again on 9/18/24 at 1:10 p.m. She said she had the chicken, eggplant parmesan, soup and chocolate ice cream for lunch on 9/18/24. She said the chicken, eggplant and soup were served cold. She said the ice cream was served melted. She said she did not enjoy the meal when it was served cold and the ice cream was melted. Resident #15 was interviewed on 9/18/24 a 1:15 p.m. She said the food was served cold and she could not eat it because it tasted so bad. She said she got the eggplant parmesan and chicken with mashed potatoes and gravy for lunch on 9/18/24. She also had soup that she said was served cold. She said the food sometimes was served warm but today it was served cold Resident #17 was interviewed again on 9/18/24 at 1:20 p.m. He said he had the chicken and eggplant parmesan for lunch on 9/18/24. He said it was served cold and he did not enjoy the chicken since he ate it almost daily. He said he was not aware there was an alternative menu or how to order something different. Resident #10 was interviewed on 9/18/24 at 4:17 p.m. He said he did not like chicken. He said he was told by a staff member to write a ham sandwich on the menu card if there was nothing else he would like from the daily menu options. He said there was not an always available menu on the menu card he was provided. III. Meal service and test tray observations Lunch meal service was observed on 9/17/24 beginning at 11:30 a.m. and ending at 1:05 p.m., the following was observed: Line cook (LC) #1 placed the pans that contained the food in the hot air wells table to maintain temperature through the end of the service to all residents. LC #1 took the temperatures of the food at 12:00 p.m. prior to leaving the main kitchen for meal service. LC #1 took the food cart to the memory care unit and served the residents. LC #1 then took the food cart to the assisted living unit and served the units. At 12:55 p.m. she started serving food to residents on the SNF unit. She did not recheck the food temperatures. A test tray for a regular diet was evaluated by two surveyors immediately after the last resident had been served their meal for lunch on 9/18/24 at 1:05 p.m. The test tray consisted of rosemary and garlic chicken, grilled flank steak with red wine sauce, roasted broccoli, sauteed shiitake mushrooms and mashed potatoes with gravy: -The chicken was 120 degrees F. -The beef was 115 degrees F. The beef tasted salty. -The broccoli was 105 degrees F. -The mushrooms were 105 degrees F. IV. Resident council meeting minutes The 6/4/24 resident council minutes revealed the residents reported if the temperature of the food they were served varied. They said the food served in the dining room was warm, but could be warmer. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The 7/2/24 resident council minutes revealed the residents reported the food was often served cold. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The 8/6/24 resident council minutes revealed the residents reported the food was not always hot, but they understood that the food had to be delivered from another building. The residents said the cold food was more of a problem for the residents who ate in their rooms. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. V. Culinary council meeting minutes The February 2024 culinary council meeting minutes documented the residents said the food was often served too cold and items were missing from the tickets, the food could be warmer, and they would like the food hotter when it was served. They said the food was cold when delivered as room trays and sometimes food was served cold in the dining room. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The April 2024 culinary council meeting minutes documented the residents said hot food should be served hot and cold food should be served cold. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The June 2024 meeting minutes documented the residents said sometimes there were long wait times between courses and the food gets cold in the dining room. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. VI. Staff interviews Line cook (LC) #2 was interviewed on 9/19/24 at 8:05 a.m. LC #2 said he was aware of the new convection ovens were installed in the kitchen about two months ago, however he did not know how to use it and was not trained on this appliance. Dietary aide (DA) #1 was interviewed on 9/19/24 at 8:25 a.m. DA #1 said the dietary staff took a weekly menu to the residents on Thursdays and asked the residents to choose food for next week. She said there was no always available menu the staff could use when residents did not like the food that was on the weekly menu. She said she usually suggested a variety of cold sandwiches to the residents if they did not like the menu options. The NHA was interviewed on 9/19/24 at 10:45 a.m. The NHAsaid he was not aware the residents did not have access to an always available menu. He said he was aware of the concerns regarding food being served cold to the residents and had been working on ways to improve the food temperature by making changes, renovations to the kitchen and working on a process improvement plan. He said there were residents that had grievances and concerns regarding the cold food that were discussed in the culinary council and resident council. The executive chef (EC) was interviewed on 9/16/24 at 10:15 a.m The EC said the food was stored, prepared and cooked in the main kitchen. He said the main kitchen was in the independent living facility. He said the food was then distributed by a vehicle to the skilled nursing facility (SNF). He said that one line cook was assigned to cook food for residents in the SNF in the main kitchen, then transported the ready to serve food to the care center, placed in the hot air wells table. The line cook served food to the residents in the kitchen in the SNF. He said the kitchen was remodeled approximately two months ago and the steam table was replaced with a new hot air table. He said two new convection ovens were installed so when the food got cold during the serving process the line cook could warm it up. The EC was interviewed again on 9/19/24 at 12:30 p.m. the EC said he was aware of residents being served cold meals. He said there were ovens in the kitchen that could be utilized to heat food and keep it hot until serving it. He said the expectation would be to serve foods at safe and palatable temperatures and if a food is lower, then before serving they should heat it up to the proper temperature. 31229

Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#3 and #6) of five out of 19 sample residents. Specifically, the facility failed to offer and invite Resident #3 and #6 to activities of choice. Finding include: I. Facility policy The Lifestyle/Activity policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/13/21. It read in pertinent part, the ongoing activities/lifestyle is designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. These programs shall provide residents with recreational, social and educational opportunities. Appropriation activities/lifestyle programs for residents include, but are not limited to: cognitive stimulation/intellectual/educational activities, community involvement, social activities and music. II. Activity schedule 12/8/21-Catholic Mass with Monsignor [NAME]-9:00 a.m., Daily chronicle-10:00 a.m., Senior weekly news discussion 10:15 a.m., Bingo-1:30 p.m and Watch mash (television show) with [NAME]-3:30 p.m. 12/9/21- Daily chronicle-10:00 a.m., National Park series-extreme Alaska-10:15 a.m., Nutrition talks with [NAME]-3:00, Watch mash with [NAME]-3:30 p.m. and Resident run bridge-6:30 p.m. 12/13/21- Daily chronicle-10:00 a.m., Visit & Fit exercise-10:15, Brain games and Trivia-10:45 a.m., Discover the unknown country of Futuna with [NAME]-2:00 a.m., Watch mash with [NAME]-3:30 p.m. 12/14/21- Daily chronicle-10:00 a.m., Visit & Fit exercise-10:15, Who am I? What am I?-10:45 a.m., Live piano with [NAME] Christmas carols-2:00 p.m., Watch mash with [NAME]-3:30 p.m. and Resident run Yahtzee-6:30 p.m. III. Resident #6 A. Resident status Resident #6, age 89, was admitted on [DATE]. According to the December 2021 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. She had clear speech and usually made herself understood and sometimes understands others. She had no rejection of care documented. She required extensive assistance with bed mobility and transfers. B. Observations On 12/8/21, at 10:30 a.m. the resident was lying on her back looking towards the ceiling without stimulation. There was a television (TV) in her room and it was not turned on. On 12/9/21 from 10:00 a.m. to 11:30 a.m., the resident was observed lying on her back looking toward the ceiling without stimulation. The TV was not turned on. There was no radio in her room for her to listen to her favorite music as indicated in her assessments (see below). On 12/9/21 from 2:23 p.m. to 3:30 p.m., the resident was observed lying on her back in bed without stimulation. There was an activity scheduled at 3:00 p.m. (see activity schedule above) no staff invited the resident to the activity. On 12/13/21, a continuous observation was done from 9:47 a.m. to 10:50 a.m. At 9:47 a.m., the resident was observed sitting at the table in the dining room. There were three residents and two staff members in the dining room. The activity assistant (AA) walked into the dining room. She invited two of the residents in the dining room to the activity. She did not invite Resident #6. At 9:55 a.m., the certified nurse aide (CNA) #3 asked the resident if she was finished with her drink. She said she would take the resident to her room. She pushed the resident via her wheelchair out of the dining room. She did not offer the resident to go to the activity. She took the resident to her room and put her in her bed. She did not turn the TV on or put her favorite music on as documented in her assessments. C. Record review The 6/17/2020 MDS assessment, Section F (Interview for Activity Preferences) revealed it was very important to listen to music she likes, keep up with the news and do her favorite activities. The comprehensive care plan, revised on 9/20/21, identified the resident chose activities of interest at her own leisure and joined many activities. Interventions included, lifestyles and staff will notify, ask and escort resident to programming of her choice. The resident will observe if she does not want to participate. She enjoys being around people. The December 2021 activity participation log was reviewed. The participation log documented the December 2021 calendar (see above schedule activities) with the resident's name and room number documented at the bottom of the calendar. -The log did not document that the resident participated in any activities on 12/8/21, 12/9/21, 12/13/21 and 12/14/21. D. Staff interviews CNA #3 was interviewed on 12/13/21 at 10:25 a.m. She said the activity and nursing staff usually invite and take the residents to the activity. She said Resident #6 had finished her breakfast and she believed the resident was tired. She said at times the resident will refuse. (however, during observation the resident was never offered/invited to activity). She said she took the resident to her room. The activity assistant (AA) was interviewed on 12/13/21 at 3:15 p.m. She said the activity director was not present in the facility at the moment and she was the only person running the activity program. She said she was responsible to invite all residents and bring them to activity. She said sometimes the nursing staff would help. She said Resident #6 usually sits in the common area by the nurse station because she likes to socialize and observe people walking around. She said she did not invite Resident #6 because she believed she was still having breakfast (during observation the resident was not eating breakfast). She said due to the absence of the activity director, inviting all residents was too much to do. She said sometimes she did not invite all residents. She said she was not aware Resident #6 was in her room all the time and was never invited to activities. She said she would communicate with the nursing staff to invite and bring all residents who want to attend to activities. The activity director (AD) was interviewed on 12/14/21 at 2:00 p.m. She said she had been out for two days. She said Resident #6 liked to sit in the common area and watch the staff walk by. She said if the resident was invited to an activity, she would come even if she did not actively participate. She liked to observe the activity program. She said the nursing staff and activity staff should have invited the resident to activity or play her favorite music while in her room. She said she would provide education to the activity assistant to ensure she invited all residents to the activity. IV. Resident #3 A. Resident status Resident #3, age 90, was admitted on [DATE] and readmitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/10/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of five out of 15. She required extensive assistance with bed mobility, transfers, locomotion off the unit, dressing, toilet use, and personal hygiene. It was very important for the resident to do things with groups of people, read, listen to music, and do her favorite activities. B. Observations On 12/9/21 at 2:40 p.m. Resident #3 was in her room lying on her bed. She was calling out hello, hello, help, can someone please take me to activities? On 12/9/21 at 3:09 p.m. certified nurse aide (CNA) #2 entered Resident #3's room. The resident asked when the activity started. CNA #2 told her it had begun at 3:00 p.m. CNA #2 helped the resident out of her bed and into her wheelchair. CNA #2 took the resident to the bathroom. The CNA and Resident #3 left the room at 3:18 p.m. to go to the elevator to attend the activity that had begun at 3:00 p.m. C. Resident interview Resident #3 was interviewed on 12/9/21 at 2:40 p.m. She said there was a group activity going to start at 3:00 p.m. downstairs. She said someone should take her when it started. She said she would turn on her call light to get staff to help get her out of bed. She said she loved attending the activities in the facility. She said she did not get invited by the staff to go to activities. She said when she wanted to go to an activity she had to ask someone to help take her to all of the events. She said sometimes she would forget an activity was happening. She said it was up to her to remember when events happened. She said she must turn on her call light to get help to attend an activity or she did not get to go. D. Record review The care plan revised 12/8/21 revealed: Resident #3 identifies activities of interest and participates in all group programming we offer. However, Resident #3 does not self initiate independent leisures of her choice, and often states she has nothing to do and is bored, forgetting she just attended programming. -However, there was no mention in the care plan the resident required assistance and reminders to attend activities. There was no documentation of Resident #3's November 2021 to 12/14/21 participation in activities provided by the activity department when requested during survey. E. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 12/9/21 at 3:19 p.m. She said the residents received the monthly activity calendar. She said the residents must read the calendar and decide if they want to go to an activity during the day. She said the residents must ask to be taken to the activity. She said that was how the facility provided activities to the residents. She said the residents were not invited to activities. She said if the residents asked to be taken to an activity then they get to go to an activity. She said the activities happen on the third and first floor and there were no activities on the second floor which was the skilled nursing floor where Resident #3 resided. She said all residents on the second floor were escorted in an elevator to other floors when they wanted to attend an event. The activity assistant (AA) was interviewed on 12/13/21 at 4:00 p.m. She said the residents must read the activity calendar on their own and then tell staff they want to be taken to an event. She said if someone had vision impairment and could not read a calendar they would need reminders from the staff. She said she did not invite people to activities because the residents read the calendars. She said a printout of the daily events were given to residents at breakfast and they should read it. She said she was aware that many of the residents had short term memory. She said the Activity Department staff did not coordinate with the staff to know who was invited, or who refused an invite. She said it was not documented by the activity department. She said she had been a CNA and she knew the CNAs did not always have time to invite the residents to group activities. She said CNAs were often busy with giving showers or feeding residents. She said she understood that the CNAs may not have time to invite the residents to groups. She said there were no activities on the second floor. She said the residents from the second floor must be escorted into an elevator to attend groups on the first or third floor where events were held. She said Resident #3 enjoyed activities almost daily. She said Resident #3 needed assistance to get to events. She said Resident #3 must remember to ask for help from the staff to get to activities. The activity director was interviewed on 12/14/21 at 1:00 p.m. via the phone. She said the activity staff do not conduct any group activities on the second floor because the second floor common area was noisy. She said all groups were provided on the first and third floors. She said a daily sheet of events was given to each resident with their breakfast. She said it was difficult to invite residents individually. She said the residents were responsible to read the calendars and tell the floor staff that they wanted to attend a group. She said the activity staff know who came regularly and take those individuals to the activity, but they did not go room to room to invite people. She said the nursing home administrator (NHA) told her it was the CNAs job to get people to activities, not the activity department staff.

Based on observations, record review and interviews, the facility failed to provide one (#17) of two residents reviewed for pressure injuries out of 19 sample residents with the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. Specifically, the facility failed to offer protective boots for Resident #17 to prevent skin breakdown according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: I. Facility policy and procedure The Medical, Nursing and Personal Care policy, revised October 2017, was provided by the nursing home administrator via email on 12/14/21 at 2:21 p.m. It revealed in pertinent part: General nursing care is provided 24 hours per day, 7 days per week and includes, but is not limited to: Medication administration; Personal care, per resident preference, including skin care. Programs to treat skin and prevent pressure injuries and/or other impairments in skin integrity; Treatment and procedure administration. II. Resident #17 A. Resident status: Resident #17, over age 90, was admitted on [DATE] and readmitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/3/21 annual minimum data set (MDS) assessment revealed the resident refused to conduct a brief interview for mental status score (BIMS). The resident had short and long term memory problems. The resident was moderately impaired with daily decision making. The resident did not exhibit any behaviors including rejecting cares. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required total dependence with bathing, and for locomotion on the unit. The resident was dependent on staff to put on and off footwear. The resident was at risk of developing pressure ulcers. III. Observations On 12/9/21, 12/10/21 and 12/13/21, at 9:30 a.m., 11:30 a.m., 12: 30 p.m., 3:00 p.m., and 4:30 p.m., Resident #17 was observed in her wheelchair in her room watching television, in the dining room in her wheelchair eating lunch, and in her bed napping. On these three days the resident was not wearing protective boots on her feet according to the physician order. IV. Record review The 2/16/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Every shift, shift one 6:00 a.m. - 6:00 p.m., shift two 6:00 p.m. - 6:00 a.m. The 11/11/21 care plan revealed, Resident #17 was at risk for pressure injuries due to a history of [CONDITION(S)], fragile skin, and decreased mobility. Blanchable (non pressure ulcer) and non blanchable skin (discoloration of the skin) was noted on numerous areas on both feet including heels, and toes. The goal was to keep Resident #17's skin integrity intact. The 12/9/21, 12/10/21, and 12/13/21 treatment administrative record (TAR) documented the resident had on the protective boots. The resident was observed not wearing their protective boots on all three days during shift one (see observations above). The TAR did not document that the resident refused to wear the boots. (see below under interviews) V. Resident interview On 12/9/21 at 11:03 a.m. Resident #17 said she did not know why she was not wearing her protective boots. She said the boots were somewhere in her room but she did not know where they were. VI. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 12/13/21 at 3:22 p.m. She said she was unaware that the resident did not wear her protective boots last week. CNA #1 opened the resident's dresser and pulled out two protective boots. She said the resident refused to wear her boots today. She said she notified nursing that the resident refused. She said the CNAs did not mark refusals in the electronic medical records. She said they were to notify a nurse to record the refusal in the electronic medical records Licensed practical nurse (LPN) #1 was interviewed on 12/13/21 at 3:57 p.m. She said in the resident's TAR the nursing staff had a system for recording events if a resident refused treatment. She said the nurse would put their initials in parenthesis for the shift if a resident refused a treatment. She said then below on the same page the nurse would write the resident refused and explain why they refused. The director of nursing (DON) was interviewed on 12/14/21 at 11:50 a.m. She said Resident #17 had poor circulation in her feet. She said the resident's feet turn dark, almost purple so the staff put on protective boots to prevent skin breakdown. She said even though the resident did not walk she had fragile skin that needed protection. She said she would address with the staff to record in the TAR correctly, whether the resident wore the boots or document if the resident refused to wear the boots. She said the staff should not record the resident had her boots on when she did not have them on. She said the resident should wear her protective boots in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] VII. Facility follow-up The DON was interviewed on 12/14/21 at 12:45 p.m. She said she called today and had the order changed for Resident #17. She said the facility would try a different type of boots to protect the resident's skin. She said the order was changed to, offer and encourage the resident to wear the boots as tolerated. She said she left a message with the resident's provider and the resident's husband. She said she also educated the staff on marking refusals in the electronic medical records.

