Every finding on record at Bear Creek Senior Living

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections in two of two units.Specifically, the facility failed to:-Ensure hand hygiene was performed appropriately when providing care;-Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP), including Resident #7 and Resident #33;-Ensure resident rooms were cleaned in a hygienic manner; and,-Ensure chemical dwell times were followed.Findings include: I. Hand hygiene failures A. Facility policy and procedure The Infection Prevention and Control Program (IPCP) policy, revised October 2018, was provided by the nursing home administrator (NHA) on 2/10/26 at 8:02 a.m. It read in pertinent part, An IPCP is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Important facets of infection prevention include instituting measures to avoid dissemination, educating staff and ensuring that they adhere to proper techniques and procedures, implementing appropriate isolation precautions when necessary and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). The facility has established policies and procedures regarding infection control among employees, contractors, vendors, visitors and volunteers, including those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment (PPE). The Handwashing/Hand Hygiene policy, dated 2001, was provided by the NHA on 2/11/26 at 9:12 a.m. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids or contaminated surfaces, after touching a resident, after touching a resident's environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. B. Observations On 2/10/26 at 8:15 a.m. registered nurse (RN) #1 prepared medications to administer to Resident #15, including enoxaparin sodium (Lovenox - blood thinner medication) subcutaneous injection 30 milligram (mg) per 0.3 milliliter (ml), ordered 1/31/26. RN #1 entered Resident #15's room and administered his medications, including the Lovenox injection. RN #1 prepared the left lower quadrant of the resident's abdomen for the injection by cleansing the area with an alcohol prep pad, then administered the subcutaneous injection. -RN #1 failed to perform hand hygiene between the time he last handled the medication cart and when he administered the injection to Resident #15 -RN #1 failed to don gloves before he administered the subcutaneous injection to Resident #15. RN #1 performed hand hygiene with hand sanitizer after he exited the resident's room. -However, RN #1 did not perform hand hygiene until after he touched the medication cart computer. On 2/10/26 at 8:30 a.m. RN #1 prepared medications to administer to Resident #39, including a famotidine 10 mg oral tablet, ordered 3/20/24. While RN #1 dispensed the famotidine tablets, one tablet fell from the medication bottle to the top of the medication cart. RN #1 used his ungloved hand, picked up the tablet from the top of the medication cart and added it to Resident #39's medication cup for administration. RN #1 entered Resident #39's room and administered his medications, including the famotidine tablet that fell to the top of the medication cart. -RN #1 failed to ensure medications that dropped from the medication bottle were not administered to Resident #39. Tracheostomy care was performed on Resident #7 by RN #1 on 2/10/26 at 1:37 p.m. RN #1 performed hand hygiene with soap and water in the resident's room before he donned a clean pair of gloves. -RN #1 failed to change his gloves after he removed the old inner tracheostomy cannula and before he inserted the clean inner tracheostomy cannula. C. Staff interviews RN #1 was interviewed on 2/10/26 at 8:30 a.m. RN #1 said he did not know if he should have worn gloves during a subcutaneous or intramuscular injection. He said he did not wear gloves unless he was manipulating an intravenous (IV) catheter. RN #1 said it was important that hand hygiene was performed appropriately because he could be a vector and transmit communicable diseases from the last resident or object he made contact with. RN #1 was interviewed again on 2/10/26 at 1:58 p.m. RN #1 said he did not know if he should have changed his gloves after he removed Resident #7's old inner tracheostomy cannula and before he inserted the new inner cannula, and he did not know if that posed a risk to the resident. RN #1 said he had never thought about that before. The director of nursing (DON) was interviewed on 2/11/26 at 12:20 p.m. The DON said it was important to perform hand hygiene appropriately to protect both staff members and the residents from infection. She said hand hygiene was indicated before medications were dispensed, before medications were administered and after exiting the resident's room. The DON said gloves should have been worn while the subcutaneous injection was administered because the nurse broke the resident's skin and posed a risk to pathogens. The DON said if a pill dropped to the floor or to the medication cart the nurse should have thrown it away - even if they attempted to pick up the pill with a gloved hand. She said the pill should not have been placed in the resident's medication cup because the nurse did not know what the pill landed on, or when the last time the medication cart was cleaned. The DON said gloves should be changed after working with a dirty or soiled area, such as the inner tracheostomy cannula, before moving on to a clean area, such as the clean inner tracheostomy cannula, due to the risk of contamination. She said RN #1 would receive further education on providing direct patient care. II. Enhanced barrier precautions (EBP) failures A. Professional reference Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), 4/2/24, was retrieved 2/17/26. It read in pertinent part, Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; and, wound care: any skin opening requiring a dressing. In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. B. Facility policy and procedure The Enhanced Barrier Precautions (EBP) policy, dated 2001, was provided by the NHA on 2/11/26 at 9:12 a.m. It read in pertinent part, EBPs are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs refer to infection prevention and control interventions designed to reduce the transmission of MDROs during high-contact resident care activities. EBPs apply when a resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device and does not have secretions or excretions that cannot be covered or contained; a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device and has secretions or excretions that cannot be covered or contained; and, a resident is infected or colonized with any MDRO and there is a current investigation of a suspected or confirmed MDRO outbreak. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, changing briefs or assisting with toileting, transferring, changing linens, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) and wound care. C. Observations and resident interview Resident #7 was interviewed on 2/10/26 at 9:50 a.m. Resident #7 said when the nursing staff performed tracheostomy care they had never worn a yellow gown, but they did wear gloves. Tracheostomy care was performed on Resident #7 by RN #1 on 2/10/26 at 1:37 p.m. RN #1 performed hand hygiene with soap and water in the resident's room before he donned a clean pair of gloves. -RN #1 failed to don a mask or a yellow isolation gown while he performed tracheostomy care. During a continuous observations on 2/9/26, beginning at 12:15 p.m. and ending at 12:40 p.m., the following was observed: CNA #1 and CNA #3 were observed providing assistance to Resident #33. CNA #3 put Resident #33's shoes on. CNA #3 brought the sit to stand machine into the resident's room. CNA #3 put a gait belt around Resident #33's waist. CNA #1 and CNA #3 put the sling around Resident #33's back and hooked it to the machine. CNA #3 pressed the machine's button to lift the machine up and moved it to the wheelchair. CNA #1 lowered the machine so Resident #33 was sitting in his wheelchair. CNA #1 assisted Resident #33 into the bathroom. CNA #1 and CNA #3 donned (put on) clean gloves. CNA #1 and CNA #3 transferred Resident #33 to the toilet and removed his soiled brief. Resident #33 had a foley catheter. RN #3 came into the room and donned clean gloves. RN #3, CNA #1 and CNA #3 stood Resident #33 up from the toilet and cleaned his bottom. RN #3 applied cream to the wound on Resident #33's bottom. RN #3, CNA #1 and CNA #3 pulled up Resident #33's clean brief and pants and assisted him down in the wheelchair. -RN #3, CNA #1 and CNA #3 failed to don EBP during high contact resident care areas including dressing, transferring, wound care and toileting. D. Staff interviews Certified nursing aide (CNA) #1 was interviewed on 2/11/26 at 12:00 p.m. CNA #1 said she did not know about any special precautions for a resident with a tracheostomy, and as a CNA she did not provide care to residents with tracheostomy. She said she did not need to wear any special PPE to provide direct resident care, such as dressing or toileting, to a resident with a tracheostomy. CNA #1 said there were no residents at the facility that were on EBP. RN #1 was interviewed on 2/10/26 at 1:58 p.m. RN #1 said he did not know what enhanced barrier precautions were. He said he washed his hands before he began providing resident care and used the inside of the supply packages to keep the supplies clean. The infection preventionist (IP) was interviewed on 2/11/26 at 12:00 p.m. She said any resident with an indwelling line or breakdown of skin that would put them at an increased risk for getting an infection would qualify them to be placed on EBP. She said the facility had implemented EBP in the past. She said the facility recently had COVID-19 outbreaks so a lot of the EBP signage had been replaced with isolation signs for COVID-19. She said she thought the EBP never were brought back out after the outbreak. The DON was interviewed on 2/11/26 at 12:20 p.m. The DON said a resident would be expected to be on EBP if they had an additional line (such as a catheter or tracheostomy) or breakdown of the skin that increased their chance of infection. She said there were five or six residents at the facility who were on EBP. The DON said it was important that EBP was followed appropriately to decrease the risk of infection. She said proper EBP technique meant that nursing staff wore gowns, gloves and a mask, depending on what they were doing, and if nursing staff were handling the wound or the dressing then they should use EBP in that instance. The DON said if the nursing staff were transferring a resident then she did not expect them to don an isolation gown, and she was unclear about transferring being a requirement for EBP. She said back when she was the assisting director of nursing (ADON) the facility conducted an education piece on EBP and it was probably time to re-do that education. The DON said the residents should have an order for EBP and it would be care planned. She said sometimes the door signs get switched out and the staff forget to return the original signage. The DON said Resident #7 was placed on droplet precautions three months ago and she suspected that when the droplet sign was removed staff forgot to replace the EBP sign. She said the EBP signs were on the resident's doors now. III. Failure to follow chemical dwell times and appropriately sanitize resident rooms A. Professional reference According to the Spartan (2025) product insert for NABC Concentrate was retrieved on 2/12/26 from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.spartanchemical.com/globalassets/sharepoint/product-literature--documentation---epidocuments/product-literature/L4716_NABC_Concentrate_Sell_Sheet.pdf, Non-acid bathroom cleaner (NABC) Concentrate is a broad range germicidal cleaner-disinfectant concentrate specifically designed to clean and disinfect toilet bowls, urinals and other hard, nonporous restroom surfaces. The contact time is instructed to leave surfaces wet for ten minutes. According to the Spartan (2025) product insert for Clean by 4D was retrieved on 2/12/26 from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.spartanchemical.com/globalassets/sharepoint/product-literature--documentation---epidocuments/product-literature/l1011_clean_by_4d.pdf, Clean by 4D is a healthcare disinfectant that delivers effective performance and provides a restorative clean. When used as directed for sanitization this product is effective against Staphylococcus aureus and Klebsiella pneumonia (bacteria). Treated surfaces must remain wet for 90 seconds. B. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised 2013, was received from the NHA on 2/11/26 at 9:12 a.m. It documented in pertinent part, Manufacturers' instructions will be followed for proper use of disinfecting products. Clean horizontal surfaces (examples included bedside tables, overbed tables and chairs) daily with a cloth moistened with disinfectant solution. Clean personal use items (examples included lights, phones, call bells, bedrails, etc.) with disinfectant solution at least twice weekly. C. Observations During a continuous observation on 2/10/26, beginning at 9:00 a.m. and ending at 9:30 a.m., the following was observed: Housekeeper (HK) #1 was observed cleaning resident room [ROOM NUMBER]. HK #1 sprayed down the toilet with NABC concentrate and immediately wiped it down with a rag. HK #1 sprayed the commode with the NABC concentrate and immediately wiped it down with a new rag. HK #1 moved her cart to resident room [ROOM NUMBER]. HK #1 took out the trash. HK #1 sprayed down a rag with NABC Concentrate and wiped down the bedside table. HK #1 sprayed a clean rag with Clean by 4D and wiped down the grab bar in the bathroom. HK #1 sprayed the NABC concentrate on the bathroom sink counter and immediately wiped it with a clean rag. HK #1 sprayed the outside of the toilet with NABC Concentrate and immediately wiped it down with a clean rag. HK #1 swept and mopped the room. -HK #1 failed to disinfect the high touch surfaces. -HK #1 failed to follow the appropriate dwell times for chemicals used to clean resident rooms. During a continuous observation on 2/10/26, beginning at 9:35 a.m. and ending at 10:05 a.m., the following was observed: HK #2 was cleaning resident room [ROOM NUMBER]. HK #2 sprayed the bathroom sink, counter and mirror with NABC concentrate. HK #2 immediately wiped the mirror with a clean rag, replaced the rag, and wiped down the sink and counter with a new rag. HK #2 cleaned the inside of the toilet with toilet bowl cleaner and a brush. HK #2 sprayed NABC concentrate on the outside of the toilet and immediately wiped it down with a clean rag. HK #2 sprayed the grab bar in the bathroom with NABC concentrate and immediately wiped it down with a clean rag. HK #2 sprayed a clean rag with Clean by 4D and wiped down the side table in the room. -HK #2 failed to disinfect the high touch surfaces. -HK #2 failed to follow the appropriate dwell times for chemicals used to clean resident rooms. D. Staff interviews The environmental services director was interviewed on 2/11/26 at 11:21 a.m. She said the dwell time for Clean by 4D was two minutes and the dwell time for NABC concentrate was 10 minutes. She said she trained the housekeepers to spray down surfaces with the chemicals first as they started to clean the rooms and let it sit on the surfaces while they took the trash out and swept the floors. She said they get into a hurry sometimes. The environmental services director said the housekeepers were expected to disinfect high touch surfaces including light switches, door knobs, the bathroom door and main door above and below the door knobs, furniture, handles on the furniture, bedside tables and the legs on them, lamps, call lights and the arms of chairs. The IP was interviewed on 2/11/26 at 12:00 p.m. She said high touch surfaces in the residents' rooms including remotes, call lights, bedside tables, door knobs, phones and bed side rails should be sanitized daily to help prevent the spread of germs. She said the dwell time of chemicals used to clean resident areas should be followed in order to clean off the spread of germs.

