Every finding on record at Advanced Health Care of Colorado Springs

Based on observations, interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#7) of two residents reviewed for falls out of 18 sample residents. Specifically the facility failed to timely implement appropriate and effective interventions to prevent five falls in a two week period. Findings include: I. Facility policy The Fall Prevention policy, updated 9/28/22, was provided by the director of nursing (DON) on 3/15/23 at 4:30 p.m., read in part: Safety interventions will be implemented and monitored with appropriate documentation as indicated .Based upon the calculated score of the Fall Risk Assessment, the fall risk protocol and care plan will be completed and the appropriate interventions initiated. The admitting nurse/nurse manager will be responsible for insuring that interventions are initiated and communicated to appropriate staff for follow through .The assigned licensed nurse will be responsible for ensuring safety checks are in place as care planned and will initial the TAR (treatment administration record) indicating checks are completed and document in nursing notes for verification. II. Resident #7 A. Resident status Resident #7, age 79, was admitted on [DATE]. According to the March 2023 clinical physician orders (CPO) diagnoses included encounter for orthopedic aftercare following surgical amputation, right below knee amputation, diabetes mellitus and heart failure. The 2/26/23 minimum data set (MDS) assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score 15 out of 15. She required extensive assistance with bed mobility and dressing, limited assistance with transfers and toilet use, supervision with eating, and she was independent with personal hygiene. B. Record review The comprehensive care plan, dated 2/27/23, included the following: Patient will improve self-care and mobility function and achieve discharge goals as identified on MDS (minimum data set) section GG. Approaches included: functional performance will be evaluated with discharge from skilled services. Functional discharge goals will be determined on admission. Baseline functional performance will be determined upon admission. Patient identified at risk for falls related to: Mobility and/or functional deficits. Impaired safety awareness and balance deficits. Goal: Risk of falls and/or injury related to falls will be minimized throughout stay. Approaches included: Monitor for adverse side effects of medication regimen; consult with MD (physician) as needed. Ensure proper placement of call light and assistive devices for ease of access. PT (physical therapy) and/or OT (occupational therapy) evaluation and treatment to address functional deficits. Educate patient and/or family regarding fall risks and safety needs. Encourage patient to call for assistance with transfers and ambulation. Assist with transfers and ambulation as needed. -The risk for falls care plan was not revised with new interventions after Resident #7's falls. Patient requires/receives staff assist with ADL (activities of daily living) completion r/t (related to) limited mobility and generalized weakness due to s/p (status post) Rt BKA (right below knee amputation). Goal: Patient will increase strength and endurance to regain independence per skilled therapy goals throughout stay. Patient will present a clean and neat appearance, clean clothing, properly adjusted, hair combed and neat throughout stay. Approaches included: Oxygen as ordered. Monitor of s/s (signs and symptoms) of lethargy/fatigue/dizziness r/t (related to) medication use; notify MD (physician) if s/s (signs and symptoms) occur. Monitor labs as ordered; notify MD (physician) of abnormal results. Monitor vital signs as ordered; notify MD (physician) of abnormal results. Functional mobility is expected to improve throughout the patient's stay. More or less assistance may be needed depending on progress, acute illness, time of day and/or psychosocial needs. Ensure call light is within patient's reach. Assist with ambulation or wheelchair mobility as needed. Monitor for s/s (signs and symptoms) of pain; assess pain at least every shift and PRN (as needed). Encourage patient to rest in between activities. PT (physical therapy) & OT (occupational therapy) to evaluate and treat per MD (physician) order. Staff to allow for and encourage patient choices and preferences. Staff to encourage independence/participation with ADLs (activities of daily living) as able. Falls On 2/28/23 a nurse documented: Pt (patient) stated she slipped out of w/c (wheelchair) and hit face on carpet, noted abrasion to bridge of nose, no other visible injuries noted. Given cool washcloth for abrasion. ROM (range of motion) good and neuro checks initiated d/t (due to) unwitnessed fall and are wnl (within normal limits). Pt (patient) on scheduled hydrocodone (pain medication). Pt (patient) is assisted back into bed with call light within reach. On call DON (director of nursing) notified of fall. On 3/4/23 a nurse documented: pt (patient) was trying to transfer from w/c (wheelchair) to recliner. Pt (patient) has BKA (below knee amputation) and thought her leg was whole. When trying to 'step' out of w/c (wheelchair), she fell on her right side. She was found sitting up on the floor and was upset that she did this. No increased pain than pt (patient) already has. Assessment negative. Neuro's (neurological assessment) started and wnl (within normal limits) so far. On 3/9/23 a nurse documented: Pt (patient) found sitting upright against the side of the sink in the bedroom. W/C (wheelchair) was in front of the bathroom door. She stated she slid from W/C (wheelchair). Pt (patient) assessed for injury with no injuries noted at this time. Neurological assessment in place and are WNL (within normal limits), ROM (range of motion) intact. Assisted back to bed. Bed in lowest position with call light in reach. DON (director of nursing) notified. On 3/10/23 a nurse documented: patient found sitting on floor by her room door. Assessed for injury and no noted. Patient denied any pain or discomfort, patient very drowsy. Assisted back to bed. Neuro checks commenced per facility policy. Follow-up note revealed: Patient found sitting on floor by the door to her room. Her w/c (wheelchair) was noted to be in the bathroom. When asked what happened she stated that she was going to the bathroom. On 3/14/23 a nurse documented: Pt (patient's) neuro checks are completed this shift. Pt (patient) continues to self-transfer, pt (patient) is seen hopping on 1 (one) leg with transfer and did not look safe. Encouraged pt (patient) to call for assistance with transfers and/or to use a slide board to which pt (patient) refuses. Notified pt (patient) that her scheduled pain medication was decreased this eve from 5mg to 2.5mg. Pharmacy also notified. On 3/15/23 a nurse documented: Pt (patient) found sitting upright on the fall mat next to the bed. She stated she was trying to get into the W/C from the bed. Follow-up note revealed: Assessed for injury with none noted at this time. Assisted back to bed. Neuros initiated and are WNL (within normal limits), ROM (range of motion) intact. DON (director of nursing) notified. Call light in reach, fall mats in place and bed in lowest position. C. Resident observations and interview Resident #7 was observed on 3/15/23 between 11:00 a.m. and 2:30 p.m. She was in her room seated in her wheelchair at the table. At 11:30 a.m. the resident brought a pillow from her bed and placed it on the table. At 12:00 p.m., Resident #7 was observed sleeping at the table, with her head on a pillow. Resident #7 was interviewed on 3/15/23 at 12:01 p.m. She said she fell last night and a couple times before that. She said she realized she was weak and needed help, however she did not remember to use the call light. The resident's lunch meal was delivered to her room by a certified nurse aide (CNA) #2, and the tray was placed on the table. The CNA removed the pillow and placed it on the bed. At 1:15 p.m. the resident was observed sleeping with head down on the table, her lunch meal tray was pushed back. The resident said she was not hungry. At 2:25 p.m. the resident closed the door to her room. CNA #1 was asked to check on the resident. At 2:30 p.m. the CNA said the resident was trying to transfer herself from wheelchair to bed. During the observations, the staff did not offer the resident assistance to use the restroom or if she needed to rest in bed. III. Staff interviews Registered nurse (RN) #1 was interviewed on 3/15/23 at 11:42 a.m. She said Resident #7 was very impatient and frequently transferred herself from her wheelchair to the toilet and to her bed. She said the resident did not remember to use the call light. She said the resident was not aware she was an amputee and was at high risk for falls. She said she was not aware of any new fall prevention approaches except for reminding the resident to use the call light. CNA #2 was interviewed on 3/15/23 at 11:45 a.m. She said the standard was to check on each resident every two hours. She said she was not aware of Resident #7 falls. She said she reminded the resident to use her call light when she needed help. The director of therapies (DOT) was interviewed on 3/15/23 at 2:12 p.m. She said the unit nurse communicated with the therapy team about residents' falls. She said the interdisciplinary team was reviewing falls during morning stand-up meeting and appropriate approaches were discussed. She said Resident #7 refused the do not get up on your own - call for help signs placement in her room. She said one of the approaches to prevent falls for Resident #7 was initiating a check light, the call light system was automatically turned on every 15 minutes to alert staff to check on the resident. The DON was interviewed on 3/15/23 at 4:30 p.m. She said she was aware of the resident's frequent falls. She said the resident did not remember she had her right lower leg amputated and tried to transfer herself to and from the toilet, and to and from bed. She said the resident did not use her call light for assistance. She said the interdisciplinary team recommended the check light. She said the resident's call light should be set to activate at every 15 minutes intervals for the staff to check on her, however this was not initiated until this afternoon.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable interventions and objectives for one (#12) of three out of 18 sample residents. Specifically, the facility failed to develop a person centered care plan for Resident #12's mental illness that included interventions, behaviors, and non-pharmaceutical approaches. Findings include: I. Resident #12 A. Resident status Resident #12, age 74, was admitted to the facility on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included bipolar II disorder and unspecified dementia without psychotic disturbance. The 2/11/22 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a score of ten out of 15. No behaviors were indicated. B. Record review The mood care plan, revised on 2/17/23 revealed the resident was taking an anticonvulsant for bipolar II disorder. The goals were to be without injury related to use of an anticonvulsant. The approaches were to administer the medication as ordered and report to the medical director. There were no interventions, behaviors, or non-pharmaceutical approaches related to mood. The psychotropic drug usage care plan, revised on 2/17/23 revealed the resident required the use of an antipsychotic medication related to a diagnosis of psychosis. The goals were for the resident to not exhibit any adverse side effects related to the medication. The approaches were: -offer counseling -encourage resident to express needs, wants, and feelings -encourage family to visit -monitor for changes in behavior -educate family and resident on side effects -review regime and conduct gradual dose reduction as appropriate -review medication for appropriate does, diagnosis, and usage per psycho pharmacological review -administer medication as ordered. -The resident's care plan failed to identify individualized behaviors, person centered interventions, and non-pharmaceutical approaches. The March 2023 medication administration records (MAR) revealed the following physician orders for psychotropic medications: -Divalproex (Depakote) 250 MG one time a day for bipolar ordered on 2/8/23; -Divalproex (Depakote) 500 MG to equal 1000 MG one time a day at bedtime for bipolar ordered on 2/8/23; -Lamotrigine (Lamictal) 25 MG one time a day for bipolar ordered on 2/8/23; and, -Quetiapine (Seroquel) 25 MG to equal 75 MG at bedtime for psychosis ordered on 2/8/23. The hospital nursing record dated 2/6/23, two days prior to admission to the facility, revealed the resident was experiencing dysphoric mood (depression, irritability, aggression and anger). The resident was prescribed Depakote 500 MG for mania associated with bipolar disorder. Target behavior tracking from 2/12/23 to 3/13/23 revealed: -Divalproex and Lamictal for behaviors of erratic mood swings or erratic behaviors started on 2/8/23 with no behaviors marked. -Quetiapine for behaviors of hallucinations/auditory or visual started on 2/8/23 with no behaviors marked. -Review of resident's progress notes dated 3/15/23 through 2/8/23 failed to reveal any notes regarding care conferences or care planning. II. Resident interview and representative interview The resident was interviewed on 3/15/23 at 10:30 a.m. He acknowledged he has a diagnosis of bipolar disorder and stated that no therapy or counseling has been offered to him, and he would have liked for it to have been offered. He stated he had never been invited to a care conference meeting since being at the facility. The resident's representative was interviewed on 3/16/23 at 8:52 a.m. She stated that the resident had been receiving psychological services in the community but had not been offered since admitting to the facility. She was aware there were routine care conferences held but she had to ask to attend, but the resident nor her were invited. She said that the staff had interviewed the resident regarding if he was experiencing depression but they did not ask her about his history of behaviors, interventions, or what approaches had worked for him in the past. The last significant episode he had was two years prior. He had been experiencing manic behaviors and depression, resulting in a fall and hospitalization . While at the hospital, he had been treated with Prozac (depression medication) which increased his manic behaviors. He had another injury and required 24- hour supervision while at the hospital. Manic behaviors for him manifested as excessive energy, bouncing off the walls, apathy, and chronic depression. III. Staff interviews Registered nurse (RN) #2 was interviewed on 3/14/23 at 10:47 a.m. RN #2 stated the resident did not have any behaviors that he knew of. RN #2 pulled up the resident's target behavior tracking and could not tell which behavior was being tracked for Lamotrigine and the Divalproex because the tracker was combined. He acknowledged he could effectively track the behavior with one tracker for two medications. He could not explain what behaviors he was to be watching for according to the behaviors listed on the target behavior tracker. CNA #1 was interviewed on 3/14/23 at 11:00 a.m. CNA #1 stated resident had behaviors of confusion but no other behaviors that she was aware of. The admissions coordinator (AC) was interviewed on 3/14/23 at 11:19 a.m. She stated she did the admission and intake with the new residents. She would interview the resident and their family regarding any behaviors and would look in the resident's hospital records. She included that information on their target behavior tracker. If a resident had started taking several psychotropic medications at the same time, then they would be included on the same tracker. She could not explain how the staff would know which behavior they were tracking for which medication. RN #1 was interviewed on 3/15/23 at 10:44 a.m. RN #1 stated the resident had memory problems but no other behaviors she was aware of and she could not explain the behaviors she was tracking the resident for. She said what she thought erratic behavior meant a person was dangerous, she did not know what mood swings or hallucinations looked like for the resident. Management had not elaborated what behaviors staff were to be watching for on the tracker or in the resident care plan. The DON was interviewed with the AC present on 3/15/23 at 11:03 a.m. The DON stated the behaviors management wanted nursing staff to track were on the target behavior tracker. These were the behaviors that have been determined to be associated with the medication on the tracker. The AC did the interview with the family and the resident at time of admission. She would ask what behaviors they have associated with their mental illness and what did that look like. When the information was vague, the DON or AC would contact the psychologist that came to the facility to meet with the resident to help determine what their behaviors were. The MDS coordinator entered the care plan in the resident's electronic medical record and gathered her information from the staff and the records, she worked remotely. They acknowledged that they had not contacted their psychologist to meet with Resident #12 for counseling, to clarify behaviors or interventions for the resident. The MDS coordinator was interviewed with DON on 3/15/23 at 1:29 p.m. The MDS coordinator stated that if a resident was stable with their mental illness, she dis not include their behaviors or interventions in the resident's care plan. The MDS coordinator did not indicate why the behaviors on the target behavior tracker had not been included in Resident #12's care plan. The DON stated that even if the resident had a diagnosis of mental illness, if they were not showing behaviors, had not had any episodes for years, and were reportedly stable then the care plan would not include behaviors, approaches or non-pharmacological interventions for that diagnosis. The DON and the MDS coordinator acknowledged Resident #12's care plan did not include person centered information regarding behaviors, interventions and approaches.

Based on record review and interviews, the facility failed to ensure one (#24) of six residents reviewed for medication administration out of 22 sample residents that had physician-ordered medications available for administration. Specifically, the facility failed to ensure Resident #24 received [MEDICATION(S)], prescribed to treat chronic heart failure. The medication was not available and Resident #24 missed 11 doses from November to December 2021. Findings include: I. Facility policies and procedures The Patient Agreement signed by the resident on 11/15/21, was provided by the director of nursing (DON) on 12/15/21 at 12:10 p.m. It read, in pertinent part, Most pharmaceuticals as ordered by the patients's physician are included in Medicare Part A coverage. The facility provides prescriptions through its own contracted pharmacy providers while on this coverage. The undated Pharmacy Services policy was provided by the DON on 12/15/21 at 12:10 p.m. It read, in pertinent part, The facility provides routine and emergency drugs and biologicals to residents supplied by contracted services and administered by facility staff. The pharmacy must dispense and the facility must ensure that necessary drugs and biologicals are provided in a timely basis. The Medication Management policy and procedure, updated on 5/25/21, provided by the DON on 12/15/21 at 12:10 p.m. It read, in pertinent part, The objective of the policy is to promote a safe and accurate medication management system for each individual resident, to ensure a system for accurate process of assessment, planning, implementation and monitoring and staff competency to promote a quality of care, increase resident safety and safeguard against adverse events. II. Resident #24 A. Resident status Resident #24, age 79, was admitted on [DATE] and discharged [DATE]. According to the December 2021 computerized physician orders (CPO), diagnoses included [CONDITION(S)] due to enterococcus, type 2 diabetes, [CONDITION(S)], systolic heart failure, [CONDITION(S)] heart disease of native coronary artery without [CONDITION(S)] pectoris and hypertension. The 11/21/21 minimum data set (MDS) assessment the resident was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. He required limited one person assistance with dressing, transferring and ambulation and was independent with self care. B. Record review The November 2021 admission physician's orders were reviewed on 12/13/21 at 9:56 a.m. The orders documented that the resident was prescribed on 11/15/21, [MEDICATION(S)] 24-26 milligrams (MG) twice daily for chronic heart failure, [MEDICATION(S)] 100 (MG) one time daily for depression, The December 2021 physician's orders were reviewed on 12/13/21 at 9:56 p.m. The orders documented that the resident was prescribed on 11/15/21, [MEDICATION(S)] 24-26 milligrams (MG) twice daily for chronic heart failure. Review of Resident #24's medication administration record (MAR) for November and December 2021 revealed the resident missed 11 doses of his [MEDICATION(S)] tablets 24-26 mg during his stay at the facility. The November and December 2021 MAR documented: -On 11/15/21 the evening dose was unavailable and not administered; -On 11/16/21 the morning dose was unavailable and not administered, nurse noted the family was asked to bring the medication in for Resident #24; -On 11/16/21 the evening dose was unavailable and not administered; -On 11/17/21 the morning dose was unavailable and not administered; -On 12/11/21 the morning dose was unavailable and not administered; -On 12/11/21 the evening dose was unavailable and not administered, nurse noted not sent by the pharmacy; -On 12/12/21 the morning dose was unavailable and not administered; -On 12/12/21 the evening dose was unavailable and not administered, nurse noted the pharmacy was contacted; -On 12/13/21 the morning dose was unavailable and not administered; -On 12/13/21 the evening dose was unavailable and not administered; -On 12/14/21 the morning dose was unavailable and not administered; -On 12/14/21 the evening dose was unavailable and not administered; and, -On 12/15/21 the morning dose was unavailable and not administered. Review of the pharmacy refill order sheet provided by the director of nursing (DON) on 12/15/21 at 5:10 p.m., revealed the facility faxed over a refill request for the [MEDICATION(S)] 24-26 mg tablets on 12/14/21 at 1:46 p.m. III. Family and staff interviews The sister of Resident #24 was interviewed on 12/15/21 at 9:40 a.m. Resident #24's sister said the facility had asked for them to bring in certain medications from home in the past. She said the facility asked them to bring in the [MEDICATION(S)] when he initially admitted to the facility, but they had not asked them to bring in any additional medications since. She said she was not aware of him missing any doses during his stay. She said the facility had not notified her of any missing doses. The director of nursing (DON) was interviewed on 12/15/21 at 9:50 a.m. She reviewed Resident #24's November and December 2021 MARs. She said she was not aware that the resident had not been given [MEDICATION(S)] for multiple days. She said the [MEDICATION(S)] was a medication covered by the facility under his diagnosis and would be ordered by the facility and delivered by the pharmacy. She said the facility's process for when there was a medication unavailable was to contact the pharmacy for a refill. If the pharmacy was not able to deliver the medication in a timely manner or the medication was unavailable, then the facility would ask the family to supply the medication until the pharmacy was able to deliver the medication. The goal was to not have the resident go without the medication or miss a dose. She reviewed the MAR for November and December 2021 and agreed the resident missed 11 doses of the medication. She said the family was asked to bring the medication in for the resident in November at the time of his admission and he missed four doses in November and missed seven doses in December. She said the pharmacy was notified in December to supply the medication, but the medication had not been received or administered since 12/11/21. Registered nurse (RN) # 1 was interviewed on 12/15/21 at 10:00 a.m. She said she reviewed the MAR for Resident #24. She said the [MEDICATION(S)] was not available to administer on 12/14/21. She said she entered a note into the MAR that read the medication had been ordered but not received. She said the family did provide the [MEDICATION(S)] at time of admission and she was not sure if the pharmacy had supplied the medication in the past for this resident. She said she notified the DON when the medication was unavailable on 12/14/21. She said the process for ordering medication was to pull the sticker on the medication card and place it on the order refill form and fax it to the pharmacy. She said if the medication was not available or delayed then she would notify the DON or the clinical nurse manager for assistance. The pharmacy representative was interviewed on 12/15/21 at 4:05 p.m. She said the [MEDICATION(S)] 24-26 mg tablets were listed in Resident #24's active medication list, however the pharmacy had not supplied the medication for the resident. She said the facility never ordered the medication through the pharmacy. She said there was a note in his pharmacy record on 11/15/21 that read the facility would not cover the medication because of the cost. She said the DON was notified of the cost and the decision not to fill the order. The admission nurse was interviewed on 12/15/21 at 4:17 p.m. She said the DON reviewed the admission paperwork and medications before a resident was admitted to the facility. She said the DON would decide if a resident would be admitted to the facility based on the care needs. She said once a resident was admitted , the facility would cover all of the medications unless there was a medication specifically identified prior to admission, for example a medication that was not covered under the resident diagnosis for the rehabilitation stay. She said the family would not be responsible for medications related to the admission diagnosis. The DON was interviewed for a follow up interview at 4:30 p.m. She said the admission coordinator would review the medication list prior to admission as well as herself. She said the facility would not decline an admission based on the cost of medications. She said the facility reviewed the medications and cost prior to admission, but the facility would cover the cost of all the medications ordered by the physician unless there was a specialty medication outside of the covered diagnoses. The [MEDICATION(S)] for Resident #24 was a covered medication and should have been provided by the facility.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #131) of one out of 22 sample residents. Specifically, the facility failed to: -Ensure a barrier was placed before setting down clean items for wound care; -Change gloves from dirty to clean;and, -Perform hand hygiene during wound care with Resident #131. Findings include: I. Facility policy Handwashing policy, not dated, provided by the director of nurses (DON) on 12/14/21 at 2:45 p.m. read in pertinent part; Hand washing before and after contact with any resident was the most important measure that can be taken to prevent the spread of infection. The standard precautions, policy updated 6/4/21, provided by the DON on 12/14/21 at 2:45 p.m., read in pertinent part; To aid in the prevention of the spread of infections between residents and or staff. Procedure: Standard precautions are the minimum precautions utilized on all residents when there is potential or actual contact with body fluids which may or may not contain blood and infectious organisms. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items whether or not gloves are worn. Wash hands immediately after gloves are removed, between resident contacts and when otherwise indicated to avoid transfer of microorganisms to other residents and environments. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching non-intact skin. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contamination items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.`` II. Resident #131 A. Resident status Resident #131, age 76, was admitted on [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) assessment for Resident #131 was not completed. Resident were alert and oriented on admission. B. Observations Licensed practical nurse (LPN) #1 was observed on 12/14/21 at 1:00 p.m. to perform wound care with Resident #131. He washed his hand and donned gloves. The wound supplies were laid on the table next to the resident who resided in bed. He did not disinfect the bedside table prior. LPN took off the soiled dressings to the right and left shin area and the right foot. He cleaned the wounds one at a time with a wound cleanser and then took out the scissors in his pocket, cut the sterile dressings to fit around the wounds. He failed to perform hand hygiene and to change gloves from dirty to clean processes. The scissors were put back in his pocket without disinfecting them. III. Interviews LPN #2 was interviewed on 12/15/21 at 11:30 a.m. She said standard wound practices were to change gloves from dirty to clean procedures and to perform hand hygiene. Infection preventionist (IP) was interviewed on 12/15/21 at 1:00 p.m. She said hand hygiene was performed before and after glove use. She said gloves were changed when performing wound care from dirty to clean. She said when gloves were not changed and hand hygiene was not completed, infection could occur to the wounds. The director of nurses (DON) was interviewed on 12/15/21 at 1:30 p.m. She said she expected anyone doing wound care to perform hand hygiene and change gloves from dirty to clean. She said cross contamination and infection could occur otherwise. The scissors were supposed to be cleaned with micro kill disinfectant before and after each use.