Based on observations, interviews and record review, the facility failed to implement infection control measures to prevent possible cross-contamination with Coronavirus disease (COVID-19). Specifically, the facility failed to: -Ensure staff had all updated training and information about COVID-19 prior to caring for residents; -Ensure resident hand hygiene was performed prior to meals; and -Ensure all staff were properly screened prior to entering the facility to care for residents. Findings include: I. Professional references According to the Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Survey for Nursing Homes, 3/20/2020, page 2, staff should assist residents to perform hand hygiene after toileting and before meals. According to the Centers for Medicare and Medicaid Services (CMS) website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (Retrieved 5/19/2020), Ensure that healthcare providers (HCP) are educated, trained and have practiced the appropriate use of personal protective equipment (PPE) prior to care for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin and the environment during the process of removing such equipment. Educate them about new policies for source control while in the facility. Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of shortness of breath, new or change in cough, sore throat, and muscle aches, nausea, vomiting, diarrhea, abdominal pain, headache, runny nose, fatigue. According to the Colorado Department of Public Health and Environment (CDPHE), Communicable Disease Branch, COVID-19 Preparation and Rapid Response: Checklist for Long Term Care Facilities, 4/24/2020, All staff should be screened at the beginning of their shift for fever (take temperature) or symptoms (cough, shortness of breath, difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new olfactory (smell) and taste disorder; consider also rhinorrhea, diarrhea, nausea or vomiting). II. Failure to ensure resident hand hygiene A. Observations On 5/5/2020 from between 12:04 and 12:15 p.m. certified nurse aide (CNA) #1, CNA #2 and CNA #3 passed lunch trays out to residents on the hallways without assisting the residents with hand hygiene prior to the meal. B. Staff interviews CNA #3 was interviewed on 5/5/2020 at 12:23 p.m. She said she forgot to assist the residents with washing their hands when she delivered their meal tray but it should be done before every meal. She said she would use a wet washcloth to wash their hands. The director of nursing (DON) was interviewed on 5/5/2020 at 12:30 p.m. She said hand hygiene should be provided to all the residents when their trays were served at meal times. She said the staff had been educated on this but she would provide retraining immediately. III. Failure to ensure proper screening of staff A. Record review On 5/11/2020 review of the employee screening tools from 4/28/2020 to 5/5/2020 revealed holes in the documentation: on 4/30/2020 and 5/3/2020 the name of the screener was omitted and a temperature for a CNA was not recorded. B. Staff interview The concierge was interviewed on 5/5/2020 at 11:35 a.m. He said all staff and visitors have to come through the front doors to be screened prior to entering the facility. He said the screening tools needed to be filled out completely including the person's temperature and the name of the person doing the screening. He said if he had any questions about whether to let someone in or not he would refer to management. IV. Failure to ensure current education and training A. Record review Review of the 5/5/2020 facility training records revealed three of the nine staff members providing care or scheduled to provide care to the residents on 5/5/2020 had not completed the Respirator and PPE Usage for Caregivers training. B. Staff interview The DON was interviewed on 5/5/2020 at 12:30 p.m. She said all staff should be educated with any updated information prior to working their shift. She said all staff members currently working had completed the above training and all other staff would complete the training prior to working their shift.

Based on observations, record review and interviews; the facility failed to prepare, distribute and serve food in accordance with professional standards for food service in two of two kitchens. Specifically, the facility failed to ensure the thermometer was sanitized between use, hairnets were utilized during meal service and the dishwasher was at the proper temperature for sanitization. Findings include: I. Facility policy and procedure The Sanitation and Safety policy, revised 5/2011, provided by the registered dietitian (RD) on 4/1/19 at 11:02 a.m. revealed, in part, Thermometers are chosen for specific purposes and are washed, rinsed, sanitized and air-dried before and after each use. When taking temperatures of several different food items at one time, special attention is devoted to preventing cross contamination .Staff cleans and sanitizes all pots, pans, dinnerware, silverware and glassware to reduce the risk of foodborne illness. II. Standards of reference According to the Food Code (2017) by the U.S. Food and Drug Administration, retrieved from: https://www.fda.gov/downloads/food/guidanceregulation/retailfoodprotection/foodcode/ucm 0.pdf, pages 54 and 138, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens . In a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be .less than 180 degrees Fahrenheit (F). III. Thermometer use and interview On 3/28/19 at 4:25 p.m. cook #1 checked the temperatures on the steam table, in the care center kitchen. She rinsed the thermometer with water and then dried it with a paper towel. She proceeded to check the temperature of the sliced meat. Afterward, she rinsed the thermometer with water and then dried it with a towel. She tested the poached fish and then rinsed the thermometer with water and then dried it with a towel. She then tested the sausage and peppers with the thermometer and rinsed it with water and then dried it with a towel. She continued this same process with all of the food items she tested . Throughout this process she did not sanitize the thermometer with any sanitizer. The RD was interviewed on 4/1/19 at 10:20 a.m. She confirmed that the thermometer needed to be sanitized in-between foods. She confirmed that they (kitchen staff) should have used the sanitizer wipes. IV. Hairnets and interview On 3/28/19 at 4:24 p.m. staff were preparing for the dinner meal service. A server #3 was cutting up bread loaves into slices, near the beverage station in the care center kitchen. She was not wearing a hair restraint during this food preparation. -At 5:03 p.m. cook #1 was observed behind the steam table with a hat. She had approximately two to three inches of hair out the back of the hat, uncovered. Several staff members were walking through the kitchen area, without hair nets. During meal service, cook #1 was also preparing plates of salad (ready-to-eat food). On 4/1/19 at 9:12 a.m cook #2 was preparing food for the care center lunch meal, in the main kitchen. She was wearing a hat, with hair in a loose bun out the back, uncovered. The air conditioner was blowing her hair as she prepared food. Loose strands of hair were out the back, uncovered. Several staff members were observed walking through the kitchen, throughout meal prep areas, without hair restraints. The RD was interviewed on 4/1/19 at 9:46 a.m. She said the staff in the care center kitchen did not need to wear a hairnet because it was not a food prep area. The cooks had hats. They needed to wear a hairnet, if they did not have a hat. V. Dish machine temperature record review and interview The (MONTH) 2019 dish machine temperature log revealed the temperature was below 180 degrees F, 31 out of 31 days for Breakfast; 31 out of 31 days for Lunch; and one out of 31 days for Dinner. The logs revealed the desired rinse temperature was 180-194 degrees F. The (MONTH) 2019 dish machine temperature log revealed the temperature was below 180 degrees F seven out of seven days documented for Breakfast (21 days were missing documentation); seven out of eight day documented for Lunch (20 days were missing documentation); and one out of 17 days for Dinner (11 days were missing documentation). The (MONTH) 2019 dish machine temperature log revealed the temperature was below 180 degrees F for 15 out of 31 days for Breakfast; nine out of 31 days for Lunch ; and one out of 31 days for Dinner. There was some missing documentation. The (MONTH) 2019 dish machine temperature log revealed the temperature was below 180 degrees F for breakfast with a temperature of 157 degrees F documented. The executive chef (EC) was interviewed on 4/1/19 at 9:46 a.m. in the main kitchen. Regarding the dish machine this morning, he said the rinse never kicked on. The measure of the rinse cycle on the dish machine read 148-150 degrees F. He said it ' s stuck, at approximately 150 degrees F. An outside agency was supposed to come to look at the dish machine this coming Wednesday. He said, the rinse cycle had not been turning off since last Friday. He said he would call them to come in sooner to look at the machine. The dish machine had the capacity to switch from a high temperature to a chemical sanitizer, when needed. It was currently being used as a high temperature machine. The RD was interviewed on 4/1/19 at 10:20 a.m. She said there were some items from the care center that would have been cleaned using the dish machine in the main kitchen.

Based on observation and interviews; the facility failed to post the results of recent survey findings in a place readily accessible to residents, and family members and legal representatives for a census of 23 residents. Specifically, the facility failed to ensure the survey results were readily available. Findings include: I. Observations On 3/27/19 at 9:30 a.m. there was a small sign located on the top shelf, behind the business cards, at the front desk. The sign revealed Attention: the facility ' s most recent survey results are located at the concierge desk. Please ask the concierge if you would like to review. II. Interviews Four members of the resident council group, chosen by the facility, were interviewed on 3/27/19 at 3:18 p.m. They said they were not sure where the survey results were located. They assumed it was near the other postings in the building. They said they would probably be able to see it if they asked for them from staff. Resident council president was interviewed on 3/28/19 at 9:04 a.m. He said he did not know where to find the state inspections. Probably with management. He had not seen it posted in the past six months. He was unable to describe where it was located. The concierge staff was interviewed on 3/28/19 at 9:30 a.m. She took out the survey results book, located behind the front desk, out of sight. This was out of reach of the residents. She said it was available if someone asked for it. She said, over the past six months, no residents had asked to see the results and one family member had asked to see the results. The NHA was interviewed on 3/28/19 at 9:35 a.m. She said the process had always been like this. The results were available if someone asked for them. She was not aware that the survey results needed to be readily available, without having to request to access them.

Based on observations, record review and interviews, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial wellbeing for two (#24 and #29) of two residents reviewed for activities of 21 sample residents. The findings included: 1. Facility Policy The facility Activities/Lifestyle policy, revised 6/12, was provided by the lifestyle manager on 8/16/16 at 10: 28 a.m. The policy required the lifestyle manager planned an activities program with each resident, which provided the resident with recreational, social and educational opportunities. The resident's participation in and response to the lifestyle program was documented at least quarterly. Current attendance records were to be maintained of each resident's participation in the activity program. 2. Resident #24 Resident #24, age 82, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The resident was admitted to hospice for palliative care on 4/13/15. Resident Status According to the 4/20/16 annual minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. It was very important for the resident to listen to music, do things with groups of people and participate in her favorite activities. She was dependent for bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Special treatment and programs included oxygen therapy and hospice care. The care plan, last revised 7/21/16, revealed the resident declined invitations to activities. The goal was the resident would attend a social activity and entertainment or music therapy once a week. The approaches included one to one (1:1) sessions with the resident; and invite, encourage and assist the resident to activities of her choice. Staff were to vary the physical environment to different areas including the library, and encourage resident participation. The care plan was not individualized to reflect the resident's varied activity interests (see activity assessment and progress notes below). Observations On 8/10/15 from 12:20 p.m. to 1:35 p.m., the resident was observed in the dining room eating lunch. Subsequent review of the resident's activity participation record revealed she was inaccurately marked as participating in activities at that time. On 8/10/16 at 2:57 p.m., the resident was observed lying in her bed visiting with her husband. Her husband said the family did not want the resident to be bothered, but preferred she stayed in bed and listened to music or watched television (TV). On 8/11/16 at 10:05 a.m., the resident was observed alone in her geri chair in her room sleeping. The TV was off. No music was playing. Art with Denise and Zoey the Dog Visitor were offered activities of interest for the resident at this time (see calendar below). The resident was not observed being invited or encouraged to attend. Art supplies were not observed being brought to her room, and the dog was not observed being brought to visit her. On 8/11/16 from 1:26 p.m. to 1:35 p.m., the resident observed in her room. She was left alone in the room with no music playing. The TV was off. She was observed looking out toward the window once a while. The resident was not observed being invited to any activity, or being provided a 1:1 visit. On 8/15/16 from 10:10 a.m. to 10: 30 a.m., the resident was observed in bed sleeping. There was no music and the TV was off. The room was silent. The resident was not observed being invited to any activity, or being provided a 1:1 visit. On 8/15/16 from 5:15 p.m. to 5:45 p.m., the resident was observed in the room sitting in her geri chair with her husband. They were observed watching TV together for about 30 minutes. The resident was smiling and was able to answer yes or no to questions. The resident was never observed being visited 1:1, invited or encouraged to attend an activity. She was not observed being offered or provided music, art, pet visits, movies, going outside to watch and feed the birds, or small group social activities. Record Review The annual activities assessment dated [DATE] revealed the resident preferred to have activities in her room, the day/activity room, inside the nursing home and off unit. Program style preferences included 1:1 and small group. Participation barriers included ambulation/mobility, mental status and physical endurance. Leisure interests included socially interactive activities, pet therapy, music therapy, art therapy/craft activities and intellectually stimulating activities. Additional activity interests were painting, drawing, sketching, movies, news, classical music, watching and feeding birds, pets and attending social hours. The resident's annual activity progress note dated 4/25/16 documented the resident enjoyed visiting with residents, staff and family, especially her husband. She enjoyed attending music therapy, entertainers and art classes. A hospice note dated 8/8/16 documented the resident was having delusional behaviors. She thought she was going to die and go to hell. The resident was offered activities but usually declined. On 8/15/16 at 4: 15 p.m., resident's participation and response log requested from the life style manager (LM). The LM provided an activity calendar marked with blue and yellow highlighter. The blue colored indicated declined and yellow colored indicated active participation. According to the activity calendar provided by the lifestyle manager (LM) on 8/15/16, the following activities were offered during the survey: 8/10/16 - Wednesday 8: 00 Daily Chronicle 10: 00 Short Stories 11:00 Fitness with Elyse 1:15 Music Therapy 2:30 Tea & Topics 3:00 Bridge Club 6:00 Fitness with Michelle 8/11/16 - Thursday 8: 00 Daily Chronicle 10: 00 Art with Denise 10:15 Zoey Dog Visitor 11:00 Fitness with Elyse 1:30 Depart for Active Minds at the Lodge 2:30 Movie Matinee 8/15/16 - Monday 8: 00 Daily Chronicle 10: 00 Chicktionary 11:00 Fitness with Elyse 1:30 Bingo 2:30 Bridge Club 3:30 Daily Devotional Staff Interviews The registered nurse (RN) hospice care manager was interviewed on 8/15/16 at 12:30 p.m., in the resident's room during a nurse visit. She said the resident goes through periods of in and out of life style and having cognitively declining. She said it was very difficult to predict what was going to happen next with the resident, we are just taking one day at a time depending on the resident's situations and mood. The RN said the resident would benefit from 1:1 visitation and music therapy to stimulate her cognition and provide comfort, especially towards the end of life period. The LM was interviewed in her office on 8/16/16 at 10: 15 a.m. She said her goal for every resident was to attend one activity every week. She said the facility offered music therapy once a week to stimulate residents and increase encouragement. She said the facility also provided 1:1 visitation with residents daily for at least 15 minutes, for residents who wanted to stay in their rooms. However, she did not document 1:1 activities. She said she marked on the calendar with a highlighter to indicate a resident participated or declined. She said for music therapy, each resident room had cable that provided music. Regarding resident #24, she said the resident liked to look out to the sun and listen to music. She said the consequences of not providing the resident with activities she liked was the resident was denied end-of-life enrichment and comfort. Licensed practical nurse (LPN) #1 was interviewed on 8/16/16 at 12:03 p.m. She said the resident liked to interact and watch people going around. She said in the evening she liked to go down for happy hour once in awhile. The resident also liked to listen to music and watch animal planet in her room. However, she noticed the resident's TV was off, and she did not know why. 3. Resident #29 Resident #29, age 96, was admitted on [DATE] and readmitted on [DATE]. According to the 8/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 6/12/16 minimum data set (MDS) assessment, the resident had some cognitive impairment with a brief interview for mental status (BIMS) score of 12 out 15. No mood or behavior symptoms were noted. He required extensive assistance for bed mobility, transfers, grooming, and toilet use. -The 2/16/16 admission MDS assessment noted the activity preferences considered by the resident to be very important were: keeping up with the news, doing his favorite activities, going outside to get fresh air, and participating in religious services. Care Plans The resident's psychosocial well-being care plan, initiated 5/5/16 and revised 8/2/16, documented the following problem: (Resident) present with [MEDICAL CONDITION]. He has been awake, restless, and out of bed throughout the night. He then can be very lethargic throughout the day. One approach listed on this care plan read, Continue taking resident to common areas when he is up and does not want to lay in bed. The activities care plan, initiated 2/18/16 and revised 6/7/16, identified the resident refused invitations to activities. There was one approach listed on this care plan, and it read, Staff will provide resident with a monthly calendar of activities. Staff will invite, encourage, and assist resident to activities of his choice. Staff will check with resident to see if materials are needed for independent leisure. The care plan did not identify the resident's activity preferences. The mood state care plan, initiated 2/25/16 and revised 6/7/16, identified the resident made statements about being unhappy and was sometimes anxious. One of the listed approaches on the care plan read, Provide 1:1 activities, take resident outside as tolerated, for restless behaviors. Review of the resident's record revealed no documentation the resident was provided with one-to-one activities on a regular basis. Observations Intermittent observations of the resident during the day on 8/10/16, 8/11/15, and 8/15/16 revealed he spent the majority of the day on his bed resting. The following observations were made on 8/10/16: -At approximately 11:10 a.m., the resident was observed to be sleeping on his bed during the group exercise activity. -At 12:05 p.m., staff wheeled him into the dining room while he was sleeping. The lunch meal was served to the resident at 12:30 p.m., but the resident did not eat because he was still sleeping, even as staff tried to rouse him. -At 12:35 p.m., the resident was brought back to his room and assisted back into bed. Family Interview A family member was interviewed on 8/10/16 at 3:35 p.m. She said she felt the resident would benefit from a structured one-to-one activities program, because he was sometimes sleeping when the group activities were taking place. She said that the resident did not often attend group exercises. She thought the resident would benefit from an ongoing one-to-one restorative or exercise program to maintain his muscle tone. Record Review Review of the resident's record on 8/15/16 revealed there was no admission activities assessment specifying the resident's leisure interests. An activity assessment, dated 5/26/16, indicated the resident's preferred program style was one-to-one or small groups. There was no documentation in the record indicating the resident was receiving a one-to-one activities program. A care conference report, dated 5/31/16, included, He can get confused . Discussed his sleep/wake schedule being off. Lifestyles had been asking if he would like to attend Mass at the Lodge, but he has declined. He enjoys 1:1 time playing checkers, sitting outside. He mostly declines coming to scheduled activities . According to the 8/2016 activity calendar, approximately five group activities were offered to residents every day. An exercise class was scheduled daily at 11:00 a.m. Church services were planned for every Sunday morning. Review of the resident's activity participation record on 8/15/16 showed he did not attend any group activities on 8/2, 8/3, 8/4, 8/5, 8/6, 8/9, and 8/11. He attended one religious service on 8/3. The resident's 7/2016 activity participation record was incomplete, with just the first 13 days of the month tracked. The record showed that from 7/1 through 7/13, the resident did not attend any group activities on 7/1, 7/2, 7/3, 7/5, 7/6, 7/7, 7/8, 7/9, and 7/10. The resident's 6/2016 activity participation record showed he did not attend any group activities on 6/2, 6/6, 6/7, 6/9, 6/11, 6/12, 6/13, 6/14, 6/16, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/25, 6/28, 6/29, and 6/30. He did not attend any religious services or exercise classes during the month of June. There was no documentation the resident received one-to-one activities on the days he did not attend group activities. There was no documentation staff regularly offered the resident his favorite activities, such as playing checkers or going outside. Staff Interviews The unit registered nurse was interviewed on 8/15/16 at 4:15 p.m. She said the resident spent much of the day sleeping due to his propensity for often being awake during the night. When asked about his participation in group activities, she said staff offered to take him to activities if he was awake. The lifestyle manager (LM) was interviewed on 8/15/16 at 2:58 p.m. She said that an activity assessment for the resident, including a list of his leisure interests and preferred activity schedule, was not completed upon admission. The LM said the resident enjoyed music, playing checkers, and playing cards. She said, He spends a lot of time in his bed resting. He sleeps in a lot, and then he'll miss fitness. He's a lot more active in the afternoon He declines often. He really enjoys being outside. He seems to get more out of it when we're sitting there visiting. He'll stay awake more. He can carry a conversation with you especially in topics he's interested in. He's very intelligent. The LM said that six residents, including resident#29, had been identified as needing one-to-one visits from activities staff because they did not come out of their rooms very often. She said the facility did not have a structured one-to-one activities program. She said there were no protocols specifying how often a resident would be provided with one-to-one activities, and how the program would be tracked, care planned, and evaluated. She said that currently, these six residents received one-to-one activities in their rooms once a week, but the visits were not documented.