Based on record review and interviews, the facility failed to provide a written discharge notice to to the resident or their representative and the State Long-Term Care Ombudsman at least 30 days before the resident's discharge for one (#1) of three residents reviewed for transfer/discharge out of three sample residents. Specifically, the facility failed to: -Provide Resident #1 and her representative an appropriate written notice of discharge from the facility that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -The location to which the resident was transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request; and, -The name, address (mailing and email) and telephone number of the Office of the State; and, -Provide written notice to the ombudsman of Resident #1's facility-initiated discharge. Findings include: I. Facility policy and procedure The Transfer or Discharge, Facility-Initiated policy and procedure, undated, was provided by the assistant director of nursing (ADON) on 1/30/25 at 3:20 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation and documentation, as specified in this policy. Facility-Initiated transfer or discharge means a transfer or discharge which the resident objects to, and/or is not in alignment with the resident's stated goals for care and preference. If the facility does not permit a resident's return to the facility based on inability to meet the resident's needs, the facility will notify the resident and his or her representative in writing of the discharge, including notification of appeal rights. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC (long term care) Ombudsman. If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. The resident and his or her representative are given a thirty (30)-day advance notice of an impending transfer or discharge from the facility. The resident and representative are notified in writing of the following information: -The specific reason for the transfer or discharge, including the basis; -The effective date of the transfer or discharge; -The specific location to which the resident is being transferred or discharged ; and, -An explanation of the resident's rights to appeal the transfer or discharge to the state, including the name, address, email and telephone number of the entity which receives such appeal hearing requests. A copy of the notice is sent to the office of the state long-term care ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. II. Resident #1 A. Resident status Resident #1, age greater than 65, was initially admitted on [DATE] and readmitted after hospitalization s on 8/15/24, 11/20/24 and 12/24/24. According to the January 2025 computerized physician orders (CPO), diagnoses included alcoholic cirrhosis of the liver, type 2 diabetes mellitus with other diabetic kidney complication, acquired absence of left leg above the knee, dependence on wheelchair, type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, alcohol dependence, in remission, anxiety disorder, hepatic encephalopathy, Parkinsonism and cognitive communication deficit. The 11/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision for most functional activities of daily living (ADL). The assessment documented the resident had no behavioral symptoms, including physical, verbal, or other and there was no rejection of care. She was administered insulin injections, antianxiety, antidepressant, antibiotic, diuretic and hypoglycemic medications daily. III. Record review -Review of Resident #1's electronic medical record (EMR) revealed the facility failed to provide a written notice for the facility-initiated discharge to Resident #1, to include her appeal rights, and failed to send a written copy of the notice to a representative of the office of the state long term care ombudsman. -The facility failed to provide a reason for the sudden discharge. Cross-reference F626 for failure to permit a resident to return to the facility following a discharge. On 1/30/25 at 4:50 p.m., the ADON provided a statement that Resident #1's representative was notified verbally by the director of nursing (DON) and the social services director (SSD) of the facility's decision to not readmit the resident after her hospitalization . -However, the facility failed to provide documentation of the discharge notice and notification to the ombudsman (see interviews below). Review of Resident #1's EMR revealed the following progress notes: The 1/10/25 nurses note revealed Resident #1 refused to take her medications because her stomach was upset and she was afraid she would throw up. The note documented that due to the management's previous instruction, the nurse proceeded to call the resident's representative, who came to the facility and the resident took her medications. On 1/14/25 the ADON documented that on Friday 1/10/25 at 3:45 p.m., Resident #1's representative requested the resident be sent to a hospital, because she said the resident was lethargic. The ADON further documented Resident #1 appeared to be at her baseline per nursing assessment. The 1/14/25 interdisciplinary team (IDT) note documented the IDT team discussed the resident's status at the hospital. It was determined with the regional nurse that the facility was not able to accept her back due to not being able to meet her needs, as the resident would not allow interventions to be put in place to accommodate her safety to prevent abuse physically and verbally. PACE (program of all-inclusive care for the elderly), the ombudsman, the resident's representative and the hospital caseworker were involved in the conversation. Review of Resident #1's EMR on 1/29/25, revealed the following: -There was no discharge summary or assessment documentation; -There was no documentation of appropriate orientation and preparation of the resident prior to transfer or discharge; and, -There was no written discharge notice documentation. IV. Interviews A frequent visitor (FV) was interviewed on 1/30/25 at 2:34 p.m. The FV said she did not receive a facility-initiated discharge letter from the facility when Resident #1 was discharged . She said Resident #1 and her representative did not receive the discharge letter and were not aware of the appeal rights. The FV said the resident's representative told her that she would like to appeal the discharge, however she did not know how to appeal. The DON and the ADON were interviewed together on 1/30/25 at 3:10 p.m. The ADON said the facility did not send a written facility-initiated discharge notice to Resident #1 and her representative, or to the ombudsman office. The DON said the IDT made the decision of not accepting Resident #1 back due to the resident refusing to take her medications which had led to her mental status changes and hospitalization s.

Based on record review and interviews, the facility failed to allow resident to return to the facility after transfer to a hospital for one (#1) of three residents reviewed for facility-initiated transfers out of three sample residents. Specifically the facility failed to permit Resident #1 to return after a hospitalization on [DATE]. Findings include: I. Facility policy and procedure The Transfer or Discharge, Facility-Initiated policy and procedure, undated, was provided by the assistant director of nursing (ADON) on 1/30/25 at 3:20 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, and/or is not in alignment with the resident's stated goals for care and preference. Residents who are sent emergently to an acute care setting are considered facility-initiated transfers, not discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. A resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. The facility will document that the resident or, if applicable, resident representative, received information regarding the risks or refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others. II. Resident #1 A. Resident status Resident #1, age greater than 65, was initially admitted on [DATE], and readmitted after hospitalization s on 8/15/24, 11/20/24 and 12/24/24 and discharged to the hospital on 1/10/25. According to the January 2025 computerized physician orders (CPO), diagnoses included alcoholic cirrhosis of the liver, type 2 diabetes mellitus with other diabetic kidney complication, acquired absence of left leg above the knee, dependence on wheelchair, type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, alcohol dependence, in remission, anxiety disorder, hepatic encephalopathy, Parkinsonism and cognitive communication deficit. The 11/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision for most functional activities of daily living (ADL). The assessment documented the resident had no behavioral symptoms, including physical, verbal, or other, and there was no rejection of care. She was administered insulin injections, antianxiety, antidepressant, antibiotic, diuretic and hypoglycemic medications daily. III. Record review Review of Resident #1's comprehensive care plan, dated 9/15/23, revealed the following: -Resident #1 was admitted for long-term care with an intervention to evaluate the resident's motivation to return to the community. -Resident #1 declined to take her medications and get up in the mornings. The interventions included educating the resident and her family of the possible outcome(s) of not complying with treatment or care. The 1/10/25 nurses note revealed Resident #1 refused to take her medications because her stomach was upset and she was afraid she would throw up. The note documented that due to the management's previous instruction, the nurse proceeded to call the resident's representative, who came to the facility, and the resident took her medications. On 1/14/25 the ADON documented that on Friday, 1/10/25 at 3:45 p.m., Resident #1's representative requested the resident be sent to a hospital, because she said the resident was lethargic. The ADON further documented Resident #1 appeared to be at her baseline per nursing assessment. The 1/14/25 interdisciplinary team (IDT) note documented the IDT team discussed Resident #1's status at the hospital. It was determined with the regional nurse that the facility was not able to accept her back due to not being able to meet her needs, as she would not allow interventions to be put in place to accommodate her safety to prevent abuse physically and verbally. PACE (program of all-inclusive care for the elderly), the ombudsman, the resident's representative and the hospital caseworker were involved in the conversation. IV. Interviews The nursing home administrator (NHA) was interviewed on 1/29/25 at 9:30 a.m. The NHA said the IDT team made the decision to not permit Resident #1's return to the facility because of her medications refusals. Licensed practical nurse (LPN) #1 was interviewed on 1/30/25 at 1:20 p.m. LPN #1 said the resident's medication, lactulose, was very important for her to prevent hepatic encephalopathy. He said when Resident #1 declined to take this medication for a few days, she experienced a mental status change and required hospitalization . LPN #1 said the resident refused this medication because it made her nauseated in the morning. A frequent visitor (FV) was interviewed on 1/30/25 at 2:34 p.m. The FV said she did not receive a facility-initiated discharge letter from the facility. She said Resident #1 and her representative did not receive the discharge notice/letter and were not aware of the appeal rights. The FV said the resident's representative would have liked Resident #1 to return to the facility, if she had a chance to appeal the facility's decision of discharge. The director of nursing (DON) and the ADON were interviewed together on 1/30/25 at 3:10 p.m. The DON said the IDT team made the decision of not accepting the resident back due to the resident refusing to take her medications, which led to her mental status changes and hospitalization s.

Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases. Specifically, the facility failed to: -Ensure the facility monitored the water for the growth of Legionella; and, -Ensure Resident #12 was offered the COVID-19 vaccine. Findings include: I. Water management A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Toolkit: Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings,(3/25/21), retrieved on 5/4/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires' disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia called Legionnaires' disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team; -Describe the building water systems using text and flow diagrams; -Identify areas where Legionella could grow and spread; -Decide where control measures should be applied and how to monitor them; -Establish ways to intervene when control limits are not met; -Make sure the program is running as designed (verification) and is effective (validation); and, -Document and communicate all the activities. Principles: In general, the principles of effective water management include: -Maintaining water temperatures outside the ideal range for Legionella growth; -Preventing water stagnation; -Ensuring adequate disinfection; and, -Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. Monitoring Water Quality Parameters: The water management program team should regularly monitor water quality parameters, such as disinfectant residual and temperature levels. By monitoring these parameters, the team can ensure that building water systems are operating in a way to minimize hazardous conditions that could encourage Legionella and other waterborne pathogens to grow. If the team finds that a control limit temperature, disinfectant residual) is not being met, their next step will be to take corrective actions to get conditions back to within an acceptable range. Examples of chemical and physical control limits to reduce the risk of Legionella growth include: -Maintain hot water temperature at the highest temperature allowable by state regulations or codes and outside the favorable range for Legionella growth (77-113 degrees (fahrenheit) F). -Ensure disinfectant levels are detectable where water enters the building and at points of use. According to CDC' s Controlling Legionella in Potable Water Systems, (2/3/21) retrieved on 5/4/24 from, Store hot water at temperatures above 140 degrees F and ensure hot water in circulation does not fall below 120 degrees F. Recirculate hot water continuously, if possible. Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 degrees F); Legionella may grow at temperatures as low at 68 degrees F. B. Facility policy The Water Management Program policy, undated, was received by the director of nursing (DON) on 5/2/23 at 10:32 a.m. and read in pertinent part, Monitoring and verification plan, cold water service monitoring task included: -Cold water temperature should be checked weekly. The limit is less than 77 degrees Fahrenheit (F). -Legionella culture test annually on a rotating basis. Hot water service, centralized, water storage systems monitoring. -Water storage or supply temperature should be checked weekly. -The temperature limit is 140 to145 degrees Fahrenheit with a thermostatic mixing valve (TMV) or 130 to 135 degrees Fahrenheit without a TMV. -Legionella culture test should be completed annually on a rotating basis. C. Record review The Legionella testing and watering monitoring results for March 2024 and April 2024 were requested from the DON on 5/2/24. A review of the March 2024, April 2024 and May 2024 work history report revealed the log marked the hot water was tested on [DATE], 3/9/24, 3/16/24, 3/23/24, 3/30/24, 4/6/24, 4/13/24, 4/20/24, 4/27/24 and 5/4/24. On 5/6/24 at 2:40 p.m. the maintenance director (MTD) provided the water temperature testing results for April 2024 and May 2024 from the direct supply electronic logbook. The logbook documented the following water temperature monitoring: On 4/3/24, the water temperature was tested in a resident room on the memory care unit. It was 113 degreesF. On 4/11/24, the water temperature was tested in resident room [ROOM NUMBER]. The temperature was 114 degrees F. On 4/19/24, the water temperature was tested in a non-specified resident room on the skilled unit. The temperature was 112 degrees F. 4/27/24 the water temperature was tested in a non-specified location on the memory care unit. The temperature was not recorded. On 5/2/24, the water temperature was tested in a non-specified location on the memory care unit. The temperature was 113 degrees F D. Interviews The DON was interviewed on 5/6/24 at 10:00 a.m. The DON said she shared the infection preventionist (IP) role with the assistant director of nursing (ADON). She said the IP was not a water management team member. She said she knew about the program but had not been responsible for the implementation or monitoring of the water testing for Legionella. The DON said if the water temperatures were out of range, an additional control measure was not used to monitor or test the water. The DON said the MTD tested water temperatures monthly and they sent a water sample on 5/1/24 for the annual analysis. She said the facility ordered the analysis to be completed because the water temperatures were not always in the range to prevent Legionella growth. She said waiting for a laboratory water analysis could delay follow-up monitoring when the follow-up to missed control measures is urgent. The DON said she would review testing and monitoring options for immediate results if water temperatures were not within control limits. The MTD was interviewed on 5/6/24 at 2:57 p.m. The MTD said he was unaware the hot water temperatures had not met the control measure temperature for hot water storage or supply of 130 to 135 degrees Fahrenheit (control without TMV). He said he entered the result into the log when he measured water temperatures. The MTD said when water temperatures were within the favorable range for Legionella growth which was 77 to 113 degrees F. He said there was no additional monitoring until the 5/1/24 water analysis was completed. The MTD said the facility tested the water one time a year. He said the water sample was collected by a third-party laboratory and was collected on 5/1/24. The MTD said the facility cooling tower/chiller included an oxidizing biocide, a chemical to kill microorganisms in the water. He said the chemical level was included in the water analysis and he was unaware of what level of the chemical was necessary to prevent the growth of Legionella. II. COVID-19 vaccine failure A. Professional reference The CDC' s Stay Up to Date with COVID-19 Vaccines (3/7/24) was retrieved on 5/7/24 from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html and read in pertinent part, The CDC recommends the 2023-2024 updated COVID-19 vaccines. Everyone aged five years and older should get one dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19 .People aged [AGE] years and older who got the previous COVID-19 vaccine(s) before 9/12/23 should get one updated COVID-19 vaccine. People who are up to date have a lower risk of severe illness, hospitalization , and death from COVID-19 than people who are unvaccinated or who have not completed the doses recommended for them by CDC. B. Facility policy The COVID-19 Ongoing Vaccination Plan, dated 7/1/23, was provided by the NHA on 5/1/24 at 9:05 a.m. It read in pertinent part, Immunization with a safe and effective COVID-19 vaccine is a critical component of the strategy to reduce COVID-19 related illnesses. Facility COVID-19 vaccination coordinator is responsible for organizing and overseeing any COVID-19 vaccination efforts at the facility. The vaccination coordinator is responsible for organizing the COVID-19 vaccination clinic. The registered nurse vaccination director is responsible for documenting and reporting vaccinations and received training from nursing school and the pharmacy that provided the vaccinations. The facility procedure to determine if residents have been fully vaccinated for COVID-19 is to ask the resident for their vaccination card and log the vaccine information into the facility vaccine tracking portion of the electronic medical record. The facility promotes the COVID-19 vaccine to residents by emailing residents and family members in a group email. C. Resident #12 1. Resident status Resident #12, over the age of 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included generalized arthritis and muscle weakness. The 2/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score o f15 out of 15. 2. Record review -A review of Resident #12' s EMR on 5/2/24 revealed the resident was not offered the COVID-19 vaccination since being admitted to the facility on [DATE]. The EMR did not indicate if the resident had received any COVID-19 vaccinations prior to admission to the facility. D. Staff interviews The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 5/6/24 at 10:00 a.m. They said they shared the responsibility of keeping track of resident vaccination status. The ADON said when residents were admitted to the facility, she or the DON reviewed the medical records to gather the resident' s vaccination history. The ADON said if the resident had not received the most recent COVID-19 vaccine, the facility offered the vaccine upon admission. The ADON said the information was documented in the electronic medical record (EMR) if the facility administered a vaccine. The ADON said if the resident had previously received vaccines, the vaccine documentation was scanned into the EMR and filed under the miscellaneous tab. The ADON said the facility did not otherwise track and document resident immunization information. The ADON said she was unable to find documentation which indicated Resident #12 was educated, offered, received or refused the COVID-19 vaccine since her admission on 11/3/23. The DON said the facility should follow state and CDC guidelines for offering vaccines and documenting the vaccination status of each resident in their EMR.