Based on observations, interviews and record review, the facility failed to provide meaningful, engaging activities to meet the interests of one (#176) of one resident reviewed for activities out of 22 sample residents. Specifically, Resident #176 was observed spending all of her time in her room, unengaged in activities to prevent loneliness and boredom, and improve her quality of life. Findings include: I. Facility policies The Activity Program policy, was provided by the director of nursing (DON) on 12/14/21 at 2:53 p.m. The policy read in pertinent part: The facility will provide, based on the comprehensive assessment, care plan and the preferences of each resident, an ongoing program to support patients in their choice of activities. Facility sponsored group activities, individual activities and independent activities are designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident while encouraging both independence and interaction within the community. The Recreational therapy policy, was provided by the director of nursing (DON) on 12/14/21 at 2:53 p.m. The policy read in pertinent part: The facility will provide an ongoing program of individual and group activities and therapeutic interventions designed to meet the interests, and attain or maintain the highest particicable physical, mental, and psycho-social well-being of each resident in accordance with the comprehensive assessment. II. Resident #176 A. Resident status Resident #176, age 82, was admitted on [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 11/23/21 minimum data set (MDS) assessment, Resident #176 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. She needed set up assistance to partial one person assistance with activities of daily living (ADLs) including transfers, dressing, mobility, personal hygiene and cognition. The 11/23/21 full admission MDS assessment for activities documented phone use, reading, listening to music, animals, doing things with other people, outside time and religious services were very important to her. B. Resident interview Resident #176 was interviewed on 12/13/21 at 3:15 p.m. She was sitting in her wheelchair at her table facing the wall. She did not have the television or music on in her room. She said she did enjoy listening to all kinds of music. She said she liked to read and had her reading glasses sitting next to her on the table. She said she did not have anything to read in her room. She said She said she enjoyed watching television, but did not know there was a television in a cabinet to the left of where she had been sitting. She said she enjoyed talking with other people, but she was tired. She said thank you for the visit. C. Observations The resident was observed during survey observations from 12/13/21 to 12/16/21. She was on isolation precautions for multi drug resistant organisms in urine and did not leave her room during survey observations. On 12/13/21 during continuous observation from 10:33 a.m. until 1:39 p.m. the resident sat at her table, facing the wall in her wheelchair. Her lights were off and the room was quiet with no television or music on in the room. She did not have staff enter her room until 12:46 p.m. when the dietary staff set up her lunch tray in front of her. She did not have assistance with her lunch and sat with her food untouched in front of her from 12:46 p.m. until a certified nursing assistant entered her room at 1:21 p.m. to assist her with eating. During continuous observation Resident #176 did not have any independent activities or one to one visits offered. The resident's phone was observed to ring multiple times during continuous observation and was not within reach for her to answer and staff did not assist her. -At approximately 10:30 a.m. her phone rang and was not within to answer; -At 11:52 a.m. her phone rang and was not within reach to answer, and; -At 12:49 p.m. her phone rang and was not within reach to answer. On 12/14/21 the resident was observed throughout the day seated at her table in her wheelchair facing the wall. She did not have her television or music on for stimulation. She had her head down multiple times and would rest her head on her hand. She did not have any leisure materials or activities offered during the day. -At 1:00 p.m. she was seated in her wheelchair facing the wall with her head down; -At 1:47 p.m. she was seated in her wheelchair facing the wall with her head down; -At 2:00 p.m. she was seated in her wheelchair facing the wall with her head down; -At 2:20 p.m. she was seated in her wheelchair facing the wall with her head down; -At 3:00 p.m. she was seated in her wheelchair facing the wall with her head down; -At 3:30 p.m. she was seated in her wheelchair facing the wall with her head down, and; -At 3:58 p.m. her wheelchair was turned facing out towards her door and she was awake and said hello to staff as they walked by her room. D. Record review The initial activity assessment completed on 11/18/21 revealed the resident was a former social worker, enjoyed reading, writing, watching television, music, talking with others and religious activities. The care plan revised on 12/12/21 did not have an activities care plan completed. There was no documentation regarding Resident #176's activity focus areas, goals or approaches to support her leisure interests. The care plan was updated on 12/15/21 by the minimum data set (MDS) coordinator to include the activities section of the care plan after it was brought to the attention of the director of therapy (DOT), overseeing the activity department. Activity participation records provided by the director of nursing (DON) on 12/14/21 for November and December 2021 revealed the resident participated in two activities out of 30 offered in the past 30 days. The records documented the resident refused to participate in 28 out of 30 activities offered. The records revealed the resident had zero one to one visits from family or staff during the past 30 days. III. Staff interviews The activities director (AD) was interviewed on 12/15/21 at 12:45 p.m. She said she was responsible for completing the initial activity assessment. She said the assessment and daily participation was on paper in her book. She said the therapy staff and the MDS would enter the information into the computerized records. She said she worked one hour a day from 2:00 p.m. to 3:00 p.m. Monday through Friday in activities and the rest of her hours she worked at the front desk and assisted with the visitor and staff check in screening process. She said she did not write activity progress notes and only kept a daily participation log for activities. She said Resident #176 did enjoy music, television, reading and visiting based on her activity assessment. She said she did not participate in group activities and chose to stay in her room. She said she did not offer one to one visits and did not have a one to one program. She said Resident #176 preferred to be alone in her room, although she did not offer her visits in her room. She said she stopped asking resident #176 to join activities because she did not want to bother her. She said she would ask her to join in the future and offer her more visits to allow her to say yes or no. She said the therapy staff would help identify if a resident wanted leisure materials like books and puzzles, however Resident #176 did not have any leisure activities in her room. The director of therapy (DOT) was interviewed on 12/15/21 at 1:20 p.m. She said the therapy department did oversee the activity department. She said the AD was scheduled to work one hour a day in activities, but she could get coverage from other departments if she needed to step away from the front desk to complete an activity assessment. She said the residents main goal during their stay was therapy so the therapy staff knew the residents best. She said the activity programs were offered at 2:00 p.m. because it did not interfere with the therapy program. She said the AD completed the initial assessment and the daily participation records and the MDS would enter the information into the resident's computerized record. She said the MDS would complete the care plan. She said every time she visited with Resident #176 she did not mention wanting any leisure activities like listening to music or reading. She said the resident had declined her visits and would not want to participate in therapy. The DOT did acknowledge therapy and leisure needs are different and the resident could have declined therapy, but would agree to participate in activities. She said she did notice the resident sitting in her room with nothing to stimulate her like television or music. She said she would work with the staff to offer leisure activities of interest. She said residents do change their mind and may agree to participate one day and not the other and will start to offer more activities for her. She said she was not aware of the care plan not being completed. She said the care plan should be completed to assist the staff with understanding the resident's activity interests and needs.

Based on interviews, observations and record review, the facility failed to ensure five (#135, #128, #137, #138, and #176) of 10 out of 11 sampled residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to ensure Resident #135, #128, #137, #138, and #176 had complete and thorough physician's order, documentation of use and response to oxygen therapy and a person-centered care plan for oxygen use. Findings include: I. Facility policy and procedure The Oxygen Administration (version A0717) policy and procedure, undated, was provided by the nursing home administration on 9/22/2020 at 9:00 a.m. It revealed, in pertinent part, Appropriate safety precautions are utilized to provide safe administration and storage of oxygen. -Preparation: Verify that there is a physician's order for administering oxygen. If the order is unclear or incomplete, clarify the order with the physician. Review the physician's orders or facility protocol for oxygen administration. Review the patient's care plan to identify any special needs of the patient. -Documentation: After completing the oxygen setup or adjustment, document the following in the patient's medical record: .The rate of oxygen flow, route, and rationale; The frequency and duration of the treatment; All assessment data obtained before, during and after the procedure: How the patient tolerated the procedure . II. Resident #135 A. Resident status Resident #135 age 75, was admitted on [DATE]. According to the September 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. Due to the resident's recent admission the minimum data set (MDS) assessment had not been completed. A brief interview for mental status (BIMS) score revealed the resident was cognitively intact with a score of 13 out of 15. B. Observations and resident interview Resident #135 was interviewed on 9/22/2020 at 8:32 a.m. The resident was in bed with oxygen at one liter, by nasal cannula. Resident #135 said the oxygen was helpful, but no one had talked to her about her use of oxygen, if she will need it long-term or if the oxygen would be taken off at some point. C. Record review The resident's electronic medical record revealed an order for [REDACTED]. Document LPM (liters per minute) QS (every shift). May titrate/discontinue while maintaining SpO2 >90%. The order start date was 9/18/2020. The order did not specify a starting oxygen LPM flow rate, parameters for titrating the oxygen flow rate up or down in response to the oxygen saturation level assessment, parameters for notifying the prescribing physician, or parameters to discontinue the oxygen. The resident's treatment administration record for oxygen administration documented the residents oxygen saturation levels from 9/18/2020 to 9/23/2020. -The document revealed the resident's oxygen saturation levels ranged between 91% and 95%, but did not document if the resident was receiving oxygen therapy or liter flow per minute of any administered oxygen therapy. The resident's baseline care plan dated 9/18/2020, did not document that the resident was or oxygen or provide a care focus for the prescribed oxygen therapy. The resident's vital signs record for oxygen saturation levels documented the residents oxygen saturation levels from 9/18/2020 to 9/23/2020. When the resident's oxygen saturation level was 92% with an oxygen LPM flow varied from one to two LPM. When the oxygen saturation level was 91% the oxygen LPM flow ranged from one two LPM. -There was no consistency or correlation between the administered oxygen flow rate and the oxygen saturation level. The resident's medical record failed to show documentation of the delivery of oxygen treatment in response to the assessed oxygen saturation level or rational for the administered oxygen liter flow. III Resident #128 A. Resident status Resident #128 age 82, was admitted on [DATE]. According to the September 2020 CPO, [DIAGNOSES REDACTED]. Due to the resident's recent admission the MDS assessment had not been completed. The BIMS score revealed the resident was cognitively intact with a score of 15 out of 15. B. Observation Resident #128 was observed on 9/22/2020 at 10:22 a.m. The resident was up sitting in a recliner and was receiving oxygen therapy at four liters, by nasal cannula. C. Record review The resident's electronic medical record revealed an order for [REDACTED]. Document LPM QS. May titrate/discontinue while maintaining SpO2 >90%. The order start date was 9/16/2020. The order did not specify a starting oxygen LPM flow rate, parameters for titrating the oxygen flow rate up or down in response to the assessment of the resident's oxygen saturation level, parameters for notifying the prescribing physician, or parameters to discontinue the oxygen. The resident's treatment administration record for oxygen administration documented the residents oxygen saturation levels from 9/16/2020 and 9/23/2020. -The record revealed the resident's oxygen saturation levels ranged between 94% and 99%, but did not document if the resident was receiving oxygen therapy or liter flow per minute of any administered oxygen therapy. The resident's baseline care plan dated 9/16/2020, did not provide intervention details for the resident's prescribed oxygen therapy. The resident's vital signs record for oxygen saturation levels revealed oxygen saturation levels between 92% and 99% with a consistent oxygen liter flow of three LPM; except for a bump in oxygen to four LPM, twice when the oxygen saturation levels were at 94%. -The record did not document whether the oxygen liter flow was adjusted based on the oxygen saturation level assessment. The resident's medical record failed to show documentation of the delivery of oxygen treatment in response to the assessed oxygen saturation level or rational for the administered oxygen liter flow. IV. Resident #137 A. Resident status Resident #137 age 84, was admitted on [DATE]. According to the September 2020 CPO, [DIAGNOSES REDACTED]. Due to the resident's recent admission the MDS assessment had not been completed. The BIMS score revealed the resident cognition was moderately impaired with a score of 12 out of 15. B. Observation Resident #137 was observed on 9/22/2020 at 9:02 a.m. The resident was in bed and was receiving oxygen therapy at two liters, by nasal cannula. C. Record review The resident's electronic medical record revealed a physician's order for oxygen therapy. The order read: oxygen per (by) nasal cannula to maintain SpO2 > 90 %. Document LPM QS. May titrate/discontinue while maintaining SpO2 >90%. The order start date was 9/16/2020. The order did not specify a starting oxygen LPM flow rate, parameters for titrating the oxygen flow rate up or down in response to the assessment of the resident's oxygen saturation level, parameters for notifying the prescribing physician, or parameters to discontinue the oxygen. The resident's treatment administration record for oxygen administration documented the residents oxygen saturation levels from 9/16/2020 and 9/23/2020 revealed the resident's oxygen saturation levels ranged between 89% and 98%, but did not document if the resident was receiving oxygen therapy or liter flow per minute of any administered oxygen therapy. The resident's baseline care plan dated 9/16/2020, did not provide intervention details for the resident's prescribed oxygen therapy. The resident's vital signs record for oxygen saturation levels results revealed oxygen saturation levels between 89% and 98% with varying oxygen liter flow from one to three LPM, sometimes being three LPM with an oxygen saturation level of 98% and two LPM with an oxygen saturation level of 90%. -The record did not indicate whether the oxygen liter flow was adjusted based on the oxygen saturation level assessment. The resident's medical record failed to show documentation of the delivery of oxygen treatment in response to the assessed oxygen saturation level or rational for the administered oxygen liter flow. V. Resident #138 A. Resident status Resident #138 age 82, was admitted on [DATE]. According to the September 2020 CPO, [DIAGNOSES REDACTED]. Due to the resident's recent admission the MDS assessment had not been completed. The BIMS score revealed the resident was cognitively intact with a score of 13 out of 15. B. Observation Resident #138 was observed on 9/22/2020 at 12:02 p.m. The resident was sitting up eating lunch, and was receiving oxygen therapy at one liters by nasal cannula. b. Record review The resident's electronic medical record revealed a physician's order for oxygen therapy. The order read: oxygen per (by) nasal cannula to maintain SpO2 > 90 %. Document LPM QS. May titrate/discontinue while maintaining SpO2 >90%. The order start date was 9/11/2020. The order did not specify a starting oxygen LPM flow rate, parameters for titrating the oxygen flow rate up or down in response to the assessment of the resident's oxygen saturation level, parameters for notifying the prescribing physician, or parameters to discontinue the oxygen. The resident's treatment administration record for oxygen administration documented the residents oxygen saturation levels from 9/11/2020 and 9/23/2020 revealed the resident's oxygen saturation levels ranged between 90% and 98%, but did not document if the resident was receiving oxygen therapy or liter flow per minute of any administered oxygen therapy. The resident's baseline care plan dated 9/11/2020, did not provide intervention details for the resident's prescribed oxygen therapy. The resident's vital signs record for oxygen saturation levels results revealed oxygen saturation levels between 90% and 98% with no oxygen therapy/liter flow being documented until 9/22/2020. Once the resident started on oxygen therapy, the reported oxygen liter flow was one LPM regardless of the oxygen saturation level. -The record did not indicate whether the oxygen liter flow was adjusted based on the oxygen saturation level assessment. The resident's medical record failed to show documentation of the delivery of oxygen treatment in response to the assessed oxygen saturation level or rational for the administered oxygen liter flow. VI. Staff interview Registered nurse (RN) #2 was interviewed on 9/23/2020 at 12:30 p.m. RN #2 said it was a goal of the facility to wean the resident off oxygen before discharge. The nurses were expected to monitor the respiratory status of each resident prescribed oxygen. The assessment was to include lung sound, respiratory rate, any sign of shortness of breath, respiratory distress and oxygen saturation level and then document the assessment. If a resident's oxygen situation level was below 90%, she said she would raise the oxygen liter flow up by one liter at a time until the residents oxygen saturation level stabilized above 90%. If the resident's oxygen saturation level was above 90%, she did not adjust the oxygen liter flow. She said the oxygen orders did not provide a specific oxygen liter flow rate. If the resident's oxygen saturation level was maintaining at 100% she would consult with the physician and respiratory therapist for additional recommendation for the oxygen therapy. She was not sure if the facility had a clinical procedure/protocol for titrating and weaning the resident off oxygen. The director of nursing (DON) was interviewed on 9/24/2020 at 12:26 p.m. The DON said most of the residents in the care of the facility had never been on oxygen before coming to the facility and were prescribed oxygen therapy while at the hospital. The primary goal of the facility was to provide rehabilitation services and get the resident to the highest functional level for discharge, which included weaning the resident off oxygen therapy before discharge. At admission, the discharging hospital provided a report of the resident's status including the oxygen liter flow they were discharging the resident on. She added, from now on we will use that liter flow in our order as a starting point for oxygen therapy. The DON said she expected the nurses to monitor the resident's oxygen saturation levels every shift per the physician's orders, titrate the oxygen liter flow to maintain the resident oxygen saturation level at 88% or higher and document the results of the oxygen therapy. She said for example, if a resident diagnosed with [REDACTED]. The DON was interviewed on 9/24/2020 at 2:23 p.m. The DON said she reviewed the resident's oxygen orders and would be retraining the nurses to look for complete oxygen orders and on proper titration procedure. VII. Resident #176 A. Resident status Resident #176, age 75, was admitted on [DATE]. According to the September 2020 computerized physician orders (CPO) [DIAGNOSES REDACTED]. The 9/3/2020 minimum data set (MDS) assessment revealed Resident #176 had a brief interview for mental status (BIMS) score of seven, indicating severe cognitive impairment. Oxygen was not indicated. B. Record review The 9/2020 CPO included an oxygen order that read; Oxygen (O2) per nasal cannula (NC) to maintain oxygen saturation (SpO2) > (greater than) 90%. Document liters per minute (LPM) every shift. May titrate/discontinue O2 LPM as tolerated while maintaining SpO2 >90%. The order did not indicate parameters to include specific LPM or to notify the physician of changes in the resident's respiratory status. The care plan, initiated 9/15/2020 indicated Resident #176 had alteration in respiratory function related to [MEDICAL CONDITION], chronic [MEDICAL CONDITION], and experienced cough and or respiratory congestion. Interventions included: - Assess lung sounds and monitor vital signs and O2 saturation at least daily and as needed (PRN) for signs and symptoms of respiratory distress. -O2 per medical doctor (MD) order -Observe for confusion, dyspnea (difficult or labored breathing), cyanosis (bluish color of mucous membranes and/or skin), and report changes to licensed nurse and/or MD. -Notify physician of any abnormal labs or changes in patient's condition. The oxygen saturation documentation from 9/3/2020 to 9/23/2020 revealed the oxygen LPM ranged from zero to five and a half and her SpO2 ranged from 87% to 99%. The 9/5/2020 nursing note documented by registered nurse (RN) #3 at 3:58 p.m. read: Patient had taken O2 off and OT went into work with patient. Pulse Ox decreased 57%. Patient put on O2/4L NC and PO increased to 88% then O2 increased to 5L and PO 90%. Nurse decreased O2 to 4L. Patient maintained at 93%. Informed Evening shift to decrease O2 and check O2 Sat. The 9/6/2020 nursing note documented at 11:15 p.m. by an unknown nurse read in part: Bilateral lungs exhibit rails in all lobes pt does become hypoxic removes NG O2 was 83% placed NG increased O2 4L rearranged pt O2 was 87%, has wet cough, HOB elevated. -There was no documentation of what LPM her oxygen had been on when the nurse increased it to 4 LPM. C. Staff and family interview Resident #176's son was interviewed on 9/22/2020 at 11:55 a.m. He said when she was at home she required oxygen continuously via an oxygen concentrator and it was normally set on four to five LPM. He said he was unaware of what LPM the facility had her oxygen set on. RN #1 was interviewed on 9/24/2020 at 12:10 p.m. She said when she arrived for work she checked the report and vital signs sheets to know what LPM a resident's oxygen should be set on. She said she did not normally check the physician order but the order for the oxygen LPM was on the treatment administration record.