Based on record review and staff and resident interviews, the facility failed to prevent accident hazards and provide supervision and assistance to prevent falls for two (#8 and #5) of nine residents reviewed for falls of 21 sample residents. Specifically, the facility failed to thoroughly investigate un-witnessed falls and ensure effective interventions were implemented for resident #8 and resident #5. The findings included: I. Facility Policies and Procedures On 8/16/16 at 12:37 p.m. the director of nursing (DON) provided a copy of the facility's fall prevention protocol. The policy documented, in pertinent part, This protocol describes mechanisms for assessing residents at risk for falls and providing interventions to reduce the likelihood of falls. Desired Outcome: To reduce both the number of resident falls and injuries related to those falls . Definition of a fall: A sudden, involuntary and/or unanticipated drop to a lower position that may or may not result in a physical injury . Post-Fall Guidelines . The staff obtains any information necessary from the resident and/or witnesses . Follow-up of post-fall interventions are conducted to determine the level of effectiveness . A referral for evaluation for physical therapy is considered . Documentation of the event, the assessment of the resident and post-fall interventions are recorded in the resident's medical record . In cases of resident falls, an incident report is completed and maintained . For those residents considered at risk for falls on admission, a care plan is developed . These documents are updated for falls that occur after admission . II. Resident #8 A. Resident Status Resident #8, age 93, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 6/1/16 annual minimum data set (MDS) assessment, the resident displayed moderate cognitive impairment. She experienced hallucinations and delusional thinking and had minimal depression. She required supervision for all of her activities of daily living (ADLs), with the exception of personal hygiene, for which she was independent. According to the fall care plan, initiated on 5/29/15 and revised during the survey process on 8/11/16, the resident was at risk for falls related to pain, unrealized limitations, history of falls, and hallucinations and delusions. Interventions included use of a green tag, which indicated she was safe for independent walking; verbal reminders not to ambulate without assistance; and to provide a safety device (wheelchair or walker). On 6/19/15 an intervention was added to wait on putting curtains on the resident's windows per family preference. On 12/1/15 additional interventions were added to place the call light within the resident's reach and to encourage the resident to use the call light when needing assistance. A mobility care plan, initiated 7/8/15 and revised 6/7/16, revealed the resident was non-compliant with her walker at times. Interventions were to provide explanations and remind her to use her walker. An ADL care plan, initiated 5/29/15 and revised 6/7/16, indicated the resident believed herself to be independent with her care. Interventions included assisting with ADLs as needed and allowed, and the resident was a green sticker. Two fall risk assessments were completed. One was completed on 5/29/16 and indicated the resident was at moderate risk for falling. The second fall risk assessment was completed during the survey process on 8/10/16 and also indicated the resident was at moderate risk for falling. B. Fall on 10/25/15 A post fall report, dated 10/25/15, revealed resident #8 had an un-witnessed fall in her room when she bent over and slid off her bed while attempting to take off her shoes. The document indicated the resident had a history of [REDACTED]. The report documented the resident was wearing regular socks and taking antipsychotics and sedatives at the time of the fall. Neurological assessments were completed post-fall. A progress note, created on 10/25/16, revealed at the time of the fall the resident hit her chin on the bedside table. She sustained a 1.5x1.5cm bruise with slight swelling on the right side of her chin. A progress note, dated 10/26/16, documented the resident's daughter requested pain medication for the resident's pain related to the fall on 10/25/16. An immeasurable bruise from the fall was also identified to the resident's left hand. An interdisciplinary team (IDT) progress note, dated 10/30/15, documented the team's review of the resident's most recent fall. The note identified the resident had been wearing new shoes, which were tight fitting, and staff encouraged her to sit on a chair when taking off her shoes. The fall care plan was not updated until 12/1/15, when placing the call light within reach and encouraging use was added as an intervention. No follow-up fall assessment was completed. C. Fall on 3/1/16 A post-fall report, created on 3/1/16, revealed the resident experienced another un-witnessed fall. She was found in her room sitting on the ground between the bed and her nightstand with her back against the wall. The resident reported she was attempting to turn off the light on her bedside table and slid off her bed on to the floor. The report indicated she requested a lamp that would be easier to turn off. At the time of the fall the resident was taking narcotics and wearing regular socks. The report documented the resident had not had previous falls. Neurological assessments were completed post-fall. The progress note, dated 3/1/16, revealed the resident's room was dark at the time of the fall, and staff notified the resident's daughter of her request for a more accessible light. An IDT note, dated 3/4/16, documented the staff notified the family to bring in a more accessible bedside light for the resident's room. A physical therapy plan of care, dated 3/8/16, indicated the resident was referred for treatment related to lifting her walker when turning and maneuvering. The note did not mention the resident's recent fall related to loss of balance. The fall care plan was updated next on 5/20/16, documenting the resident was a green tag. No follow-up fall assessment was completed. D. Fall on 7/26/16 A post fall report, dated 7/26/16, revealed the resident fell in her room un-witnessed. The resident was found sitting halfway on her bed and halfway on her bedside table with the bedside table sliding away from the bed. The nurse was able to assist the resident before reaching the floor. The resident reported she was attempting to turn her light off but lost her balance. The report indicated the resident was taking antipsychotics and sedatives at the time of the fall. Further care was indicated as not necessary. Neurological assessments were not conducted. The progress note, dated 7/26/16, revealed the resident was experiencing hallucinations prior to the incident. An IDT progress note, dated 7/29/16, documented the team's review of the resident's fall. The note documented the resident was reminded to call for assistance, and the pharmacist was requested to complete a medication regimen review. No further documentation indicated medication changes related to the fall. No new interventions were added to the fall care plan. No follow-up fall assessment was completed. E. Fall on 8/7/16 A progress note, dated 8/7/16, documented the resident reported an un-witnessed fall related to loss of balance and was able to get herself back up. The resident informed the nurse she had hit her chest on her table and fell on her right side. Two new bruises were observed on the resident, one on her right elbow and one on her left hand. The resident also reported pain in her right hip and arm. X-rays were ordered. Neurological assessments were completed post-fall. A progress note and the clinical report from the daily meeting notes on 8/8/16 revealed the resident sustained [REDACTED]. No post fall report was completed for this incident. No new interventions were added to the fall care plan, and no follow-up fall assessment was completed. F. Fall on 8/9/16 A post fall report, dated 8/10/16, identified the resident had an un-witnessed fall in her room on 8/9/16. The resident was sitting on the end of her bed putting socks on at the time of the fall. The report documented she was wearing regular socks and had just woken up. The resident remained on antipsychotics and sedatives at the time of the fall. No care was indicated as necessary related to the incident. Neurological assessments were completed post-fall. The clinical report from the daily meeting notes on 8/10/16 documented the resident would be referred to therapy for a follow-up and her Klonopin would be decreased. No new interventions were added to the fall care plan. The occupational therapist (OT) provided a copy of the plan of care beginning 8/15/16. The plan of care indicated the resident was referred for an evaluation related to recent falls. G. Staff Interviews Certified nurse aide (CNA) #1 was interviewed on 8/15/16 at 10:04 a.m. She said the resident slipped off her bed on 8/10/16. She said it was reported to her the resident was attempting to get her shoes on but her comforter was slick, causing her to slide off her bed. She said now the staff tried to fold the comforter down or take it off during the day. She said the staff also checked in on her often. Registered nurse (RN) #1 was interviewed on 8/15/16 at 10:18 a.m. She said the resident fell twice recently. She said the most recent fall was caused by the resident sitting on the edge of her bed while attempting to put her socks on. The nurse said falling was rare for this resident, as she was usually independent. She said the resident had been experiencing increased hallucinations and had recently had her Klonopin increased. After the most recent fall, she said, the staff decreased her Klonopin and were encouraging the resident to call for help. The social services manager (SSM) was interviewed on 8/15/16 at 11:14 a.m. She said the resident's Klonopin dose had been increased due to her hallucinations. She said it was then decreased because the resident was experiencing falls. The occupational therapist (OT) was interviewed on 8/16/16 at 10:10 a.m. She said a referral was made on 8/11/16 for the resident to receive an occupational therapy evaluation related to the most recent fall; however, the resident's insurance verification had not gone through yet. She said a different occupational therapist was working on 8/12/16; therefore, the start of care for the resident did not begin until 8/15/16. She said this was the first referral she had received related to the resident's falls. The DON was interviewed on 8/16/16 at 10:37 a.m. She said upon admission, and again 24 hours later, an assessment was completed to determine a resident's fall risk. Following the assessment, she said a care plan was developed and updated as needed by the MDS coordinator. She said when a resident had a fall the nurse completed a post fall assessment to determine any injury and the precipitating factor causing the fall. As soon as possible after the fall, she said, interventions were implemented to prevent future falls and/or injury. She said some interventions included a low bed, a floor mat, or meeting an unmet need. She said if a fall was un-witnessed or the resident hit their head, the staff conducted neurological checks. In regards to resident #8, she said the staff spoke to her about not sitting on the edge of her bed, and she now had looser fitting shoes and a shoe horn. She said the resident's daughter bought her new shoes after the fall on 10/25/15, although this was not documented. After the 3/1/16 fall, the facility staff called the resident's daughter to notify her of the need for a different lamp. However, the lamp was never changed. She confirmed the fall on 7/26/16 was also related to the lamp being difficult for the resident to turn on and off. She said the intervention implemented for the fall on 7/26/16 was for the pharmacist to review the medications. However, she said she was unable to find any changes made to the resident's medication regimen or other interventions. She was also unable to determine an intervention that was put in place after the 8/7/16 fall. She confirmed effective interventions were not implemented after the resident's falls and her recent therapy evaluation had been delayed. She also confirmed the fall care plan had not been updated with appropriate interventions. Licensed practical nurse (LPN) #1 was interviewed on 8/16/16 at 11:45a.m. She said right after a resident's fall, a nurse completed an assessment to see what caused the fall. An intervention was then put in place as soon as possible to prevent future falls. She said sometimes temporary interventions were put in place and later replaced with a more permanent one. She explained if a resident was on a green tag it meant they were able to walk independently. Resident #8 was interviewed on 8/16/16 at 11:55a.m. She said when she experienced a fall she ached because it shook her up. III. Resident #5 A. Resident Status Resident #5, age 94, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 6/10/16 annual minimum data set (MDS) assessment, the resident displayed moderate cognitive impairment. He experienced minimal depression and required was dependent for all ADLs, with the exception of walking which did not occur. According to the fall care plan, initiated on 6/8/16 and revised on 7/27/16, the resident was at risk for falls related to weakness, foley catheter and oxygen tubing. Interventions included encouraging the resident to use the call light and keeping it within the resident's reach. On 6/17/16 the interventions were updated to include offering naps, keeping environment clear of clutter, observing frequently, providing a two person assist for transfers, and allowing time to rest. On 7/27/16 a low bed with a fall mat was added as an intervention. The DON provided a copy of the temporary care plan initiated on 5/27/16, prior to the fall risk assessment. The care plan was not found in the resident's electronic or paper chart. The care plan identified the resident as at risk for falls. The intervention was to encourage the use of the call light. Admission fall risk assessments were completed on 5/28/16 and 6/3/16 and identified the resident was at high risk for falls. B. Fall on 6/6/16 A post fall report, dated 6/6/16, identified the resident had an un-witnessed fall. The resident was found on the floor of his room beside his bed. The resident's head was under his bed and he was unaware of how he got there; however, he sustained no apparent injuries. Prior to the incident the resident had been observed in his bed wearing socks with skid grips. A progress note, dated 6/6/16, summarized the post fall report. No further investigation or follow-up fall assessment was completed. C. Fall on 7/17/16 A post fall assessment, dated 7/17/16, indicated the resident had an un-witnessed fall in his room. The assessment documented the resident was in his wheelchair prior to the fall and said he attempted to pick something up off the floor. A progress note, dated 7/17/16, revealed the resident hit his head when he fell and sustained a 2cm x 2.4cm hematoma to his forehead, a bruise on his right elbow, and skin tears to his nose, left arm, right arm, left wrist, right wrist, and right hand. An IDT note on 7/22/16 documented a review of the resident's fall on 7/17/16. Anti-rollback brakes were added to the resident's wheelchair to prevent future falls. A follow-up fall assessment was completed, indicating the resident was at high risk for falling. No further investigation was completed. D. Fall on 7/27/16 A post fall assessment, dated 7/27/16, revealed the resident had an un-witnessed fall in his room. The resident had been last seen in his bed and was found kneeling on the floor with his head and arms on the bed. A progress note, dated 7/27/16, documented the resident was unable to remember how he fell . An IDT note on 7/29/16 documented a review of the resident's fall on 7/27/16. A low bed with a floor mat was added as an intervention. No further investigation or follow-up fall assessment was completed. E. Interviews CNA#1 was interviewed on 8/15/16 at 10:03 a.m. She said she had not been aware of the resident having any falls. She said, however, his bed was kept low with a fall mat to prevent injury. RN #1 was interviewed on 8/15/16 at 10:15 a.m. She said the resident had two falls since admission. She said both times were after dinner when the resident was attempting to transfer himself to his bed. She said now the staff put him in bed after dinner, and he had a low bed with a fall mat. The resident, she said, sustained abrasions and bruises from one of his falls. The DON was interviewed on 8/16/16 at 12:45 p.m. She provided a copy of his temporary care plan. She confirmed the fall care plan did not have new interventions put in place after the 6/6/16 fall until 6/17/16.