Based on interviews and record review, the facility failed to ensure residents were free from significant medication errors for three (#18, #6, #188) of 11 residents reviewed for medication errors out of 23 sample residents. Specifically, the facility failed to: -Ensure physician's hospital discharge orders for antibiotics to treat a urinary tract infection (UTI) from the hospital were initiated when Resident #18 admitted to the facility; -Ensure Resident #18's antibiotic medication and an inhaler were available timely for administration per physician's order; -Ensure Resident #6's nasal spray was available for administration per physician's orders; and, -Ensure Resident #188's pain medication was available for administration per physician's orders. Findings include: I. Facility policy The Medication Administration policy, revised April 2019, was provided by the director of nursing (DON) on 5/6/24 at 5:38 p.m. It read in pertinent part, Medications are administered in a safe and timely manner and as prescribed. Policy interpretation and implementation: the director of nursing (DON) supervises and directs all personnel who administer medications. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors considered include enhancing the optimal therapeutic effect of the medication and medications are administered within one hour of the prescribed time, unless otherwise specified. II. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE] and was discharged to the hospital on 4/21/24. According to the April 2024 computerized physician orders (CPO), diagnoses included UTI, acute kidney injury and COPD. The 4/3/24 minimum data set (MDS) assessment documented Resident #18 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial/maximum assistance with bathing, toileting and transfers. He required partial/moderate assistance with dressing and hygiene. The assessment documented Resident #18 was admitted with an indwelling urinary catheter and he was prescribed antibiotics -However, the antibiotics were not administered as ordered (see record review below). B. Record review 1. Amoxicillin 500 milligrams (mg) twice daily for five days. A review of the 3/31/24 hospital discharge summary revealed the resident was prescribed Amoxicillin 500 mg twice daily for five days for treatment of a UTI. The April 2024 CPO included the following physician's order: Amoxicillin capsule 500 mg to treat a UTI, take one capsule by mouth two times a day for five days, ordered on 4/2/24. -The initial physician's order for Amoxicillin prescribed by the hospital physician upon the resident's discharge from the hospital on 3/31/24 was not in the April 2024 CPO. -Due to the antibiotics order not being entered into the physician's orders when Resident #18 admitted to the facility, the resident did not receive two doses of the Amoxicillin on 4/1/24. -There was no documentation in the electronic medical record (EMR) indicating the physician was notified the resident had missed two doses of the Amoxicillin on 4/1/24. -The facility's physician evaluated Resident #18 on 4/2/24, noted the Amoxicillin order was not in the resident's physician's orders and reordered the Amoxicillin as initially prescribed. -Despite the physician reordering the Amoxicillin on 4/2/24, a review of the resident's EMR revealed the resident was not administered the Amoxicillin 500 mg capsule two times a day on 4/2/24 or 4/3/24 and one dose of the medication on 4/4/24 because the medication was unavailable or on order. -There was no documentation in the EMR indicating the physician was notified that the resident had missed five doses of the Amoxicillin on 4/2/24, 4/3/24 and 4/4/24. -Between 4/1/24 and 4/4/24, Resident #18 missed seven doses of the Amoxicillin which had initially been ordered on 3/31/24 upon the resident's discharge from the hospital. 2. Umeclidinium/Vilanterol (inhaler used to treat COPD) 62.5 mcg (micrograms)-25 mcg/inh (inhalation). Take one puff orally once a day to prevent bronchospasm (sudden constriction of the lungs) caused by COPD. The April 2024 CPO included the following physician's order: Umeclidinium/Vilanterol 62.5 mcg-25 mcg/inh. Take one puff orally once a day to prevent bronchospasm (sudden constriction of the lungs) caused by COPD, ordered 4/1/24. -A review of the resident's EMR revealed the resident was not administered the Umeclidinium/Vilanterol medication on 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24, 4/8/24 and 4/10/24 because it was not available. -There was no documentation indicating the physician was notified that the resident missed the doses on 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24 and 4/8/24. The 4/6/24 nursing progress note documented the nurse followed-up with the pharmacist. The progress note documented the medication exceeded the facility's maximum price allowance for medication and the DON needed to approve the medication prior to filling the prescription. -A review of the resident's EMR did not indicate follow-up with the DON was completed to obtain approval for the medication. III. Resident #6 A. Resident status Resident #6, age 74, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included bipolar disorder, anxiety, muscle weakness, hypertension (high blood pressure) and malnutrition. The 4/18/24 MDS assessment documented Resident #6 was cognitively intact with a BIMS score of 15 out of 15. She required substantial/maximal assistance with bathing and partial/moderate assistance with toileting and dressing. She needed set-up assistance for eating and hygiene. B. Resident interview Resident #6 was interviewed on 5/6/24 at 12:15 p.m. Resident #6 said she used the nasal spray medication at night because it relieved her respiratory symptoms to help her sleep. She said when she did not have the medication, she felt miserable. Resident #6 said she had asked the staff about why the nasal spray was missing multiple times and never received a helpful response from the staff. She said she was told the medication had been ordered or had not arrived from the pharmacy. C. Record review The May 2024 medication orders included: -Fluticasone 50 mcg/act nasal suspension spray (medication used to control symptoms of nasal congestion, runny nose, sneezing and itching), two sprays in each nostril at bedtime for rhinitis (runny nose), ordered 4/12/24. -A review of the resident's EMR revealed the resident was not administered the Fluticasone 50 mcg/act nasal suspension spray on 4/12/24, 4/13/24, 4/14/24, 4/17/24, 4/18/24, 4/19/24, 4/21/24, 4/22/24, 4/24/22, 4/25/24, 4/26/24, and 5/2/24 because the medication was not available. The resident refused the medication on 5/1/24. The 4/16/24 nursing progress note documented the medication was unavailable because it was on order from the pharmacy. The 4/20/24 nursing progress note documented the medication was unavailable because it was on order from the pharmacy. -There was no documentation indicating the physician was notified the medication was not administered. -There was no documentation indicating the pharmacy had been contacted to determine when the medication would be delivered to the facility. IV. Resident #188 A. Resident status Resident #188, age greater than 65, was admitted on [DATE], discharged to the hospital on 4/24/24 and readmitted to the facility on [DATE]. According to the May 2024 CPO,diagnoses included Alzheimer's dementia, stroke, non-Hodgkin's lymphoma (cancer), aphasia (loss of ability to understand or express speech) and cognitive communication deficit. The 4/24/24 MDS assessment documented Resident #188 had severe cognitive impairment with a BIMS score of four out of 15. She required partial/moderate assistance with bathing, toileting, dressing and transfers. She needed assistance with bed mobility, eating, and hygiene. B. Record review The April 2024 CPO documented the following physician's order: Hydrocodone-Acetaminophen (Norco) 5-325 mg give one tablet by mouth three times a day, ordered 4/26/24. The 4/26/24 nursing progress note documented the resident did not receive the 8:00 p.m. dose of the Hydrocodone-Acetaminophen tablet because the medication was not available. -A review of the resident's EMR did not reveal the physician was notified that the resident had missed the 8:00 p.m. doses of the Hydrocodone-Acetaminophen tablet. The 4/27/24 nursing progress note documented that all three doses of pain relief medication were not administered that day because the medication was not available. The note documented the medication had been ordered. -A review of the resident's EMR did not reveal the physician was notified that the resident missed all three doses of the Hydrocodone-Acetaminophen tablet. The 4/28/24 nursing progress note documented that all three doses of the pain relief medication were not administered that day because the medication was not available. The note documented the medication had been ordered. -A review of the resident's EMR did not reveal the physician was notified that the resident missed the three doses of the Hydrocodone-Acetaminophen. V. Staff interviews Registered nurse (RN) #2 was interviewed on 5/2/24 at 1:12 p.m. RN #2 said the admitting nurse was responsible for verifying and entering the physician's orders upon admission into the resident's EMR. RN #2 said after the orders were entered, the orders were automatically sent to the pharmacy electronically. She said medications were delivered to the facility the next time the pharmacy delivered medications to the facility. RN #2 said the pharmacy delivered medications twice a day to the facility. RN #2 said medications for a newly admitted resident were sometimes not included with the next medication delivery. She said sometimes it took the pharmacy more time to fill new prescriptions before the next delivery was sent out. RN #2 said the facility had an automated medication dispensing machine which stored several medications for emergency use. She said when the pharmacy did not deliver medications on time, a nurse could obtain in-stock medications from the dispensing machine while they waited for the pharmacy delivery. RN #2 said urgent medications, such as antibiotics, blood pressure, and pain medications, were usually in the dispensing machine. She said some medicines required pharmacy authorization for the nurse to access the medications. RN #2 said she had worked at the facility for approximately 18 months and received education on medication ordering from the MDS nurse and other coworkers. She said she did not recall other education on medication ordering and follow-up. She said several months ago, during a staff meeting, a co-worker nurse raised concerns about late/missing medication deliveries from the pharmacy. RN #2 said she understood when medications had not been received after the first or second pharmacy delivery, the nurse should call the pharmacy to follow-up on the order and delivery status. She said the nurse should notify the physician about medication delays and missing medication doses. RN #2 said it was important to notify the physician of a missing or late medication so the physician could consider a substitute medication or change treatments. RN #2 said if the physician was not informed about medication delays, the resident could experience adverse outcomes like declining health or delayed healing. RN #2 said if there was a delay in an antibiotic administration, a resident could experience worsening of an infection. RN #2 said there was a shift report twice daily and nurses discussed medication concerns that needed follow-up. RN #2 said when residents were administered antibiotics, nurses needed to monitor their responses to medication, especially when antibiotics had been administered. She said it was essential to assess allergic reactions, monitor vital signs, focus on the infectious process and consider if the resident tolerated the medication. RN #2 said the assessments were documented in the resident's EMR when they were completed. RN #2 said medication delays could contribute to negative outcomes such as withdrawal, prolonged discomfort and delayed healing. The DON was interviewed on 5/2/24 at 1:43 p.m. The DON said when medications were unavailable, the nurse was prompted to enter a progress note to document the information. The DON said the nurses' progress notes populated to the 24-hour report and she and/or the assistant director of nursing (ADON) reviewed the report daily. The DON said when the ADON or herself reviewed the 24-hour report they were alerted when medications were unavailable for administration. The DON said the nurse progress notes were overlooked on the 24-hour report for Residents #18, #6 and #188. The DON said when she noted medications were missed she called the pharmacy to attempt to expedite medication delivery when necessary. The DON said each medication delay would have a different reason, so the delay's causes varied. The DON said if the first dose of a medication was unavailable, the nurses needed to utilize the dispensing machine. She said the machine included just about every medication, so missed or late doses should not happen. The DON said the facility had a maximum price watch budget which meant they needed to be careful when high cost medications were ordered. However, the DON said she was not notified of Resident #18's high cost inhaler and she was unaware of the medication delays and missed medication doses for Residents #18, #6 and #188. The DON said nurses received education on medication ordering and follow-up from co-workers when they were hired. The DON said the pharmacy had provided ordering information handouts and were available at the nurse's desk at all times. The DON said she had not provided education on medication ordering and follow-up when medications were unavailable. She said the nurses learned the medication ordering process during orientation and should ask a coworker or a nurse leader for assistance.