Based on record review and interviews, the facility failed to provide the assistance needed to maintain an ability to complete activities of daily living (ADLs) for one (#135) of three residents reviewed for showers out of 26 sample residents. Specifically, the facility to ensure Resident #135 received showers as care planned. Findings include: I. Facility policy and procedures The Shower/Bath policy and procedure (version A0717), undated, was provided by the nursing home administrator (NHA) on 9/24/2020 at 7:23 a.m. It read in pertinent part: Shower/ baths are scheduled two times per week. Patients will be educated on shower/bath schedule on admission. If a different schedule is requested arrangements will be made. -Report any findings to the nurse. Document shower/ bath in point of care. The Facility Introduction Welcome document was provided by the NHA on 9/24/2020 at 9:35 a.m., the document read in pertinent part: Welcome. We appreciate you trusting your care with us. Just a few details we want you to be aware of during your stay . -Showers are scheduled two times a week for every patient Rooms 511-515 are scheduled on Tuesday and Saturday . If you would like to be showered on a different schedule than posted, please let our staff know and we will do everything we can to make that happen. II. Resident #135 A. Resident status Resident #135 age 75, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. Due to the resident's recent admission the minimum data set (MDS) assessment had not been completed. A brief interview for mental status (BIMS) score revealed the resident was cognitively intact with a score of 13 out of 15. B. Resident interview and observation Resident #135 was interviewed on 9/22/2020 at 8:32 a.m. The resident was in bed with her legs elevated. Her hair was a little matted. Resident #135 said she was admitted Friday afternoon (9/18/2020) and was told she would have her first shower on Saturday (9/19/2020). She was looking forward to the shower, because it had been seven days since she had a shower due to her being in the hospital and having surgery. When Saturday came, she was not provided a shower and was feeling bad about herself. I am starting to smell, and I feel terrible. The nursing staff told her they were short staffed without the shower aide on duty and could not give her a shower Saturday as care planned. She was told that her shower would be rescheduled to her next planned shower day which was Tuesday (9/22/2020). She was very frustrated and disappointed with her admission over those first few days in the facility because she was really looking forward to getting clean. C. Record review The admission note dated 9/18/2020 5:15 p.m., read in pertinent part: Note discipline: Nursing Progress Note: Resident #135 was admitted to room following right ankle surgery to remove infected hardware .Reviewed facility procedures and shower schedule . Right foot incision is covered with a bandage, ABD pad, ace wrap and boot with [DEVICE] (VAC) from hospital attached and functioning at 125 mmHg, continuous. Nursing progress note dated 9/18/2020 at 5:15 p.m., read in pertinent part: Resident was admitted to room from the hospital after surgery .Admission and intake completed with patient. Reviewed facility procedures and shower schedule. The baseline care plan revealed the resident: - Needed assistance with activities of daily living (ADLs) involving the upper and lower extremities, bathing, and toileting; -Was incontient of urine and wore briefs. The unit shower sheets for 9/19/2020 through 9/21/2020 were requested on 9/24/2020 at 9:35 a.m. The NHA provided the documents on 9/24/2020 at 9:48 a.m. The director of nursing (DON) said they were unable to locate the shower sheet for 9/19/2020. The shower sheets dated 9/20/2020 and 9/21/2020 revealed no documentation of Resident #135 getting a shower or refusing a shower on either day. There was a notation on 9/21/2020 that Resident #135 requested a shower. The occupational therapy evaluation and plan of treatment note, dated 9/21/2020, read in pertinent part: Reason for skilled services: patient requires skilled occupational therapy services to increase safety awareness, increase independence with ADLs, increase functional activity tolerance, minimize safety hazards/barriers, develop and instruct on compensatory strategies and develop and instruct on adaptation techniques in order to enhance patient's quality of life by improving ability to be able to return to prior level of living. -Assessment: resident has a number or performance deficits, identified as three to five deficits in areas of physical, cognitive, psychosocial skills resulting in activity limitation or participation restrictions. -Patient presents with impairments in balance, gross motor coordination, mobility and strength resulting in limitations and/or participation restrictions in the areas of mobility and self-care. The point of care notes documented one note for Resident #135 bathing/shower. The note revealed the resident did not have her first shower until 9/22/2020. The shower note in point of care dated 9/22/2020 at 1:31 p.m., read in pertinent part: How did the resident bathe? Physical help limited to transfer. Staff support provided for bathing? One (1) person physical assist. Type of bath? Shower. Review of the nursing progress notes revealed no documentation of why there was a delay in the resident getting a shower. III. Staff interview Certified nurse aide (CNA) #2 was interviewed on 9/23/2020 at 4:05 p.m. CNA #2 said showers were only given on the day shift. If a resident refused or missed their shower for any reason it would be up to the nurses to discuss a plan/options and let the CNAs know if they were to give a shower; it could be done, but the nurses have never requested the evening CNAs to give a shower during any of the CNAs evening shifts. CNA #1 was interviewed on 9/24/2020 at 9:46 a.m. CNA #1 said if a resident refused a shower or did not want a shower the CNAs would notify the nurse; the nurse would talk with the resident about other shower options and when they would like to reschedule their shower. A resident's shower could be rescheduled on the next day or during their occupational therapy time as a goal of therapy. She said a lot of time residents did not feel good when shower time comes around after being first admitted so the staff tried their best to accommodate the resident with their scheduled shower day; it's no problem to reschedule when all (staff and resident) are in agreement. CNA #1 said it was hard to get all care tasks done and meet the daily shower schedule since they eliminated the daytime shower aide position. Since COVID hit, it takes extra time to care for the residents in the facility. The director of nursing (DON) was interviewed on 9/24/2020 at 9:55 a.m. She said if a resident refused or did not get a shower, she wanted her staff to offer the next day and/or let therapy know. She said often therapy would provide showers for the residents when they refused or missed a shower from the floor staff. She said showers were a part of therapy. She said if a resident requested a shower in the evenings, the facility could accomodate the request. She said showers were typically scheduled on the day shift. She said she was the one who reviewed the shower records (she did not specify how often and which resident records she reviewed). She said she was not aware the resident had not had not had her shower when admitted . She said she was providing more education on showers to the nursing staff.

Based on interviews and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (#4) of five residents reviewed out of 18 sample residents. Specifically, the facility failed to provide social services for Resident #4 during the pre-admission, admission and assessment and discharge planning process, and throughout the resident's stay at the facility. Findings include: I. Facility policy and procedure According to the Social Services policy and procedure, provided by the director of nursing (DON) on 3/20/19 at 3:00 p.m., in pertinent part: -The facility shall identify, plan care for, and meet the identified emotional and social needs of each resident to enhance resident psychosocial health and wellbeing. -Social services staff shall be involved in the pre-admission process, providing input as to appropriateness of placement from a psychosocial perspective. -Social services staff shall assist residents in coping with the psychosocial aspects of their stay in the facility. -Social services staff shall assist residents in planning for discharge. -Social services staff shall participate in resident assessment and care planning and shall provide social services to residents. II. Resident status Resident #4, age 82, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 3/19/19 minimum data set (MDS) assessment, he had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He felt down, and felt bad about himself. III. Resident interview Resident #4 was interviewed on 3/18/19 at 8:57 a.m. He said he was not asked if there was anything he wanted to bring to make him feel at home. He said he would like to have his computer, felt he had no control of his care, his daughters were squabbling about his trust, his girlfriend was not in charge of his care, he did not know where he would live after discharge (his name was on his girlfriend's house), he had turmoil and internal conflict with his girlfriend and daughters, and he could use more clothes. Resident #4 was interviewed a second time on 3/19/19 at 3:34 p.m. He said a psychologist met with him last week. She did not ask how he was doing or how he was feeling, and he had not seen her since then. He said he had not been seen by a facility social worker since admission. He said today he felt confused because he started a plan to move to another city with one of his daughters and then talked to his girlfriend who said she'd take him back. He said there was no social service staff helping him with his discharge plans. He said he did not know when he would see the psychologist again; she did not tell him when she would return. He said he felt angry, depressed and sad, did not want to be at the facility, and felt out of control in the facility and in his personal life. He said since admission he had felt anxious, and did not know what medications they were giving him. He said he wanted to take medication for his anxiety because he felt uncomfortable in his present mindset. He said he felt like he was bouncing off the walls, and felt shook up (he shook his arms and hands in front of his body while he said this). He said he was not happy with things at the facility. He said he could benefit from eye movement desensitization and reprocessing (EMDR) therapy, as it had helped him in the past. III. Record review The resident's 3/14/19 baseline care plan identified: -His needs were finding a place to live. -His goals were to have a place to move to. -His life history was his concern with his relationship with his girlfriend. -His preference was for someone to help him find a place to live. The care plan, initiated on 3/18/19, identified he had an alteration of mood. Interventions included to provide one-to-one interactions and reassurance. The interventions did not include social services staff would provide interactions to meet his daily emotional and social needs. According to the social service progress notes, there was no documentation a social service staff person was involved with his pre-admission, admission, or discharge plan. According to the 3/14/19 nurse progress note, the resident felt like he let everyone down because he had been at the facility before and that alcohol had gotten the best of him again as it usually had. According to the 3/20/19 nurse progress note, the resident said his daughter wanted to move him to another city to live in a one- bedroom apartment where he would be alone and have nothing to do, and then his daughter hung up on him in disgust. He said he had lived with a girlfriend in the area near the facility for four years, that it was his home, and they did a lot of things together. He said he had a right to make his own decisions. According to the 3/14/19 psychologist progress note, the resident had symptoms of depression, was experiencing cognitive issues related to detoxification from alcohol, and was focused on returning to his girlfriend's home to live after discharge from rehabilitation. According to the 3/19/19 psychologist progress note, the resident was anxious and depressed due to his discharge plans. He had significant depression; he felt dissatisfied with his life, helpless, worthless and fatigued; his sleep was disturbed; he felt unable to conduct daily activities; and the psychologist recommended an antidepressant would benefit him. review of the resident's medical record revealed [REDACTED]. -A care conference was offered to him to discuss his psychosocial needs; -A social service assessment was conducted on pre-admission or on admission; or -A social service staff member discussed his discharge needs and plans. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 3/19/19 at 3:50 p.m. She said the psychologist came when the facility called her. She was not scheduled to visit Resident #4 on a regular or weekly basis. She said the facility had a psychiatrist who saw residents on a weekly basis, if the need was identified, or within a few days when called upon. She said the facility acquired an order, today, for the resident to be seen by a psychiatrist as soon as she was available. RN #1 said the facility did not have a social service department which operated on a daily basis. She said Resident #4 was a returning resident with a history of alcohol dependence. She said he was his own responsible party. She said his goal was to be with his girlfriend on discharge, and he had been tearful off and on about losing her. She said the resident's daughter planned to move him to another city. She said there was no one discussing his needs and plans when it was time for his discharge. She said the facility did not plan care conferences for newly admitted residents if their stays were short term. She said care conferences were only planned if requested by residents, families the therapy department. Certified nurse aide (CNA) #1 was interviewed on 3/20/19 at 12:15 p.m. She said the resident had anxiety about getting care and services on time, and his hands shook when he was anxious. The licensed practical nurse with administrative duties (LPNAD) was interviewed on 3/20/19 at 12:34 p.m. He said he was the admissions and discharge coordinator. He conducted most of the admission assessments, and he was the only one involved in the admission and discharge process. He said there was no social service assessment done on admission and there was no social services designee in the facility. He said he only provided social service information on admission or discharge upon request. The psychologist was interviewed on 3/19/19 at 4:26 p.m. She said when she saw the resident today she determined he could benefit from receiving medication to treat his depression and anxiety. She said she was not involved in the admission or discharge process. She said she only saw residents identified by the facility on an as-needed basis. The nursing home administrator (NHA) was interviewed on 3/19/19 at 4:47 p.m. He said the facility did not have a social services department, or regularly staffed social service personnel. He said the facility managed the medically necessary social services of their residents. He said the LPNAD was the admissions and discharge coordinator for all their residents. He said RN #1 contacted the psychologist as needed and coordinated with the director of nursing (DON) and therapy department director to determine the social services needs of the facility residents. He said for the medically complicated social service needs of their residents, a hospital would be used as a psychosocial resource. He said because the facility was a 34 bed facility there was no dedicated social service personnel or department. He said the psychologist could see residents within 24 to 48 hours when contacted.

Based on observation, interview and record review, the facility failed to provide sanitary care and services for one (#11) of one out of 18 sample residents. Specifically, registered nurse (RN) #2 and licensed practical nurse (LPN) #1 did not perform proper hand hygiene while providing catheter care for Resident #11, creating the potential for cross contamination. The findings include: I. Facility policy and procedure According to the Handwashing policy and procedure, provided by the director of nursing (DON) on 3/20/19 at 3:00 p.m., in pertinent part: -Handwashing before and after contact with any patient is the most important measure that can be taken to prevent the spread of infection. -Wash hands before applying and after removing any personal protective equipment (PPE). II. Resident status Resident #11, age 85, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The resident was newly admitted and did not yet have a minimum data set (MDS) assessment. III. Observations An observation on 3/19/19 at 1:32 p.m. revealed: -RN #2 changed gloves after she wiped around Resident #11's urinary catheter, without performing hand hygiene. -RN #2 handled the outside of the package of wipes she used to provide catheter care with the same gloved hands used to provide catheter care -RN #2 reached into her scrubs pocket with the same gloved hands used to provide catheter care, retrieved and opened a packet of lubricant with the same gloved hands used to provide catheter care, and then applied the lubricant around the catheter insertion site. An observation on 3/20/19 at 3:22 p.m. revealed: -LPN #1 changed gloves twice without performing hand hygiene while providing urinary catheter care for Resident #11. -LPN #1 handled the resident's catheter with the same gloved hands used to wipe around his catheter. -LPN #1 wiped away from the tip of the catheter then toward the tip of the catheter, with the same gloved hands and with the same wipes on three different occasions. IV. Record review The (MONTH) 2019 CPO revealed an open-ended order, initiated 3/10/19, for the resident to receive routine indwelling catheter care every shift. The 3/10/19 baseline care plan identified he had an indwelling catheter. The care plan, initiated on 3/20/19, identified he had an alteration of elimination. The interventions included to monitor for signs and symptoms of a urinary tract infection. V. Staff interviews RN #2 was interviewed on 3/19/19 at 1:45 p.m. She said she should perform hand hygiene between glove changes when providing resident care to prevent infection. She said she should not have pulled the lubricant out of her scrub pocket and applied it with the same gloves used to provide catheter care, as it could have caused an infection. She said she should not have handled the outside of the package of wipes with the same gloved hands used to provide catheter care, as it could have caused an infection. She said she should have set up the supplies for catheter care prior to performing the care. LPN #1 was interviewed on 3/20/19 at 3:40 p.m. He said he should have washed his hands between glove changes to prevent infection during catheter care. He said he was supposed to wipe away from the catheter, not toward it. The director of nursing (DON) was interviewed on 3/20/19 at 3:40 p.m. She said gloves were PPE utilized to prevent infection when providing resident care. She said staff were to wash their hands before and after changing gloves because their hands could be dirty regardless if it was an unused glove. She said if hand washing was not done it could cause contamination and spread contamination from the bacteria on their hands. She said her job was to protect her residents so she was going to incorporate urinary catheter care into the facility's quality assessment performance improvement (QAPI) plan. She said she was going to monitor urinary catheter care through the QAPI plan for the nurses and CNAs and monitor their competencies in urinary catheter care.