Based on observation, record review, and resident and staff interview, the facility failed to ensure that hot water temperatures at resident-accessible sinks remained at safe and comfortable levels. The findings include: A. Professional Reference regarding Hot Water Temperatures According to the Consumer Protection Safety Commission, Avoiding Tap Water Scalds, Publication 5098, http://www.cpsc.gov/PageFiles/ 2/5098.pdf, (5/1/12): The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five . Burns will .occur . with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns. B. Observations During environmental review of various, sampled, resident rooms on 7/20/15, the hot water temperature at the private sinks of six resident rooms was as follows: - At 11:50 a.m., room 5220's hot water registered 125.4 degrees Fahrenheit (F) - At 11:58 a.m., room 5214's hot water registered 128.8 degrees F - At 12:01 p.m., room 5215's hot water registered 125.7 degrees F - At 12:05 p.m., room 5221's hot water registered 120.3 degrees F - At 12:25 p.m., room 5207's hot water registered 121.0 degrees F - At 12:27 p.m., room 5211's hot water registered 120.8 degrees F C. Resident Interview On 7/20/15 at 12:01 p.m., resident #5 stated, Sometimes (the hot water) feels too warm on my hands, but I just turn it down. D. Staff Interviews and Observations On 7/20/15 at 12:50 p.m., the director of nursing (DON) was asked to feel the hot water temperature at a resident sink with her hand. The DON noted the water felt too hot. On 7/20/15 at 12:51 p.m., the DON and nursing home administrator (NHA) stated they currently had no cognitively impaired residents who were capable of traveling to the room sinks independently. The facility had no instances of resident burns by scalding. On 7/20/15 at 1:07 p.m., the director of facilities services (DFS), facilities supervisor (FS), NHA and DON observed and tested hot water temperatures at the resident sinks. The DFS felt the hot water coming out of the sink in room 5214 with his right hand and stated, That's definitely hot. The DFS then measured the temperature, which registered 122 degrees F. The DFS noted maintenance personnel were alerted to the issue and had already started to work on the system to get the hot water temperatures to decrease, stating, When they start working on the valves, the (hot water temperatures) go down real quick. At 1:09 p.m., the DFS felt the hot water coming out of the sink in room 5220 with his hand and stated, I don't even need to use a thermometer (the water is too hot). By 1:13 p.m., room 5219's hot water registered 110 degrees F, room 5223's hot water temperature was comfortable to the hand, and room 5224's hot water temperature measured 105 degrees F and was comfortable to the hand while immersed in the flow of hot water. At 1:18 p.m., the NHA indicated the DFS and FS planned to continue checking temperatures to ensure they remained in a safe range for the residents. On 7/20/15 at 1:52 p.m., the DFS and FS were interviewed. The DFS stated both maintenance and security staff conducted daily testing of the hot water temperatures in three random resident rooms. The DFS noted hot water temperature measurements outside of 110-118 degrees F required the generation of a work order, which the maintenance department acted upon as a high priority item, which was described as requiring action with 45 minutes. The DFS explained the facility's water was hard (water that has high mineral content) which contributed to mineral build-up, requiring facility staff to rebuild (clean) the valve weekly, as opposed to typical quarterly maintenance of the valve. The DFS attributed the fluctuating water temperatures to mineral debris and build-up on the tempering valves. The DFS explained he and the FS monitored the logs generated by maintenance and security staff at least every other day for temperature outliers to ensure work orders were generated and to look for trends. The DFS noted the facility purchased electronic thermometers to help ensure reliable temperature readings and calibrated the thermometers before sending them out into service. However, he was uncertain if the facility periodically calibrated the thermometers to ensure their ongoing accuracy. Policies and procedures regarding environmental controls, including expected parameters and monitoring of water temperatures, were requested from the DFS and the FS. On 7/20/15 at 4:07 p.m., the DFS reported both tempering valves were rebuilt and acceptable hot water temperatures were being maintained according to hourly checks. On 7/20/15 at 4:25 p.m., the FS reported the facility lacked the requested policies. In lieu of a policy, the facility used a statement listed on the water temperature logs as a staff directive regarding the expected handling of water temperature readings. E. Water Temperature Logs Review of the facility's Water Temperature Log revealed maintenance staff was directed as follows: If temperature is NOT between 110 (degrees F) to 115 (degrees F) then Corrective Action is required and a Work Order must be generated. Review of maintenance staff water temperature logs from 1/18/15 to 7/20/15 revealed maintenance staff failed to identify corrective action was required for out-of-range water temperatures (outside of 110-115 degrees F per the log directive) on 49 separate occasions. Consequently, no work orders were generated in order to investigate and/or rectify the out-of-range temperatures. Of the 49 out-of-range water temperatures, 44 instances occurred from 5/2/15 to 7/20/15. Review of the facility's Water Temperature Log revealed security staff was directed as follows: If temperature is NOT between 110 (degrees F) to 118 (degrees F) then Corrective Action is required and a Work Order must be generated. Review of maintenance staff water temperature logs from 12/28/14 to 7/18/15 revealed security staff failed to identify corrective action was required for out-of-range water temperatures (outside of 110-118 degrees F per the log directive) on 16 separate occasions. Consequently, no work orders were generated in order to investigate and/or rectify the out-of-range temperatures. Per the security water temperature logs, water temperatures spiked from 5/4/15 to 5/8/15, leveled out somewhat, then spiked to the 123-124 degree F range on 7/16/15 and 7/17/15, three days before the beginning of the survey. F. Facility Follow-Up On 7/22/15 at 12:47 a.m., the DFS reported the facility planned to purchase and install an electronic surveillance system to monitor the water temperatures. The DFS noted the electronic system had the capability to sound an alarm and page personnel when water temperatures were out-of-range. The DFS also noted security staff would continue recording nightly water temperatures in random rooms. The DFS confirmed maintenance and security staff recorded fluctuating water temperatures outside of specifications which were not acted upon through the creation of work orders. The DFS added, We will review the logs better.

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 the spread of food-borne illness. The following sanitation concerns were found: --Lack of hair restraints worn during meal service. --Hand washing sink located in the food preparation area without splash guards to prevent contamination. --Potential of food contamination storing raw meats with ready to eat foods. Findings include: 1. Hair Restraints Facility Guideline: As it pertains, the Food Safety Standards and Practices for All Personnel were reviewed and revealed, " Restrain or cover hair at all times. This includes facial hair. " Observations: On 9/25/14 at 10:30 a.m., the dietary cook (DC) was observed in the main kitchen wearing a black baseball cap. The DC had his hair pulled back with a rubber band however, the rest of his hair as not covered with a hair protector. On 9/25/14 at 11:05 a.m., the DC was observed in the designated area of the satellite kitchen with his hair uncovered. A hair net was not used to restrain all of his hair. Interviews: On 9/25/14 at 2:08 p.m., the consultant registered dietician (RD), executive chef (EC), dietary manager (DM), and nursing home administrator (NHA) were interviewed. The DM stated there was a standing dress code of jackets, aprons, and shoes, including hair restraints and hair nets. The expectation was to follow the policy and procedure associated with hair restraints. 2. Hand washing sink located in food preparation area On 9/25/14 at 11:05 a.m., meal service was observed in the satellite kitchen of the facility. The steam table was approximately five feet in length. Beside the right side of the steam table was a preparation table approximately five feet in length also, with a miniature grill approximately one half foot in length and size, a one half foot container of vegetables and raw meat bathed in a shallow layer of ice, hamburger buns, a cutting board and other miscellaneous items stored on the table. The preparation table had an added extension of a sink parallel to the steam table and a miniature refrigerator at the side of the sink. On 9/25/14 at 12:09 p.m., the DC was observed washing his hands at the prep sink where food was being prepared. There was a plate of food near the sink where he was washing his hands. There was splash back water observed around the sink where food was being prepared and there were no splash guards to reduce the amount of splashes. -At approximately 12:30 p.m., the DC turned on the water at the sink to fill part of a pan and place cooked hamburger patties on the steam table. The sink was used as a hand washing and food prep sink. On 9/25/14 at 12:55 p.m., the DC was observed washing his hands at the prep sink with plates of food around the outer edge of the sink. The surrounding counter was seen with water splash back from the amount of times the DC had been seen washing his hands at the prep sink during meal service. The potential for food contamination was present as the DC washed his hands at the sink while dishes of ready to eat food were left around the sink counter. Interviews: On 9/25/14 at 2:08 p.m., the RD, EC, DM, and NHA were interviewed. The DM stated the prep sink was converted into a designated hand washing. She stated the actual hand washing sink was poorly located and made meal service difficult to conduct when the DC had to walk to the sink each time to complete hand washing tasks. The DM reported no food preparation was conducted in the sink near the steam table: although, the DC used the sink during observation to place water in a pan for the cooked hamburger patties. The DM acknowledged water splash back on the counters was observed where the DC prepared the meals served to residents. The EC acknowledged the potential for contamination and splash back regarding the location of the sink in the kitchen area. The EC and DM acknowledged the sink did not have splash back boards to eliminate or reduce the potential for food contamination. 3. Raw meats stored with ready to eat foods. On 9/25/14 at 11:05 a.m., meal service was observed in the satellite kitchen of the facility. The DC was observed setting up his kitchen. He obtained ice from the ice machine to create an ice bath for both ready to eat foods and raw frozen hamburger patties. The DC kitchen setup was to place the ready to eat food next to the grill and the raw frozen hamburger patties in the bucket furthest from the grill. -At approximately 12:45 p.m., the DC was observed taking two thawing raw hamburger patties from a container located in an ice bath and dragging them across the ready to eat foods to place on the grill. The potential for raw meat and liquid from the thawing patties was present as the DC took the tongs and carried the meats over the ready to eat foods. Interviews: On 9/25/14 at approximately 1:00 p.m. the DC was interviewed. He acknowledged the raw meat and ready to eat foods were stored together in an ice bath and the raw meat was poorly located. He stated there was a possibility of food contamination with raw meats located at the far end of the ice bath. On 9/25/14 at 2:08 p.m., the RD, EC, DM, and NHA were interviewed. The EC and DM acknowledged the raw foods stored next to the ready to eat meats could be a potential for food contamination. The EC stated ready to eat foods should be stored far enough away from raw meats to prevent food dangers and hazards. The DM stated the DC should have placed the raw meats closest to the grill in order to carry the patties the shortest distance to the grill instead of over the ready to eat food.

Based on resident interviews, observations, staff interviews, and menu review; the facility failed to consistently serve food that was palatable, attractive, and at the proper temperature. The findings include: Professional Reference: According to " Nutrition Management and Restorative Dining for Older Adults " 2001 edited by Gretchen E. Robinson, MS, R.D, FADA and Betty J. Leif, RD, page 2, " . . . Nutritional deficits in elderly clients who reside in nursing homes generally occur for three reasons: inadequate food intake, increased caloric requirements, and altered nutrient metabolism . . . " "Krause ' s Food, Nutrition, and Diet Therapy, " 2004 by L. Kathleen Mahan and Sylvia Escott-Stump, page 335, emphasized that " The nutritional care of those in institutions must be directed toward long-term identification and responses to changing physiologic and psychological needs. Serving attractive and palatable food in an atmosphere that encourages independent eating or provides assistance when necessary helps promote the nutritional well-being of the residents." Stage One Resident Interviews: Five out of the ten residents interviewed during stage I reported concerns with the facility food quality (appearance, palatability, and temperature); representing 50% of the survey sample. Resident #20 was interviewed on 9/23/14 at 2:04 p.m. She reported it took time for meals to come from where they were prepared (outside of the facility) and brought to the floors. She reported the food was cold by the time she received her meals and would have to request to have her meals reheated. On 9/24/14 at 9:31 a.m., resident #12 was interviewed. She reported the food tasted bland and the menu did not provide variety. She stated the menu options were often the same such as a grilled cheese sandwich. Resident #1 was interviewed on 9/23/14 at 11:24 a.m. The resident stated the food did not taste good. She reported she was an active member of the facility food committee. On 9/23/14 at 2:47 p.m., resident #27 was interviewed. She stated she didn ' t know anything about making menus but she felt the menu was repetitive and the food did not taste well. Resident #35 was interviewed on 9/23/14 at 2:32 p.m. The resident stated food was served lukewarm and not at an adequate temperature. Observations: On 9/25/14 at 1:00 p.m., the dietary cook (DC) was observed preparing a turkey sandwich for resident #35. The DC located gluten free bread and two thin slices of deli meat. He placed the deli meat between the slices of bread. The meat slices did not cover the bread entirely as it was served to the resident; the deli meat did not appear to be an adequate serving size and disproportionate to the thick slices of onion, leaf of lettuce and slice of tomato. The DC prepared additional sandwiches for resident #24 and resident #16 during meal service and again, the serving size of protein was inadequate. The dietary manager (DM) was present during discussion of the inadequate portion size. The DM asked the DC if the meat was weighed at the main kitchen and the DC located the pre-sliced deli meat and informed the DM the pre-sliced turkey was used according to the serving size recommendations listed on the label. -The DC was interviewed at 1:15 p.m. He reported he followed the manufacturer guideline to ensure an adequate serving size was served to residents. The DC said he recalled two slices of thin deli meat was used to prepare the sandwich for resident #35. DC verified on the manufacturer guideline for an adequate protein size, three slices of deli meat should have been served. At the end of meal service, a review of the scoop sizes were discussed with the DC due to the starch portion sizes compared to protein. The DC stated a two ounce scoop was used for the mashed potatoes. He stated he dished two scoops per each request. He said the gravy was served using a one ounce ladle, garlic cream sauce with lemon was served using a two ounce ladle; brown rice was served using a four ounce scoop, and stewed tomatoes were dished to resident using a three ounce ladle. -The DC stated he knew what an appropriate serving size should be by the guide posted on the board. A review of the guide showed no authorizing signature from a registered dietician. The information did not appear to be a corporate policy or procedure since there was no identifying information made available. Menu Review: A review of the facility menus from 8/4/14 through 9/28/14 failed to show or list extensions to determine caloric and nutrient-intake needs of each resident were met. The guide used by the DC had information including the following: " Always available items include scrambled eggs or egg beaters, mashed potatoes, applesauce, ice cream etc. One piece bread, one teaspoon butter, eight ounces whole or skim milk, and five ounces coffee or tea will be offered. " " Portions: Six ounces of soup; two, four ounce salad/appetizer; three, eight ounce entrees, four ounce starch, four ounce vegetables, four ounce fruit, entree provide two-three ounce protein. " " No Add Salt Diets will not be offered table salt. " " Consistent Carbohydrate Diets will be served a regular diet, offered sugar substitute and are encouraged to choose low sugar dessert or fruit. " " Mechanical Soft Diets; all items are moist and in bite size pieces and may be changed in texture or consistency by cooking, grinding, chopping, mincing, or mashing. " " Puree Diets; all of the above foods are appropriate in the portion stated and pureed to a smooth pudding like consistency using an appropriate liquid and/or thickener; fresh fruits and vegetables with tough skins, hard seeds, nuts and dried fruits may be substituted. " Note: The Nutrition Services Diets document provided by the executive chef (EC) on 9/25/14 at 4:20 p.m. provided contradictory information regarding the puree diet stating fresh fruits and vegetables with tough skins, seeds will be substituted not may be substituted as the dietary cooks have posted as a guide during meal service. There was no information on the nutrition services diets document to show adequate portion sizes. " Food intolerances, food allergies and other diet modifications will be addressed individually. " The menus provided to the surveyor team were not dated nor signed by a registered dietician to indicate the nutritive and caloric values of the menus were reviewed within an adequate amount of time. The facility did not provide information during the survey to show the dietician reviewed the menus. The facility did not submit additional information for consideration after the survey. Staff Interviews: On 9/25/14 at 2:08 p.m., the consultant registered dietician (RD), executive chef (EC), DM, and nursing home administrator (NHA) were interviewed. The EC stated there was no formal training to discuss modified diets with staff. He stated the campus did not have formal menu extensions. The EC expressed the kitchen worked on a 52 week schedule. -The DM and EC reported the therapeutic diet sheet used by dietary cooks was created by a previous employee who no longer worked for the company. The EC reported he retained a copy of the information to determine how the therapeutic guidelines were created. The DM reported she did not have a copy of the direction from the previous dietician. -The DM acknowledged the onion slices on the plates during the 9/25/14 were thick and could be seen as unattractive to residents. -The EC expressed scales should have been used to ensure adequate portions of turkey were served to residents. He stated when pre-sliced meats were used during meal service; it was easy to get the portion sizes incorrectly if the scales weren ' t in use during service. Food Committee Resident Interview: On 9/26/14 at 9:42 a.m. the food committee representative (resident #1) was interviewed. She stated the committee consisted of people with an interest in their diet. She reported Sunday night meals were terrible and consisted of leftover meals. She expressed food temperatures were inconsistent. The resident said the turkey sandwiches served on 9/25/14 of turkey sandwiches were disproportioned. She said the onion slices on the plate were large and there was barely any turkey. She stated the onions were odorous and unattractive on her plate.