Based on observations, record review and interviews, the facility failed to ensure a resident who received respiratory care and services that is in accordance with professional standards of practice for one (#17) of one resident reviewed for oxygen therapy out of 23 sample residents. Specifically, the facility failed to ensure the physician's order for oxygen use was clarified to include when Resident #17 was to use her supplemental oxygen. Findings include: I. Policy and procedure The Oxygen Administration policy, revised October 2010, was received by the director of nursing (DON) on 5/6/24 at 5:38 p.m. read in pertinent: The purpose of this procedure is to provide guidelines for [NAME] oxygen administration. Preperation: verify that there is a physician's order for this procedure. Review the physician's order's or facility protocol for oxygen administration; and, review the resident's care plan to assess for any special needs of the resident. Assessments:before administering oxygen, and while the resident is receiving oxygen therapy assess for the following:vital signs. Documentation:after completing the oxygen setup or adjustment, the following information should be recorded in the resident's chart:the frequency and duration of the treatment; and,the reason for the PRN administration. A. Resident status Resident #17, age 67, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disorder (COPD) (group of diseases causing airflow blockage and breathing-related problems). The 4/1/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required extensive assistance of two staff members for transferring and toileting and partial assistance with personal hygiene. The 4/1/24 assessment indicated Resident #17 was utilizing oxygen therapy and did not specify if the resident was using the oxygen continuously or intermittently. B. Resident interview and observation Resident #17 was interviewed on 5/1/24 at 11:09 a.m. Resident #17 was lying in bed watching television. There was an oxygen concentrator in her room turned on and set at 2 liters per minute (LPM). Resident #17 said she only wore oxygen at night. Resident #17 was interviewed again on 5/6/24 at 1:30 p.m. Resident #17 was sitting up in her bed eating lunch and watching television. There was an oxygen concentrator in the room in the off position. Resident #17 said she only wore oxygen at night because she had COPD. C. Record review The May 2024 CPO revealed an order for oxygen, revised on 3/27/24, for oxygen at 2 LPM via nasal cannula. -However, the physician's order did not indicate if Resident #17 needed to wear the oxygen continuously or intermittently. An outside provider company packet with a date range of 3/26/24 to 4/4/24 indicated Resident #17 was dependent on oxygen for both continuous and nocturnal use. The oxygen care plan, initiated on 4/10/24, revealed Resident #17 utilized oxygen therapy for a diagnosis of COPD. It indicated Resident #17 would have no signs or symptoms of poor oxygen absorption through the review date. Pertinent interventions included giving medications as ordered by the physician, monitoring and documenting side effects and effectiveness or medication and the oxygen setting was 2 LPM continuously. C. Staff interviews Registered nurse (RN) #1 was interviewed on 5/6/24 at 1:35 p.m. RN #1 said Resident #17 had a physician's order for supplemental oxygen. She said the physician's order did not include documentation that the oxygen was being used. RN #1 said she was unaware if Resident #17 wore oxygen continuously and would need to clarify the order with the physician prior to updating it. The DON was interviewed on 5/6/24 at 2:00 p.m. The DON said the nurse who put the physician's order for oxygen in the medical record did not indicate if it was for continuous use or just at night. The DON said she was unsure if Resident #17 was using 2 LPM of oxygen continuously. The DON said RN #1 was in the process of clarifying the order with the physician. D. Facility follow up A 5/6/24 progress note (during the survey) indicated the facility had contacted the physician for Resident #17 and the order was clarified for Resident #17 to supplemental oxygen during hours of sleep (HS) and as needed (PRN). The May 2024 CPO revealed the resident had a physician order to receive 2 LPM per nasal cannula at bedtime and as needed, ordered 5/6/24 (during the survey).

Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal vaccines for one (#12) of five residents reviewed for vaccinations of 23 sample residents. Specifically, the facility failed to ensure Resident #12 was offered the pneumococcal vaccine. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations website, revised 9/21/23, was retrieved on 5/7/24 from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html. It read in pertinent part, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older. II. Facility policy The Pneumococcal Vaccine policy, revised March 2022, was provided by the director of nursing (DON) on 5/6/24 at 1:21 p.m. It read in pertinent part, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series unless medically contraindicated. Assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission. Residents have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record. For each resident who received the vaccination, the appropriate information is documented in the resident's medical record. III. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included generalized arthritis and muscle weakness. The 2/10/24 minimum data set (MDS) documented Resident #12 had no cognitive impairment, as evidenced by a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated the pneumococcal vaccine status had not been assessed. B. Record review -A review of the resident's electronic medical record (EMR) on 5/2/24 revealed the resident had not been offered the pneumococcal vaccine since she was admitted to the facility on [DATE]. The EMR did not indicate if the resident had received any pneumococcal vaccinations prior to her admission to the facility. IV. Staff interviews The assistant director of nursing (ADON) and the DON were interviewed together on 5/6/24 at 10:00 a.m. They said they shared the responsibility of keeping track of resident vaccination status. The ADON said when residents were admitted to the facility, she or the DON reviewed the medical records to gather the resident's vaccination history.The ADON said if a resident had not received the pneumococcal vaccine, the facility offered the vaccine upon admission. The ADON said the information was documented in the EMR if the facility administered a vaccine. The ADON said if the resident had previously received vaccines, the vaccine documentation was scanned into the EMR and filed under the miscellaneous tab. The ADON said the facility did not otherwise track and document resident immunization information. The ADON said she was unable to find documentation which indicated Resident #12 was educated, offered, received or refused the pneumococcal vaccine upon her admission on 11/3/23. The ADON said the DON and herself missed reviewing Resident #12's immunization history upon admission to determine if she was due for a pneumococcal vaccination. The DON said the facility should follow state and CDC guidelines for offering vaccines and documenting the vaccination status of each resident in their EMR

Based on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#82) of two residents reviewed for falls out of 14 sample residents. The facility failed to timely and appropriately implement interventions including assistance with all activities of daily living as documented in her 1/10/23 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light due to severely impaired cognition. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent falls for Resident #82, with a fall that resulted in injuries that required transfer to a hospital. Due to the facility's failures, lack of appropriate supervision and effective interventions resulted in three falls within three days since the admission. Fall on 1/10/23 resulted in major injury with bilateral nasal fracture and nasal cavity hemorrhages and required hospitalization for eight days. Findings include: I. Facility policy The Falls -Clinical Protocol policy, revised March 2018, was provided by the director of nursing on 1/25/23 at 1:30 p.m., read in part: The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and the caregiver or family about a history of falling. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. II. Resident #82 A. Resident status Resident #82, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 clinical physician orders (CPO), diagnoses included history of falling, vascular dementia, depression, cerebrovascular disease (stroke) and fracture of nasal bones. The 1/10/23 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired. Wandering behavior was noted in one to three days of the seven day assessment period. The resident required extensive assistance of one person with bed mobility, supervision with transfers, extensive assistance with dressing, toilet use and personal hygiene. The resident was independent with eating. Section J indicated the resident had one fall since admission with major injury. The resident received an antipsychotic medication and antibiotic. B. Resident observation and interviews Resident #82 was observed on 1/23/23 at 12:17 p.m. in the dining room, eating her lunch. She had fading bluish and yellowish bruises around her nose and on the forehead. A frequent visitor with knowledge of the facility was interviewed on 1/23/23 at 11:00 a.m. The frequent visitor said she observed a female resident in the dining room during supper on 1/10/23. The resident was leaning to one side in her wheelchair for more than 20 minutes. The frequent visitor said at least four staff walked by her table and no staff repositioned this resident. The frequent visitor said at one moment she had heard other residents calling for staff, yelling loudly and saw the female resident on the floor in a puddle of blood around her head. The frequent visitor said at that moment there were no staff in the dining room; she went to the nurses' office and asked the nurse to come to the dining room. Resident #82's granddaughter was interviewed on 1/24/23 at 1:00 p.m. She said her grandmother had fallen at home prior to her hospitalization and was at high risk for falls due to her declining physically and mentally. She said the facility was aware of her grandmother's fall risk and that was also the reason the family decided to put a camera in her room and someone from the family was watching her in case she had fallen with no staff around, the family member would call the facility. She said when the first fall happened on 1/8/23, her father called the facility staff to get her grandmother off the floor. The resident's daughter was interviewed on 1/24/23 at 4:25 p.m. She said upon her mother's initial admission to the facility on [DATE] she repeatedly told all staff, nurses and CNAs (certified nurse aide) that her mother was very high risk for falls. She said that was the reason we placed the camera in her room so we can watch her and in case she tried to get out of bed we could talk to her or call the facility. The daughter said that happened on 1/8/23. She said her husband was watching her mother getting out of the wheelchair and falling. She said there were no staff coming to the room so he dialed the facility's phone number and asked the nurse to go to her mother's room and pick her off the floor. She said the staff was supposed to check on her mother frequently and help her to lie down after meals. She said if the staff paid more attention to her mother, she would not have had a fall with injury on 1/10/23 and would not have had to be hospitalized for eight days. C. Record review The comprehensive care plan revealed the following: - (Resident #82) is at risk for falls. H/O (history of) falls (prior to admission) PTA. Fall Risk evaluation done with admission, score of 20 (high risk for falls). Risk factors include use of psychoactive RX (medication), deconditioning & impaired cognition. The resident experienced a fall on 1/8/23 with attempted self-transfer. Staff are to offer to lay the resident down after meals. Experienced 2 (two) falls 1/10/23. The first fall was in her room when she was attempting to get out of bed. The second fall was from the WC (wheelchair) in the dining room. The second fall resulted in a trip to the ER (emergency room ), (and the resident was) subsequently admitted . Hospital staff reported (the resident's) 'nose fractured. When making rounds, verify (the resident's ) position in bed or chair, reposition as needed. Staff to make frequent rounds to check for unmet needs. (dated 1/12/23). On 1/20/23 the following was added to the care plan: Staff to make frequent rounds to check for unmet needs. readmitted [DATE], falls risk score of 22. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Bed in a lowered position when in bed. Encourage the resident to wear appropriate footwear when transferring, toileting, ambulating. Extensive assistance with bed mobility & transfers. Gait belt as needed for transfers. (1/9/23). Staff to make frequent rounds to check for unmet needs. When making rounds, verify position in bed or chair, reposition as needed (1/12/23). -(Resident #82) has an alteration in musculoskeletal status; after the fall with nasal fractures (dated 1/19/23) -The facility failed to monitor the effectiveness of Resident #82's care planned interventions and implement effective interventions. The 1/8/23 Fall Risk Data Collection revealed the resident had a history of falls, her balance was impaired and she was able to stabilize with physical assistance. Score was 20 (high risk for falls). The 1/10/23 Fall Risk Data Collection score was 22 (high risk for falls). D. Nursing notes: On 1/8/23 a nurse documented: Pt (patient) was in the main area with nursing staff at change of shift. At approximately 6:30 (a.m.) she wheeled herself into her room and attempted to transfer to the bed unaided. Family called the nurse's station at 6:30 (a.m.) to report that the patient had fallen. Staff found the patient sitting on the floor with legs outstretched and her arms behind her. Pt reported pain in the lower back. Follow up phone call was made with the family who reported that she slipped when trying to transfer to the bed and landed on her buttocks. Neuro (neurological) checks initiated, VS (vital signs) taken, pain assessed and pt (patient) placed back in wheelchair and within sight of nursing staff. Pt (patient) given Tylenol for the pain. Provider notified. On 1/9/23 a nurse documented: Patient admitted for skilled services with dx (diagnoses) of: atherosclerotic heart disease of native coronary artery without angina pectoris. She has two surgical incisions to left groin, on antibiotics due to infection in one of the sites. Patient has hx (history) of dementia and is confused. She has a wanderguard in place and the family provided security cameras with sound in the patient's room. Patient has non-skid socks on, falls mats in place, bed in low position and a call light within reach. She has poor safety awareness. Pleasant and cooperative with cares. The patient can be continent at times, incontinence care being managed by staff. PT/OT (physical therapy/occupational therapy) as ordered. Call light within reach, will monitor. On 1/10/23 SBAR revealed: Altered mental status Bleeding (other than GI (gastrointestinal)) Falls Fever Trauma (fall related or other) . Nursing observations, evaluation, and recommendations are: Resident #82 fell at 1620 (4:20 p.m.), this writer and (name) RN (registered nurse) assessed the resident. Resident stated 'I was trying to get out of bed and I fell .' No injury noted. Neuro (neurological assessment) WNL (within normal limits). Neuros started. Resident was in chair with nurse and was talking with nurse. Resident was taken to the dining room. Resident was noted by another family member leaning left side. Then resident suddenly fell forward and hit her face at 1740 (5:40 p.m.). Resident (#82) started bleeding from the nose. (name) LPN (licensed practical nurse) put pressure on residents nose per RN request. RN called 911.' On 1/10/23 at 6:54 p.m. a nurse documented: Resident after being evaluated by paramedics was taken to (name) Hospital. Daughter and MD (physician) were notified. On 1/23/23 a nurse documented: Patient readmitted for skilled services s/p (status post) fall with nasal fx (fracture). Patient has hx (history) of dementia and is confused and forgetful. Family provided security cameras with sound in the patient's room. Patient has non-skid socks on, falls mats in place, bed in low position and the call light within reach. She has poor safety awareness, frequently reminded to use call light for assistance. Pleasant and cooperative with cares, does refuse at times, usually in the evening/bedtime but can be easily redirected. The patient was mostly incontinent, being managed by staff. PT/OT as ordered. Call light within reach, will monitor. On 1/24/23 a nurse documented: Patient son in law called the nurse's station during shift change and stated that the patient had pressed her call light six times, that she needed to use the bathroom and no one was coming to help her. (This was most likely observed through their security cameras that the family had set up in the patient's room.) This nurse went directly to the patient's room and her call light was not on and two CNAs were in the patient's room asking her if she needed to use the toilet to which she responded, 'No, I want to go to bed.' Call light was within reach, patient reminded to use call light for assistance but quickly forgets and has poor safety awareness. Bed in low position, fall mats in place. Will monitor. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/25/23 at 11:30 a.m. CNA #1 said the nursing staff could find all of the assigned resident information, including risk for falls, on the Kardex. The DON was interviewed on 1/25/23 at 12:25 p.m. The DON said Resident #82 had three falls in the facility. After the fall on 1/8/23 at approximately 6:30 a.m. the facility implemented frequent checks. She said usually the staff were to check on the residents every two hours, however she expected nursing staff would check on residents who are at risk for falls more often. She said fall mats were placed on each side of the resident's bed to prevent injuries if the resident fell from the bed. She said the resident had a fall on 1/10/23 at 4:40 p.m. in her room with no injuries, and the staff brought the resident to the common area, lobby, so she would be close to a nurse. She said there was no investigation completed after this fall because an hour later the resident had fallen again, in the dining room. She said the dietary staff was present in the dining room and witnessed the resident's fall. She said she was not aware the resident was left in the dining room without nursing staff present. The DON said she was not aware the frequent visitor had to find a nurse when the resident was on the floor. She said she would provide extensive training with all staff in the facility on falls prevention within the next few days. CNA #2 who was assigned on the unit where Resident #82 resided, was interviewed on 1/25/23 at 12:55 p.m. She said she was not informed Resident #82 was a high risk for falls. She said she did not work with this resident before, however she concluded the resident may be at risk for falls because of the camera in her room. She said sometimes there was a lack of communication, sharing information about residents between nursing staff during shift changes. She said the standard was to check on residents every two hours for repositioning or provide incontinence care. She said if she was aware of a resident's risk for falls, she would try to check on that resident every 15 minutes. CNA #3 was interviewed on 1/25/23 at 2:46 p.m. She said the CNAs could check all of the information about assigned residents on their tablet, in the electronic charting system, under care plan in Kardex ( a condensed version of the resident care plan). She opened Resident #82's Kardex and read the CNAs should check on the resident frequently. She said the Kardex did not specify how often. She said the staff checks on residents approximately every two hours, however for residents who were at a high risk for falls should be checked more frequently, every 15 minutes and the Kardex should specify that exact time. LPN #1 was interviewed on 1/25/23 at 3:05 p.m. She said she worked on 1/10/23 the afternoon shift. She said Resident #82 fell in her room before supper, was transferred to her wheelchair and she was taken to the dining room. She said she did not observe the resident leaning to one side during the meal. She said after the supper meal the frequent visitor called her to the dining room and said a female resident had fallen and was on the floor. She observed Resident #82 on the floor with her face down and in a puddle of blood. She said she called the RN and they were trying to stop the bleeding. She said the RN went to the nursing office and called for an ambulance and the operator told her not to move the resident. She said the ambulance arrived before 7:00 p.m. so the resident was on the floor, in the dining room, for approximately one hour. -The facility failed to provide staff education and increase resident's supervision to prevent falls.