Based on observation, record review and interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being regarding pain management for three (#97, #225 and #215) of 26 sample residents; and failed to provide diabetic management for three (#213, #224 and #223) of 26 sample residents. Specifically, the facility failed to: -Ensure residents #97's, #215's and #225's pain was adequately managed, contributing to the residents experiencing pain rated at five to 10 out of 10 for extended periods; and -the facility failed to ensure diabetic management orders were followed for residents #213, #224 and #223. The findings included: I. Pain management A. Facility policy and procedure The pain management policy and procedure was received from the director of nursing (DON) on 8/25/16 at 10:15 a.m. The policy included, Patients will have appropriate pain control measures to optimize comfort and wellbeing. Pain levels shall be controlled at acceptable levels to maximize recovery and facilitate participation in daily treatments and activities of daily living (ADLs). All patients will be assessed for pain upon admission and educated regarding pain management, current orders and facility policies. All patients will be routinely assessed for pain on a continuous basis throughout their stay as part of general nursing practice to include both formal and informal assessment with ongoing evaluation of responses to treatments. As needed (PRN) medications will be administered following assessment of pain for location, onset, duration and intensity. Administration of PRN medications shall be evaluated for effectiveness within 30-60 minutes following administration and the results documented appropriately . B. Resident #97 Resident #97, age 78, was admitted on [DATE]. According to the 8/16 computerized physician orders (CPOs), [DIAGNOSES REDACTED]. According to the 8/14/16 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance of one to two staff members for bed mobility, transfers, ambulation, dressing, toileting and personal care. The resident was coded as having pain frequently that limited her day-to-day activities, rating it 10/10. Resident interview Resident #97 was interviewed on 8/23/16 at 9:33 a.m. She said she was in a lot of pain at that time in her legs and back. She said she told the certified nurse aide (CNA) and her husband told the nurse. However, she was still waiting for pain medication. She said that it was common to have to wait for pain medication. The resident was interviewed again on 8/25/16 at 9:27 a.m. She said she had not received her routine medications yet including her pain medication. She said she was supposed to get them before 9 a.m. She said her pain was two to three as long as she was lying flat. She said when she had to get up to use the bathroom her pain increased to eight or nine. Observations On 8/23/16 at 9:33 a.m. the resident was observed to be in a lot of pain, grimacing at times and restless. She attempted to put the head of her bed up but was unable to because she said it increased her pain too much. She remained lying flat on her back. The nurse was observed to not bring in the pain medication until 9:51 a.m. almost an hour after the resident requested it. On 8/25/16 at 9:27 a.m. during an interview with the resident she was observed to grimace in pain when she attempted to raise the head of the bed up. On 8/25/16 at 9:48 a.m. registered nurse (RN) #2 was observed carrying medications including pain medication in to resident #97's room. RN #2 documented on the MAR they were charted late due to patient care. Record review According to the 8/14/16 care area assessment (CAA) pain was triggered. The CAA detail worksheet noted the resident had pain that disturbed her sleep, adversely affected her mood, limited day to day activities and limited independence with at least some ADLs. She experienced pain from L3-S1 posterior fusion/laminectomy. She was encouraged to ask for PRN medications and notify staff of changes in pain. Medications were reviewed and adjusted by the physician. Additional adjustments to pain medications to be made as needed. Pt continued to attend therapy and participate with ADLs to work toward goal or discharge to home. Staff was to monitor for signs and symptoms of pain. No additional referrals were needed, proceed with supportive care plan. The care plan, revised 8/10/16, identified alteration in comfort related to L3-S1 posterior fusion/laminectomy and [MEDICAL CONDITION] joint disease. Interventions included: -Administer medication per physician's orders. -Assess for signs and/or symptoms of pain with each encounter; offer treatment and/or pain medication per physician's orders. -Assist to reposition for comfort as needed. -If current regimen is ineffective in managing pain, notify the physician. -Observe and report signs/symptoms of discomfort. -Observe for relief within 30-40 minutes of administration of medication. -Offer alternative pain relief methods, such as heat/cold application, deep breathing and diversion. Pain Management Plan According to the 8/16 medication administration record (MAR): -Throughout the month the physician order for [REDACTED]. The changes were: -[MEDICATION NAME] 5mg every six hours as needed for pain rated one to five and 10mg for pain rated six to 10 ordered 8/2/16. --On 8/11/16 the order was changed to [MEDICATION NAME] 10 mg as needed (PRN). No parameters for how often the PRN medication was to be given were included. --On 8/14/16 the order was again changed to 10 mg PRN with blood pressure parameters to hold medication if systolic blood pressure was less than 90. This was ordered related to the resident's blood pressure being low at night. No parameters were included for how often the medication was to be given. --On 8/15/16 the order was changed to [MEDICATION NAME] 10 mg every four hours as needed. Blood pressure parameters continued but there was no documentation of blood pressure being checked before the medication was given. -Other pertinent medications included: -- [MEDICATION NAME] 750-1,500 mg every six hours as needed for muscle spasms ordered 8/2/16. --[MEDICATION NAME] 5 mg every six hours as needed for muscle spasms ordered 8/2/16. -- [MEDICATION NAME] 300 mg twice a day for [MEDICAL CONDITION] ordered 8/11/16. The medical record failed to show a pain assessment. No tolerable level of pain was documented. The facility failed to assess the characteristics of the resident's pain, including the intensity, type and patterns of the resident's pain; or the location, [MEDICAL CONDITION], frequency, timing and duration of the pain. No documentation was found that non-pharmacological interventions were being used. No pain scale was documented. Review of the MAR showed the resident experienced pain levels in excess of five out of 10. However, the resident's pain was not controlled, and the facility failed to reassess the resident to see if the medication was effective. 8/3/16 -At 5:50 a.m. the resident received [MEDICATION NAME] 10mg and [MEDICATION NAME] 750mg for pain rated eight out of 10. The resident's pain was not reassessed until 9:48 a.m. with results of pain medication documented as somewhat effective and pain continued to be rated eight out of 10. [MEDICATION NAME] 10mg and [MEDICATION NAME] 5mg were given. No non-pharmacological interventions were documented as being provided. 8/4/16 -At 1:40 p.m. the resident received [MEDICATION NAME] 10mg and [MEDICATION NAME] 5mg for pain rated eight out of ten. The resident's pain was not reassessed until 4:43 p.m. with results of pain medication documented as somewhat effective. She received [MEDICATION NAME] 1,500 mg at 4:43 p.m. and [MEDICATION NAME] 10 mg at 7:42 p.m. The resident's pain was not reassessed until 8/5/16 at 1 a.m. with results of pain medication documented as somewhat effective, pain rated three to four out of 10. She did not receive any more pain medication until 4:42 a.m. when pain was rated eight out of 10. 8/6/16 -At 8:36 a.m. the resident received [MEDICATION NAME] 10mg and [MEDICATION NAME] 1,500 mg for pain rated eight out of 10. -At 10:25 a.m. the pain was reassessed and results of pain medications were documented as being somewhat effective. She did not receive any more pain medication. -At 4:26 p.m. her pain was rated seven out of ten. She received [MEDICATION NAME] 10 mg and methocabamol 1,500 mg. The resident's pain was reassessed at 6:39 p.m. with results of pain medication being documented as somewhat effective. 8/7/16 -At 1:24 p.m. the resident received [MEDICATION NAME] 10 mg and methocabamol 1,500 mg for pain rated seven out of 10. The resident's pain was not reassessed until 7:00 p.m. with results of pain medication being documented as somewhat effective. 8/12/16 -At 8:19 a.m. the resident received [MEDICATION NAME] 10 mg for pain rated seven to eight out of ten. Pain was reassessed at 10:50 a.m. with results of pain medication documented as somewhat effective. The resident did not receive any more pain medication. -At 3:07 p.m. she received [MEDICATION NAME] 10 mg for pain not rated. Pain was reassessed at 6:46 p.m. with results of pain medication documented as somewhat effective. She did not receive any more pain medication until 9:04 p.m. for pain unrated. 8/14/16 -At 7:05 a.m. the resident was given [MEDICATION NAME] 5 mg for anxiety related to pain, however was not given any pain medication until 12:40 p.m. Pain level not documented. 8/18/16 -At 8:08 a.m. the resident received [MEDICATION NAME] 10 mg and [MEDICATION NAME] 750mg for pain rated seven out of 10. The resident's pain was reassessed at 10:30 a.m. with results of pain medication being documented as somewhat effective. The resident did not receive any more pain medications that day. 8/22/16 -At 1:36 p.m. the resident received [MEDICATION NAME] 10 mg for pain rated six out of 10. -At 8:06 p.m. she received methocabamol 750 mg. Pain was not reassessed until 8/23/16 at 2:41 a.m. and was rated as ten out of ten. No pain medications were administered until 9:51 a.m. According to progress notes on 8/11/16 the physical therapist (PT) documented the resident's pain was reportedly nine to ten out of ten, especially to the left lower extremity. She was unable to tolerate sitting, ice had been used but the resident reported ice increased pain. She had poor activity tolerance. She fluctuated with moderate to minimal assistance with all transfers and bed mobility. Gait with front wheeled walker (FWW) 36 feet with caregiver assistance. She required max voice commands for encouragement to participate due to her high pain levels. The progress note documented pain medication scheduled prior to therapy. The physician responded with new orders to add [MEDICATION NAME] 300 mg twice a day and to increase [MEDICATION NAME] to 10mg every four hours as needed for pain. If she did not see leg pain improvement, then an MRI was to be done. According to the PT therapy weekly summary for week one 8/8/16, the resident had been seen four times since admit on 8/3/16. She had persistent severe pain across her low back but primarily in her left thigh. She reported that she was able to get more relief lying flat with pain rated two out of 10. Once she raised the head of the bed up or attempted bed mobility her pain would increase to six to nine out of 10. Due to the severity of pain with sitting, standing and mobility, the resident's progress was slow with slight improvement noted in sit to stand and stand pivot transfer to commode. According to the PT weekly summary for week two 8/15/16, the resident was to start a new pain medication for nerve pain and increased dosage of other pain medication to help decrease the resident's pain from nine to ten out of ten to left lower extremity in order to increase functional mobility. She still reported pain nine out of ten to left lower extremity with all functional movements. She had increased complaints of pain when sitting up in her reclining wheelchair. C. Resident #215 Resident #215, age 83, was admitted on [DATE]. According to the 8/16 CPOs, [DIAGNOSES REDACTED]. According to the nurse's admission note, the resident was alert and oriented times four although drowsy from pain medication. Resident interview The resident was interviewed on 8/23/16 at 10:37 a.m. He said he had a good pain management system at home of taking his pain medications routinely. But it got messed up at the hospital, and he had not been able to get the facility to comply with it. He stated what they were doing for him was not effective. He said the biggest problem was timing. He would ask for a pain pill but would sometimes have to wait an hour to an hour and a half for the nurse to give it to him. By then, his pain would be harder to control. The resident was interviewed a second time on 8/25/16 at 2:45 p.m. with one of his daughters present. He said he wished the facility had contacted his primary physician about his pain medications at the start of his stay. The resident's daughter said the [MEDICATION NAME] was too much, causing him to have increased confusion and not controlling his pain. She said she caught the physician's assistant (PA) out in the hallway and asked him to change the pain medication to what he was taking at home. The resident stated the biggest problem was the time it took for the nurse to bring him his pain medication, sometimes having to wait an hour and a half to two hours. The daughter confirmed this. Record Review Pain Management Plan According to the 8/16 CPO, the resident had the following orders: -[MEDICATION NAME] (Tylenol) 325 milligrams (mg) two tabs every four hours PRN, ordered 8/20/16 and -[MEDICATION NAME] 10mg every three hours as needed (PRN) for pain rated one to five and 15mg as needed for pain rated six to ten ordered on [DATE]. -According to the 8/21/16 physician telephone order the resident was prescribed [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5-325mg one tab every four hours as needed. Review of the 8/16 MAR showed the resident experienced pain levels in excess of five out of 10. However, the resident did not receive the appropriate dose amount based on the physician-ordered parameters. On 8/19/16 at 8:34 a.m., the resident had pain rated at six out of 10 and was administered 10 mg of [MEDICATION NAME]. -12:47 p.m., the resident had pain rated at seven out of 10 and was administered 10 mg of [MEDICATION NAME]. -9:57 p.m., the resident had pain rated at six out of ten. The MAR documented the medication was not effective, however, the resident did not receive any other pain medication until 8/20/16 at 1:45 a.m. for a pain level of eight out of 10. The MAR documented this as being somewhat effective. The resident did not receive any other pain medication until 5:02 a.m. 8/21/16 -At 4:14 p.m. the resident had pain rated at six out of 10 and was administered [MEDICATION NAME] 10 mg. This was documented as not effective and he received Tylenol 650mg at 5:05 p.m. 8/22/16 -At 5:31 a.m. the resident received Tylenol 650mg for pain with rating not documented. It was documented as somewhat effective. He did not receive any more pain meds until 9:41a.m., when he received [MEDICATION NAME] 5/325mg for pain with rating not documented. 8/23/16 -At 12:02 p.m. the resident received [MEDICATION NAME] 5/325mg for pain rated five out of 10. He then received Tylenol 650mg at 2:33 p.m. These were documented as somewhat effective at 3:32 p.m. No other pain medication was documented as being given. The initial care plan, initiated upon admission, identified an alteration in comfort due to hip replacement with three to four out of ten being an acceptable level of pain. Interventions included: -Give medication as ordered. -Monitor for signs and symptoms of pain and medicate as needed per order. -Evaluate pain for cause, site and intensity before and after medication is given. -Notify physician if current regimen was ineffective. -Assist with ice pack and position for comfort as needed. The medical record failed to show a pain assessment. The facility failed to assess the characteristics of the resident's pain, including the intensity, type and patterns, location, [MEDICAL CONDITION], frequency, timing and duration of the pain. No documentation was found that non-pharmacological interventions were being used. No pain scale was documented. D. Resident #225 Resident #225, age 82, was admitted on [DATE]. According to the 8/16 CPOs, [DIAGNOSES REDACTED]. No MDS had been completed. Resident interview The resident was interviewed on 8/22/16 at 10:02 a.m. He said he had been in bad pain rated nine to ten out of ten all night. He could not find his call light to ask for help. He stated they finally came early in the morning and gave him something that took the edge off. Record Review Pain Management Plan According to the 8/16 CPO the resident had the following orders: -[MEDICATION NAME] 5/325 mg every four hours as needed for mild pain and 10/650 mg every four hours as needed for moderate pain, ordered 8/20/16. The order did not specify the difference between mild and moderate pain. - [MEDICATION NAME] 800 mg three times a day for muscle spasms, ordered 8/20/16, - Polar Ice or similar care as needed, ordered 8/20/16. This order was never placed on the MAR or treatment administration record (TAR) and was never documented as being administered. Review of the MAR showed the resident experienced pain levels in excess of five out of 10. The resident was administered the pain medication, however, the facility failed to follow up and reassess to ensure the resident's pain level was controlled. 8/22/16 -At 5:23 a.m. the resident received [MEDICATION NAME] 10/650 mg for pain rated ten out of ten. He was not reassessed until 10:14 a.m. -At 9:07 a.m. the resident received [MEDICATION NAME] 10/650 mg for a pain level of six out of 10. He was not reassessed until 8/23/16 at 1:39 a.m. at which time he received another [MEDICATION NAME] 10/650 mg for pain rated seven out of 10. 8/23/16 -At 7:41 a.m., the resident received [MEDICATION NAME] 5/325 mg for pain rated five out of ten. He was not reassessed until 3:32 p.m. The interim care plan, initiated upon admission, identified an alteration in comfort with an acceptable level of pain being between five and six on one to 10 scale. Interventions included: -Give medications as ordered. -Monitor for signs and symptoms of pain and medicate as needed per order. -Evaluate pain for cause, site and intensity before and after medications. -Notify the physician if current regimen is ineffective. Staff interviews The physical therapist (PT) #1 and certified occupational therapist assistant (COTA) #3 were interviewed on 8/25/16 at 3:00 p.m. They said they did a lot of education with the residents on pain management, such as asking for pain medications a half an hour prior to working with therapy. They stated ice packs and positioning were used as non-pharmacological interventions. The DON was interviewed on 8/25/16 at 4:45 p.m. She said the admission nurse asked the resident what his tolerable level of pain was when he was admitted and this was placed on the interim care plan. She said the nurses should be asking the resident about their pain with every encounter and it should be documented on the MAR. If a PRN pain medication was given, the nurse should have followed up within the hour to assess for effectiveness. If the current pain management plan was ineffective, the physician would be contacted for new orders. II. Diabetic management A. Facility policy and procedure [DIAGNOSES REDACTED]/[MEDICAL CONDITION] protocol, revised 2/19/16, was received from the DON on 8/25/16 at 2:30 p.m. The protocol included, If resident has a hypoglycemic (low blood sugar) episode the physician should be notified of the event, interventions and outcome. If the resident has a hyperglycemic (high blood sugar) episode, follow the physician prescribed regular insulin sliding scale. B. Resident #223 Resident #223, age 80, was admitted on [DATE]. According to the 8/16 CPOs, [DIAGNOSES REDACTED]. No MDS assessment had been completed. The interim care plan, initiated upon admission, identified a [DIAGNOSES REDACTED]. -Medications as ordered. -Blood sugars as ordered. -Bedtime snack. -Monitor for signs and symptoms of hypo/[MEDICAL CONDITION]. Record Review According to 8/16 CPOs, the resident had the following orders: Humalog insulin per sliding scale with meals; -If blood sugar is 120 to 150, give 2 units. -If blood sugar is 151 to 200, give 4 units. -If blood sugar is 201 to 250, give 6 units. -If blood sugar is 251-300, give 8 units. -If blood sugar is greater than 300, call physician, ordered 8/19/16. [MEDICATION NAME] N 14 units in the morning and 8 units in the evening. No orders for low blood sugar. There was no physician order to perform finger stick for blood sugars. According to the 8/16 MAR: -On 8/19/16 in the evening and 8/20/16 in the morning no blood sugar was recorded and no Humalog insulin was given. -On 8/20/16 noon blood sugar was 153. Resident was documented as receiving 2 units of Humalog instead of 4 units ordered. -On 8/21/16 evening [MEDICATION NAME] N and Humalog were held related to a blood sugar of 90. However, the physician was not notified. -On 8/22/16 the evening dose of Humalog insulin was held related to blood sugar of 73. However, the physician was not notified. -On 8/23/16 the evening dose of Humalog insulin was held to see if he would eat dinner. Blood sugar was not checked, insulin was not given and physician was not notified. C. Resident #224 Resident #224, age 70, was admitted on [DATE]. According to the 8/16 CPOs, [DIAGNOSES REDACTED]. No MDS assessment had been completed. The interim care plan, initiated upon admission, identified a diabetes diagnosis. Interventions included: -Give medications as ordered. -Blood sugars as ordered. -Bedtime snack. -Monitor for signs and symptoms of high and low blood sugars. Record Review According to 8/16 CPOs, the resident had the following orders: Humalog insulin per sliding scale as follows: -If blood sugar is 150-200, give 2 units. -If blood sugar is 201-250, give 4 units. -If blood sugar is 251-300, give 6 units. -If blood sugar is 301-350, give 8 units. -If blood sugar is greater than 350, call the physician, ordered 8/20/16.No parameters were ordered for low blood sugar. [MEDICATION NAME] 10 units at bedtime, ordered 8/20/16. No parameters ordered for when to hold insulin. Fasting blood glucose checks before meals and at bedtime, ordered 8/25/16. According to 8/16 MAR: -On 8/21/16 at 8:13 a.m. the resident's blood sugar was 74. The medical record failed to show the physician was notified. --At 8:29 p.m. [MEDICATION NAME] was held related to blood sugar of 103 and resident did not eat. Physician was not notified. -On 8/24/16 in the evening blood sugar was 236. Resident was documented receiving two units of Humalog instead of four units ordered. Staff interviews The corporate clinical nurse was interviewed on 8/25/16 at 9:55 a.m. and was asked to provide orders for blood sugars and blood sugar results for resident #224. She said the blood sugars should be on the MAR. She was able to show the blood sugars were being recorded with the Humalog insulin order but did not find a specific order to check blood sugars. She said it was on their physician's standing orders. After reviewing the standing orders it was determined that the order was only as needed for signs and symptoms of hypo/[MEDICAL CONDITION]. The resident was having her blood sugar checked four times a day but results were not being documented for the bedtime results consistently. At 10:34 a.m. the corporate nurse provided a new telephone order to obtain fasting glucose checks four times a day before meals and at bedtime. The DON was interviewed 8/25/16 at 4:45 p.m. She said the staff should be notifying the physician if the blood sugars were out of parameters and it should be documented in a progress note. Insulin should be given as it was ordered. D. Resident #213 Resident #213, age 67, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 8/18/16 MDS assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She did not have signs and symptoms of [MEDICAL CONDITION], such as inattention, disorganized thinking, altered level of consciousness, or psychomotor [MEDICAL CONDITION]. She required extensive assistance with bed mobility, transfers, toilet use, and required physical help with bathing. She had functional limitations on one side of the lower extremity, and utilized a walker and wheelchair for mobility. Within the past seven days of the assessment she had received seven insulin injections per physician's orders. The care plan, initiated on 8/15/16 identified the resident was dependent on insulin due to diabetes. Interventions included: - Diet per physician's orders; - Glucose levels and labs per physician's orders; - Licensed nurse to perform nail care weekly and as needed; - Medication and/or treatment per physician's orders; and - Offer bedtime snack. Resident interview Resident #213 was interviewed on 8/22/16 at 10:00 a.m. She said she had concerns regarding her insulin and diabetic management. The facility did not trust her or keep her informed in decisions about her medical care. Record review The 8/15/16 telephone orders (TOs) revealed the following pertinent information: - [MEDICATION NAME] flextouch (insulin), 40 units every morning and 20 units every evening; and - Humalog kwikpen (insulin), 100 unit/ml based on a sliding scale, subcutaneous injection for diabetes mellitus and administered before meals. If blood glucose was 121-170 one unit of insulin, 171-220 two units of insulin, 221-270 three units of insulin, 271-320 four units of insulin, 321-370 five units, and 371-420 six units. The 8/16 physician's orders revealed the following pertinent information: - Order date: 8/6/16, blood glucose before meals and at bedtime; - Order date: 8/6/16, check blood glucose as needed for signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar). If less than 80 follow the [DIAGNOSES REDACTED] protocol; - Order date: 8/6/16, humalog kwikpen, 100 unit/ml based on a sliding scale, subcutaneous injection for diabetes mellitus and administered before meals. If blood glucose was 0-120 no insulin, 121-170 one unit of insulin, 171-220 two units of insulin, 221-270 three units of insulin, 271-320 four units of insulin and call the physician, 321-370 five units of insulin and call the physician, and over 300 call the physician; - Order date: 8/6/16, [MEDICATION NAME] flextouch, 100 unit/ml, 10 units, subcutaneous injection for diabetes mellitus and administered in the evenings; - Order date: 8/6/16, [MEDICATION NAME] flextouch, 100 unit/ml, 15 units, subcutaneous injection for diabetes mellitus and administered in the mornings; and - Order date: 8/6/16, evening snack. The 8/16 medication administration record (MAR) revealed the following pertinent information: Order date: 8/6/16, blood sugar before meals and at bedtime. On 8/19 the resident's blood sugar was 72 mg/dL. On 8/24/16 the resident's blood sugar was 63 mg/dL. The comments did not reveal the physician was notified. Order date: 8/9/16, discontinued date: 8/15/16, humalog kwikpen (insulin) before meals and based on a sliding scale. If blood glucose was 0-120 no insulin, 121-170 one unit of insulin, 171-220 two units of insulin, 221-270 three units of insulin, 271-320 four units of insulin and call the physician, 321-370 five units of insulin and call the physician, and over 300 call the physician. The units of insulin administered were not documented on the following dates and shifts: - 8/7/16, during the morning, afternoon, and night shift the insulin was not available for administration; - 8/8/16, the morning blood glucose was 250 mg/dl; - 8/10/16, the morning blood glucose was 188 mg/dl; - 8/11/16, the morning, afternoon, and evening blood glucose was 167 mg/dl, 310 mg/dl, and 241 mg/dl; - 8/12/16, the morning, afternoon, and evening blood glucose was 128 mg/dl, 286 mg/dl, and 276 mg/ml; - 8/13/16, the morning and afternoon blood glucose was 161 mg/dl and 318 mg/dl; - 8/13/16, the resident was sent to the emergency department; - 8/14/16, the morning, afternoon, and evening blood glucose was 183 mg/dl, 280 mg/dl, and 303 mg/dl; - 8/15/16, the morning and afternoon blood glucose was 125 mg/dl and 335 mg/dl; and - The reasons/comments section did not reveal the physician was notified on 8/7/16, 8/11/16, 8/12/16, 8/13/16, 8/14/16, and 8/15/16. The 8/8/16, 8/10/16, and 8/13/16 nursing progress notes did not reveal the physician was notified of the resident's blood glucose. Order date: 8/15/16, humalog kwikpen (insulin) before meals and based on a sliding scale. If blood glucose was 0-120 no insulin, 121-170 one unit of insulin, 171-220 two units of insulin, 221-270 three units of insulin, 271-320 four units of insulin and call the physician, 321-370 five units of insulin and call the physician, and over 300 call the physician. The units of insulin administered were not documented on the following dates and shifts: - 8/16/16, the afternoon and evening blood glucose was 288 mg/dl and 197 mg/dl; - 8/17/16, the morning, afternoon, and evening blood glucose was 138 mg/dl, 292 mg/dl, and 308 mg/dl; - 8/18/16, the afternoon and evening blood glucose was 200 mg/dl and 296 mg/dl; - 8/19/16, the morning blood glucose was 72 mg/dl. There were no documented non-pharmaceutical interventions in the reasons/comments section; - 8/19/16, the morning and afternoon blood glucose was 252 mg/dl and 311 mg/dl; and - The reasons/comments section did not reveal the physician was notified on 8/17/16, 8/18/16, and 8/19/16. The 8/17/16 and 8/19/16 nursing progress notes did not reveal the physician was notified of the resident's blood glucose. The doctor's concern log revealed the following pertinent information: - On 8/13/16 at noon the resident's blood glucose for the past six days was 324 mg/dl, 213 mg/dl, 315 mg/dl, 310 mg/dl, 286 ml/dl, and 318 ml/dl.Increase Humalog sliding scale administration?; - The response was to increase the [MEDICATION NAME] flextouch; and - Between 8/6/16 and 8/24/16 the 8/13/16 note was the only logged concern to the physician. Staff interviews The registered dietician (RD) was interviewed on 8/25/16 at 10:20 a.m. She said the physician was responsible for writing orders for nutrition consultation as needed. She was not working with resident #213 for insulin and diabetic management. Registered nurse (RN) #1 was interviewed on 8/25/16 at 10:56 a.m. She said blood glucose monitoring was dependant on the parameters set by the physician. Physician orders were required to be followed and the results on the blood glucose test documented in the administration logs, Concern Log (physician concern log), and the nursing progress notes. Based on resident #213's blood glucose she received insulin on a sliding scale. The units of insulin received were required to be documented. If the resident's blood glucose was out of range the physician was required to be notified. If the resident's blood glucose was under 80 mg/dL, the resident required non-pharmaceutical nutrition interventions, which included food and juice. RN#5 was interviewed on 8/25/16 at 3:30 p.m. She said physician orders for insulin and diabetic management were requir