Based on observation and staff interviews, the facility failed to ensure drugs and biologicals were maintained and discarded in accordance with currently accepted professional principles. Specifically, the facility failed to ensure expired medications and biologicals were not available for use and had been discarded of timely. The findings include: A. Professional References Aplisol (tuberculin PPD, diluted) package insert from Pharmamerica states "Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency." B. Observations An audit of both nursing medication carts was conducted on 12/3/13 at 12:46 p.m. and 1:07 p.m., along with the medication room at 1:30 p.m. The audits revealed the following expired medications 1. Medication Carts A & B ?1 box of glycerin suppositories, NDC -320-71, expired 6/11/13 ?1 bubble card of hydrocodone/acetaminophen (norco) 5/325 mg tablets, expired 10/21/13 ?1 bubble card of MAPAP (Tylenol) 500 mg tabs, NDC 0904-1983-80, expired 11/27/13 ?1 bottle of guaifensen 100 mg/5 ml syrup (house stock), expired 12/12/12 ?1 bubble card of calcium antacid 500 mg chewable tablets, NDC 0904-1258-92, expired 7/24/13 ?2 bottles of Nitrostat (nitroglycerin), NDC 0071-0418-13, expired 12/21/12 & 6/16/13 ?1 bubble card of Meclizine 12.5 mg tablets, expired 9/9/13 ?1 bubble card of Zofran 4 mg tablets, expired 9/28/13 ?1 bubble card of Tylenol 325 mg tablets, expired 6/16/13 ?2 bubble cards of senna plus tablets, expired 10/30/13 and 4/30/13 ?4 bubble cards of Tylenol extra strength (E.S.) 500 mg tablets, expired 8/17/13, 9/4/13, (2 cards) expired 05/27/13 ?1 bubble card of prochlorperazine 10 mg tablets, expired 9/25/13 ?1 bubble card of Imodium 2 mg tablets, expired 9/25/13 ?1 bubble card of ondansetron HCL 4 mg tablets, expired 9/28/13 ?1 bubble card of prochlorperazine 5 mg tablets, expired 4/16/13 2. Medication Room Refrigerator ?1 open bottle Tuberculin Purified Protein Dirivitive (PPD), lot # 0, expired 5/2015, opened 9/26/13 C. Interviews -On 12/3/13 at 12:49 p.m., a Registered Nurse (RN) working medication cart A was interviewed. S/he acknowledged the expired medications and stated that they should not be available for use and removed them from the medication cart. At 1:30 p.m., the RN acknowledged that the tuberculin had been opened on 9/29/13 and stated that should be removed from use 30 days after being opened. -On 12/3/13 at 1:25 p.m., a licensed practical nurse (LPN) working medication cart B was interviewed. S/he acknowledged the expired medications and stated that they should not be available for use. The LPN removed the expired medications from use. The LPN stated that all nurses were responsible for checking for and removing expired medications from the medication carts. -On 12/9/13 at 11:00 a.m., the Director of Nurses (DON) was interviewed and stated that the expired medications should not be available for use. The DON stated that the night shift was responsible for auditing the medication carts and removing any medications that had expired.

Based on observation, record review and interviews, the facility failed to ensure services provided or arranged for one (#5) of 21 sample residents met professional standards of quality. Specifically, the facility failed to ensure skin was observed and irregularities reported, assessed and monitored, and documented. The findings include: A. Facility Policy The facility's integumentary system protocol revised 6/2011, under standards of practice, stated in pertinent part: -Evaluation of skin includes but is not limited to: color, temperature, turgor, [MEDICAL CONDITION], pain/tenderness, integrity, rashes, and bruising. -Skilled nursing (SN) residents have a formal skin evaluation performed and documented weekly by licensed staff. -In all care venues, resident skin is observed by licensed and unlicensed staff during care provided (e.g., incontinence care, bath/shower, dressing) and any impaired skin integrity is reported to the licensed staff and or healthcare provider with prescriptive authority. B. Professional Reference - Bathing According to Nursing Assistant, a nursing process approach, 9th edition, section 7, 9/4/03, Patient Care and Comfort Measures, pg. 354, guidelines for patient bathing state in pertinent part that staff should observe the patient's skin for any changes or irregularities. Note any reddened areas. Do not disturb or injure warts or moles and report anything unusual. C. Resident #5 Resident #5, age 84, was readmitted to the facility on [DATE], according to the facility face sheet. Her pertinent admission [DIAGNOSES REDACTED]. According to the minimum data set (MDS), dated [DATE], resident #5 had moderate cognitive deficits (memory problems), as evidenced by a score of 9 on her brief interview for mental status (BIMS). She required extensive assist of one to two persons for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. The resident had [MEDICAL CONDITION] but did not display any physical, verbal or other behavioral symptoms during the review period. She was receiving hospice services. 1. Resident Status According to the resident's care plan, initiated on 7/4/13, resident #5 was admitted with a stage II pressure ulcer, had a history of [REDACTED]. The pertinent care plan approaches indicated that staff should be cautious of fragile skin during transfers. Review of the computerized physician orders [REDACTED]. -[MEDICATION NAME] 100 units/milliliter (ml) give 5 units subcutaneously (SQ) at bedtime. -Fasting blood glucose (FSBS) monitoring twice daily at 6:00 a.m. and 4:40 p.m. -Weekly skin assessment to be completed every Monday on the evening shift. -Apply thin layer of A&D ointment to upper and lower extremities for fragile skin to prevent skin tears once daily between 7:00 a.m. and 3:00 p.m. Review of the resident's weekly skin assessment dated [DATE] revealed resident #5 had impaired skin integrity to her coccyx and a skin tear to her left lower extremity that measured 1 centimeter (cm) that had steri-strips (wound closure strips) in place. No other skin abnormalities were noted. Review of the hospice nurse visit notes dated 11/6/13, 11/20/13, and 11/25/13, revealed no skin issues outside of the resident's pressure ulcer. 2. Multiple Areas of Bruising a. 12/3/13 On 12/3/13 at 12:30 p.m., resident #5 was observed to have a dark blue, circular bruise, that measured approximately 1 centimeter (cm) in diameter, to the knuckle of her right ring finger and top of her left hand and a reddish/brown bruise that measured approximately 4 cm x 6 cm to her right bicep. A private sitter (caretaker) sitting in the resident's room acknowledged the bruises and stated she did not know when they occurred; however, she believed they were caused from blood being drawn from the resident. The sitter stated the phlebotomist always had trouble finding the resident's veins and made multiple attempts to collect her blood with a needle. Review of the resident's record revealed the most recent blood draw as of 12/3/13 was conducted on 11/25/13. b. 12/9/13 On 12/9/13 at 10:00 a.m., a second observation of resident #5 revealed the bruising noted on 12/3/13 was still present but fading. On 12/9/13 at 3:00 p.m., an observation of resident #5 in the presence of the facility medical director (MD) revealed bruising noted on 12/3/13 (see above). Review of the resident's record revealed the most recent blood draw as of 12/9/13 was conducted on 12/5/13. 3. Failure to ensure skin was observed and irregularities reported, assessed/monitored and documented a. Record Review Review of the 12/4/13 hospice nurse visit note revealed that resident #5 had multiple areas of skin discoloration on bilateral extremities. However, this note did not describe the skin discoloration or note that staff had been notified of the change in the resident's skin from the previous skin assessments completed by the hospice nurse. Review of the hospice aide recap of services revealed the hospice certified nurse aide (CNA) was in to see resident #5 on 12/2/13, 12/4/13, and 12/5/13 to provide care (e.g., hygiene, transfers, apply lotion, dress, and repositioning). The notes failed to indicate resident #5 had any skin issues. Review of the resident's bathing/shower records revealed that resident #5 had complete bed bath on 12/2/13, a shower on 12/3/13, and a partial bed bath on 12/6/13. There was no documentation of skin abnormalities on the bathing/shower records. Review of the 12/2013 medication and treatment administration records (MAR and TAR) revealed staff was checking the resident's FSBS twice a day, administering insulin subcutaneously into the resident's abdomen every night at bedtime, and applying A&D ointment to her bilateral upper and lower extremities every day. No skin abnormalities were documented on the 12/2013 MAR and TAR. Review of the nursing notes dated 11/25/13 through 12/8/13 failed to show resident #5 had any skin issues or bruising. b. Interviews -A licensed practical nurse (LPN) familiar with the resident's care was interviewed on 12/9/13 at 12:44 p.m., and stated residents are scheduled for two showers a week. Skin assessments are done on the first day of the week that the resident receives their shower/bath. The LPN stated that the CNAs are responsible for notifying the nurse if any new skin issues are observed when a resident receives a shower and a skin assessment is not due. A second LPN familiar with the resident care was interviewed on 12/9/13 at 1:35 p.m., and stated that the resident's skin assessments are completed on Monday evening. -The LPN stated that she was not aware of the resident's bruises until 12/9/13 when she completed a head to toe assessment (see below), although the LPN acknowledged resident #5 has her FSBS checked twice a day and A&D ointment was applied to the resident's upper and lower extremities daily on her shift. -The LPN stated that she only applies the A&D ointment to the resident's lower half of her arms and does not go above her elbows and would not have seen the bruises to her right bicep. The resident's private sitter was interviewed on 12/9/13 at 12:52 p.m., and stated that she had been working with the resident for about a month. She stated she had seen bruises to the resident's arms, but she was not sure when they occurred. She stated that she did not question the bruises because she could see that the lab had previously had a difficult time drawing blood from resident #5. A CNA familiar with resident #5's care and who provided resident #5 with showers on 12/3/13 was interviewed on 12/9/13 at approximately 2:30 p.m. The CNA stated she was not aware of resident #5 having any bruising to her upper or lower extremities and that if she had noted bruising, she would have reported it to the nurse. A second CNA familiar with resident #5's care, and who provided resident #5 with a partial bed bath on 11/30/13 and 12/6/13, was interviewed on 12/9/13 at 2:41 p.m. The CNA stated that he was not aware of any new bruises but resident #5 had old bruises that he related to the phlebotomist having trouble drawing blood. The CNA stated that he asked the nurses if they were aware of the bruises; however, he was not able to state when he had asked. The assistant director of nurses (ADON) was interviewed on 12/9/13 at 1:23 p.m., and stated that skin assessments are completed weekly on Monday and the resident's next assessment was to be done on the evening shift of 12/9/13. The ADON stated that if the resident had received a shower/bath and if the CNA observed the bruises, she would expect them to report them to the nurse; however, if the CNA did not see them during the shower/bath, then the nurse would have discovered them during the next skin assessment and then they would have followed the procedure for bruising of unknown origin. The ADON was interviewed a second time on 12/9/13 at 2:15 p.m., and stated that if staff was applying A&D ointment to the residents upper and lower extremities daily, the nurses should have noticed and followed up on the bruising. A Registered Nurse (RN) familiar with the resident's care was interviewed on 12/9/13 at 2:19 p.m., and stated she was not aware resident #5 had bruises to the top of her hands or right bicep. She also said she had not received any complaints regarding the phlebotomist having difficulty with the resident's blood draws. The Director of Nurses (DON) was interviewed on 12/9/13 at 10:25 a.m., and stated that resident #5 was very complex; she was being seen by hospice, the medical director and herself weekly. The DON stated that she was not sure where the bruising came from, that she had talked with therapy department and would need to determine what was causing the bruising. Later the DON stated that she had contacted the laboratory services and requested that certain phlebotomists not return to the facility because they were causing bruising to several of the residents. The facility medical director was interviewed on 12/9/13 at 3:00 p.m., and stated that the brushing to the resident's right bicep appeared to be from a tourniquet when blood was drawn along with the bruise to the top of the resident's left hand. The MD was not sure what may have caused the bruise to the resident's right knuckle. 4. Facility Action On 12/9/13 at approximately 10:45 a.m., the DON stated that a complete head to toe assessment of the resident was completed on 12/9/13 (during survey) and it had revealed bruising to the resident's hands, biceps and bilateral lower legs. According to the facility event documentation dated 12/9/13, resident #5 had multiple pinpoint bruises to her bilateral lower extremities, a 3 cm x 2 cm bruise to her left bicep, a 6 cm x 6 cm bruise to her right bicep, a 1 cm x 1 cm bruise to her left hand, and a 3 cm x 1.4 cm bruise to her right hand. All of which were of unknown origin. On 12/9/13 a physician order [REDACTED]. lower extremities until they were resolved.