Based on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for one of one medication and supply storage rooms. Specifically, the facility failed to discard expired medical supplies. Findings include: I. Facility policy The facility policy for storage of medical supplies was requested on [DATE]. The director of nursing (DON) stated the facility did not have a specific policy regarding storage of medical supplies and therefore referred to manufacturer recommendations. II. Observations Medication room [ROOM NUMBER] On [DATE] at 10:42 a.m., medication room [ROOM NUMBER] was observed with registered nurse (RN) #1. RN #1 verified that seven Corpak Enteral Y Extension sets each were labeled with the manufacturer expiration date of February 2021; 331 days prior. RN #1 verified the connector sets were expired and she removed the items from the medication and supply room. III. Interviews RN #1 was interviewed on [DATE] at 10:55 a.m. She stated the expired items were connectors for the enteral feeding tube system. The expired items were stored in the same basket and same shelf as the current enteral feeding tube supplies were stored. RN #1 stated the central supply technician was responsible for removing expired items from the medications and supply room. She stated the central supply technician had additional duties in the facility so it was possible some expired items were overlooked. The director of nursing (DON) was interviewed on [DATE] at 1:20 p.m. The DON stated the extension sets were used as an anti-free-flow device to prevent a possible free flow of formula incident. The DON stated expired medical supplies should be removed or separated from the new supply storage to prevent the expired items from being selected by nursing staff for use of resident care. The DON stated the facility had two residents currently receiving enteral feedings.

Based on record review and interviews, the facility the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one resident (#27) out of 14 sample residents. Specifically, the facility failed to: -Intervene when the resident had high blood pressure measurements; -Notify the physician when the prescribed blood pressure medication was not available and did and when the resident had elevated blood pressures. Findings include: I. Professional reference According to The American Heart Association published guideless, Healthy and unhealthy blood pressure ranges retrieved from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings on 1/26/23, blood pressure measurement mmHg and classifications are as follows: -normal: systolic less than 120 and diastolic less than 80 -elevated: systolic 120-129 and less than 80 -hypertension stage 1: 130-139 or 80-89 -hypertension stage 2: 140 or higher or 90 or higher -hypertensive crisis: higher than 180 and/or higher than 120. II. Facility policy The facility policy for Change in Condition was requested from the director of nursing (DON) on 1/25/23 at 1:15 p.m. and not received. III. Resident status Resident # 27, over the age of 65, was admitted on [DATE] and passed away at the facility on 1/8/23. According to the January 2023 computerized physician orders (CPO) the diagnoses included atrial fibrillation, acute and chronic congestive heart failure, hypertension, stage 3 kidney disease, and pulmonary hypertension. The 12/21/22 the (MDS) assessment coded the resident as cognitively intact with a score of 14 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. IV. Record review A. The January 2023 CPO directed antihypertensive medications -Carvedilol 25 mg two times a day for hypertension, start on 12/15/22; -Verapamil 180 mg one time a day for atrial fibrillation/ventricular rate control, start 12/15/22; -Bumetanide 1 mg one time a day for hypertension; hold for systolic blood pressure <90 (less than), start on 12/15/22. B. Nurse progress note and medication administration 12/30/22 Bumetanide, medicine unavailable; on order. The medication administration record was coded 05 which indicated hold/see nurse notes; 12/31/22 Bumetanide, hold until after delivered from pharmacy. The medication administration record was coded 05 which indicated hold/see nurse notes; 12/31/22 Verapamil, hold until delivered from pharmacy. The medication administration record was coded 05 which indicated hold/see nurse notes; 1/1/23 Carvedilol, pending prescription delivery. The medication administration record was coded 09 which indicated other/see nurse notes; 1/2/23 Carvedilol, medicine unavailable; on order. The medication administration record was coded 05 - hold/see nurse notes; 1/2/23 Bumetanide, on order. The medication administration record was coded 05 which indicated hold/see nurse notes; 1/2/23 Verapamil, medicine unavailable; on order. The medication administration record was coded 05 which indicated hold/see nurse notes; 1/2/23 Carvedilol, medication unavailable; on order. The medication administration record was coded 05 which indicated hold/see nurse notes; 1/3/23 Bumetanide, medicine unavailable; on order. The medication administration record was coded 05 which indicated hold/see nurse notes; 1/3/23 Verapamil, medicine unavailable; on order. The medication administration record was coded 05 which indicated hold/see nurse notes; 1/4/23 Bumetanide, medication unavailable, on order, will call pharmacy. The record did not include documentation of the call to pharmacy and pharmacy recommendations; 1/4/23 Verapamil, medication unavailable, on order. The medication administration record was coded 05 - hold/see nurse notes; 1/5/23 Bumetanide, hold until delivered from pharmacy. The medication administration record was coded 09 which indicated other/see nurse notes; 1/6/23 Verapamil, hold until delivered from pharmacy. The medication administration record was coded 06 which indicated other/see nurse notes; 1/6/23 Bumetanide, hold until delivered from pharmacy. The medication administration record was coded 06 which indicated other/see nurse notes. -There was no documentation in the resident's medical record that indicated the physician was notified the prescribed medications were not administered and that the resident had high blood pressure readings. The medical record also failed to show any interventions were implemented when the readings were high (see below). C. Blood pressure measurements 12/30/22 blood pressure 164/69; no documentation of reassessment, no documentation of physician notification or nursing interventions to lower the blood pressure; 12/31/22 bumetanide, hold until after delivered from pharmacy. The medication administration record was coded 05 - hold/see nurse notes; 1/2/23 blood pressure 174/107; no documentation of reassessment, no documentation of physician notification or nursing interventions to lower the blood pressure; 1/4/23 blood pressure at 6:00 a.m. was 144/120 and at 9:00 a.m. the blood pressure was 144/120; the reassessment indicated no change in the measurement occurred; there was no documentation of physician notification or nursing interventions for the hypertensive reading; 1/6/23 blood pressure 181/106 no documentation of reassessment, no documentation of physician notification or nursing interventions for the hypertensive reading; 1/7/23 blood pressure at 6:46 a.m. was 170/108 and at 9:34 a.m. the blood pressure was 170/108; the reassessment indicated no change in the measurement occurred; there was no documentation of physician notification or nursing interventions for the hypertensive reading; 1/8/23 blood pressure 181/90 at 6:32 a.m. and 181/90 at 9:22 a.m.; the reassessment indicated no improvement; no documentation of physician notification or nursing interventions for the hypertensive reading. -There was no documentation in the resident's medical record that indicates the physician was notified when the prescribed medications were not administered or available, and that the resident had high blood pressure readings. D. Care plan The care plan signed by the resident on 12/15/22 documented the resident had altered cardiovascular status from atrial fibrillation, congestive heart failure, hypertension, and coronary artery disease and the resident had a cardiac monitor implanted under her LF (left) breast, covered with a dressing. Interventions included: -administer medications as ordered by physician; -assess for chest pain during care; -monitor and document and report to physician any signs or symptoms of coronary artery disease: chest pain or pressure, especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in capillary refill, color/warm extremities; -monitor document and report to the physician changes in lung sounds on auscultation, edema and changes in weight; -monitor document report to physician and signs or symptoms of fatigue, weakness, cool pale clammy skin; -diuretic therapy related to congestive heart failure, hypertension. V. Interviews Registered nurse (RN) # 1 was interviewed on 1/25/23 at 1:10 p.m The RN stated the certified nursing aides (CNAs) took the vital signs of all the residents at the beginning of each shift. The CNAs record the vital signs on a sheet of paper and when finished, the CNA hands the vital signs to the nurse. The nurse would then enter the vital signs into the resident's record. The RN said the process allowed the nurse to identify any abnormal readings which alerted the nurse to take action. The nurse stated when a resident had high blood pressure, the nurse should take a repeat measurement to verify the result. If the reading remained high, the nurse would notify the physician and implement any interventions ordered. The nurse stated when medications were not available, the nurse should verify the medication was ordered and try to determine when the medication was going to be delivered. She also said the physician should be notified when important medications were not available to be administered as ordered. The nurse said she was aware the facility had issues with the pharmacy and was in the process of changing pharmacy providers. The RN stated she would notify the physician of a high blood pressure when the measurement exceeded 140/90. She was unsure if that parameter was included in a facility policy and stated that as a nurse she knew it was high and would know to call the physician. The director of nursing (DON) was interviewed on 1/26/23 at 8:30 a.m. The DON reviewed the resident's medical record and she was unable to find additional documentation to indicate the physician was aware the resident was not receiving the medications as ordered. The DON stated it was the expectation for the assigned nurse to notify the physician and to intervene when a resident had high blood pressure measurements. The DON did not recall if she had been notified by the nursing staff that the resident's medications were unavailable on the specified dates.

Based on observations, record review and interviews, the facility failed to safely monitor and administer enteral nutrition, the resident's sole source of nutrition to prevent possible complications of enteral feeding including aspiration pneumonia for one (#12) of one out of 14 sample residents. Specifically, staff failed to label enteral feeding formula and supplies, and failed to ensure the resident was properly positioned with her head elevated above the level of feeding. Resident with a diminished level of consciousness, improper positioning of the resident during administration of the feeding. Findings include: I. Professional reference According to Potter, P.A., Perry, A.G., et.al. Fundamentals of Nursing - e-book, eleventh ed., 2021, pp. ,d+[DATE]. (accessed on [DATE]) Implementation and safety guidelines of enteral feeding: -Place resident in high-Fowler's position or elevate the head of bed at least 30 degrees (preferably 45 degrees). For patients to remain supine, place in reverse Trendelenburg's position (tilting the entire bed with feet towards the floor); -Label enteral feeding equipment with resident name, room number, formula name, rate, and date and time of initiation, and nurse initials. -Position the patient upright or elevate the head of the bed a minimum of 30 (preferably 45 degrees) unless medically contraindicated; -Maximum hang time for formula is 8 hours in an open system and 24 hours in a closed, ready-to hang system, if it remains closed. There is an increased risk of bacterial growth in feedings that exceed the recommended hang time. II. Facility policy The Enteral Tube Feeding via Continuous Pump policy, revised in 2018, was provided by the director of nursing (DON) on [DATE] at 2:15 pm. In read in pertinent part, Position the head of the bed at ,d+[DATE] degrees (semi-Fowlers position) for feeding, unless medically contraindicated. Initiate the feeding; on the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. III. Resident status Resident #12, over the age of 65, was admitted on [DATE]. She was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. According to the [DATE] computerized physician orders (CPO) the diagnoses included hypertension, kidney failure, Alzheimer's dementia, history of a stroke and failure to thrive. The [DATE] minimum data set (MDS) assessment coded the resident with a severe cognitive impact with a score of one of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance of two staff members for bed mobility, dressing, toileting, and personal hygiene. IV. Observations On [DATE] at 9:40 a.m., the resident was observed sleeping in her bed. She was on her back, with the head of her bed elevated less than 30 degrees. The enteral tube feeding was being administered by a Kangaroo feeding pump. There were two syringes used for medication administration on the resident's bed side table. The syringes were dated [DATE], which was 18 days prior. At 2:20 p.m., the resident was observed in the same position and the enteral feeding continued. On [DATE] at 8:40 a.m., the resident was observed in her bed. She was on her back. The head of the bed was in a position between 30 and 45 degrees. However, the resident had slouched downward in her bed and in a position where her head was not above the level of the feeding tube insertion site. The formula was labeled with the resident's name, and date/time the feeding was initiated. The enteral feeding administration tube set was not labeled with a date it was opened. There was no piston syringe in her room on [DATE]. V. Record review A. The [DATE] computerized physician's orders (CPO) directed: -enteral feeding 1.5 calorie at 90 ml/hour, check residual every flush, call MD (medical doctor) if residual >(greater than) 200 ml. -replace piston syringe once daily -position head of the bed ,d+[DATE] degrees while feeding B. The resident's care plan dated [DATE] included a focus for the tube feeding for her failure to thrive. The care plan focus for feeding included three goals: -to remain free of side effects or complications related to tube feeding; -to maintain nutritional and hydration status and weight stable; -no signs or symptoms of malnutrition or dehydration, and the resident to remain free of aspiration. Interventions included: -monitor/document/report to physician aspiration, fever, shortness of breath, tube dislodged, infection at tube site, self extubation, tube dysfunctions or malfunction, tenderness, constipation, or fecal impaction, diarrhea, nausea/vomiting, dehydration. VI. Interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 2:20 p.m. She observed and stated the resident's formula bag was not labeled with the resident's name, date or time the administration began, or the type of formula and flow rate. She stated she would look in the trash can for the empty formula container to know what formula was to be used for the enteral feeding. She stated the formula bag should be labeled with specific feeding information when the feeding administration began to help monitor the feeding and prevent complications with expired formula. The LPN verified the resident's CPO and labeled the formula. LPN #1 observed and stated the resident was not in a position of ,d+[DATE] degrees during her feeding. The resident's bed was raised to a level ,d+[DATE] degrees. The LPN stated there was not a measuring system to determine the angle of position for the resident's bed and a nurse could look at the bed and determine if it positioned properly for the resident. The LPN observed and noted the two piston syringes on the residents bed-side table and were hand-dated [DATE] (see observation [DATE]). She stated a new syringe was to be used every 24 hours and it was the responsibility of the night shift nurse to place a new syringe in the resident's room. She stated that even though it was day shift, she had the access to new piston syringes and would replace the outdated syringes. The LPN discarded the outdated syringes. The director of nursing (DON) was interviewed on [DATE] at 1:30 p.m. The DON said nurses received education regarding the administration and monitoring of enteral feedings when hired and as needed. The DON stated nurses should label enteral feed supplies when the supplies were opened. She stated the enteral feeding tubes, bag system which hold the formula and water, and piston syringe should be replaced every 24 hours. The DON stated when a resident received an enteral feed, the bed should be positioned at ,d+[DATE] degrees. She stated a nurse was able to determine from looking at the bed if the position was high enough and there was not a reference available to measure more accurately the bed position. The DON stated when the bed was in the correct position, the staff should ensure the resident was positioned correctly in the bed. She stated if a resident slid down in bed, there would be a risk for formula aspiration. The DON stated she would include the correct positioning and verification with nursing staff education.