Based on observations, record review and staff interviews, the facility failed to ensure that it was free of medication error rates of five percent or greater. Specifically, the medication pass observation error rate was 14%, or four errors out of 28 opportunities for error. The findings included: 1. Professional Reference According to Clinical Nursing Skills & Techniques, by Perry, Potter & Ostendorf, 8th Edition (copyright 2014), page 480-489, Safe Medication Administration: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation -Read the label on the medication container and compare it with the MAR (medication administration record) at least 3 times: before removing the container from the supply drawer, when placing the medication in an administration cup/syringe, and just before administering the medication to the patient . -Review any pre-administration assessments (e.g., vital signs, review of laboratory results) . -Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication . -When an error occurs, the patient's safety and well-being become the top priority . 2. Observations Registered nurse (RN) #2 was observed preparing and administering medications to resident #227 on 8/24/16 at 8:30 a.m. The resident's order was for chewable aspirin 81milligrams (mg) by mouth daily. The RN administered [MEDICATION NAME] coated aspirin instead of chewable aspirin as per order. The resident also had an order for [REDACTED]. The RN documented that it was not available. The medication was found in the medication room refrigerator unopened later in the day during medication storage observation. The director of nurses (DON) was notified at that time that the nurse had documented it was unavailable. She indicated that the supply was available in the refrigerator. The medication was again documented as being unavailable on 8/25/16. This medication had been documented for three days as unavailable with no documentation that the physician or the pharmacy was notified. RN #2 was observed preparing and administering medications to resident #217 on 8/24/16 at 9:03 a.m. The resident had orders for [MEDICATION NAME] 10 mg by mouth once a day. RN #2 was observed to omit this medication. RN # 1 was observed preparing and administering medications to resident #228. The resident had orders for [MEDICATION NAME] inhaler 90 micrograms (mcg) two puffs orally three times a day. RN #1 was observed to have waited less than the recommended time between puffs and did not shake the canister prior to administering (see below). According to 2016 GlaxoSmithKline (GSK) manufactures recommendations on how to use the [MEDICATION NAME] inhaler: · Shake the canister well just before each spray. · Uncap the mouthpiece of the [MEDICATION NAME] inhaler. Breathe out fully. Put the mouthpiece into your mouth and close your lips. Breathe in slowly while pushing down on the canister. Hold your breath for 10 seconds, and then breathe out slowly. · If you use more than one inhalation at a time, wait at least 1 minute before using the second inhalation and shake the inhaler again. 3. Interview RN #4 was interviewed on 8/25/16 at 9:30 a.m. She said the nurses were aware that Calcitonin was kept in the medication room refrigerator and did not know why the RN would mark it as not available.

Based on observations, interviews and record review, the facility failed to ensure medications were labeled and stored in accordance with manufacturer instructions and practice standards. Specifically, the facility failed to ensure loose pills were not stored in the medication carts and a medication cart was locked when not in use and attended. The findings included: 1. Facility policy The medication storage policy and procedure was received from the director of nursing (DON) on 8/25/16 at 10:15 a.m. The policy included, Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. The facility will maintain an emergency drug supply. Contents of the emergency drug supply must be listed on the outside of the container and nursing staff shall document the use of contents. 2. Loose and unlabeled medications Observations Observation of the Hall #1 medication cart on 8/24/16 at 4:37 p.m. revealed one loose white pill in the bottom of the drawer. Registered nurse (RN) #5 did not know what the pill was and disposed of it in the sharps container. Observation of the Hall #2 medication cart on 8/24/16 at 4:30 p.m. revealed 11 individually packaged prescription pills in a cup in the top drawer with no resident name on them. RN #3 said she did not know why the pills were in the cup, or who they were for. She said they may have been pulled from the Pyxis emergency kit but were not used. She said they should have been given to the supervisor to be destroyed. Staff interview The DON was interviewed on 8/25/16 at 4:45 p.m. The DON said pills should not have been loose in the medication drawers. The pills in the cup were probably from the Pyxis emergency kit and should have been returned to it or destroyed. The DON explained the Pyxis was an automated medication dispensing system used in the building for emergency medications such as narcotics and antibiotics. Medications were dispensed individually packaged. The nurse must sign out the medication from the Pyxis and then administer it. If it was not given, it could be returned to the Pyxis. 3. Unlocked Medication Cart Observation A medication cart was observed unlocked on 8/23/16 at 11:18 a.m. outside resident room [ROOM NUMBER]. The cart was unattended. At 11:19 a.m. two residents wheeled past the medication cart. At 11:21 a.m. a therapy staff member walked past the cart. At 11:22 a.m. another staff member walked past the unlocked and unattended medication cart. At 11:23 a.m. a resident and a visitor walked past the unattended cart. At 11:24 a.m. two certified nurse aides and three other staff members walked past the medication cart without stopping. At 11:25 a.m. the nurse returned to the medication cart and locked it. Interviews RN #5 was interviewed on 8/25/16 at 3:26 p.m. She said the facility protocol when walking away from a medication cart was to lock it and ensure all electronic records were secured on the computer. The nursing home administrator (NHA) was interviewed on 8/25/16 at 4:41 p.m. He said he had noticed the medication cart was unlocked and unattended. The NHA said they re-educated the nurse, who was apologetic.

Based on record review and staff interviews, the facility failed to ensure an indwelling catheter was not used unless there was valid medical justification and /or was discontinued as soon as clinically warranted for one (#224) of three residents reviewed for catheter use of 26 sample residents. Specifically, the facility failed to: -Ensure an appropriate [DIAGNOSES REDACTED]. -Ensure necessity of continued use of a catheter. The findings included: A. Professional Reference According to the Centers for Disease Control and Prevention website, www.cdc.gov <http://www.cdc.gov>, Catheter-Associated Urinary Tract Infections, 10/16/15 (accessed 9/16), catheters should only be used for appropriate indications and left in place only as long as needed. A [DIAGNOSES REDACTED]. B. Resident #224 Resident #224, age 70, was admitted on [DATE]. According to the 8/16 computerized physician orders, [DIAGNOSES REDACTED]. Resident did not have a specific [DIAGNOSES REDACTED]. There was no minimum data set assessment, as the resident was newly admitted . Record review According to a nurse's progress note dated 8/20/16 at 11:00 p.m. the resident was alert and oriented and able to make needs known. The interim care plan, initiated upon admission 8/20/16, identified an alteration in bowel/bladder. Interventions included catheter care every shift and as needed. According to 8/16 physician's orders [REDACTED]. -Bowel and bladder retraining protocol as indicated; -Routine Foley catheter care per protocol; may discontinue as appropriate; and -Change Foley with a 16 French catheter monthly on day shift; may change as needed for malfunction. According to progress notes: -8/21/16 at 11:19 p.m. the Foley catheter was intact but certified nurse aide (CNA) informed the RN the resident did not have any output in the Foley itself but in the brief. After resituating the catheter, the bag began to fill with clear yellow urine. -8/24/16 at 3:16 p.m. Foley catheter was patent with cloudy sediment urine noted in catheter tubing but clear straw-colored urine was noted in drainage bag. Slight leakage was noted when the resident was first out of bed but with a shower and repositioning of the tubing, no further leakage was noted. -8/25/16 at 1:05 a.m. Foley patent with clear yellow urine, 250 milliliters (ml) out, the catheter was very positional, did not drain when resident was up in wheelchair. -8/25/16 at 8:00 a.m. Foley was draining clear yellow urine, leaking that morning. Bladder training started at 6:00 a.m. (Foley was clamped). Further record review revealed: -No urology consultations were present in the record. -No bladder retention testing or studies were present in the record. -No physician notes addressed the use of an indwelling catheter or evaluation for [MEDICAL CONDITION]. Staff Interview and Facility Follow-Up The director of nurses (DON) was interviewed 8/23/16 at 2:20 p.m. The DON provided a signed telephone order written on 8/20/16 for order clarification. The order noted the resident's [DIAGNOSES REDACTED]. The facility policy on catheter use was requested, but the policy provided addressed changing drainage bags, and not catheter use. On 8/24/16 a new telephone order was obtained to begin 48-hour bladder training/clamping schedule in am on 8/25/16 to discontinue Foley catheter. The DON was interviewed a second time on 8/25/16 at 4:45 p.m. She said once they realized [MEDICAL CONDITION] was not an acceptable diagnosis, they went through all their residents that had Foley catheters to ensure they had appropriate justification. If not, she said they were starting bladder retraining so the catheters could be discontinued.

Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (#219 and # 130) of three residents reviewed of 32 sample residents. Specifically, the facility failed to: - Provide residents with supervision and effective individualized treatment plans with interventions to prevent falls with injury; and - Ensure fall prevention measures were in place and reassessed to identify more effective safety measures. The findings included: 1. Facility policy and procedure The 1/31/11 Fall Prevention policy was provided on 8/24/16 at 12:30 p.m. by the nursing home administrator (NHA). The documented revealed the policy was developed To ensure optimal patient safety while promoting patient independence and maximizing psychosocial well-being. Safety Alarms will be placed and monitored with appropriate documentation as indicated. Discontinuation of Safety Alarms will require Interdisciplinary Team (IDT) review with appropriate documentation of rationale and supporting data . The 6/15/09 Accident and Incident policy was provided on 8/24/16 at 12:30 p.m. by the NHA. The document revealed the purpose of the policy was To provide an organized system for complete and thorough review of all accidents or incidents that occurs within the facility. To provide a systematic method of information analysis that leads to recommendations for quality improvement both for the individual and for the facility .The Licensed Nurse assigned to the patient at the time of the incident will be immediately notified to perform a physical assessment of patient's condition and take action to direct further monitoring and/or treatment as appropriate including need for immediate care and/or emergency support and/or transport .The Licensed Nurse will complete the Accident and Incident Report .The Licensed Nurse will write a description of the incident in the patient's medical record .The Interdisciplinary Team/Patient Safety Committee will review the incident for additional concerns the following day or Monday if the incident occurs on a weekend day. Documentation of subsequent action or follow-up may be added to the report . 2. Professional reference According to the Journal of Nursing Care Quality, Quality Improvement in Nursing Homes Testing of an Alarm Elimination Program, https://www.researchgate.net/publication/ 5547_Quality_Improvement_in_Nursing_Homes_Testing_of_an_Alarm_Elimination_Program, 11/13 and accessed on 8/29/16 at 1:00 p.m.: Falls are the most common cause of injury deaths and nonfatal injuries in older adults. In an effort to detect a resident's movement, many nursing homes use bed or chair alarms to alert staff that the resident may get up and possibly fall. However, there is little evidence that bed or chair alarms prevent falls, and mounting evidence that alarms can impede the functional status and negatively impact feelings of dignity among older adults in nursing homes . In nursing homes, falls normally occur in the older adult's room, especially during attempts to get in and out of bed or when trying stand up from a wheelchair . Alarms can create noise, fear, and confusion . Alarms decrease the person's overall mobility, subsequently increasing their risk for weakness, decreased balance, and increased risk of fracture with a fall . Alarms can be perceived as embarrassing and an infringement on freedom, dignity, and privacy. Immobility can lead to skin breakdown and bowel and bladder incontinence secondary to a fear of the noise and being afraid to shift position or body weight while sitting or lying in bed for prolonged periods of time. Alarms can interrupt sleep or even make sleep impossible when residents lie still for fear of setting off the alarm by shifting their position . Alarms can malfunction . Alarms give a false sense of security . 3. Resident #219 Resident #219, age 94, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The resident was newly admitted into the facility and the minimum data set (MDS) assessment was not available for review. The care plan, initiated on 8/18/16, was an interim care plan. Interventions included the following safety devices: bed alarm, wheelchair alarm, and fall mats. The care plan, initiated on 8/18/16, identified the resident was at high risk for falls. Interventions included: - Falls mats; - Occupational therapy/physical therapy consultations; - Safety alarms to bed and wheelchair; and - Bed in the lowest position. A. Observations and family interview Resident #219 was observed on 8/22/16 at 3:35 p.m. He was sitting in his wheelchair. The chair alarm was located on the left side of the wheelchair, and had a string attached to it with a clip. The clip was not observed clipped onto the back of the resident's shirt. Resident #219 was observed on 8/24/16 at 9:26 a.m. He was sitting in his wheelchair and waiting for bathing assistance from the bath aide. She was located in the bathroom, and he was fully dressed and located inside of his bedroom and next to the bed. The chair alarm clip was not observed clipped onto the back of the resident's shirt. A family member was interviewed on 8/24/16 at 11:32 a.m. He said resident #219 had a fall with a skin tear after attempting to transfer himself from the wheelchair to the bed. The resident had a hearing and vision deficit with moderate difficulty understanding and responding to questions. The bed and chair alarms were observed for placement. The chair alarm had a clip which attached to the back of the resident's shirt. The clip was not observed to be attached to the resident's shirt. The family member said the bath aide must have forgotten to place the clip back onto his shirt this morning after his shower. C. Record review The 8/14/16 General Admission H&P (history and physical examination [REDACTED]. The fall occurred after he slipped off of the bed. The 8/18/16 Fall Risk Assessment revealed the resident scored a 26 out of 34, which indicated he was a high fall risk. The 8/18/16 telephone order (TO) revealed the following pertinent information: - Tab alarms to the bed and wheelchair. Check the placement of the alarms at every shift; - Bed in the lowest position; and - Fall mat to floor when resident was in bed. The 8/16 physician's orders (POs) revealed the following pertinent information: - Order date: 8/18/16, fall mat to floor when resident was in bed; - Order date: 8/18/16, tab alarm to the bed and wheelchair. Verify the placement of the alarms at each shift; and - Order date: 8/18/16, document the number of times the resident sets off the alarm at each shift. Special instructions: refer resident to physical therapy/occupational therapy prior to discontinuing the safety alarms. The 8/16 treatment administration records (TARs) revealed the licensed nurses were signing off that the fall mat and tab alarms were in place at every shift. On 8/21/16 (afternoon) and 8/23/16 (morning) the tab alarms alerted once. The bed in the lowest position was not revealed in the POs or the TARs. The 8/21/16 Patient Incident Report revealed the following pertinent information: - The fall occurred on Sunday, 8/21/16 at 12:40 p.m.; - A visitor reported a man fell . He was found on the floor and in front of his wheel chair. He revealed he was trying to get into bed; - The fall resulted with an injury. He had a skin tear to the left hand; - First aid was administered at 12:45 p.m.; - No documented Immediate Actions Taken; - No documented Care plan up-dated; - No documented certified nursing aide (CNA) assigned to the resident at the time of the incident; - The Were Safety Alarms Ordered section was checked as No; - The Was Alarm in Place section was not checked as Yes, No, or N/A (not applicable); - The Was Alarm Functioning section was not checked as Yes or No; - The call light was not turned on, the resident did not have a change in cognition level in last 48 hours, and the height of the bed was down; - The incident occurred due to resident self transferring; and - The results of the interdisplinary team review were will add alarms. According to the 8/16 physician's orders and the fall care plan; bed and chair alarms were already an intervention. The facility failed to identify the effectiveness of the safety alarms through reassessing the interventions and identifying more effective safety measures to prevent future falls with injury. The 8/21/16-8/22/16 Neurological Assessment revealed the following pertinent information: - 8/21/16, the neurological assessment was completed at 1:40 p.m., 1:55 p.m., 2:10 p.m., 2:25 p.m., 2:55 p.m., 3:25 p.m., 4:25 p.m., 5:25 p.m., 9:25 p.m., and 8/22/16 at 1:25 a.m.; and - 8/22/16, the neurological assessment did not reveal the time. The assessment revealed AM, PM, and HS twice. D. Staff interviews CNA #3 was interviewed on 8/24/16 at 11:20 a.m. She said the bed and chair alarms created a loud beeping noise when a resident's position changed on the device. She said the alarms did not prevent falls, but notified staff when someone had moved or had a fall. After a fall was witnessed or unwitnessed the CNAs were required to notify the nurse. The nurse completed the assessments and neurological exams were completed every 15 minutes for one hour, every 30 minutes for one hour, and then every shift for 24 hours. The physical therapy assistant (PTA) #1 was interviewed on 8/24/16 at 11:35 a.m. She said fall prevention and interventions included resident education, bed and chair alarms, and working on balance through therapy. She said she had only worked with resident #219 one time. The Saturday before the fall she had educated him on utilizing the wheelchair brakes and forward weight shifting. She said after a fall with injury the fall interventions were reviewed through the interdisplinary team and were revised as needed. CNA #4 was interviewed on 8/24/16 at 11:42 a.m. She said fall interventions included beds in the lowest position, bed and chair alarms, and keeping the resident doors open. Chair alarm clips were required to be attached to the resident at all times and the findings documented on the TARs by the nurses at each shift. After a fall occurred, she notified a nurse and the nurse instructed the CNAs on an immediate safety intervention for the resident. Neurological assessments were completed every 15 minutes for one hour, every hour for four hours, and every day for three days. The neurological exam included the resident's blood pressure, body temperature, and oxygen saturation levels. She revealed resident #219 was forgetful at times, but understood basic education and instructions. She said the chair alarms were effective intervention because it encouraged the resident to sit back down in his chair when he heard the very loud noise. CNA #2 was interviewed on 8/25/16 at 10:23 a.m. She said fall interventions for a resident with cognitive deficits included activities and keeping them out of their rooms and closer to the nurses' stations. Bed and chair alarms were fall interventions, but both were also restraints. She explained the wheelchair alarm was a mental restraint due to creating the fear of movement and punishment through the alarm sounding. The certified occupational therapist assistant (COTA) was interviewed on 8/25/16 at 10:49 a.m. She said fall investigations were required to be completed in order to establish resident behaviors and patterns which may have contributed to the falls. After an evaluation was completed, customized interventions and plans were created to promote resident safety. Registered nurse (RN) #1 was interviewed on 8/25/16 at 10:56 a.m. She said the bed and chair alarms were put into place to notify staff when the resident had moved or had fallen. The intervention was not effective with preventing falls, and was a restraint when positioned on the resident incorrectly. The effectiveness of fall interventions was monitored through the nursing progress notes, and reevaluated by the interdisciplinary team. Physician's orders were required to be followed. an order for [REDACTED]. She revealed resident #219 did not like the alarms. After standing up with the alarm sounding he said to RN #1, What is this? I do not like it. He became frustrated and agitated by the loud noise. She said the alarms were a new intervention for resident #219 and he was not admitted with the alarms in place The NHA and director of nursing (DON) were interviewed on 8/25/16 at 4:58 p.m. The DON said the expectation was for the facility staff to follow the physician's orders for fall prevention. The care plans were updated as needed with new fall interventions and immediate interventions were required if an incident had occurred over the weekend. Reevaluation of the current interventions was required to determine new, more effective fall interventions. 4. Resident #130 Resident #130, age 79, was admitted on [DATE]. According to the 7/16 CPOs, admitting [DIAGNOSES REDACTED]. According to the 8/10/16 MDS assessment, the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance for bed mobility, transfers and toileting. Since admission or the prior assessment the resident had had two or more falls without injury. A. Resident Interview Resident #130 was interviewed on 8/25/16 at 10:57 a.m. The resident said she did fall sometimes, that it just happens. The resident said she now has alarms on her wheelchair and bed. The resident said she tried to leave the door open. She said the staff added an intervention to stay with her during toileting and showering. B. Record Review The facility failed to assess and implement effective measures and supervision to prevent falls with injury. Care Plans: An interim care plan, initiated on 7/29/16, identified the resident had an alteration in mobility and safety. Interventions included bed alarm, wheelchair alarm, and fall mats. The interim care plan was revised on 7/30/16 after a fall, and restated the same interventions of a fall mat and alarms. The care plan, initiated on 8/5/16 and revised 8/23/16, identified the resident was at risk for falls due to a history of recurrent falls, mobility and/or functional deficits, poor safety awareness, medication regimen, and balance deficits. Interventions included to assist with transfers and ambulation as needed, to have the bed in low position while in bed, encourage resident to keep room door open when not engaged in personal care, ensure proper placement of call light and assistive devices for ease of access, and physical and occupational therapy evaluations and treatments to address functional deficits. The care plan was revised on 8/8/16 to document the resident had gone to an emergency room to get a CT scan after a fall. The care plan was last revised on 8/23/16 to include the intervention of setting call lights to go off every 30 minutes for checks. The interventions noted on the interim care plan, including fall mats and alarms, were not transferred to the ongoing and revisable care plan for the resident. Physician Orders and Supplemental Administration Documentation: A physician order, initiated on 7/30/16 through 7/31/16, after a fall with suspected head trauma directed to perform neurological checks every 15 minutes x 4 (times), then every hour x 2 (times), then every 2 hours x 2 (times), then every 4 hours x 2 (times), and then every shift x 3 (times). Every day shift. The order did not specify all three nursing shifts. A physician order, initiated on 8/8/16 through 8/9/16, after a fall with suspected head trauma directed to perform neurological checks every 15 minutes x 4 (times), then every hour x 2 (times), then every 2 hours x 2 (times), then every 4 hours x 2 (times), and then every shift x 3 (times). Every day, evening, and night shift. A physician order, initiated on 8/17/16 through 8/18/16, after a fall with suspected head trauma directed to perform neurological checks every 15 minutes x 4 (times), then every hour x 2 (times), then every 2 hours x 2 (times), then every 4 hours x 2 (times), and then every shift x 3 (times). Every day, evening, and night shift. A physician order, initiated on 8/23/16, directed staff to perform visual checks on the resident every 30 minutes. Every day, evening, and night shift. The treatment administration record (TAR) provided only one place to document this was being followed for each shift. Electronic alarm documentation showed that the response times of each 30-minute call light checks varied throughout the day and night on 8/24/16. No physician orders specifying the use or monitoring of a wheelchair alarm, a bed alarm, or fall mats were found in the resident's medical record. Fall Documentation 7/30/16 -At 4:00 p.m. the resident reached forward from wheelchair to get water and fell to the floor on their knees. There was a small skin tear to left knee. Alarms were noted as attached and neurological checks and vital signs were within normal limits. This was not a witnessed fall. Neurological checks were begun with physician order, as noted above. -The neurological assessment for this fall documented checks every 15 minutes x 4 (times), every 30 minutes x 2 (times), every hour x 2 (times), then every 4 hours x 2 (times), then every 8 hours x 7 (times). -An interdisciplinary department review noted that the facility added tab alarms to plan of care. 8/8/16 -At 9:25 a.m. the resident was found sitting on the right side of the bed, resting on her buttocks and leaning against the bed. The resident was attempting to self transfer from wheelchair to bed and did not lock wheelchair wheels. Alarms sounded. Neurological checks, vital signs, and pupil were responsive but sluggish. This was not a witnessed fall. -The neurological assessment for this fall documented checks every 15 minutes x 4 (times), every 30 minutes x 1 (times). -An interdisciplinary department review noted there was a pad alarm now. -At 11:26 a.m. the resident was found sitting in her room on the sink side of her bed, resting on her right side. Neurological checks and vital signs within normal limits. Pupils reactive but sluggish. The fall investigation did not indicate if the fall was witnessed or if there was any injury to the head, extremity, or trunk. -Neurological checks were restarted from the earlier fall, until hospital discharge for evaluation. -An interdisciplinary department review noted to continue with the pad alarms, and to continue with therapy for transfers and strengthening. -Upon return from the hospital on [DATE], the neurological checks continued as per the physician orders. The charting documented checks on 8/8/16 at 2-10, on 8/9/16 for 10-6, 6-2, and 2-10, and on 8/10/16 at 10-6, 6-2, and 2-10. The specific hours and times of the neurological charting were not documented, which allowed for significant variation in actual vital signs. 8/17/16 -At 7:45 a.m. the resident was found lying on the floor in their room. The fall was not witnessed. -Neurological checks were documented every 15 minutes x 4 (times), every 30 minutes x 2 (times), and every 1 hour x 2 (times). -At 4:50 p.m. the resident was found sitting on the floor between the wheelchair and the recliner. This was not a witnessed fall. -Neurological checks were documented every 15 minutes x 4 (times), every 30 minutes x 2 (times), every 1 hour x 2 (times), every 4 hours x 2 (times). The subsequent checks were noted as 8/18/16 at 6-2, 2-10, and 10-6, and 8/1916 at 6-2, 2-10, and 10-6. The specific hours and times of the neurological charting were not documented, allowing for a large variance in actual hours. - An interdisciplinary department review noted they would put the resident on frequent checks and move alarms out of reach. The review indicated to have the bed in low position, fall mats when in bed, pad alarms on and secured. 8/20/16 -At 8:10 a.m. the fall investigation noted the resident came out into the hallway holding a washcloth to the left side of her head. The resident said she was in her bathroom with her wheelchair wheels locked. She went to stand and the brakes must have released and the wheelchair moved, and she fell to the floor hitting her head on the floor. The resident had a 1cm laceration noted to left side of head above her left ear. -No physician order noted to begin neurological checks was found in the resident record. -Neurological checks were noted every 15 minutes x 4 (times), every 30 minutes x 1 (times). The second 30 minute check should have been documented at 9:55 a.m., but it was not noted. A subsequent fall occurred 5 minutes later. -At 10:00 a.m. the resident was found lying on the floor in her room between the dining table and the end of the bed, resting on her back. Neurological checks were within normal limits. The fall was not witnessed. -No physician order was noted in the resident record to begin neurological checks. -Neurological checks were noted every 15 minutes x 4 (times), every 30 minutes x1 (times), every 1 ½ hour x 1 (time), every 1 hour x 2 (times), every 4 hours x 2 (times), and then on 8/21/16 at a.m., p.m., and h.s. (night), and on 8/22/16 at a.m., p.m., and h.s. (night) shifts. The specific hours and times of the neurological checks on 8/21/16 and 8/22/16 were not noted, allowing for a large variance in actual charted hours. -An interdisciplinary review documented the resident had 2 falls on 8/20/16 and the facility would continue with the same interventions and add frequent hall staff checks. 8/23/16 -At 5:41 p.m. a CNA attempted to stop the resident from standing up in the wheelchair. The resident stood up and then went to her knees onto the floor. The fall was witnessed. -An interdisciplinary team review noted that the call light system would be set to automatically ring every 30 minutes to summon staff into the resident's room for visual safety checks. -As noted above, the TAR documented the visual safety checks every shift only. Assessments A Fall Risk Assessment was completed on 7/29/16 at admission. The resident was documented as low risk. The assessment noted the resident had sustained 14 falls prior to admission. Due to a history of repetitive falls safety alarms to bed and wheelchair were noted as interventions. Fall Risk Assessments were completed after each additional fall. The resident was noted as a moderate fall risk due to the calculations. The assessment did not document any additional interventions after these falls. A Health Status, completed on 8/9/16, said the resident should be assisted/prompted to toilet upon rising, before and after meals, at bedtime and as needed. This was not noted in the resident care plan. C. Staff Interviews Registered nurse (RN) #1 was interviewed on 8/22/16 at 10:24 a.m. The RN said resident #130 had had numerous falls at the facility and that the resident hit her head. CNA #4 was interviewed on 8/25/16 at 10:13 a.m. The CNA said that resident #130 was a high fall risk. She said the resident had alarms on her bed and wheelchair, a fall mat, and a low bed. The aide said that for additional interventions the staff tried to keep the resident's door open. However, the aide said they would close the door if the resident requested it. The aide said the staff did not leave the resident alone in the bathroom. RN #1 was interviewed on 8/25/16 at 3 p.m. The nurse said that if a resident needed fall mats or alarms they would get new physician orders. If the resident had multiple falls then the facility would look again at the care plans. The RN said that if a resident had multiple falls then the physician, facility management, and therapy would discuss care concerns on Wednesday each week. RN #5 was interviewed on 8/25/16 at 3:20 p.m. The RN said there should be a physician order to monitor alarms to make sure they were being checked so they functioned properly. The RN was asked to look at the physician orders for resident #130. The RN said she could not find any. The RN said physician orders would be in the electronic record. The RN could not find orders either in the electronic record or the physician telephone orders. The admissions RN was interviewed on 8/25/16 at 3:27 p.m. The RN said the facility learned a few weeks ago that alarms required a physician order and a separate telephone order from the physician. The RN said resident #130 should have had physician orders, but there were none. The RN said the facility might have forgotten to review records of some of the already admitted residents to ensure orders were present. The director of nursing (DON) was interviewed on 8/25/16 at 4:56 p.m. The DON said that the CNAs were supposed to visualize fall alarms when they did rounds.

Based on record review and interviews, the facility failed to ensure two (#213 and #215) of three residents reviewed for choices of 12 sample residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plans of care and make choices about aspects of their lives that were significant to them. Specifically, the facility failed to determine and provide the desired number of shower opportunities for residents #213 and #215. The findings included: 1. Facility policy and procedure The Residents' Rights policy was provided on 8/25/16 at 8:00 a.m. by the nursing home administrator (NHA). The documented revealed, Knowledge of available choices and the right to independent personal decisions, which will not be infringed upon . On 8/26/16 at 12:21 p.m. (after the survey) the NHA provided a copy of the facility's welcome letter. The document revealed Showers are scheduled two times a week for every patient .Rooms 501-512 are showered on Sunday and Thursday; Rooms 513-523 are showered on Tuesday and Friday and Rooms 524-534 are scheduled on Wednesday and Saturday. If you would like to be showered on a different schedule than posted, please let our staff know and we will do everything we can to make that happen . 2. Resident #213 Resident #84, age 67, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 8/18/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She did not have signs and symptoms of [MEDICAL CONDITION], such as inattention, disorganized thinking, altered level of consciousness, or psychomotor [MEDICAL CONDITION]. She required extensive assistance with bed mobility, transfers, toilet use, and required physical help with bathing. She had functional limitations on one side of the lower extremity, and utilized a walker and wheelchair for mobility. The care plan, initiated on 8/15/16 identified the resident had a self care deficit with bathing. An intervention included assistance with bathing. A. Resident interview Resident #213 was interviewed on 8/22/16 at 9:56 a.m. She said she was not given the opportunity to choose how many times per week she took a shower. Upon admission into the facility a staff member informed her she was required to shower two days a week. This person informed her of her shower days and did not inquire about additional shower opportunities. Based on her previous routine she preferred to shower every other day and required physical assistance from staff to bathe. She revealed she had not been receiving the two shower opportunities per week on her scheduled days. B. Record review The 8/6/16-8/24/15 ADL report revealed the following pertinent information: - She did not receive a shower within 24 hours of admission into the facility; - 8/10/16, she received a shower with supervision/set up help only; - 8/11/16, she received a shower with physical help limited to transfer/one person physical assist; - 8/18/16, she received a shower with physical help in part of bathing/one person physical assist; and - Between 8/6/16-8/24/16 there were 18 opportunities for a shower and she received three out of 18 opportunities; and - She did not receive two shower opportunities per week as indicated by the facility's welcome letter and did not receive a shower opportunity every other day per resident preference. C. Staff interviews Certified nursing aide (CNA) #4 was interviewed on 8/24/16 at 11:42 a.m. She said the facility did not assess for bathing preferences. The residents had a set shower schedule based on the room they resided in. If a resident requested an additional shower the CNAs did their best to facilitate the resident's request. After the shower task was completed by the bath aide or the CNA the opportunity was documented in the online charting system and in a shower book located at the nurses' station. CNA #2 was interviewed on 8/25/16 at 10:23 a.m. She said resident showers were scheduled twice a week for the residents based on the room they resided in. The residents had the right to refuse and request additional showers. The refusals and acceptance of showers were documented in the online charting system and in the shower book. If a resident refused a shower an explanation of the refusal was required. The shower book was reviewed with CNA #2. The book revealed the resident had received showers on 8/17/16 and 8/18/16. CNA #2 said there were no documented shower refusals in the shower book. Per the facility's request all residents were required to shower within 24 hours of admission into the facility and twice a week per the schedule. She said resident #213 did not refuse shower opportunities. The resident care plans were created and updated by the assistant director of nursing (ADON)/MDS coordinator. She was not available for an interview during the survey. The certified occupational therapist assistant (COTA) was interviewed on 8/25/16 at 10:49 a.m. She said she assisted the shower aide and CNAs with the shower opportunities in order to assess the residents' safety. Showers were offered to residents within 24 hours of admission to the facility. She said showers were important because they made the residents feel good and clean. When an opportunity was missed or refused, showers were required to be offered at the next shift or day. The NHA and director of nursing (DON) were interviewed on 8/25/16 at 4:58 p.m. The DON said bathing preferences, including the number of shower opportunities, was determined upon admission utilizing the interim care plan. The residents had the right to accept, decline, and request additional opportunities. The opportunities were documented in the online charting system and the shower book. A review of the shower book revealed resident #213 did not receive additional showers or decline the opportunity to shower. The NHA said the facility's goal was to provide residents the opportunity to shower within 24 hours of admission and two times per week according to the shower schedule. The cause of the incompletion of the showers was not determined. 3. Resident #215 Resident #215, age 83, was admitted on [DATE]. According to the 8/16 CPOs, [DIAGNOSES REDACTED]. No MDS assessment had been completed. The interim care plan, initiated upon admission, identified a self care deficit due to recent right hip surgery and previous right shoulder surgery. Interventions included staff assistance with activities of daily living (ADLs) including toileting, bathing, and personal hygiene. Bathing preferences were marked for two times a week. Resident interview Resident #215 was interviewed on 8/23/16 at 10:12 a.m. The resident said he did not get to choose how many times a week he took a shower. He said he would like to have a shower at least three times a week. He said he had only had one sponge bath since he was admitted on [DATE]. The resident's daughter was present during the interview and confirmed that he had had only one sponge bath since admission. The resident was interviewed a second time on 8/25/16 at 2:15 p.m. He said again that the staff never gave him a choice on showers, however he received the shower when scheduled.