Based on observations, record review and staff interview, the facility failed to ensure one (#29) of 21 sample residents, who had a gastrostomy tube, received appropriate treatment and services to prevent complications. Specifically, staff failed to check for proper placement of the gastrostomy tube ([DEVICE]) prior to administering medications. Findings include: 1. Facility policy regarding enteral feeding was requested and received from Director of Nursing (DON) on 12/5/13 at 10:15 a.m. The policy revised on June 2011 documented, in pertinent part, the following: "Tube placement is checked prior to administering medications, tube flushes or enteral formula. Tube placement is checked via one or more of the following: -inject air into the tube using a 60 cc syringe while auscultating the gastric region of the abdomen for the sound of air coming through the end of the tube; -aspirate gastric effluent from the tube using the process described in the section of this protocol called gastric residuals. These placement checks are combined with observing the resident for s/s (signs or symptoms) of aspiration or other indications that the tube has been displaced." 2. Resident #29 Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly 10/4/12 minimum data set (MDS) assessment documented Brief Interview for Mental Status (BIMS) 13 of 15, indicating the resident was modified independent with daily decision-making. The resident required extensive to total assistance with all ADLs except eating. Record Review: Review of the computerized physician orders [REDACTED]. Observations: On 12/5/13 at approximately 9:45 a.m., administration of the medications and 500 (ml) milliliters of fluids were observed. The Registered Nurse (RN) removed the end cap (plug) from the [DEVICE], and placed the tip of an empty 60 cc (cubic centimeters) syringe into the end cap. The RN administered 30 cc of water into the [DEVICE], and immediately added the dissolved medications one by one with a rinse of fluids. After giving the medications, the RN administered more fluids (approximately 120 ml). The nurse did not check for placement of the [DEVICE] prior to administering medications. Interview: On 12/5/13 at 11:30 a.m., the RN above was interviewed. The RN confirmed she did not check placement of the [DEVICE] prior to the administration of medications. She stated she should verify proper position of the [DEVICE] every time prior to administering anything via the tube.

Based on observation, record review and staff interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically: The facility failed to prevent the spread of infection when staff did not wash their hands after each direct resident contact for which hand washing was indicated by professional practice for three (#7, #14, and #17) of 21 sample residents. The findings include: 1. Professional Reference According to the Internet web site http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf, (in pertinent part): "Recommendations: 1. Indications for handwashing and hand antisepsis I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient." 2. Observations Continuous observation of the dining room on 12/3/13 from 12:15 p.m. through 12:47 p.m., revealed a Certified Nurse Aide (CNA) as he assisted and coached three residents during their lunch meal. -Resident #7, age 91, was admitted to the facility 3/9/13. According to her 9/10/13 Minimum Data Set (MDS), [DIAGNOSES REDACTED]. -Resident #17, age 94, was admitted to facility 5/24/12. According to the 10/1/13 MDS, [DIAGNOSES REDACTED]. -Resident #14, age 96, was admitted to the facility 11/6/10. According to the 11/9/13 MDS, [DIAGNOSES REDACTED]. The three residents sat at a half round table off to the right side of the dining room in an alcove. Resident #7 sat to the far left side of the table with the window at her back, facing resident #14. Resident #17 sat to the right of resident #7, facing the wall. Resident #14 sat to the far right side of the table, to the right of resident #17, facing the window and resident #7. A Certified Nurse Aide (CNA) sat at the table to the left of resident #14. At approximately 12:15 p.m., at the request of resident #14, the CNA used his right hand to unlock the front and back brakes on the left side of the high-backed specialty rolling chair. These locks were flat paddles in direct contact with the tires on the left side of the chair. He repositioned the chair, and then relocked the brakes. The resident requested his chair be brought closer to the table, and the CNA again unlocked both brakes, pushing the chair forward and relocked the brakes. Without washing or otherwise sanitizing his hands, he placed the cloth napkin onto resident #14's lap. At the resident's request, the CNA cut his ham with a knife and fork, and then placed the fork on the resident's plate. The resident used the fork to pick up pieces of ham. On 12/3/13 at 12:38 p.m., the CNA turned to assist resident #17. Without washing or in any other way sanitizing his hands, he used the knife and fork to cut the ham. On 12/3/13 at 12:41 p.m., resident #17 was observed to use the fork and picked up pieces of ham, putting it into her mouth. She chewed the ham, and then used her right thumb and index finger to remove the partially chewed meat back on her plate. She did this with all pieces of ham on her plate. On 12/3/13 at approximately 12:41 p.m., the CNA moved his stool to sit at the right of resident #7. Without washing or in any other way sanitizing his hands, he used the knife and fork to cut her one-half hamburger in half. The resident picked up the hamburger in her hand, and intermittently used the fork to pick up the tomato. On 12/3/13 at approximately 1:00 p.m., without washing or in any other way sanitizing his hands, the CNA used a knife and fork to remove the paper wrapper from three cupcakes, and cut the cupcakes in half for each resident. Residents used their hands to pick up the cupcake pieces. 3. Interviews In an interview on 12/5/13 at 1:55 p.m., the CNA confirmed he should have cleaned his hands after touching resident #14's specialty chair. He said he usually used a hand sanitizer, located on a small table in the larger part of the dining room. Due to table decorations on that table, the hand sanitizer was not available. He confirmed he cut meat for all three residents at the table. He said he had the option of carrying a small hand sanitizer in a pocket if he wanted to, but did not have the hand sanitizer available that day. In an interview on 12/5/13 at approximately 2:30 p.m., the day charge nurse said it was her expectation that staff wash their hands after they have contact with items in the environment, including equipment. In an interview on 12/5/13 at approximately 2:15 p.m., the Director of Nursing said the CNA should have washed his hands after his contact with the resident's specialty chair. 4. Training Review of the training records for the CNA revealed he was trained in blood borne pathogens, hand hygiene, and safe food handling on 7/2/13.

Based on observation, record review and staff interview, the facility failed to have evidence that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source involving two of 24 sample residents (#9 and #18) were thoroughly investigated. The findings include: A. Facility Policy Review of the 5/07 Abuse/Neglect Prevention policy, most recently revised 6/11, revealed the following: "5. Injuries of Unknown Source are injuries for which both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent or location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Establishing a Resident Sensitive Environment: 1.1.3 Pattern Assessment: at least quarterly, the Quality Assessment and Performance Improvement Committee (QAPIC) reviews grievance identification reports, accident reports, incident reports, missing items reports and Safety Committee reports to assess possible patterns and trends of suspicious bruising of residents, unexplained accidents, or other occurrences that may constitute abuse, neglect or theft. After viewing the reports, the QAPIC determines whether further investigation and/or a change in practices is warranted. Internal Investigation of Allegations and Response: 5. Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the Administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: Name, age, [DIAGNOSES REDACTED]." B. Residents 1. Resident #9, age 93, was admitted to the facility 11/6/10. According to the Current [DIAGNOSES REDACTED]. According to the 8/27/12 Minimum Data Set (MDS), the resident was moderately hard of hearing and wore hearing aids. He had unclear speech, usually understood others, and was sometimes understood by others. He had short-term memory impairment and had symptoms of [MEDICAL CONDITION]. He required the extensive assist of one person for most activities of daily living, including bed mobility and transfers. a. Care Plan - Bruising Review of the electronic record on 9/5/12 revealed a 7/19/12 short-term acute care plan. The problem was he developed a new bruise to his left upper extremity. It was determined the cause was the resident leaning on his left wheelchair arm. -An 8/14/12 entry revealed the resident had a new bruise to his right shoulder. There was no cause identified. -An 8/30/12 entry revealed new bruising to his right upper extremity, right index finger, right middle finger, left ring finger, left middle finger x2 and the top of his left hand. Again, no potential cause was identified. The short term goal (target date 9/7/12) was the bruising would resolve without complication. Approaches included: -7/19/12 Assess for contributing factors and eliminate as possible; Continue to encourage resident to wear long sleeves/geri-sleeves for added skin protection as he will tolerate (he usually refuses); Monitor bruising each shift for worsening/changes and report to physician; Measure weekly; Notify medical durable power of attorney (MDPOA) and physician. The resident is taking Aspirin daily. -8/13/12 Encourage resident to sit in his recliner when in his room. Sitting in his wheelchair is causing bruising and can be uncomfortable; -8/14/12 Therapy to reassess the resident's transfers to see if this contributed to the formation of bruises. Re-educate the staff as necessary; -8/30/12 Check on the resident frequently when in his wheelchair. He often hits his hands when attempting to put his brakes on and off which caused bruising. Assist him with brakes and propelling the wheelchair as needed each shift; -9/4/12 Therapy had recommended that Hospice would provide a high backed wheelchair. Hospice was notified and would deliver it within two days. Review of the electronic record on 9/5/12 revealed an 8/24/12 short-term acute care plan for a new skin tear to his left elbow. This was discovered during physical therapy by the therapist. It was unknown how this occurred. The short term goal had a target date of 9/7/12. The goal was the skin tear would heal without complication. Approaches included: -8/24/12, the resident's elbow protectors were discontinued related to his refusal to wear them. The staff were to encourage long sleeves and pants per his tolerance; Monitor sites each shift for signs and symptoms of infection and changes/worsening; Provide treatment as ordered. Measure per protocol. Report to physician; Staff (including therapy) to be extra cautious during transfers and activities of daily living as the resident had poor posture causing his back to be easily scratched. b. Interviews Interviews revealed facility response to bruising included observation, documentation, and tracking of the bruising. However, facility response did not consistently include interviews with the resident, other residents, or staff. In an interview on 9/5/12 at 7:25 p.m., registered nurse (RN) #1 said the resident was a one-person assist for transfers. If staff reported a new bruise or other injury, she would look at the patient, filled out an incident report, and notify the family and physician. She measured the injury site and asked the resident or staff if they knew what happened. In an interview 9/5/12 at 7:30 p.m., licensed practical nurse (LPN) #3 said if staff found a bruise, they would report it to him. He would go see the bruise or other injury and ask the resident what caused this. He said he would ask the CNA (certified nurse aide) how it was discovered. He would write out a report and put the identification of an injury on the 24 hour report. In an interview on 9/6/12 at 12:00 noon, RN #2 said if staff notified her of a bruise or other injury, she went and assessed the resident. She said this assessment included measurement of the injured area, and asking the resident and staff individually what caused the bruise. She initiated event charting in the electronic record. She said she was not asked to do any further investigation or interviews about an incident. In an interview on 9/6/12 at 11:30 a.m., LPN #4 said if a CNA tells her of a bruise, she looks at the resident. She said she checked to be sure this was not an already-identified event, assesses the bruise, measures it and starts event charting. She completes an incident report. She would ask the staff as well as the resident how it happened. She said she was not called on to continue the investigation, as this was done by nursing administration. In an interview on 9/5/12 at 4:30 p.m. and again at approximately 5:15 p.m., the Interim Director of Nursing (IDON) confirmed he was responsible for investigation of injuries of unknown origin. -The IDON said if a CNA found a bruise or other injury during a shower or bath, the CNA would get the nurse to come into the bath room and observe the area of concern. He said the CNA staff did not use any paper record to mark the body part on a human map. -The IDON said nursing staff was responsible for writing a description of the injury, as well as monitoring the healing of the injury in the nursing progress notes on the electronic system. He said the nursing staff could do a better job of giving more information as to the location of the bruises and skin concerns. He said part of the investigative process was to have therapists observe transfers, but no specific cause could be determined for these repeated bruises. He confirmed this resident had very fragile skin. In an interview on 9/6/12 at 10:00 a.m., the Nursing Home Administrator (NHA) said the facility held a Stand Up meeting each day, Monday through Friday, where incident reports were reviewed by the entire interdisciplinary team. This team consisted of the Director of Nursing or designee, Nursing Home Administrator, all department heads including the Therapy Manager. Part of that review was to determine the cause of an injury, if possible. He said unless a resident could verbalize staff was rough, the investigation did not include talking to staff about what caused an injury. He also said there was no interview of other residents to determine if anyone else had experienced similar concerns. c. Facility Investigations Review of the following facility investigations of the bruising documented on the acute care plans revealed multiple incidents of bruising without a known cause, and no evidence of interviews with the resident or other staff and residents to identify potential abuse: -7/19/12, 19:30 (7:30 p.m.): The facility investigation of the four bruises of unknown origin to the left upper extremity (LUE), discovered during a routine skin assessment: There was no swelling. The bruises were circular in shape. The resident had no pain. The physician was notified. The follow up to the investigation showed other bruises to the right inner elbow had merged to form one bruise, and another bruise to the right bicep was fading and diminished in size and color. The writer noticed the resident was leaning on his right side and his arm got caught between the wheelchair and his body. The author wrote nursing staff was educated to reposition the resident prior to transfers. Geri-sleeves were applied to the resident's arms. -8/12/12 at 15:30 (3:30 p.m.): The facility investigation of a left upper extremity bruise measuring 2.5 x 1.1 cm. No probable cause was identified. -8/13/12 at an unknown time, a reddish blue bruise on the left forearm, 1.2 x 2 cm. Follow up form showed the resident continued to wear geri sleeves, was not to come in contact with hard surfaces, and continue to monitor. The resident was documented as being unable to propel himself in his wheelchair. -8/14/12 at 1720 (5:20 p.m.): The facility investigation of a 1 cm circular purple/black bruise to the right inner elbow. No probable cause was identified. -8/14/12 Bruise to R elbow 2 x .7: Summary: Resident states he was waiting by the nursing station to call his daughter and his elbow was caught under the counter at the nursing station. He sustained a dark purple bruise/Hematoma to his right elbow which measures 2 cm x .7 cm; No physician notified, no family contacted. No follow up form was attached. -8/14/12 at an unspecified time: The facility investigation of a 2.5 cm x 1.7 cm. bruise noted to the top of the resident's right shoulder; On the follow-up form, a bruise to the right inner elbow from an 8/12/12 investigation measured 2.5 x 1.1 cm. Nursing actions taken included monitoring of bruises every shift and continue with geri-sleeves. An environmental investigation concluded no abnormalities. The writer observed a certified nurse aide (CNA) perform a transfer. Staff would continue to monitor. No probable cause was identified. -8/24/12 at 11:50 a.m.: The facility investigation of a skin tear to the left elbow: During a hallway walk with therapy, a therapist identified a skin tear (ST) to the resident's left elbow. The cause was unknown. Was given a spa bath by the Hospice aid earlier in the morning, but that was not identified as the location of the injury. The ST was "L-shaped," and measured 1 x 0.4 cm. nursing actions included monitoring the injury every shift. The follow up form showed no signs/symptoms (S/S) of infection. The writer indicated either the wheelchair or the bath were potential causes for the injury. After a review of the resident's records, and another review of the resident's surroundings, there was no evidence of probable cause of the injury. -8/26/12 at an unknown time, investigation of a 1 cm x .1 millimeter (mm) scratch on the resident's lower back at the midline. This occurred while a CNA was dressing the resident. Noted a superficial scratch on lower back. The resident was unaware of the scratch. On the follow up form, as of 8/28/12, the scratch was healing well. Under "Further Actions," the writer reviewed the resident's records, and examined the resident's room and equipment for sharp edges. No environmental source of the injury was identified. The staff received verbal education regarding gait belt usage and transferring techniques. -8/30/12 at an unknown occurrence time: The facility investigation showed a total 7 bruises were found during a routine skin assessment. The follow up form (undated) showed bruises to the right elbow have merged together. The report noted the resident wore geri-sleeves and long sleeve shirts to protect skin. (However, the 8/24/12 investigation, see above, documented the geri-sleeves were discontinued as the resident would not wear them.) Review of the 8/30/12 electronic skin check showed bruising to right shoulder, RUE, LUE, bilateral hands. Topically-applied adhesive strips held the edges of the ST together for healing. d. Observations and Interview A resident interview was attempted 8/30/12 at 2:47 p.m. At that time, the resident's speech was slurred, and difficult to understand. He fell asleep during the interview. Observation on 8/30/12 at 2:50 p.m., revealed the following bruises on the resident's hands: -Left long finger: purple/red dime-sized bruise to the middle section of the back of the finger; -Left ring finger: dark purple swollen linear bruise on the back of the finger, distal to the back of the hand. The resident had a ring on that finger, just proximal to the bruise. -Right index finger: dark purple quarter-sized bruise on the back of the finger near the back of the hand; and -Right long finger: dark purple nickel-sized bruise to the index-finger side of the first section of the finger. The resident was observed to wear a long sleeved shirt and long slacks. The resident was sitting in his recliner with his legs up. His speech was slurred and unintelligible. Observation on 9/4/12 at approximately 9:30 a.m., revealed the bruises described above were faded to faint red speckled markings over the areas involved. Again, the resident was wearing a long sleeve shirt. He answered yes and no questions, but responses other than yes and no were not understandable. 2. Resident #18, age 91, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), dated [DATE], the resident had moderately impaired cognition, and problems with his short-term memory. The resident required extensive assistance with transfer, ambulation, bathing and dressing. He needed limited assistance with hygiene, and supervision with eating. The resident was coded as having skin tears. a. Record Review Nurses' Notes: The resident's medical record was reviewed on 9/5/12. Review of the Nurses' Notes revealed that beginning on 8/1/12, there were frequent entries documenting the condition of the resident's skin. -On 8/1/12 at 1:35 p.m., the nurse wrote "Resident has multiple bruises to BL (bi-lateral) hand and arms. MD notified - stated that aspirin could cause bruising. Nurses to monitor sites q (every) shift. Family also notified of condition. S/T (skin tear) to R(ight) elbow healing well. Will continue to monitor." -Further review of Nurses' Notes for 8/12 revealed additional entries for the month. -On 8/30/12, two entries were made. At 3:25 p.m., an entry read: "Resident on f/u (follow-up) for s/t and bruises to BLUE (bilateral upper extremity) bruises are healing no c/o pain or discomfort L(eft) arm s/t looks red and warm to touch. Triage nurse for Dr (Name) notified, said that he will let PA (Physician Assistant) look at it on Friday. If it gets worse to call the on call (physician) any time. Will continue to monitor." At 6:17 p.m., an entry read: "Resident continue in F/U for bruises, intact with no s/s of infection, LFA (left forearm skin tear) with intact steri strips. Redness around area. Warm to touch. Denies any pain or discomfort and will continue monitoring." -On 8/31/12, two entries were made. At 2:56 p.m., the nurse wrote "Skin tear on LFA has small amount of drainage and redness surrounding areas. Notified (Name), PA for Dr. (Name) who is here to the resident. Will continue to monitor." At 9:39 p.m., "Resident started on ABX (antibiotics) for LFA ST possible infection, dressing change as ordered. Intact bruises. Denies any pain or discomfort. Use w/c (wheelchair) for ambulation. Will continue monitoring." Care Plan: Review of the resident's Care Plan indicated that on 8/1/12, the following Problem was identified for the resident: "Mr. (Resident's last name) has multiple bruises to his BUE (bi-lateral upper extremities) including a bruise to his right forearm and LUE (left upper extremities) r/t (related to) ASA (aspirin) use. MD has been notified and believes the benefit of taking ASA is better than risks." An update to the Problem was added on 8/31/12 that read as follows: "Bruise to left forearm is open. Mr. (Resident's last name) taking ABX (antibiotics) r/t drainage and redness to site." "Short Term Goal 9/12/12, Bruising will resolve without complications" and on 9/5/12, "Left forearm skin tear will heal without complication. Redness and draining will resolve." The Approaches included: "Instruct (resident's name) and family on how to prevent injury further bruising as needed. - Measure per protocol. - Monitor bruising each shift for s/s (signs/symptoms) of worsening or changes. Monitor for other signs of active bleeding (blood in stool/urine, etc.). Report to MD. - Notify MDPOA (Medical Durable Power of Attorney). - Administer medication as ordered. Monitor QS (every shift) for s/s of adverse reactions and/or contraindications. Report to MD. - Provide dressing/treatment as ordered. Measure per protocol. Monitor QS for s/s of worsening/improvement. Report to MD. - VS (vital signs) per protocol.." Telephone Orders (TO): Review of the Telephone Orders revealed a TO dated 8/10/12 that read "Resident to wear geri-sleeves (fabric skin protectors) on in a.m. and off in p.m." Skin Assessments: Review of the Skin Assessments revealed the following comments on the resident's Weekly Skin Assessments. -8/29/12 - "Intact bruises to upper extremities." -8/22/12 - No comments written -8/15/12 - No comments written -8/8/12 - "BUE (bilateral upper extremity) bruises intact with no s/s of infection -8/1/12 - "Multiple bruises to bilateral arms, ST intact and dry with no s/s of infection." b. Observations On 9/5/12 at 6:49 p.m., the resident was observed sitting in his room in his wheelchair. He was wearing a neatly pressed long sleeved blue shirt. The bruises and skin tears on his arms were not visible. Observation of the resident's closet revealed approximately twelve long sleeved shirts hanging from the rod. c. Interviews On 9/6/12 at 8:55 a.m., the Nursing Home Administrator (NHA) was asked to provide the above investigations. On 9/6/12 at 12:00 p.m., the NHA provided an Internal Incident Report for the injuries discovered on 8/1/12. On 9/5/12 beginning at 5:15 p.m., the IDON was interviewed regarding how CNAs were to handle any skin injuries that they found when working with the resident. He stated that if the CNA found skin issues during showers, the CNAs were to get the nurse. The nurse would then document the injury on an Event Form. On 9/6/12 at 9:00 a.m., a CNA was interviewed about the resident and the bruising. She stated that the resident was usually a one person assist because he could pivot and hold on to the grab bar. The CNA said that the resident liked to propel himself in his wheelchair, but he often bumped into walls and tables. She stated that the resident always liked to look well dressed, and that he usually wore long sleeved shirts which helped protect his arms. The CNA said that the resident would agree to wear geri sleeves (protective arm coverings) on some days, and other days he would not. d. Facility Investigations On 9/5/12 at 5:30 p.m., investigations of the resident's injuries on 8/1/12, and the skin tear which required antibiotics on 8/31/12, were request from the IDON. At 5:45 p.m., the IDON stated that he was still looking for the investigations. On 9/6/12 at 8:55 a.m., the Nursing Home Administrator (NHA) was asked to provide the above investigations. On 9/6/12 at 12:00 p.m., the Nursing Home Administrator provided the requested investigation for the injures found on 8/1/12. Review of the investigation - titled the Internal Incident Report and dated 8/1/12, revealed the following documentation: "INTERNAL INCIDENT REPORT Date occurred - unknown Time occurred - unknown Name - (Name of resident) Room - (Number of resident's room) Location of incident - unknown Type of Event: other - bruises Summary of Event: Resident has multiple bruises to BL (bi-lateral) hand and arms. Unknown origin. Resident is on aspirin 81 mg po q day (milligrams by mouth every day)" Mobility device in use - walker and wheelchair Family contacted - (Name of son) at 1330 (1:30 p.m.). Physician notified (Name of Physician) on 8/1/12 at 10:04 am. Physician recommendation - monitor bruises q (every)shift. " The Incident Report was reviewed and signed by both the Supervisor and Executive Director. A separate Incident Report, dated 8/31/12, for the skin tear that required antibiotic treatment was not provided. Without a detailed investigation, it was not possible to determine if the skin tear was the result of the bruises found on 8/1/12, or a new injury.