Based on interviews and record review, the facility failed to provide choices for five (#1, #2, #3, #4 and #6) of six residents reviewed out of six sample residents. Specifically, the facility failed to provide showers/baths choices were offered and honored for residents (#1, #2, #3, #4 and #6) based on the resident's preference and care plan. Findings include: I. Resident #1 A. Resident status Resident #1, age 91, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/29/22 minimum data set (MDS) assessment, Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He needed extensive physical assistance with bathing. B. Resident interview Resident #1 was interviewed on 8/9/22 at 3:30 p.m. He said he did not always get his showers when scheduled. He said he was scheduled to have two showers a week, however he usually received one shower a week. He said he would prefer to have at least two showers a week. C. Record review The resident's ADL care plan, revised on 7/22/22, identified the resident preferred showers twice a week on Tuesdays and Thursdays and he needed extensive physical assistance with bathing. The resident's bath records were reviewed for the past 10 weeks from 6/1/22 to 8/10/22 and revealed the resident received a shower or bed bath 10 times out of the possible 20 showers scheduled. He received three showers out of the eight scheduled for the past 30 days from 7/11/22 to 8/10/22. II. Resident #2 A. Resident status Resident #2, age 88, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/29/22 minimum data set (MDS) assessment, Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She needed extensive physical assistance with bathing. B. Resident interview Resident #2 was interviewed on 8/9/22 at 3:30 p.m. She said she had gone for almost two weeks at a time without a shower. She said she was scheduled to receive two showers a week, however she did not always receive two showers and sometimes would only get one shower or a bed bath a week. She said she preferred to have at least two showers a week. C. Record review The resident's ADL care plan, revised on 7/22/22, identified the resident preferred showers twice a week on Wednesdays and Saturdays and she needed extensive physical assistance with bathing. The resident's bath records were reviewed for the past 10 weeks from 6/1/22 to 8/10/22 and revealed the resident received a shower or bed bath 11 times out of the possible 20 showers scheduled. She received six showers out of the eight scheduled for the past 30 days from 7/11/22 to 8/10/22. III. Resident #3 A. Resident status Resident #3, age 73, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 5/12/22 minimum data set (MDS) assessment, Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She needed extensive physical assistance with bathing. B. Resident interview Resident #3 was interviewed on 8/9/22 at 3:10 p.m. She said she preferred to have a shower twice a week and she did not always get two showers a week. She said she had gone for two weeks without getting one shower in the past. She said she preferred to have two showers a week. C. Record review The resident's ADL care plan, revised on 6/02/22, identified the resident preferred showers twice a week on Tuesdays and Fridays and she needed extensive physical assistance with bathing. The resident's bath records were reviewed for the past 10 weeks from 6/1/22 to 8/10/22 and revealed the resident received a shower or bed bath 9 times out of the possible 20 showers scheduled. She received four showers out of the eight scheduled for the past30 days from 7/11/22 to 8/10/22. IV. Resident #4 A. Resident status Resident #4, age 59, was admitted on [DATE]. According to August 2022 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/29/22 MDS assessment revealed the resident's cognition was intact with a BIMS score of 15 out of 15. No rejection of care was noted. She required extensive assistance of two staff with bed mobility, transfers and toilet use, one person extensive assistance with dressing and personal hygiene, and eating with supervision. She was totally dependent on staff with bathing. She was occasionally incontinent of urine and bowel. B. Resident interview Resident #4 was interviewed on 8/10/22 at 9:08 a.m. She said her preference was to have at least two showers a week, however the staff missed her shower days sometimes and occasionally did not come and offer her shower at all. C. Record review The comprehensive care plan revealed Resident #4 has MS ([CONDITION(S)]) with RUE & LLE (right upper extremity and left lower extremity) weakness. Date initiated 4/2/22. Interventions included: Assist with ADLs (activities of daily living) as needed, extensive assist 2 (two) staff. (Resident) has an ADL (activities of daily living) self-care performance deficit. admitted from ALF (assisted living facility) for increased care needs. DX (diagnosis) of MS ([CONDITION(S)]), uses electric WC (wheelchair). Date initiated: 4/2/22. Interventions included: Extensive assist with showers Tuesday & Friday day shift. Review of Resident #4's electronic medical record under Tasks/Showers revealed the resident did not receive showers/baths in the past 70 days. On 8/10/22 the director of nursing (DON) provided a Bath Look Back records that documented showers/baths provided to the resident. According to the record Resident #4 received eight showers and three bed baths from 6/1/22 to 8/10/22 out of 20 showers scheduled. V. Resident #6 A. Resident status Resident #6, age 92, was admitted on [DATE]. According to August 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/14/22 MDS assessment revealed the resident usually made self-understood and usually was able to understand others. Her cognition was moderately impaired with a BIMS score of 10 out of 15. No rejection of care was noted. She required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, and supervision with eating. She was totally dependent on staff with bathing. B. Family and resident interviews The resident's family member was interviewed on 8/10/22 at 9:30 a.m. She said she visits the resident daily to help her with morning grooming and hygiene. She said she also assisted her with eating. She said Resident #6 was not receiving her showers as it was initially planned, two times a week. She said she was washing the resident as often as she could, however that was not an acceptable substitution for showers. She said the showers would get the resident out of bed at least a couple times per week for a couple hours. Resident #6 was interviewed on 8/10/22 at 10:55 a.m. She said she would like to have a shower twice a week, however she was not getting as many as she should. C. Record review The comprehensive care plan revealed Resident #6 has an ADL (activities of daily living) self-care performance deficit. Date initiated: 7/8/22. Interventions included: extensive assist with bathing (Monday & Thursday day shift). On 7/10/22 a nurse documented: Resident is here for skilled services. Dx (diagnosis) failure to thrive. She is A/O x1 (alert and oriented to self). Frequent checks by staff as resident does not use call light. She requires assist with adl's (activities of daily living). Appetite poor. Fluids encourage. Incontinent of B/B (bladder and bowel). Review of Resident #6's medical record under Tasks/Showers revealed the resident required total assistance and received showers on the following days: 7/14/22, 7/18/22, 7/21/22, 8/1/22 and 8/4/22. The resident received five showers since her admission to the facility out of 10 showers scheduled. VI. Staff interview Certified nurse aide (CNA) #1 was interviewed on 8/10/22 at 11:00 a.m. She said there was a problem with the afternoon and evening shifts getting showers done. The director of nursing DON was interviewed on 8/10/22 at 11:25 a.m. She said the certified nurse aides (CNAs) did have problems with completing the shower tasks as well as documenting when showers were given. She said she identified showers not being completed back in June 2022 and created a performance improvement plan (PIP) on 6/14/22. She said she did not have the time to follow up on the PIP and implement interventions. She said the nurses were told to provide oversight and supervise the CNAs when the shower tasks were not completed, however she had not provided the follow up and implementation of the PIP. She said the five residents identified did not have sufficient showers in the past 10 weeks from 6/1/22 to 8/10/22 after she reviewed the documentation.

Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accident hazards as possible for two (#84 and #2) of six residents reviewed for accidents out of 21 sample residents. Resident #84 required two staff assistance with transfers and staff dependent for toileting. The facility failed to ensure Resident #84 had two staff assistance when she was provided incontinence care on 8/2/21 when she rolled off the bed. Due to the facility failures, the resident sustained a closed fracture of neck of left humerus (upper arm) and refracture of her rib (see hospital records). In addition, the facility failed to ensure Resident #2's appropriate interventions were implemented to prevent two falls, the interdisciplinary team conducted a thorough falls investigation, and the primary care clinicians were aware of the resident's falls. Findings include: I. Facility policy The Falls and Fall Risk policy, was received via email on 11/9/21, from the director of nursing (DON). The policy read in pertinent part, the staff along with the attending physician will implement a resident-centered fall prevention plan for each resident risk factor. II. Resident #84 A. Resident status Resident #84 was admitted on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, [CONDITION(S)], diabetes mellitus, COVID-19, [CONDITION(S)] and end stage renal disease with hemodialysis. The resident was discharged to hospital on 8/2/21. The 8/2/21 minimum data set (MDS) assessment revealed the resident had clear speech, made self-understood and was able to understand others. Her cognitive skills were moderately impaired with a brief interview for mental status (BIMS) score nine out of 15. She required extensive assistance of one person with bed mobility, two persons extensive assistance with transfers, limited assistance with dressing, and supervision with eating and personal hygiene. She was totally dependent on staff with toilet use. The resident was always incontinent of urine and bowel. B. Care plan -(Resident) is at risk for falls. Fall risk eval(uation) done with admit(ion), score of 16 (score 10 and above indicated high risk). Risk factors include deconditioning .Experienced a fall from bed during incontinence care. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Check for incontinence on rounds. Provide incontinent care as needed. Dependent 2 (two) staff for Hoyer lift transfers. Turn and reposition as needed, extensive assist 2 (two) staff. Date initiated 8/1/21. When making rounds, ensure that she is in the middle of the mattress. Ensure when being positioned for pericare that she is in the middle of the mattress. Revised 8/2/21. C. Nursing notes -On 8/2/21 at 2:35 a.m. a registered nurse (RN) documented: This nurse called to patient room by CNA (certified nurse aide) at 0005 (12:05 a.m.), patient was being changed and was turned onto right side, flung her leg over the bed and rolled onto the floor, landing on her left side. Resident stated, 'I rolled on over to the floor.' This nurse and CNA assisted patient back to bed via Hoyer lift. Assessed for injuries, resident had no c/o pain at this time, neuros WNL (within normal limits). At 0105 (1:05 a.m.), called to room by CNA as resident was now having c/o (complained) pain. '12 out of 10 in left shoulder.' Resident has AV fistula in left arm and bruising up and down arm prior to incident. Resident asked to be transferred to hospital. Called (provider), transfer non-emergent to hospital . Patient left with (ambulance) with glasses and cell phone at 0135 (1:35 a.m.) . The IDT (interdisciplinary team) post-fall report documented: IDT reviewed circumstances regarding resident's fall. Staff instructed to ensure resident is in the middle of the bed prior to and during all cares. Staff to also anticipate resident's needs to decrease the need of resident reaching and repositioning herself. D. Hospital records The 8/2/21 emergency department discharge to hospital summary revealed Resident #84 was admitted with medical diagnosis of closed fracture of neck of left humerus. The 8/2/21 radiology pertinent diagnostic results revealed: 1. Current findings demonstrate refracture rib previously healing comminuted spiral fracture of the mid humeral shaft now with significant angulation and mild to moderate displacement. 2. Interval comminuted fracture of the humeral head/neck junction mildly displaced and mildly angulated. The resident's care plan addressed two staff with turning and repositioning. The facility failed to prevent resident's fall with major injuries, refractured rib and humeral bone fracture. E. Staff interview Registered nurse (RN) #1 was interviewed on 11/4/21 at 11:58 a.m. She said she was working the night shift that started on 8/1/21 at 6:00 p.m. until 6:00 a.m. on 8/2/21. She said there was one CNA on the skilled rehab unit. She said shortly after midnight the CNA called her for help when Resident #84 fall of her bed during incontinence care. She said the resident did not complain of pain immediately after the fall. She said an hour later Resident #84 started complaining of excruciating pain in her left shoulder. She said the resident was transferred to a hospital by an ambulance. She said the CNA did not anticipate the resident would roll off the bed and was not aware that two staff were needed with repositioning. III. Resident #2 A. Resident status Resident #2, age 79 was admitted on [DATE] with diagnoses of cerebral infarction, metabolic [CONDITION(S)], [CONDITION(S)], polyneuropathy, anxiety and [CONDITION(S)]. The 8/18/21 MDS assessment revealed moderate cognitive impairment with a brief interview for mental status (BIMS) score eight out of 15. She required extensive assistance of two staff with bed mobility and transfers, extensive assistance of one person with dressing, toilet use and personal hygiene, and limited assistance with eating. B. Resident and family interviews Resident #2 was interviewed on 11/4/21 at 8:40 a.m. She said she remembered she fell two times from her bed. She said she did not remember what caused the falls. Resident's daughter was interviewed on 11/4/21 at 12:30 p.m. She said she was aware of one fall. She said her mother was very independent prior to her stroke. She said it was hard for her mother to adjust to the new situation and her illness. She said it would prevent the falls if the facility staff checked on her mother more often during the first month of her stay in the facility. C. Care plan The resident's comprehensive care plan was reviewed and revealed: -(Resident) is at risk for falls. Falls risk eval(uation) done with admit(ion), score of 18 (score 10 and above indicated high risk). Risk factors include recent [CONDITION(S)] ([CONDITION(S)] accident) with LT (left) sided weakness, use of hypnotic RX (prescribed medication). Experienced a fall from bed. (Revised 8/29/21) -(Resident) has LT (left) sided [CONDITION(S)]/[CONDITION(S)] r/t (related to) recent [CONDITION(S)]. Is Left hand dominant. (Date 8/12/21) -(Resident) has a potential for a communication problem. S/P [CONDITION(S)] (status post [CONDITION(S)] accident) with [CONDITION(S)]. Has difficulty at times with word finding. Communication is improving. (Date 8/31/21) -(Resident) is on anticoagulant therapy ([MEDICATION(S)]). (Date 8/12/21) -(Resident) is on sedative/hypnotic therapy ([MEDICATION(S)]) for sleeplessness. (Date 8/12/21) -(Resident) uses antipsychotic medications ([MEDICATION(S)]) for anxiety. (Date 8/24/21) D. Nursing notes 1. Fall #1 -On 8/27/21 at 10:02 p.m. a nurse documented: She is A/O (alert and oriented) x 2-3 tonight. Needs are anticipated by staff .[MEDICATION(S)] (a sedative, hypnotic medication) and [MEDICATION(S)] (an antipsychotic medication) given at HS (night), appears to be working well. Resident had 1 (one) hour yelling out tonight, but then calmed down. Resident is resting well at this time. Call light is positioned so she can use it with her right hand. Turned and repositioned Q 2 (every two) hours and PRN (as needed) by staff. Bed in low position, fall mat in place. She is on isolation as she is unvaccinated and a new admit. -On 8/29/21 at 12:15 a.m. a nurse documented (SBAR): This nurse found resident on floor between bed and window, on fall mat. Bed was in low position and her call light was still attached to her gown. When asked what happened, resident stated she was trying to reach for her bible. Resident assisted back into bed by this nurse and CNA. Resident states she did not hit her head. No injuries noted at this time. Vitals/Neuros initiated as fall was unwitnessed. Will monitor patient. -On 8/29/21 a nurse documented: Daily skilled charting for (Resident): She is A/O (alert and oriented) x 1-2. Needs are anticipated by staff d/t (due to) a [CONDITION(S)] ([CONDITION(S)] accident) and left sided weakness and is here for skilled services and rehab. Boot on left lower extremity. She is NWB (non-weight bearing) and is a Hoyer lift (for transfers). Her speech is a little unclear. Resident resting with eyes closed, have not observed her calling out this evening. She did have c/o left arm and left foot pain, PRN (as needed) [MEDICATION(S)] (pain medication) given .No c/o pain from fall last night. Resident turned and repositioned Q 2 (every two) hours and PRN (as needed) by staff. Bed in low position, fall mat in place, call light within reach but resident does not remember how to call for assistance - frequent checks for safety, will monitor. -On 8/30/21 a nurse practitioner documented in the skilled visit progress note: No falls -On 9/2/21 the IDT (interdisciplinary team) post-fall report documented: After IDT review, staff reminded to ensure resident is in the center of the bed prior to, during, and after cares. Staff to also anticipate resident's needs. The facility failed to implement appropriate approaches to prevent Resident #2's fall. The facility failed to thoroughly investigate resident's fall. The facility failed to communicate resident's fall with her primary care clinician. 2. Fall #2 -On 9/17/21 at 9:35 a.m., a nurse documented: Daily skilled charting for (Resident): Resident alert and oriented x 3 able to make needs known, but sometimes with difficulty expressing herself, L. (left) sided weakness post [CONDITION(S)], maintaining O2 (oxygen) saturation at 90% on RA (room air). Resident had an unwitnessed fall this shift w/o (without) any injuries, neurocheck initiated and all at resident's baseline so far, resident educated to use call light to call for assistance, bed in low position and call light within reach. -On 9/18/21 SBAR (situation, background, assessment and recommendation) revealed: Resident was found lying on the fall mat next to her bed on her L. (left) side. Resident stated that her son was coming to visit and she was trying to get up out of bed to go see him when she fell . Resident was assessed and noted with no injuries. Resident stated she did not hit her head, resident was assisted off the floor and back to bed by staff, call light was placed within reach and bed in low position. -There was no incident report and investigation in resident's medical record. -On 9/23/21 resident's physician documented in the skilled visit progress note: Patient feeling badly as her L (left) leg and her L (left) foot were hurting badly .No falls The facility failed to implement appropriate approaches to prevent Resident #2's second fall. The facility failed to thoroughly investigate resident's fall. The facility failed to communicate resident's fall with her primary care clinician. IV. Staff interviews The director of nursing (DON) was interviewed on 11/4/21 at 11:50 a.m. She said she has been the DON in this facility for just a couple weeks. She said she had learned there was a lot of documentation not completed after residents' falls. She said she will implement a thorough investigation after each resident's fall and provide all staff education on how to prevent falls with appropriate interventions and how to complete a post fall investigation.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19. Specifically, the facility failed to -Ensure staff wore personal protective equipment (PPE) while providing care to a resident in isolation; -Ensure staff were performing hand hygiene between different resident cares; and, -Ensure visitors and staff were actively screened for the signs and symptoms of COVID-19. Findings include: I. Staff wearing PPE appropriately and performing hand hygiene A. Professional reference According to the CDC guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, retrieved on 11/16/21 online from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf: PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (e.g., retying gown, adjusting respirator/facemask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care. B. Observations On 11/1/21 at 12:53 p.m. an agency social worker was observed in droplet precautions room [ROOM NUMBER] visiting with the resident. She wore a gown, gloves and a surgical mask. Prior to leaving the room she took her backpack and a purse from the resident's bed, put it on the floor next to the red colored trash bin, took off her gown and gloves, disposed of it in the red trash bin, picked up the backpack and purse and walked out of the room. She did not wash or disinfect her hands. She did not wear a N95 mask during the visit with the resident on isolation. On 11/1/21 at 1:05 p.m. certified nursing aide (CNA) #2 entered into resident room [ROOM NUMBER] who was on droplet isolation precautions with gloves and a surgical mask. She had in hand the residents' meal tray for lunch and assisted her with eating. She had picked up the resident's walker and moved it over the resident's lunch tray. She did not change her gloves or perform hand hygiene and began to assist the resident with eating. The registered dietitian walked by the room and reminded the CNA she needed to sit down with the resident to assist her. CNA#2 moved the resident ' s wheelchair, brought a folding chair and sat down next to the resident. Without changing gloves and washing her hands the CNA began assisting the resident with eating her lunch meal. On 11/1/21 at 3:56 p.m. certified nursing aide (CNA) #1 entered room [ROOM NUMBER] (resident on isolation with droplet precautions) straight from the hallway without appropriate PPE. She moved oxygen tubing, adjusted the resident's nasal cannula in the resident's nose and walked out of the room. C. Interviews The agency social worker was interviewed on 11/1/21 at 1:00 p.m. She said she was not aware she needed to use a N95 facemask in the resident ' s room who was on isolation with droplet precautions. She said she did not realize she did not disinfect her hands after she left the room. CNA #2 was interviewed on 11/1/21 at 1:45 p.m. She stated she wore a gown that was splash-proof and eye protection when she would provide direct care such as giving the resident a bath. She said she needed only a surgical mask to go into the facility and to resident rooms. She said she was not aware she needed a N95 facemask while entering the resident's room with droplet precautions. She said she should have changed gloves after touching multiple surfaces in the resident's room before she touched the utensils and assisted the resident with eating. CNA #1 was interviewed on 11/1/21 at 3:58 p.m. She said she is a staffing agency CNA. She said she was not aware the resident was on isolation and droplet precautions. She said she observed the resident ' s oxygen tubing was not connected appropriately to the nasal cannula and wanted to make sure the oxygen was flowing into the resident ' s nose, however she did not notice the sign on the door. The director of nursing (DON) was interviewed on 11/1/21 at 4:02 p.m. She said there was signage on the resident ' s door as well as an isolation bin with gown, gloves, N95 masks and eye protection. She said the signs were there to remind staff to use appropriate PPE before entering the room with droplet precautions. II. Screening process/for vendors and visitors A. Professional reference According to The Centers for Disease Control and Prevention (CDC), Preparing for COVID-19 in nursing homes, last updated 9/10/21, retrieved on 11/11/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html documented in pertinent part, Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19 symptoms. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Screen visitors for fever (temperature=100.0°F), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. Ask visitors to inform the facility if they develop fever or symptoms consistent with COVID-19 within 14 days of visiting the facility. B. Observations and interviews On 11/3/21 at 9:10 a.m., a medical supply company employee was observed pushing a cart with a pallet with several boxes of medical supplies through the front door of the facility. He went through the hallway, next to residents' rooms and unloaded the boxes in the area near the end of the hall by a storage rooms. On his way out, he stopped and talked to the nurse at the medication cart that was close to the main entrance. The medical supply company employee was interviewed on 11/3/21 at 9:15 a.m. He said a staff member opened the main door for him. He said no one asked him about screening for COVID-19 or checked his body temperature. He said he was not aware he should be screened in the facility for signs and symptoms of COVID-19. On 11/3/21 at 2:00 p.m. a visitor entered the facility through the front double doors. He walked in and turned right down the resident hallway to room [ROOM NUMBER] which was three doors down on the left. He was not stopped and screened by staff. -At 2:15 p.m. three visitors entered through the front doors. They stopped and waited for about three minutes and were not greeted or screened by staff. The visitors walked to the resident ' s room straight down past the nurses station. The DON was interviewed on 11/3/21 at approximately 4:30 p.m. She said every visitor and vendor should be screened for signs and symptoms of COVID-19 immediately after entering the facility. On 11/4/21 at 8:20 a.m. a visitor entered the facility through the front door let in by a CNA. The visitor stood by the door for five minutes then walked into the conference room. III. Facility COVID-19 The NHA was interviewed on 11/4/21 at 10:45 a.m. She said they had zero COVID-19 positive residents and zero COVID-19 positive staff. She said there were zero presumptive positive COVID-19 residents and zero pending COVID-19 tests for staff.

Based on record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for three (#83, #79, and #77) out of 21 sample residents. Specifically, the facility failed to ensure for Resident #83, #79, and #77 were provided with showers according to their schedules and resident preferences. Findings include: I. Resident #83 A. Resident status Resident #83, older than 85, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 was discharged from the facility on 3/2/21. The 2/17/21 minimum data set (MDS) assessment revealed moderately impaired cognition with a brief interview for mental status (BIMS) score nine out of 15. She required extensive assistance of one person with bed mobility and dressing, extensive assistance of two staff with transfers and toilet use, and supervision with eating and personal hygiene. The resident had functional limitation in range of motion (ROM) of upper extremity. She had an indwelling urinary catheter. B. Record review 1. Care plan Review of Resident #83's comprehensive care plan revealed: -(Resident) has an alteration in musculoskeletal status, fracture of the RT (right) ulna, RT (right) radius. Splint in place, NWB to RUE (no weight bearing on right upper extremity). Date initiated 2/11/21 -(Resident) has an ADL (activities of daily living) self care performance deficit, S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Splint in place, NWB to RUE (no weight bearing on right upper extremity) Date initiated 2/10/2021 Interventions included: Encourage the resident to participate to the extent possible with each interaction. Provide resident with encouragement for all efforts at self care. The Resident requires staff assistance with bathing/showering. Extensive assist with bathing. Wednesday & Saturday evening shift. Keep RUE splint clean & dry. 2. Bath Look Back Resident #83's bath/showers record during her stay in the facility, dated 2/10/21-3/2/21, was provided by the director of nursing (DON) on 11/4/21 at 11:17 a.m. The record review revealed the resident did not receive baths/shower. The facility staff annotation on 2/11/21, 2/15/21, 2/18/21, 2/19/21, 2/22/21, 2/25/21 and 2/26/21 read, 8 - ADL activity itself did not occur. -The resident did not receive her bathing as documented in the care plan. C. Staff interview The DON was interview on 11/4/21 at 11:18 a.m. She said according to the record, Resident #83 did not receive a bath or shower in the facility during her stay. She said there was no record of resident #83 refusing her showers. II. Resident #79 A. Resident status Resident #79, age 75, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS assessment was not completed. B. Record review Care plan -She has an ADL (activities of daily living) self care performance deficit, S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Extensive assist with dressing. Extensive assist with showers, Wednesday/ Saturday evening shift. Keep incision clean & dry. A review of the Preferred Bath record dated 10/28/21-11/3/21, revealed, activity did not occurred. C. Resident interview Resident #79 was interviewed on 11/3/21 at 8:40 a.m. She said she did not receive her bath or shower since the admission. She said her husband, who is [AGE] years old, helped her wash her hair in the sink. She said she could not stand herself not being bathed since she was hospitalized and being in the facility for six days without a shower or bath. III. Resident #77 A. Resident status Resident #77, age 77, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS assessment was not completed. According to the admission record, dated 10/28/21, indicated moderately impaired cognition with a brief interview for mental status (BIMS) score 11 out of 15. According to the admission record, dated 10/28/21, Functional Abilities and Goals, Resident #77 required partial/moderate assistance with ADLs. B. Record review Care plan -The resident has an ADL (activities of daily living) self care performance deficit. Date initiated 10/27/21. Intervention read, extensive assist with showers, Monday & Thursday evening shift. A review of the Preferred Bath record dated 10/27/21-11/4/21, revealed, activity did not occur. The resident did not receive her bath or shower for eight days. C. Resident interview Resident #77 was interviewed on 11/3/21 at 3:20 p.m. She said she did not have a bath or shower since the admission and staff did not offer her one either. She said no one offered her a bath or asked about her preference. She said she would like to have her showers any time after breakfast and before lunch.