Based on record review and resident and staff interviews the facility failed to allow participation after each assessment for four (#3, #148, #217 and #7) of four out of 24 sampled residents. Specifically the facility failed to invite the residents to their care conference. The findings include: A. Resident #7 Resident #7 Resident #7, age 94, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) According to the MDS dated [DATE], the resident had a brief interview of mental status score of 15/15 indicating the resident was cognitively intact. She did not have abnormal behaviors. She required extensive assistance of 2 people with bed mobility, transfers, and toilet use. She required extensive assistance of one person with locomotion while in her wheelchair, dressing, personal hygiene, and bathing. She was always continent of both bowel and bladder. Care Plan The facility care plan dated 7/23/15 documented: Problem - the resident will return to community, anticipated discharge to private home, alone. Goal - the resident will have a safe and coordinated discharge to an appropriate setting. Approaches - the facility will arrange for family and or patient care conferences as needed to discuss discharge needs. Assist patient and or family in arrangement for discharge care needs. As recommended will ensure durable medical equipment, prescriptions, home healthcare, support services will be coordinated with discharge goals and needs with patient and or family. The facility will educate the patient and/or family regarding recommendations for discharge care needs and instructions. The facility had weekly interdisciplinary team meetings to monitor concerns and progress towards discharge. Weekly facility IDT, interdisciplinary team, meeting notes read: On July 22, 2015, Dear Ms. Resident name Each week, we meet as an interdisciplinary team to discuss discharge planning for each of our patients. We discussed your progress related to therapy and any medical issues that may affect your potential discharge date s. We use this team approach to ensure the transition home is safe and well planned. Your team will work with you to identify goals that focus on allowing you to reach your highest functioning level. These goals need to be obtained prior to discharge in order to facilitate a successful return to home. Once your goals have been achieved and you are medically stable, we will assist in coordinating your needs to ensure safe departure from the facility. Based on our meeting this week, we have estimated your discharge time as: six weeks. Please understand that there are many factors that make planning an exact discharge date difficult to determine at this time. We will continue to evaluate and adjust this time frame forward or backward, based on your medical and physical progression. If you have any concerns regarding the discharge plan forecasted above, please speak with one of your assigned therapists . The facility interdisciplinary team note dated July 29, 2015 read as above, with the exception of the discharge time being four weeks. The facility provided interdisciplinary team meetings documented twice, 7/22/15 and 7/29/15, as above. Interviews: The resident #7 was interviewed related to her discharge to home and the interdisciplinary team meetings on 8/6/15 at 3:40 p.m. The resident said she had not attended an interdisciplinary team meeting, but that she would like to have a meeting to discuss her discharge, and what would happen when she was able to go home. She said that her son would need time to make the arrangements to come from out of state and he would like to know the exact date as soon as possible so that he could make flight arrangements. She said she had no idea how all of this would worked. She said she had lived alone and when she goes home she knew she would need some help. She said her son would probably be able to stay with her a few days, but he would need to know in advance to make arrangements. She said that the facility had told her they were going to move her discharge date up from four weeks to three weeks. She said she had not been invited to any care conference or interdisciplinary team meetings. The director of nurses was interviewed on the evening of 8/6/15. The director of nurses said the facility had a meeting every week to discuss resident progress and discharge plans. She said the facility would have a meeting with the family or the resident if they requested to attend a meeting. She said the residents and family typically did not attend the weekly meetings, but on request, the facility would provide a care plan conference/interdisciplinary team meeting. The Clinical Nurse Manager (CNM) was interviewed on 8/6/15 at 6:45 p.m. The CNM stated that if a resident wanted to have a care plan meeting they could come tell her, the Director of Nurses, or the MDS Coordinator so that a meeting could be set up. She said that sometimes the therapy department would request to have a care plan meeting with the resident and or family member. II. Resident #3 Resident, age 84 was admitted to the facility on [DATE]. According to the face sheet she had [DIAGNOSES REDACTED]. The 30 day minimum data set (MDS) assessment documented the resident had a 13 out of 15 on the Brief Interview for Mental Status (BIMS) which revealed no cognitive impairment. She needed extensive assistance with bed mobility, transfers and toilet use. She was able to eat, ambulate, dress and complete personal hygiene independently. A. Resident interviews On 8/6/15 at 2:18 p.m. the resident provided a copy of interdisciplinary team (IDT) progress/discharge letter. She reported the letter was on her table when she came into her room. She stated I do not know why people think when you are old you do not care; I care and I want to go home. She reported she was concerned about going home and whether there would be help for her at home. She reported she was surprised no one at the facility talked with her about her progress. She reported it was important to her to be included in conversations about her progress and confirmed no one had invited her to any meetings with her therapist or nurse. B. Record review The interdisciplinary team (IDT) progress/discharge letter dated 8/5/15 documented, Each week, we have discharge planning for each of our patients. We discuss your progress related to therapy and any medical issues that may affect your potential discharge date s. We use this team approach to ensure the transition home was safe and well planned. The letter continued to document Based on our meeting this week, we had estimated your discharge time as two weeks. This letter revealed the IDT met without the resident to discuss her progress and discharge plans. III. Resident #148 Resident, age 91 was admitted to the facility on [DATE]. According to the face sheet she had [DIAGNOSES REDACTED]. The 30 day MDS dated [DATE] documented the resident had a 14 out of 15 on the BIMS which revealed no cognitive impairment. She required extensive assistance with bed mobility, transfers, dressing and toileting. She required supervision for walking and eating. She was independent with personal hygiene. A. Resident interview On 8/6/15 at 1:40 p.m. the resident reported she had not been invited to a care conference since admission. She reported no one at the facility had ever talked with her about her discharge plan. She stated, They just tell me what to do. B. Record review The IDT progress/discharge letter dated 8/5/15 documented, Each week, we have met as an IDT to discuss your progress and discharge plans. After a thorough discussion, we have determined that it is now appropriate to set a discharge date . Based on our meeting this week, we anticipate your discharge to be 8/12/15. This letter revealed the IDT met without the resident to discuss her progress and schedule a discharge date . IV. Resident #217 Resident, age 86 admitted to the facility on [DATE]. According to the face sheet she had [DIAGNOSES REDACTED]. The five day MDS assessment dated [DATE] documented the resident had a score of ten out of 15 on the BIMS which indicated moderate cognition. She required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She was able to eat with supervision. A. Resident interviews On 8/6/15 at 3:35 p.m. resident stated it was very important she was informed and included in her plan of care. She reported she had not been involved in decisions about her care or gone to any meeting where her care was discussed. B. Staff interview On 8/5/15 at 4:10 p.m. the director of nursing (DON) reported discharge planning for resident #217 was straight forward therefore she did not need a care conference . C. Record review The IDT progress/discharge letter dated 7/22/15 documented, Each week, we have met as an IDT to discuss your progress and discharge plans. After a thorough discussion, we have determined that it is now appropriate to set a discharge date . Based on our meeting this week, we anticipate your discharge to be 7/30/15. The letter revealed the IDT met without the resident to discuss her progress, discharge plans and schedule a discharge date . V. Staff interviews On 8/5/15 at 4:10 p.m. DON reported the IDT met weekly to discuss each resident ' s progress and discharge plan. She reported the IDT would pick a date for anticipated discharge based on therapy progress and clinical status. She reported once the date had been selected a letter would be provided to the resident to notify them of the anticipated discharge date . On 8/6/15 at 7:35 a.m. the MDS coordinator reported she had limited involvement in care conferences. She reported they are scheduled on an as needed basis and generally for discharge planning. She reported they would be scheduled by the former admit/discharge registered nurse (RN) #7 and only RN #7, a therapist and the nurse practioner (NP) would attend. On 8/6/15 at 8:15 a.m. RN #7 reported care conferences are only scheduled if the family, a nurse, the NP and/or the therapist requests a conference. She reported a care conference was typically held because of a concern or discharge planning. She reported there was not a schedule followed; care conferences were only scheduled as needed. On 8/6/15 at 8:52 a.m. the DON confirmed care conferences were generally initiated by a therapist and would be scheduled by the RN #7. She reported they are scheduled only by request. IV. Record review The Care Conference Signature Sheet/Conference Notes were provided by RN #7. The RN reported staff would normally use this form when a care conference was held for the resident. She confirmed resident #3, #148, #217 and #7 did not have this form in their medical record.

Based on observations, resident and staff interviews and record review the facility failed to provide a resident the appropriate treatment and services to maintain or improve his or her abilities. Specifically the facility failed to assist with activities of daily living for bathing for three (#217, #148, and #7) of four out of 24 sampled residents. The findings include: I. Facility policy A. Facility Policy: Policy: ADL's Bathing/Showers Schedule. Patients will be scheduled and offered two baths/showers a week. They may request more as desired. Procedure: The bath aide assigned to the patient will offer the assigned patients a shower/bath on the assigned days, as outlined in the patient information letter and or bath schedule. The patient has the right to refuse if desired. The patient may request a bath at another time if desired . II. Patient information letter The patient information letter provided by the nursing home administrator (NHA) on 8/6/15, documented, Showers are scheduled two times a week for every patient. III. Resident #217 Resident, age 86 admitted to the facility on [DATE]. According to the face sheet she had [DIAGNOSES REDACTED]. The five day minimum data set (MDS) assessment dated [DATE] documented the resident had a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognition. She required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She was able to eat with supervision. She required physical help in part with bathing. A. Resident interview On 8/6/15 at 3:35 p.m. the resident reported she could not recall if she had ever taken a shower since admission to the facility. She reported it was very important to her to take showers regularly. B. Record review The shower and skin check schedule revealed the resident was to receive showers on Tuesday and Friday. The shower list revealed the resident had received a shower on 7/22/15, the day after admission. This was the only shower the resident had received since her admission. The shower list documented the resident had been offered a shower and refused on 7/26/15 and 7/31/15. The resident, since admission, should have been offered and received four showers. The resident had received one. There was not documentation in the nurses' notes documenting why the resident refused or whether the resident had been approached again by staff to encourage a shower. IV. Resident #148 Resident, age 91, was admitted to the facility on [DATE]. According to the face sheet she had [DIAGNOSES REDACTED]. The 30 day MDS dated [DATE] documented the resident had a 14 out of 15 on the BIMS which revealed no cognitive impairment. She required extensive assistance with bed mobility, transfers, dressing and toileting. She required supervision for walking and eating. She was independent with personal hygiene. She required set up only for bathing. A. Observation On 8/4/15 at 9:24 a.m. the resident had a strong odor of urine and feces. There were also multiple pairs of dirty underwear in a basin in her bathroom. The dirty underwear would have been retrieved if the resident had received her scheduled showers. B. Resident interview On 8/6/15 at 1:40 p.m. the resident reported she did not mind receiving only two showers a week. She reported that she did not sweat therefore the two showers were adequate. She reported, however the two showers she received weekly were important C. Record review The shower and skin check schedule revealed the resident was to receive showers on Sunday and Thursday. The shower list revealed the resident had received a shower on 7/6/15, 7/9/15, 7/12/15, 7/19/15 and 8/2/15. The shower list documented the resident had been offered a shower and refused on 7/16/15 and 7/26/15, 7/30/15, 7/31/15 and 8/6/15. The resident, since admission, should have been offered and received 11 showers. The resident received five showers and refused five. There was not documentation in the nurses ' notes documenting whether the resident had been approached again by staff to encourage a shower. V. Staff interview On 8/6/15 at 4:40 p.m. the director of nursing (DON) was interviewed and reported there was no formal policy for bathing or when a resident refused a bath or shower. She stated in a perfect world a nurse would write a note documenting the resident's refusal and the re-approaches attempted. On 8/6/15 at 4:30 p.m. registered nurse (RN) #2 reported when a resident refused a shower he would generally attempt to talk them into taking a shower. He reported if the resident continued to refuse he would document the attempts made and talk to the DON about the resident who refused. On 8/6/15 at 5:00 p.m. the DON confirmed there were no notes available regarding the resident's refusing their showers. On 8/6/15 at 5:35 p.m. the NHA confirmed the activities of daily living (ADL) bathing/shower schedule P&P was written on 8/6/15 during the survey by the facilities clinical manager. Resident #7 Resident #7, a [AGE] year old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) According to the MDS dated [DATE] the resident had a brief interview of mental status score of 15/15 indicating the resident was cognitively intact. She did not have abnormal behaviors. She required extensive assistance of 2 people with bed mobility, transfers, and toilet use. She required extensive assistance of one person with locomotion while in her wheelchair, dressing, personal hygiene, and bathing. She was always continent of both bowel and bladder. Care Plan The care plan dated 7/23/15 related to activities of daily living/rehabilitation potential: Problem- Self care deficit with bathing hygiene, grooming, dressing, elimination and dining due to weakness/debility resulting from a left [MEDICAL CONDITION] with repair. Goal- The resident will participate in activities of daily living to the highest level of independence throughout the next 90 days. Approaches- Allow resident adequate time to finish her activities of daily living on her own as able. The staff will provide assistance with bathing. The staff will provide assistance, supervision and set-up with dining. The staff will provide assistance with dressing, grooming, hygiene, and toileting. Therapy services will be provided as ordered. Record Review Review of the facility Shower and Skin Check Schedule was made out by the facility to be assigned the bath days according to the room numbers. Resident #7 was scheduled for each Sunday and Thursday. Review of the facility Shower List daily from 7/15/15 through 7/30 15 revealed one resident refusal was documented related to not feeling well on 7/30/15. The facility electronic Point of Care History documented between 7/16/15 through 8/2/15 the resident was provided one shower on 7/26/15. The one refusal was dated 7/30/15. There was no documentation provided to indicate the staff offered again later on 7/30/15, or on another day. Observations/Interviews On 8/3/15 at 3:29 p.m. the resident was in her room awake sitting on the side of her bed and was moving a little, but very slow to prevent from hurting her hip. She said that she was doing much better and moving better. She said that the therapy she received had helped a lot but that her feet were still swollen and her left was more swollen than the right. She did not have body odor and her clothes appeared clean. On 8/3/15 at 3:29 p.m. during the interview, the resident said the facility had not discussed her bath schedule with her and she liked to take a shower at least every other day. She said she had one shower since she had been in the facility. She said she did ask someone this morning about the showers and they told her they would get her the information and get back with her. She said at this time she was still waiting. On the evening of 8/6/15 the Director of Nurses (DON) was interviewed about the bath schedule. She said the facility had the showers/baths on a routine schedule of 2 times per week. She said the assignments were made according to location, the facility room numbers. She said that if a resident wanted a shower/bath more often they could ask and the facility would provide more than 2 showers/baths per week. When the DON was asked how the facility gathered the information on resident preferences for bathing she said by the MDS information. She said the information was gathered during the first 5days of admission for the first initial 5 day MDS assessment.

Based on record review and staff interview, the facility failed to inform two out of three residents (#38, #111) from a sample of 24 residents, of changes in services covered by Medicare, in a timely and appropriate manner. Specifically: -The facility failed to demonstrate that residents who previously received skilled nursing facility services (SNF), funded through Medicare benefits, had received timely and appropriate written notice of discontinuation of benefits and notice of liability. The findings include: A. Medicare Coverage Notice of Medicare Non-Coverage The Notice of Medicare Non-Coverage (Form CMS- ) letters (also called NOMNC Notice, are provided to residents receiving Skilled Nursing Facility (SNF) services funded through Medicare benefits. Non-Coverage letters document residents and/or their legal representatives received written notification that discontinuation of Medicare coverage is imminent. B. Facility policy: When to deliver the NOMNC A Medicare provider or health plan must give an advanced, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services not later than two days before the termination of services. This notice fulfills the requirement at 42 CFR & 405.1200(b) (1) and (2) and 42 CRF 422.624(b) (1) and (2). In situations where the termination decision is not delegated by a health plan, the plan must provide the services for timely delivery to occur. On 8/5/15, the facility was asked to provide a list of residents whose Medicare benefits had ended. Review of three residents' NOMNC letters on 8//15 at 11:30 a.m. revealed two of the residents had not received timely notification from the facility that therapy services would be discontinued: Record Review 1. Resident #38 The Notice of Medicare Provider Non-Coverage (NOMNC) for resident #38 was not delivered in a timely manner. According to the facility, the last covered day (LCD) was 3/2/15. The form was signed by the resident on 3/1/15, one day prior to discontinuation of services. 2. Resident #111 The Notice of Medicare Provider Non-Coverage (NOMNC) for resident #12 was not delivered in a timely manner. According to the facility, the last covered day (LCD) was 3/12/15. The resident signed the notification page on 3/11/15, one day prior to discontinuation of services. Interview The facility Director of Nurses was interviewed on the evening of 8/6/15. She confirmed the notifications for the two residents listed above were not provided timely as per the documentation on the NOMNC form. She said she was not sure what happened that it did not occur timely but she would check on it.

Based on resident, family and staff interviews and record review the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to provide safe discharge planning services for one (#217) of four out of 24 residents. The findings include: Cross reference - F280 Failure to provide the residents the right to participate in planning care and treatment. I. Resident #217 Resident, age 86, was admitted to the facility on [DATE]. According to the face sheet she had [DIAGNOSES REDACTED]. The five day minimum data set (MDS) assessment dated [DATE] documented the resident had a score of ten out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognition. She required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She was able to eat with supervision. A. Resident interview On 8/5/15 at 6:45 p.m. the resident reported she was scared to return to where she was living. She reported another resident had punched her, kicked her and pushed her. She stated I do not want to go back; I am going to tell her (the nurse) that I need to stay a little longer. B. Record review The nurses' note dated 7/24/15 documented, in pertinent part, .(son) informs me that his mother was a resident of an ALF and she does not like it there. The nurses' note dated 7/28/15 documented, in pertinent part, .when presented with Medicare notice of non coverage, resident stated 'I have nowhere to go.' The nurses' note, dated 8/6/15 at 9:53 a.m. documented, .per therapy .new discharge date set for 8/13/15. The nurses' note, dated 8/6/15 at 10:11 a.m., written during the survey, in pertinent part, documented, .resident stated she was afraid to return to her prior living situation. Spoke to son; he stated he cannot afford any other place. Offered to assist him by contacting ALF .he expressed appreciation . The nurses' note, documented 8/6/15 at 10:41 a.m., written during the survey, documented Spoke to one of the marketing directors at (memory care ALF) and explained the situation. She will make some phone calls and call back - she believes that the community will be able to support a transfer. C. Family interview On 8/6/15 at 11:10 a.m. the resident's son reported he had received a call from registered nurse (RN) #7 on this date offering to assist him with finding a different assisted living facility (ALF) for the resident to discharge to after she met her therapy goals. He reported during their conversation the RN was helpful; he stated he felt encouraged. He reported he did not want the resident to return to the ALF where she was involved in an altercation but was uncertain about his other options, concerned about finances and did not know whether he had a choice. C. Staff interview RN #7 was interviewed on 8/5/15 at 9:55 a.m. The RN #7 stated the resident was given an anticipated discharge date of [DATE] and that she was aware the resident was not pleased about returning to the ALF where she was living prior to her admission to the facility. She confirmed she had not documented the resident ' s dissatisfaction or pursued any other placement. On 8/5/15 at 4:10 p.m. director of nursing (DON) reported RN #7 who was the former admit/discharge nurse, handled discharge planning. She reported the resident's son did not want her to go back to the facility where she had been involved in an altercation but he was unable to find anything else. The DON was interviewed a second time on 8/6/15 at 9:49 a.m. The DON stated the discharge date had been extended for the resident due to her therapy needs. She reported the resident would return to the facility where she was living, where the altercation occurred. She stated that the facility was not responsible to locate alternative placement. On 8/6/15 at 10:06 a.m. RN #7 reported she had not talked with anyone at the ALF but was aware the resident had to return there because of finances. She reported she had talked to the resident ' s son since her admission but confirmed she had not documented in the nurses ' notes any of the conversations. The certified occupational therapy assistant (COTA) #6 was interviewed on 8/6/15 at 10:45 a.m. The COTA #6 reported when the resident initially started receiving therapy services the resident stated she did not want to return to her prior living arrrrrangements because she did not want to see the lady that beat her up. She reported she had not shared the resident ' s concern with any of the other staff.