Based on record review and staff interviews, the facility failed to adequately assess one of three sample residents (#1) to maintain his highest practicable well-being. Specifically, sample resident #1 started complaining of pain in the hip and nursing staff did not adequately assess the source of pain. The next morning, the resident was noted to have a right hand fracture and a right [MEDICAL CONDITION], injury of unknown origin. A concern was filed with the health department regarding this resident's safety. The resident was dependent on staff for all cares. The resident was hospitalized with two fractures of unknown origin. An onsite visit occurred at the facility to investigate the events. The findings include. I. On 11/23/11, the resident was admitted to the hospital with [REDACTED]. The resident was dependent on staff for all cares, safety and mobility needs. A. Record review of the resident's functional status and safety needs prior to 11/23/11: Sample resident #1, [AGE] years old, was admitted to the facility on [DATE]. According to the facility admission sheet, the medical [DIAGNOSES REDACTED]. According to the 10/25/11 Minimum Data Set (MDS), the resident scored an 11 on the cognitive score, indicating moderate impairment. The resident required extensive assistance with Activities of Daily Living, required human assistance to maintain balance and had no falls or pain issues. Staff reported the resident had occasional [MEDICAL CONDITION] on this MDS. The 8/4/11 care plan revealed the resident was limited in ability to transfer self related to his [MEDICAL CONDITION], poor safety awareness and unsteady gait. Staff was directed to provide the walker, gait belt and assist of one for transferring. Staff was to remind the resident not to transfer without assistance. An 8/4/11 care plan identified the resident was at risk for falls related to [MEDICAL CONDITION], visual deficits, unsteady gait, poor balance, fall risk score of 12, fluctuating activities of daily living (ADLs), incontinence and history of falls. The resident had a private companion six hours a day. Safety approaches included reminding the resident to use his call light, keep light within reach, wear non-skid shoes, and utilize a low bed at night (not all inclusive). An 8/19/11 care plan identified the resident to be at risk for pain. Staff was directed to assess effects of pain on activity disturbances, monitor and record any complaint of pain including location, duration, quantity, quality, alleviating factors, aggravating factors every shift and as needed. Staff was directed to monitor and record for any non-verbal signs of pain. An 8/1/11 care plan identified the resident was at risk for decrease in ability to perform his ADLs related to impaired mobility, [MEDICAL CONDITION], dementia and lack of coordination. The resident required extensive assistance of one for ADLs. The resident utilized both a wheelchair and walker depending on how he felt that day. II. Sample resident #1 began complaining of pain on the evening of 11/22/11 and told staff he fell (this is what he told staff when they asked about his pain - established through staff interviews conducted by the facility - there were no reports of a fall from staff). Nursing staff administered Tylenol for pain but did not complete a thorough assessment through the evening and night of 11/22/11. On 11/23/11, the next morning, the resident had a [MEDICAL CONDITION], a bruised/[MEDICAL CONDITION] fractured hand and a skin tear on the right forearm. The following events were revealed through record review and staff interviews: A. Review of the medical chart and nurse's notes revealed the resident had no pain complaints prior to the 11/22/11 (three months prior). Nursing staff assessed pain every shift and the records indicated no complaints of pain. B. On 11/22/11 around 7:10 p.m., the resident complained of right hip pain to a caregiver, providing ADL cares. Certified Nurse Aide (CNA) #1 expressed the resident had difficulty transferring in and out of the wheelchair and had pain. The Licensed Practical Nurse (LPN) was notified of the resident's pain and administered two tablets of Tylenol for a pain level of 3/10. The LPN documented the initial dose of Tylenol was effective and the pain level decreased to zero around 9:00 p.m. Later that evening, the resident complained to another CNA of hip/knee pain. The nurse was notified. There was no further administration of pain medications. Around 4:00 a.m. or 5:00 a.m. (staff wrote over the number and it was difficult to determine the exact time of administration), the following morning, the resident complained of pain in the right hip to the night CNA # 6. CNA #6 was initiating morning cares with the resident. The nurse was notified. The night nurse administered more Tylenol for pain relief at 4-5 a.m. The pain level was a 3/10 and decreased to a 1/10. Nursing staff assessed pain levels but did not further assess the resident's new onset of pain, even after the resident told a caregiver he fell and that was the reason for pain. C. Review of the 24 hour reports, dated 11/22/11, showed nursing staff was aware of the resident complaints of pain. Nursing staff documented on the 3 p.m. - 11 p.m. shift, "right hip pain - Tylenol 7:15 p.m." Nursing staff documented on the 11 p.m. - 7 a.m. shift, "denies pain - give Tylenol at 400 for right hip." There were no further assessments of the resident's pain. --Review of a few CNA assignment sheets for 11/22/11 revealed, "knee pain. Right hip pain - to down his knees - heat pad. Right hip pain 3/10 Tylenol 7:15 p.m." --When the resident complained of pain to the staff on 11/22/11, the nurse administered Tylenol but there was no further assessment of the resident's hip to include range of motion, palpation or a visual inspection. Through interviews (see below), the resident had told staff he fell that evening (to three different staff members). Staff did not assess the resident except for administering Tylenol. --There were no nursing entries or assessments for 11/22/11 until 11/23/11 at 5:19 p.m. D. The next morning on 11/23/11, staff got the resident out of bed. After breakfast, sometime around 9:30 a.m., CNA #5 attempted to transfer the resident to the restroom. The resident had difficulty standing and a second staff member, CNA #4, was summoned to assist with the transfer. The resident was toileted and brought into the bedroom area. The day LPN was summoned to the room due to inability to transfer the resident and complaints of pain. Review of the MAR indicated [REDACTED]. The pain level decreased to 4/10. It was at this time, the day LPN and the Director of Nursing (DON) noted the right hip/knee area was tender to touch and the resident stated it hurt when moved. The resident's right hand was bruised and swollen (fresh trauma) and there was a skin tear down the back of the right forearm (wrist down to elbow). The day before, on 11/22/11, two nurses observed the resident's skin (although a late entry - the note was entered on 12/1/11 at 3:56 p.m.). There were no bruises or skin tears identified one day before the injuries on 11/23/11. -On 11/23/11 at 11:00 a.m., stat (immediate) x-rays were ordered for right hip pain and for right hand bruising/[MEDICAL CONDITION]. While awaiting the x-ray results, the resident's respiratory status changed and further tests were ordered, chest x-ray and urinalysis, around 1:00 p.m. The x-ray results were received around 2:19 p.m. that showed an acute non-displaced [MEDICAL CONDITION] metacarpal (finger), left lower lobe infiltrate and an inter-trochanteric fracture (undiagnosed fracture of a major long bone/pelvis). -On 11/23/11 at 5:19 p.m., the LPN documented, "Nurse was called in to see the resident for complaints of right hip pain. I asked resident to show me where the pain was and to describe the pain. Resident pointed to his right hip and stated if doesn't hurt if is still, when he moves it hurts. Nurse asked resident if she could transfer him to his bed so I could examine him. A gait belt was placed on the resident and this nurse and a CNA transferred resident from his wheelchair to his bed. Upon positioning him in bed I noticed a large bruise with swelling to his right hand measuring 15 cm x 10 cm. I immediately called the RN into assist with the rest of his examination. Resident was unable to give me a pain scale number, he was then asked if it hurt a little, medium, or a lot, he stated it hurt a lot. He was given Tylenol 650 mg for pain. DON was notified and orders received from Physician Assistant (PA) for (MD name) to order a stat R-hand and R hip x-ray. Resident stated pain was decreased but not totally gone. Daughter was notified and she stated she would be over at approximately 12:00. Shortly after lunch, resident's face was all red, VS (vital signs) were 116/70, 100.1, 87, 18, oxygen 80% on RA (room air). Placed another call into PA, who ordered a chest x-ray, UA and FLU A&B. Received x-ray results and reported them to PA, who spoke with the family and orders to send to the hospital..Resident transported out of facility at approximately 4:45 p.m." The resident was transferred to the hospital for treatment. Review of the 11/23/11 hospital documents confirmed the resident had a right intertrochanteric [MEDICAL CONDITION] without displacement. Surgery was required to fix the fracture. The right hand showed a fourth metacarpal fracture, which was splinted (mildly displaced oblique [MEDICAL CONDITION] metacarpal diaphysis with mild overlap of fracture fragments with osteopenia). E. After the resident's transfer to the hospital, staff entered the following nursing entries. The 11/22/11 pain event was incomplete and did not address a full pain assessment: On 11/28/11 at 9:39 a.m. for 11/23/11 at 10:30 a.m. (late entry), the Director of Nursing documented, "DON summoned to resident's room to visualize bruise on right hand, and evaluate right hip pain. Upon entering the room, the resident is resting in bed. Purple bruise noted to dorsal side of right hand. Swelling noted and resident complains of pain when the area is palpated. Superficial scratch noted to the ventral side of the right forearm. No active bleeding noted. Upon evaluation of the right hip, resident's legs are slightly elevated with a pillow under the resident's knees for comfort. Mild shortening and external rotation noted of the right leg when extended. Right hip area has mild fullness, no bruising noted. Resident complaint of pain when right hip area is palpated. Resident is unable to give an account of what happened to cause the bruising and pain. Shift nurse will notify the physician and get further orders." On 11/30/11 (date of re-admission back to the facility from the hospital), nursing staff documented notes about the 11/22/11 7:00 p.m. pain event. The nurse documented, "resident complained of right hip pain when transferring to the toilet." The physical assessment area was blank. The assessment prompted the nurse to identify the pain site, character of pain, frequency of pain, pain levels (rating the severity of pain on a 1 - 10 level), and duration of pain, onset of pain, expressions of pain, change in ADL status, mental status, possible contributing factors, interventions and outcome. The form prompted nursing staff to alert the physician if there was extremity pain with noticeable changes in alignment or inability to do ROM (range of motion). The physician and family were notified about the resident's complaint of pain on 11/23/11 around 10:00 a.m. III. Interviews: An attempt was made to interview the resident on 1/4/12 without success. On 1/4/12 at 10:59 a.m., the Occupational Therapist (OT) stated she worked with the resident on 11/23/11 during breakfast. The OT stated she assisted the resident with feeding techniques and did not see any bruising on the right hand that morning. The OT stated in her professional opinion the resident would not be able to get off the floor independently. On 1/4/12 at 11:37 a.m., CNA #4 stated CNA #5 (day CNA for 11/23/11) summoned her to the restroom to help transfer the resident on the toilet. CNA #4 stated the resident was not supporting his weight and the resident complained of pain in the hip. CNA #4 stated she did not see any bruising or skin tear during this transfer. The bruise on his hand and skin tear was not discovered until shortly afterwards when he was transferred onto the bed for the nursing assessment. On 1/4/12 at 12:12 p.m., the Activity Director (AD) stated the resident attended an outing on 11/22/11 to the aquarium and showed no difficulty with transfers or had any complaints of pain. The AD stated the personal caregiver (hired by the family) had toileted the resident at the aquarium. There were no reports of any difficulties during this outing. On 1/4/12 at 12:24 p.m., CNA #3 stated the resident used his call light on the evening on 11/22/11 and indicated he had pain in his hip and knee. CNA #3 commented the resident did not normally complain of pain. CNA #3 continued she was aware the nurse administered Tylenol previously and passed this information onto the nurse. The CNA stated the resident usually required assist of one for transfers. CNA #3 was unaware of any falls. On 1/4/12 at 3:05 p.m., the evening LPN (that worked 11/22/11) stated the resident complained of pain in the right hip area. The LPN stated the resident did not want pain medications initially but received it the second time he complained. The LPN commented the resident had some facial grimacing with movement. The LPN stated it was unusual for the resident to complain of pain. The LPN expressed she felt he might have had pain related to the long day with the special outing. The LPN did not further assess the resident's pain in the hip. The LPN stated she administered his 8:00 p.m. medications and took his blood pressure on the left upper extremity. The LPN did not visualize any bruising. The LPN was unaware of any falls. On 1/4/12 at 3:30 p.m., the evening RN (that worked 11/22/11) stated he was not aware of the resident having any pain until their end of shift report and nothing out of the ordinary was reported, i.e. fall. The RN did not conduct an assessment of the resident. On 1/4/12 at 4:04 p.m., the DON stated she was summoned to the resident's room on 11/23/11 to assess the resident. The DON recalled the resident's hand was swollen. There was no bruising to the right hip but had 'fullness' to the area. There was a scratch on the underside of the arm from the elbow to the wrist which was dry. There was spotty blood on the resident' pajamas (still in the hopper). The hand was purple with gravitation of the swelling/discoloration into the resident's fingers. The DON stated x-rays were ordered. The police were called. The DON stated the resident stated he had hit a wall and then changed it to a door. An investigation was initiated. The staff reported he told them he had fallen the night before. There was no conclusion to how this happened. The DON expressed that these injuries might have occurred at different times due to the resident's medical history of [REDACTED]. The DON commented some residents had personal caregivers in the facility and at times provided personal cares (such as toileting, etc.). On 1/5/12 at 1:15 p.m., CNA #1 (the CNA that worked with him on 11/22/11 in the evening) stated the resident complained of pain when she attempted to transfer him to the commode and he was dragging his leg. The CNA commented the resident grimaced but did not express pain. The CNA continued when she assisted the resident into bed, the resident expressed he was in 'excruciating pain' and she notified the nurse. The CNA stated she checked on him later that evening and he stated he was still having pain. The CNA stated the nurse was unable to give him more Tylenol at that point. This CNA stated she did not see any bruising or skin tears. CNA #1 stated the resident did not fall. On 1/5/12 at 1:37 p.m., CNA #6 (night CNA for 11/22/11 - 11/23/11 a.m.) stated she was told the resident had pain through report but he did not complain of pain through the night. When she went in for morning cares between 4-5 a.m., the resident complained of pain in the hip. The nurse was contacted and she administered pain medications. After the pain medications were administered, the resident was able to get up. The CNA stated she dressed him that morning and did not see anything. On 1/5/12 at 2:11 p.m., CNA #5 (day CNA for 11/23/11) stated she worked with the resident on 11/22/11 during the outing and the resident was able to transfer without any problems. CNA #5 stated the resident was not able to stand on 11/23/11 in the morning, after breakfast. CNA #5 needed help with the transfer to the toilet. CNA #5 commented the resident grimaced during the toilet transfer but did not express pain. The resident did not void. CNA #5 stated she did not notice anything on his hand during the toilet transfer. When the resident was transferred into bed for the nursing assessment, the bruising was noted on the hand (shortly afterwards). CNA #4 and CNA #5 completed a toilet transfer with the resident even when they noted a change in the resident's functional status. The resident was grimacing, expressed pain and had difficulty standing. A nurse was not immediately summoned to assess the resident at this time. On 1/5/12 at 4:40 p.m., CNA #2 stated CNA #3 had told him the resident was complaining of pain (the evening of 11/22/11) because he fell . On 1/27/12 at 8:15 a.m., the DON stated staff had up to 24 hours to initiate a pain event in the computer system (event charting notes a change in the resident's condition). The DON noticed a pain event had not been initiated on 11/22/11. A pain event was opened one week later as noted in the computer system (noted above). The DON stated a comprehensive assessment would include observation of the area, palpation and range of motion assessments. The DON acknowledged the nursing staff did not complete a full assessment on the evening of 11/22/11 when the resident started complaining of pain. Review of the facility's interviews with staff, revealed the resident had told three different staff members that he fell on the evening of 11/22/11. Although, staff did not report a fall or assisting the resident off the floor. Within 15 hours, after the resident initially complained of pain and without a complete nursing assessment, the resident now had two fractures and a skin tear.

Based on observation, record review and staff interview, the facility failed to ensure that it was free of medication error rates of five percent or greater. Specifically, the facility had a medication error rate of 10%, five errors out of 50 opportunities for error. The findings include: 1. Resident #18 Resident #18, [AGE] years old, was admitted to the facility on [DATE] with a re-admitted [DATE]. According to the facility face sheet, the resident's [DIAGNOSES REDACTED]. Record review: According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -[MEDICATION NAME] 100 mg, two capsules by mouth once a day. -Tylenol 650 mg by mouth three times a day after meals. -[MEDICATION NAME] HFA aerosol 110 mcg/inh one puff inhalation According to the computerized physician orders, dated May 2011, the resident had orders for the following medications: [REDACTED] -[MEDICATION NAME] 100 mg; give 2 capsules by mouth once a day. -Tylenol 650 mg by mouth three times a day after meal. -[MEDICATION NAME] HFA aerosol 110 mcg/inl 1 puff inhalation. According to a telephone order (TO), dated 4/1/10 at 7:00 p.m. and signed by the physician on 4/5/11 (the other two orders on the page were dated 4/7/11 and 4/4/11), the current [MEDICATION NAME] order was to be discontinued and changed to [MEDICATION NAME] 100 mg, 2 capsules by mouth every evening at bed time as needed. Observation: On 5/12/11 at 9:00 a.m., a licensed practical nurse (LPN) was observed as s/he administered: -[MEDICATION NAME] 100 mg, two capsules -Tylenol 325 mg, two tablets -[MEDICATION NAME] 5 mg -k-dur 20 meq -[MEDICATION NAME] 20 mg -[MEDICATION NAME] 25/100 mg, 1 ? tablets -nasal saline spray, one spray each nostril -[MEDICATION NAME] 110 mcg/inh two puffs. 2. Resident #21 Resident #21 was admitted to the facility on [DATE]. According to the facility face sheet, his [DIAGNOSES REDACTED]. Record review: According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]>150. Call Dr. (name) @303-***-**** if blood sugar is >450 mg/dl is crossed out with d/c (discontinued) 5/2/11 written next to it. Observation: On 5/12/11 at 11:00 a.m., the LPN checked the resident's blood glucose; the result was 232 mg/dL. The LPN returned to the nurses' station and referred to the resident's MAR for the sliding scale dose calculation. The LPN calculated the results, 232-150=82/50=1.64. The LPN drew up and administered 1 unit of humalog sliding scale insulin, instead of the ordered 2 units. 3. Resident #41 Resident #41, [AGE] years old, was admitted to the facility on [DATE]. According to the facility face sheet, her [DIAGNOSES REDACTED]. Record review: According to the MAR, dated May 2011, revealed the resident had an order for [REDACTED]. -[MEDICATION NAME] with vitamin D 200 units by mouth three times a day. -Senna S tablets 50 mg-8.6 mg by mouth every evening at bed time. -Keflex 500 mg by mouth three times a day. -[MEDICATION NAME] 4 mg by mouth once a day. -[MEDICATION NAME] 60 mg by mouth once a day. -[MEDICATION NAME] 0.25 mg by mouth twice a day. Observation: On 5/16/11 at 9:15 a.m., the LPN was observed to administer: -[MEDICATION NAME] 500 mg with vitamin D 200 units, [MEDICATION NAME] coated cut in half. -Senna S, two tabs. -Keflex 250 mg: The LPN attempted to administer two 250 mg capsules but the resident dropped one of the capsules; the LPN did not replace the capsule. -[MEDICATION NAME] 4 mg -[MEDICATION NAME] 60 mg -[MEDICATION NAME] 0.25 mg According to the facility's medication variance report, dated 5/16/11, the physician's orders [REDACTED]. The description of the variance was medication given at 9:45 a.m. The action taken was physician notified, skip HS dose for 5/16/11 and resume dose every HS on 5/17/11. Staff Interviews: On 5/16/11 at approximately 9:35 a.m., the LPN returned to the medication cart to sign off the medications she had just administered to the resident. She stated "Oh no, I gave the Senna and it's scheduled for HS (at bed time)." The nurse walked to the nurses' station where the Director of Nurses (DON) was sitting and she stated "I just made a med error." On 5/16/11 at 1:35 p.m., the DON was interviewed. She indicated that her expectations were that the nurses administered medication as the physician orders [REDACTED]. -Resident #18 received two puffs of his [MEDICATION NAME] inhaler and the physician order [REDACTED]. -Resident #21's sliding scale insulin was incorrectly administered. -Resident #41 had received only half of her antibiotic and Senna S was given in the morning instead of at bed time. The DON said her expectations where that the nurse replace the dropped keflex 250 mg to ensure the resident received the correct dose. She stated that the Senna S medication variance had already been completed.

Based on record review and interviews, the facility failed to revise the care plan for one (#19) out of 20 sample residents. Specifically, the facility failed to update the fall care plan with current interventions and to identify specific behaviors related to the use of an anti-anxiety medication. The findings include: 1. Failure to update the fall care plan Resident #19, [AGE] years old was admitted to the facility on [DATE] with a re-admission date of [DATE]. According to her face sheet, her [DIAGNOSES REDACTED]. Cross-reference F323; accidents. According to the medical record the resident had a fall on 3/17/11, 4/8/11, 4/9/11, 4/21/11, 4/25/11, 5/2/11 and 5/12/11. The falls on the 3/17/11, 4/21/11 and 4/25/11, were in the bathroom or right outside the bathroom on the way back to bed after using the bathroom. Review of the resident's care plan, dated 4/22/11, revealed the goal was that the resident would have no more falls before the next review. The interventions included: -alarm to be in place at all times to alert staff of unsafe transfers and the bed in low position at all times. -assure the resident is wearing her eye glasses; keep them clean and in good repair. -assure the floor is free from glare, liquids and foreign objects. -keep call light within reach while resident is in her room. -keep personal items and frequently used items within reach. -provide an environment free from clutter. -provide proper, well maintained footwear as she progresses from surgical shoes on her left foot to adapted shoes. -provide toileting assistance as resident requests, remind resident to use call light to ask for assistance to the bathroom and the bedside commode which she uses at night. -use a gait belt when ambulating or transferring the resident. On 5/16/11 at approximately 1:10 p.m., a certified nurse aide (CNA) was interviewed related to the resident's falls. He indicated that the resident was "absolutely" a fall risk, she had a low bed and a sensor mat next to the bed so that when she starts to get up it goes off. He said, "We have to stay with her in the bathroom because it seems to be her most vulnerable place." The CNA stated that the resident was on hospice and had been declining for a while. On 5/16/11 at 1:21 p.m., the charge nurse, who is a registered nurse (RN), was interviewed. She indicated that the resident should not be left alone in the bathroom since the fall on 4/21/11; she stated the resident also had a fall outside the bathroom on 3/17/11, after using the bathroom. The nurse said that usually, the staff put that intervention (not leaving resident alone in bathroom) into place if the resident falls more than once in the bathroom or if they fall right outside it on the way to the bathroom. When asked how this message is relayed to all staff, the RN responded, well it's on the care plan and then it should be relayed from shift to shift in report, everyone should know. On 5/16/11 at 1:35 p.m., the director of nursing (DON) was interviewed. She indicated that the resident should not be left alone in the bathroom. She said she could not recall the exact date that this intervention was put into place but it was prior to the fall on 4/21/11. She indicated that the nurses on the floor, either the medication nurses or the charge nurse, and the MDS (minimum data set) RN can update the care plans. She indicated that it was her expectation that the care plan be updated and that the interventions that are in place related to the resident's falls be reflected on the care plan. See care plan above; there was no intervention on the care plan related to the resident not being left alone in the bathroom. 2. Failure to identify the use of an anti-anxiety medication on the care plan. Review of the care plan, dated 4/25/11, revealed the resident has an identified problem that read: [MEDICATION NAME] added per hospice for anxiety prn (as needed). The goal was for the resident to not exhibit drug related side effects or adverse drug reactions through next review. The approaches included: -assess record effectiveness of drug treatment. Monitor and report signs of sedation, [MEDICAL CONDITION], or [MEDICATION NAME] symptoms. -try non-pharmacological interventions such as music, TV, being in a quiet area, and talking with family/staff as needed. There are no behaviors identified on the care plan for the use of the anti-anxiety medication. On 5/16/11 at 1:35 p.m., the DON was interviewed. She indicated that it was her expectation that the care plan reflect the target behavior that the anti-anxiety medication was to address. She indicated that the responsibility to care plan these behaviors was shared between the charge nurse, MDS nurse and the social service department.

Based on record review and staff interview, the facility failed to provide adequate notice of Medicare termination of benefits for one resident (#3) out of 20 sample residents. Specifically, the facility notified resident #3 on the same day skilled nursing/therapy services were terminated and failed to advise her of the potential liability for further services or allow her the opportunity to appeal the facility's decision. The findings include: Three Medicare beneficiaries were randomly selected by the QIS Survey Tool for review of Medicare Liability Notice and Beneficiary Appeal. Copies of the notices provided by the facility to the three residents named were reviewed and revealed the facility failed to provide timely notice, as set forth below. Record Review: Resident #3 was notified by the facility, using Form Number CMS , "Notice of Medicare Provider Non-Coverage." The form documented "The effective date coverage of your current physical and occupational therapy services will end on 11/19/10." The form was signed by the resident on 11/19/10, the same day as her coverage was ended by the facility. Policy Review: The nursing home administrator provided a copy of the facility's policy and procedure for "Advanced Beneficiary Notice (ABN)/Notice of Exclusion from Medicare Benefits (NEMB) Protocol." The protocol outlined the following procedures for providing Medicare beneficiaries notice of non-coverage, in pertinent part, as follows: Under the section titled "standards of practice" Continued Stay Determination (page 2): 1. The team determines the resident no longer qualifies for SNF Part A coverage due to a lack of medical necessity or non-covered custodial care. 1.1 The resident will continue in the SNF under a different payor source. 1.1.1. Issue ABN-SNF letter on or before the last covered day. 1.1.2. In addition, issue Generic Notice of an expedited review two days prior to last covered day. Under the section titled "expedited determination notices" (EDNs),(page 7): 1. Residents are provided notice of right to an expedited determination. 1.1. The Benefits Improvement and Protection Act (BIPA) provides Medicare beneficiaries with a right to fast track appeal (within 72 hours) by an independent organization known as Quality Improvement Organization (QIO). 2. Two forms may be used. 2.1. Notice of Medicare Provider Non-Coverage (Generic Notice). 6. The timing of the issuance of the EDN is outlined herein. 6.1 Generic Notice: must be issued no later than two days in advance of "last covered day." Can be issued earlier if "last covered day" is known." Under the section titled "valid notices," (page 10) -Must use CMS standardization form with specific language; -Issued two days before "last covered day." Staff Interview: The social worker was interviewed on 5/16/11 at 3:00 p.m. She stated that she was the one who gives Medicare notices to the residents after she is notified by the therapy department that a resident's services are ending. She stated she usually gives the notices at least one day in advance prior to the resident's last covered day of services.