Based on observation, record review, and interviews, the facility failed to ensure two of 24 sample residents (#217 and #229) received the care and services necessary to attain and/or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically: -Resident #217's pain was not adequately managed, creating the potential for the resident to experience unrelieved hip pain. -The facility failed to ensure resident #229's pain was evaluated and addressed to achieve satisfactory pain management for the resident. The facility documented the pain medications were effective despite knowing what pain level was acceptable to the resident. The resident was not offered scheduled pain medications and/or different medications or nonpharmacological interventions for her unrelieved pain. This failure created the potential for the resident to experience unrelieved pain. The findings include: A. Pain Management I. Facility Policy and Procedures The Pain Management policy (dated 4/15/13) was requested and received on 8/6/15 from the Director of Nursing (DON). The policy read in pertinent part: Patients will have appropriate pain control measures to optimize comfort and well-being. Pain levels shall be controlled at acceptable levels to maximize recovery and facilitate participation in daily treatments and activities of daily living. The Procedure outlined in the policy was in pertinent part: Assessment 1. All patients will be assessed for pain upon admission and educated regarding pain management, his/her current orders and facility policies. 2. All patients will be routinely assessed for pain on a continuous basis throughout his/her stay as a general nursing practice to include both formal and informal assessment with ongoing evaluation of response to treatments. 3. If able, patients will be assessed for intensity of pain utilizing a standard pain scale of 0-10. The FLACC scale shall be used to assess patients who may be unable to comprehend or verbalize a response to the standard 0-10 scale. The FLACC scale scores pain indicators in 5 categories on a 0-2 scale which are then totaled for a final score of 0-10. 4. Persistent pain not relieved with the current regimen will be re-evaluated and the physician notified for further orders/interventions. 5. A Comprehensive Pain Assessment may be completed as part of the evaluation and shared with the patient ' s physician. Addition referrals to pain specialists or counseling services may also be indicated and ordered per the attending physician. 6. Staff will be routinely educated regarding accurate pain assessment, documentation and optimal management of pain symptoms. Treatment 1. Patients expressing or demonstrating pain will be provided with pain relief options which may include: a. Rest b. Positioning c. Relaxation Techniques d. Diversion Techniques e. Heat/Cold Applications f. Routine/PRN Pain Medications (PRN means as needed) g. Adjunctive Medications (anti-spasmodics, anxiolytics, etc.) 2. PRN medications will be administered following the assessment of pain for location, onset, duration and intensity. 3. Administration of PRN medications shall be evaluated for effectiveness within 30-60 minutes following the administration. 4. Prescribed medications that include dosing such as 1-2 tabs or 10-20 mg shall be clarified based on the pain intensity as per the 0-10 scale or FLACC numerical scale. Pain intensity from 1-5 should receive 1 tab or the lowest dose and a score from 6-10 shall receive 2 tabs or the highest dose. Occasionally, physician may order medications with a wider variance and those shall be clarified as well, but split accordingly. 5. Due to the variable perception, definition and tolerance to pain, patients will be given the right to defer the above guidelines and request alternative dosing within the physician's order [REDACTED]. Alternately, a patient stating a pain intensity of 4 may not receive optimal pain control with only 1 tab and may request 2 tabs instead. Documentation 1. Routine pain medications will be documented on the MAR (Medication Administration Record) and the administration noted by the administering nurse ' s initials in the corresponding time and date box. Administration of routine allows for a 1 hour variance before or after the scheduled time. 2. Documentation of PRN medication administration shall include the administering nurse ' s initials on the front of the patent ' s MAR on the appropriate day. Additionally, the administering nurse shall complete the back of the MAR to include the date and time administration, the medication given, route of the administration and the site of injection if indicated, reason given to include location and intensity of pain as per the 0-10 scale or FLACC numerical score and the administering nurse. 3. Administration of PRN medications shall be evaluated for effectiveness within 30-60 minutes following administration and the results documented on the corresponding line of the back of the MAR and initialed appropriately. Results should identify the intensity of current pain as per the 0-10 scale or FLACC numerical score . II. Professional reference The Hartford Institute For Geriatric Nursing on their website <http://consultgerirn.org/uploads/File/trythis/issue07.pdf> (retrieved 3/23/10) provides the following information related to assessing pain in older adults: Studies on pain in older adults (persons [AGE] years of age and older) have demonstrated that 25%-50% of community dwelling older people have persistent pain. Additionally, 45-80% of nursing home residents report pain that is often left untreated. Pain is strongly associated with depression and can result in decreased socialization, impaired ambulation and increased healthcare utilization and costs. Older adults tend to minimize or not report their pain or are unable to due to sensory and or cognitive impairments. A significant barrier in treating pain in older adults is inadequate pain assessment. Therefore, a proactive, consistent approach must be taken to screen and assess older adults for persistent pain . III. Resident #217 Resident #217, age 86 admitted to the facility on [DATE]. According to the face sheet she had diagnoses of [MEDICAL CONDITION], hypertension and [MEDICAL CONDITION]. The five day minimum data set (MDS) assessment dated [DATE] documented the resident had a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognition. She required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She was able to eat with supervision. She had frequent pain which limited her day to day activities. a. Observation On 8/3/15 at 3:58 p.m. the resident was screaming out in pain. The resident stated When I sit too long my hip hurts worse. The registered nurse (RN) #7 was notified by the surveyor that the resident had increased pain. The RN reported the resident frequently had pain at this time of day. The RN reported he would give the resident something for pain. According to the Medication Administration Record (MAR) the RN gave the resident 2.5 mg of [MEDICATION NAME] at 4:16 p.m. According to the MAR the resident reported ten out of ten pain all over. The RN documented (time unknown) The patient calmed considerable and had no outward signs of pain with the RN in the room. At 5:17 p.m. the RN documented on the MAR the PRN medication was not effective and documented The patient (was) calling out help me, related to pain, patient being assisted to bed as sitting up in wheelchair had caused hip pain. b. Resident interview The resident was interviewed on 8/5/15 at 6:45 p.m. The resident stated I'm always in pain, the pills help a little but my hip always hurts. The resident was interviewed a third time on 8/6/15 at 8:20 a.m. The resident stated staff did not come back and ask her whether the pain medication was effective. She stated I do not have a problem telling them but they do not ask. c. Pain Management Plan The resident's CPO dated 8/15 and recent Physician Telephone Orders revealed current orders for pain control included: --[MEDICATION NAME] gel 2 grams to each knee to be applied topically four times a day. --[MEDICATION NAME] 2.5 mg; oral every four hours as needed for pain --[MEDICATION NAME] 5 mg; oral every four hours as needed for pain scale one to five --[MEDICATION NAME] 10 mg; oral every four hours as needed for pain scale six to ten --[MEDICATION NAME] OTC (over the counter) 1000 mg three times a day for pain. --[MEDICATION NAME] 50 mg every eight hours for pain. There were no orders on the physician's orders [REDACTED]. b. Change in Condition The following nurses notes identified the resident was experiencing uncontrollable pain. The notes were as follows: --7/24/15 the nurses note documented, .requested and received PRN pain medication, patient had difficulty expressing pain but rocks and chants . The MAR documented the medication was somewhat effective, an ice pack given and an pain ranged from two out of ten to eight out of ten. The MAR documented the patient was moaning and stating oh, oh, oh during activities of daily living (ADL); --7/30/15, in pertinent part, documented, .PRN pain medication administered throughout the day with moderate results reported . The MAR documented the pain ranged from two out of ten to six out of ten. --7/31/15, in pertinent part, documented, .patient refusing Tylenol and becoming agitated when it was offered. Requested other pain control options to control pain . The MAR documented the resident received [MEDICATION NAME] 2.5 mg four times on 7/31/15. -- 8/3/15, in pertinent part, documented, .Able to make most needs know to staff .Medicated this morning per physicians orders for complaints of pain . The MAR documented the resident ' s pain ranged from one out of ten to ten out of ten. The MAR documented the resident stated help me and the pain was all over . c. Failure to assess and manage resident #217's pain 1. Assessment The MDS pain assessment dated [DATE] documented the resident reported her pain as a nine out of ten. The medical record failed to have an initial pain assessment which included frequency, where the pain was and pain level tolerance. 2. Medication Administration Record The review of the resident's MAR dated 7/21/15 - 8/5/15 revealed the resident was to receive [MEDICATION NAME] as needed every four hours for pain. The MAR did not specify where the pain was located. The MAR did not specify a number on the pain scale. The MAR specified that if the resident expressed pain of a one to five on the pain scale then 5 mg of [MEDICATION NAME] should be given. The MAR documented the resident should receive 10 mg of [MEDICATION NAME] if the resident reported a six to ten on the pain scale. The MAR dated revealed the resident received PRN [MEDICATION NAME] 2.5 mg 44 times from 7/23/15 through 8/5/15. The MAR documented the following comments, all included the resident had left hip pain and left lower extremity pain: -7/23/15 pain ranged from five out of ten pain, medication effective to somewhat effective; -7/24/15 somewhat effective, ice pack given, pain ranged from two out of ten to eight out of ten, patient moaning and stating oh, oh, oh during activities of daily living (ADL); - 7/25/15 dressing change, pain ranged from two out of ten to six out of ten, medication effective to somewhat effective; - 7/26/15 pain ranged from four out of ten to six out of ten, medication effective to somewhat effective; - 7/27/15 pain ranged from five out of ten to six out of ten; - 7/28/15 pain ranged from one out of ten to five out of ten; - 7/29/15 pain ranged from three out of ten to four out of ten; - 7/30/15 pain ranged from two out of ten to six out of ten; - 7/31/15 pain ranged from five out of ten to ten out of ten; - 8/1/15 resident sleeping in wheelchair and complaining of seven out of ten pain prior to medication given; - 8/2/15 pain ranged from one out of ten to five out of ten; - 8/3/15 pain ranged from one out of ten to ten out of ten; - 8/4/15 pain ranged from two out of ten to ten out of ten; - 8/5/15 resident resting with eyes closed and complaining of five out of ten pain prior to medication given; and - 8/6/15 resident requesting pain medication to resident resting in bed. The documentation revealed it was somewhat effective to effective. The documentation revealed, on each occasion the medication was not effective another dose would be given at the time ordered. However, when the documentation revealed the medication was effective, another dose was given at the time ordered. The nurse practitioner (NP) note dated 7/27/15, in pertinent part, documented, .Last week I spoke to son to discuss scheduling some medication for pain, informed him that [MEDICATION NAME] was scheduled. The [MEDICATION NAME] will continue PRN . The NP note dated 7/30/15 at 4:47 p.m., in pertinent part, documented, .increased left hip pain, ice pack in place . The nurses' note dated 7/30/15 at 6:47 p.m., in pertinent part, documented, .PTA assisted patient into bed and provided ice pack for her Lt (left) hip . The NP note dated 8/3/15, in pertinent part, documented, .Nursing reporting scheduled pain medication helping with control. Episodes of increased agitation in the late afternoon . The interim care plan (CP) dated 7/21/15 identified the resident had an alteration in comfort. The goal of the CP was to have the resident report adequate pain control. The interventions included medications as ordered, monitor for signs and symptoms of pain and medicate as needed, evaluate pain for cause, site and intensity, position for comfort as needed and notify physician if current regimen is ineffective. The CP failed to include any non-pharmacological interventions. The medical record failed to show that the physician was contacted to inform of the increased level of pain. d. Interviews: The resident's son was interviewed on 8/6/15 at 11:10 a.m. The resident's son stated his mother always had a low tolerance for pain. He reported after completing the resident's last doctor's appointment, which was on 7/31/15, he and his mother waited for the facility van to pick them up. He reported waiting for an hour and a half. He reported the pain medication had worn off and his mother complained of pain and cried out consistently during the entire wait. The MAR, on the day of the appointment documented patient states a ten out of ten after appointment. One hour and 13 minutes later the MAR documented PRN result: somewhat effective, six out of ten, ice pack administered. The assistant director of nursing (ADON) was interviewed on 8/5/15 at 3:33 p.m. reported the only pain assessment used for the residents was the pain assessment from the MDS. She confirmed the only time the pain interviews were completed was when the MDS was scheduled. The Registered Nurse (RN) #1 was interviewed on 8/6/15 at 7:25 a.m. The RN stated she would generally treat her expressed pain with PRN medication as if it were scheduled. She stated We have to keep up with her medication because any movement at all caused her pain. The RN #1 was interviewed on 8/6/15 at 10:55 a.m. She reported the resident will frequently sit in her room and become restless and call out. The RN #2 was interviewed on 8/6/15 at 2:45 p.m. She reported the resident frequently complained of pain and anxiety. He reported her pain increased when she sat in the chair for a long period of time. He reported when the resident would lie down and nap she would appear to have less pain and decreased anxiety upon rising. This was not documented in the care plan (see above). The director of nursing (DON) was interviewed on 8/6/15 at 5:49 p.m. The DON stated she would expect her nurses to notify the doctor if a resident was using as needed (PRN) pain medication with increased frequency. She reported the way the nurses communicated to the physician and the nurse practitioner would be through the doctors ' concern log. She confirmed there was no documentation in the log related to increased use of PRN pain medication. She confirmed there was no documentation in the nurses ' notes regarding any contact with the physician for the increased use of pain medications. IV. Resident #229 1. Sample resident #229, [AGE] years old, was admitted to the facility on [DATE] with diagnoses that included chronic pain, bilateral lower extremities [MEDICAL CONDITION], depression, [MEDICAL CONDITION], and Type II Diabetes Mellitus (taken from physician ' s progress notes). The Minimum Data Set ((MDS) dated [DATE], revealed the resident scored 9/15 in the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognitive status. The resident was coded as needing extensive assistance of two staff with bed mobility, transferring, and for toilet use and needed extensive assistance of a staff member with locomotion off and on the unit, dressing, and with personal hygiene. The resident was continent of bowel and bladder. The MDS indicated the resident frequently had pain over the last five days and that The pain made it hard for her to sleep at night. When asked to rate her worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain she could imagine; she scored her pain as a 10. The interim care plan dated 7/23/15 included the concern for alteration in comfort. The goal was listed the patient will report adequate pain control. The interventions listed included: --Medications as ordered, --Monitor for signs and symptoms of pain and medicate as needed per order, --Evaluate pain for case, site, and intensity before and after administration of PRN medications. --Position for comfort as needed, and --Notify the physician if current regimen is ineffective. The current (8/3/15) physician orders [REDACTED]. Review of the Admission assessment dated [DATE], revealed the resident was asked three questions about pain. They included, At any time in the last 5 days, has the patient: -Been on a scheduled pain medication regime? No or Yes -Received PRN pain medications? No or Yes, and -Received non-medication intervention for pain? No or Yes. The resident answered No to the first question and Yes to the last two. The facility ' s pain assessment included the exact questions as were asked in the MDS Assessment for pain (see above). This assessment, as the previous assessment, failed to identify the resident's acceptable level of pain. The interventions that made her pain better, such as social interaction, and activity, were not added to the care plan or further defined in order to direct staff in implementing these non-pharmacologic interventions. There was nothing documented as far as what was an acceptable pain level for the resident or what pain level was tolerable for the resident, how did the pain affect their function ability and their quality of life? What made the pain better or worse? What was the resident ' s goal for pain relief? Pain is subjective. b. Pain Management Plan According to the resident's medication administration record (MAR), her pain was to be assessed with [REDACTED]. The instructions in the MAR entry included to document how the resident rated their pain and to assess pre-medication and post-medication using the 0-10 scale. c. Failure to ensure the resident's pain was evaluated and addressed to achieve satisfactory pain management as expected per facility policy. (1) Failure to identify the resident's acceptable level of pain Review of the resident's record revealed the facility failed to identify the resident's acceptable level of pain and failed to ensure steps were taken to attain such a pain level. The care plan, nursing assessment, pain management tool, medication administration record (MAR) and MDS above failed to identify the resident's acceptable level of pain. a. Resident Status - Presence of Pain Review on 8/6/15 of the MAR from 7/23/15 - 7/31/15 revealed repeated documentation of pain levels. Specifically: Pain levels for the prn pain medication administration revealed: -A pain level of 5 at 9:40 p.m. on 7/23/15. -A pain level of 5 three times and a pain level of 8 once on 7/24/15. -A pain level of 6 once and pain level of 7 three times on 7/25/15. -A pain level of 6 (at 12:59 a.m. which was too early to repeat medication), four times and a pain level of 7 once on 7/26/15. -A pain level of 5 four times, a pain level of 6 once, and a pain level of 7 once on 7/27/15 -A pain level of 5 once, a pain level of 6 once and a pain level of 7 twice on 7/28/15 -A pain level of 5 once, a pain level of 6 twice, and a pain level of 7 twice on 7/29/15. -A pain level of 5 five times on 7/30/15. -A pain level of 5 one time, a pain level of 6 twice and a pain level of 7 twice on 7/31/15. Review on 8/6/15 of the MAR from 8/01/15 - 8/06/15 revealed: -A pain level of 5-6 twice, a pain level of 6 twice and a pain level of 7 twice on 8/01/15 -A pain level of 3 once, a pain level of 4 once, a pain level of 5 once, and a pain level of 6 once and a pain level of 6-7 once on 8/02/15 -A pain level of 3 once, a pain level of 4 once and a pain level of 5 three times on 8/03/15 -A pain level of 4 twice, a pain level of 5 once, a pain level of 6 once and a pain level of 7 once and a pain level of 8 once on 8/04/15. -A pain level of 3 once, a pain level of 5 twice, a pain level of 5-6 once and a pain level of 6-7 once on 8/05/15. -A pain level of 3 once, a pain level of 5 twice, and a pain level of 6 once 8/06/15. (2) Failure to adequately evaluate and address elevated pain levels a) While the current (8/3/15) physician orders [REDACTED]. p.m. on 8/5, and at 4:24 a.m. on 8/6/15.) b) Nurses' notes 7/23/14 - 8/27/14 revealed no discussion of the resident's elevated pain levels, no re-evaluation of the resident's care planned interventions and non-pharmacological approaches, no interdisciplinary team discussions regarding additional steps to manage the resident's pain, and no communication of the resident's elevated pain levels to the physician/mid-level provider (until 8/5/15 after discussed with the DON-see below). -A nurse documented on 8/1/15 at 4 p.m., Constantly requesting pain medications after only 2-3 hours instead of the 4 hour limit per doctor orders but no non-verbal s/s of pain noted when pt is requesting meds. States that she cannot propel herself in wheelchair as it hurts too much, how can they expect me to do this on my own, I need help with everything but pt wanting to be able to do things on her own in her room. Can stand and pivot from wheelchair to toilet or to bed without asst. 2+ non-[MEDICAL CONDITION] BLE, pedal pulses present BLE. [MEDICATION NAME] effective in decreasing hip/leg pain (also using [MEDICATION NAME] cream) from 6-7 down to 1-2 on 0-10 pain scale but pt states that it doesn ' t last 4 hours. -On 8/3/15 at 3:26 p.m. a nurse documented, Pt is refusing to get up for breakfast and demanding pain meds .Pt did not go to the DR (dining room) today and refused her lunch tray but later asked for a full lunch including a sandwich, chips and tea. She has taken PRNs ATC (around the clock) today for pain and was yelling if her meds where not given to her right at 4 hours. Pt had to be woke up every time meds were delivered. (3) Review of the physician/NP progress notes in pertinent parts revealed: -On 7/27/15 at 7:59 a.m. The [MEDICAL CONDITION], neuropathic foot pain and ankle pain (suspected gout), along with chronic back pain, resulted in significant functional impairment and she was admitted to the hospital 7/19/2015 . Palliative care saw her to help with pain management, determine resuscitation status and define her goals of treatment. She remains at a low functional level and is transferred to (name of the facility) now for rehabilitation .She is in the dining room awaiting breakfast. Did not sleep well and never does. Up often to watch TV .Previously on [MEDICATION NAME] and requested to be taken off. Now on high dose [MEDICATION NAME] and [MEDICATION NAME] for chronic pain. She is receiving the [MEDICATION NAME] about 6 times daily and feels quite comfortable with this. Her goal is to be up and walking again and she is a bit anxious about starting therapy. Chronic pain: off [MEDICATION NAME], now on high dose [MEDICATION NAME] with [MEDICATION NAME] dosing of [MEDICATION NAME] 70 mg/day. I have asked for PP Palliative care to manage her pain as this higher dosing than recommended outpatient and will need pain management on board. I have increased the [MEDICATION NAME] to 600 mg TID, max dose and will monitor renal function. She requested [MEDICATION NAME] gel but we discussed using increased [MEDICATION NAME] for now to see if this works first. Concerns with NSAIDs and CKD stage IV . -On 7/28/15 at 7:35 p.m. She has taken PRNs ATC today for pain. - On 8/3/15 at 4:53 p.m.is having increased pain at the hip. She has requested her [MEDICATION NAME] 15 mg and receives this. Nursing tells me she refused to get out of bed today and participate in therapy. Of note: she has requested to have [MEDICATION NAME] discontinued on transfer to this facility and it was stopped. -On 8/4/15 at 6:01 p.m. Chronic pain: off [MEDICATION NAME] . She declined palliative care. Improved pain control with increased [MEDICATION NAME]. [MEDICATION NAME] gel added at her insistence. Discussed with RN long half life of [MEDICATION NAME] and that her pain may increase as the [MEDICATION NAME] leaves her system. (4) Observations/Interviews. -On 8/3/15 at 12:30 p.m., the resident was observed sitting in her w/c by a table in her room. She stated she finally got her pain pill after hour of waiting; They kept telling me the nurse was on the phone. Isn ' t there anyone else here that can give medications? She was observed rubbing her back and trying to get comfortable in her chair. -In an interview with the resident again on 8/5 at 12:15 a.m., the resident stated she had to wait for her pain pill 20 minutes today. She stated they did give her medications before therapy. -In an interview with the Director of Nursing on 8/5/15 at 3:30 p.m., it was discussed that the physician's order [REDACTED]. However, the E MAR read [MEDICATION NAME] 5 mg; administer 15 mg, orally for pain scale of 1-5. The DON was asked what they gave the resident if her pain was higher than a 5? The DON stated she would need to clarify this order (see above). The DON also verified the only pain assessment completed by the facility was the copy asked by the MDS person (see above). -At 8/5/15 at 3:35 p.m., the resident was interviewed. She was observed sitting on side of bed and rocking back and forth with her arms crossed and moaning and groaning. She stated she needs her pain pill every four hours and they did not give it to me when it was due. (Last one given at 10:51 a.m. per the EMAR) They know I need it. I am in pain all the time. It wakes me up at night. I can't do therapy with the pain. Without doing well in therapy, I won't be able to walk and then I can't go home. The others have all ready started to walk outside. I can't even walk. -In an interview at 3:45 pm on 8/5/15 with the Licensed Practical Nurse (LPN) who was in charge of the unit upon which the resident resided, stated the resident was always in pain. The LPN continued the resident thinks she needs that pill every four hours, however; she needs to ask for it. The LPN stated she was yelling at the CNA that she was in pain and she had missed her last dose by over 30 minutes. She was sleeping then. She needs to do therapy. She is lazy. She gets anxious when she is in pain and so I give her an [MEDICATION NAME]. Summary It was not until after a discussion with the DON on 8/5/15 about whether or not the resident had been offered scheduled pain medications and additional medication for breakthrough pain, this addendum dated 8/5/15, was documented by the NP. Later in the day, at the IDT meeting, it was discussed that her [MEDICATION NAME] 15 mg is ordered for pain 1-5 and has been administered for pain 6-10. I have been requested to address this with the patient and I have. She tells me that her pain is in her lower bacjk (sic) and radiates to the left buttocks and hip, sometimes her pain is 10/10 and that when (sic) she gets the 15 mg [MEDICATION NAME], it is reduced to 5/10. I have offered to start her on BID oxycotin while making the [MEDICATION NAME] available for breakthrough pain and she is reluctant to do this. I have also offered [MEDICATION NAME] for pain and she is also reluctant to do this. Additionally, she tells me she is fearful of her PCP ' s reaction when she learns that she stopped the [MEDICATION NAME]. She stopped her [MEDICATION NAME] without any weaning she tells me, though a weaning schedule was offered, she declined and preferred to stop abruptly. After much discussion concerning pain, medications, narcotics and [MEDICATION NAME] ' s long half-life, she is comfortable having an increased dose of [MEDICATION NAME] available for pain 6-10.