Based on observations, interviews and record review the facility failed to implement an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) communicable diseases and infections for two out of four units. Specifically, the facility failed to: -Ensure laundry staff wore appropriate personal protective equipment (PPE) when handling potentially contaminated clothing/linens; -Actively screen and document nursing personal working on the isolation unit; -Ensure staff working on the isolation unit wore the appropriate PPE (N95) and encourage residents to wear face coverings during interactions with staff; -Ensure staff on the isolation unit performed appropriate hand hygiene before and after glove use; -Ensure staff on the isolation unit offered hand hygiene to residents prior to meal service; and, -Ensure visitors COVID-19 screening assessments were thoroughly completed and temperatures documented prior to entrance to the facility. Findings include I. Laundry staff's failure to use proper PPE when handling potentially contaminated clothings/linens Observation and staff interview Housekeeper (HSK) was in the laundry room on 9/30/2020 at 10:01 a.m. She had googles on her face. She wore her face mask below her chin and had latex gloves on her hands. She was not wearing a gown as she took linens from the laundry bin and put them into the washing machine. She identified the two bins as one from the skilled side of the facility and the other from isolation precaution rooms. She was unable to tell which linen was from the isolation precaution room separate from those which were not from the isolation room. She identified the bags containing the linen from both the isolation rooms and non-isolation rooms as trash bags. She said she knew to bag dirty linen from isolation precaution rooms in a sugar bag but the process was hindered because nursing staff on the isolation precaution unit bagged the dirty linens and she only picked them up to wash. She said she exited the building through a side door and went around from the outside to avoid going into the isolation precaution unit. She said when she arrived at the unit's back door, nursing staff had already bagged the dirty linens and sat them at the door where she picked them up and returned to the laundry unit. She said she was required to wear full PPE when she came in contact with dirty linens from isolation based precaution rooms. She however acknowledged she was not wearing her gown and that she had her mask below her chin while she put the dirty linens into the washing machine. Certified nurse aide (CNA) #2 was interviewed on 9/30/2020 at 11:15 a.m. She said when residents from the isolation based precaution rooms needed their linens washed, she picked them up from the individual resident's rooms, bagged them and put the bag containing the potentially contaminated linens out by the doorway. She said she went on the radio to announce that the laundry department needed to pick up the laundry. She identified the bag she used bagging dirty linens from the isolation unit as a regular trash bag. She said she took the job as a CNA at the facility two weeks prior and had not received any training relating to COVID-19 or how she was not supposed to bag a potentially contaminated linens from the isolation unit a trash bag. She added that the facility scarcely had sugar bags available hence she had been using a regular trash bag. She said she had knowledge of how to care for residents who tested positive or were symptomatic of COVID-19 from the facility she worked prior to joining the facility. She accessed the four isolation carts on the isolation unit and acknowledged there was no sugar bag in either of them. Registered nurse (RN) #1 was interviewed on 9/30/2020 at 11:22 a.m. She said when nursing staff picked up dirty linens from residents on isolation based precaution, they placed them in a sugar bag. She said nursing staff wore their gowns, N95 masks, gloves and google when they collected the linens and when the bags were picked up. She said nursing staff took care to ensure that the bag did not make contact with their body. She said sugar bags were designed to dissolve when placed in the washing machine and as such it protected laundry staff from the potential risk of exposure. She said trash bags were not to be used in the place of sugar bags as it made it impossible to identify linens from isolation rooms separately from those not in isolation. She said she would bring the observation to the attention of the facility's administration. The maintenance director (MDR) was interviewed on 9/30/2020 at 11:44 a.m. He said when housekeeping/laundry staff were newly hired, they were provided education on how to operate machines utilized for cleaning purposes. He said they were trained on all appropriate chemicals to be used at different stages of cleaning. He said when dirty linens were collected from residents on isolation precaution rooms, they were placed and secured in a sugar bag. He said sugar bags were readily available in the isolation carts which were stationed at every resident's door who tested positive or were suspected of having symptoms consistent with COVID-19. He said laundry/housekeeping staff who picked up the dirty linens from the isolation based precaution unit wore full PPE. He described full PPE in the context of handling potentially contaminated linens from residents who were positive or suspected of having COVID-19 as a gown, N95 mask google and gloves. He said the aforementioned practice was repeated when housekeeping/laundry staff sorted the linens in the laundry room. He said the trash bag was not to be used for collecting potentially contaminated linens. He checked with the nursing staff in the isolation unit and acknowledged that there were no sugar bags in the isolation carts. He said he did not have a documented record of training provided to housekeeping staff on how to handle potentially contaminated linens and use of PPE during the laundry process. He said he would educate his staff based on the identified concerns going forward. II. Screening concerns A. Professional reference According to the Centers for Disease Control and Prevention (CDC) updated 6/25/2020, retrieved on 10/2/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, included the following recommendations: Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility. B. Observation On 9/30/2020 at 2:15 p.m. CNA #1 accessed the isolation unit through a back door which provided direct access to the isolation unit. She approached CNA #2 and was debriefed about the events which took place in the early hours of the morning. The debriefing was centered around resident care. Immediately afterwards, CNA #1 took to the floor and started caring for residents. She did not complete the staff checklist for COVID-19. C. Record review The COVID-19 screening Checklist for visitors and staff was provided by the nursing home administrator. The undated document read On March 13,2020, CMS and CDC updated guidance on restricting all Long Term Care (LTC) visitors and non-essential healthcare personnel, except for certain [MEDICATION NAME] care situations. All individuals (staff, other health care workers, family, visitors, government officials, e.t.c) entering the building must be asked the following questions: The visitor sign-in COVID-19 assessment form (not dated) revealed each visitor should answer yes or no to two questions. (1) have you washed your hands or used an alcohol based hand rub prior to entering the facility? (2) do you have any of the following respiratory symptoms: cough, shortness of breath, fever, repeated shaking chills, headache, new loss of taste or smell, diarrhea, chills, muscle pain, sore throat or vomiting ? The checklist directed that if an individual answered YES to any of the aforementioned questions, the individual should not visit the facility until they have been symptom free for at least three days. -The checklist also had a designated portion for recording the temperatures of health care providers (HCP) e.g agency staff, regional or corporate staff, health care workers such as hospice, EMS, [MEDICAL TREATMENT] technicians that provide care to residents. The checklist directed that if an individual recorded a temperature over 100.4, the individual should not visit the facility until they have been symptom free for at least three days. In addition, the form also revealed each visitor should answer yes or no to whether or not the individual completing the form had worked at facilities or locations with recognized COVID-19 cases ? and whether the individual had been out in the community without a mask or within six feet of an individual that was not their immediate family? Furthermore, the form had a designated portion for the name, date and resident or staff member being seen. A review of the checklists completed from 9/1/2020 through 9/30/2020 revealed that there were 109 visitor entries during this time-period. The following concerns were noted in 24 (26.16%) of the checklists reviewed: -Four visitors who were at the facility on 9/2/2020 failed to answer one or multiple yes or no questions asked on the checklist. One of the four visitors also did not complete the temperature portion of the checklist. -Two visitors who were at the facility on 9/3/2020 failed to answer one or multiple yes or no questions asked on the checklist. One of the two visitors also did not complete the temperature portion of the checklist. -Four visitors who were at the facility on 9/4/2020 failed to answer one or multiple yes or no questions asked on the checklist. Two of the four visitors also did not complete the temperature portion of the checklist. -Nine visitors who were at the facility on 9/6/2020 through 9/11/2020 failed to answer one or multiple yes or no questions asked on the checklist. -Three visitors who were at the facility on 9/11/2020 through 9/13/2020 failed to complete the temperature portion of the checklist. -Two visitors were at the facility but did not record their names nor the name of the resident they visited. They also did not record the date they visited the facility. D. Interview RN #1was interviewed on 9/30/2020 at 4:20 p.m. The RN said she was an agency nurse and had worked a couple of times on the isolation unit. She said staff came into the isolation unit using a separate rear entrance that led them straight into the isolation unit. She said she was not screened into the facility. She said she had never completed a checklist at the main entrance or on the isolation unit prior to resuming her shift. She said she was not provided any education or informed about the need to undergo a screening prior to working the floor. She said when she came on shift, she relieved the nurse who worked the previous shift and immediately started caring for residents. She said she had not received any training about COVID-19 from the facility. CNA #1 was interviewed on 9/30/2020 at 2:30 p.m. She said she was an agency nurse. She said she was not aware there was a screening process into the facility. The nursing home administrator was interviewed on 10/1/2020 at 9:12 a.m. He said the screening checklist for visitors and staff was one of the guidance put out by CDC and CMS to ensure anyone visiting the facility was screened by asking the questions contained within the checklist. He acknowledged some of the checklists were not thoroughly completed. He said no one reviewed the visitors checklists to identify any parameter that might be a red flag. He acknowledged that not documenting the temperatures of the individuals who had access to residents at the facility could potentially result in exposing and cross-contaminating residents if those individuals whose temperatures were missed were positive for COVID-19. He said the process for screening nursing staff into the isolation unit was that the outgoing nurse screened the incoming nurse. He said he did not realize that the information was not communicated to the nurses who worked on the isolation unit. He acknowledged there was no document which recorded the screening of staff in the isolation unit. The NHA said Without having a record of the screening, I was unable to tell if a nurse reported on the job with symptoms that would have warranted they ' d be sent back home. He said, most of the nurses who worked on the isolation unit were agency nurses. He said he did not have evidence of a training on COVID-19 provided to those individuals before they worked the floor. He added that he did not have evidence which addressed the need for nursing staff to actively screen for COVID-19 symptoms before they came into the facility. He said he would educate nursing staff on the isolation unit on the importance of screening going forward. III. Failure to ensure staff working on the isolation unit wore the appropriate PPE (N95) and encouraged residents to wear face coverings during interactions with staff. A. Professional reference According to the Centers for Disease Control and Prevention (CDC) updated 6/25/2020, retrieved on 10/2/2020 from ttps://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, included the following recommendations: Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. B. Observation On 9/30/2020 at 11:35 p.m. The isolation based precaution unit was observed. Certified nurse (CNA) #2 conducted routine checks and performed direct care on all the six residents who were on the unit. Before entering the rooms, CNA #2 had a full PPE on, however, she failed to advise /encourage the residents she cared for to put their face masks on or protect their faces by any means. None of the six residents protected their faces when they received care from CNA #2. On 9/30/2020 at 4:12 p.m., CNA #1 was observed in room [ROOM NUMBER] when she responded to a call light. There was an isolation cart outside the room and a sign on the door that read droplet precautions. She entered the room wearing a disposable gown, gloves, surgical mask and eye protection. The resident in the room was positive for COVID-19. CNA #1 failed to wear a N95 mask which was required in a COVID-19 positive room. The resident she was caring for had no face mask and was not protecting her face by any means. CNA #1 was also observed as she repeated the foregoing in room [ROOM NUMBER], #193 and #194. The residents in the later rooms also tested positive for COVID-19. IV. Hand hygiene issues A. Professional reference The Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidance, retrieved from: https://www.cdc.gov/handhygiene/providers/guidelin.html (updated 1/30/2020, retrieved on 10/2/2020), read in part, Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. B. Observation On 9/30/2020 at 11:35 p.m. The isolation based precaution unit was observed. Certified nurse (CNA) #2 conducted routine checks and performed direct care on all the six residents who were on the unit. CNA #2 began caring for the resident in room [ROOM NUMBER]. The residents on the unit were cohorted and nursing staff used the same gown, N95 and google when they cared for the residents. They were required to change gloves between each resident. CNA #2 did not perform hand hygiene before she donned a new pair of gloves going into room [ROOM NUMBER] and after she discarded a used pair of gloves. Two of the isolation rooms (#191 and #193) had double occupancy. CNA #2 failed to replace her gloves and perform hand hygiene between caring for the two residents who occupied the rooms. CNA #2 spent approximately 15 minutes before she exited the rooms on each visit. Upon exiting the room, she did not perform hand hygiene before walking off to the nurse station. On 9/30/2020 at 12:50, CNA #2 served the first room tray on the isolation unit in room [ROOM NUMBER]. The meal was a sandwich (considered a finger food). The CNA failed to perform hand hygiene prior to handling the meal tray. She did not offer hand hygiene to the resident prior to serving the meals. The CNA neither performed nor offered hand hygiene to the other five residents who lived on the unit. On 9/30/2020 at 12:55 p.m., RN #1 was observed while she prepared medication and nutrition supplement at her med-cart. RN #1 repeatedly opened and closed the med-cart with a bunch of keys. She kept the bunch of keys in her pocket after each use. RN #1 served the nutrition supplement and administered the pills which she poured in small sized disposable cups to an unidentified resident residing in room [ROOM NUMBER]. RN #1 held the cups containing the nutrition supplements and pills around the mouth piece and administered the same to the resident. She did not perform any type of hand hygiene the entirety of the observation. By failing to perform hand hygiene in-between going in and out of several residents room and also handling of medication and nutrition supplement cup around the mouth piece, the RN had potentially cross-contaminated the cup containing the resident's medication and nutritional supplement with whatever contaminant might have been on her hands from handling med-cart keys, touching her clothes and likewise touching door knobs. V. Secondary entrance to the facility observation and interviews On 9/29/2020 at 1:00 p.m., the nursing home administrator (NHA) said staff entered the facility using the shipping entrance located at the back of the facility. The staff had to walk from this entrance, to the nurse's station on the long-term care portion of the facility, to be assessed for COVID-19. He said this door required a code to enter the facility. On 9/20/2020 at 1:55 p.m., the NHA walked with the surveyor from the shipping entrance to the nurse's station. There was no COVID-19 assessment station at this entrance. The walk consisted of two short hallways from the shipping entrance to the closed fire doors leading onto the long-term care portion of the facility. From the closed fire doors, a staff member had to walk past six occupied resident rooms to emerge onto the common area. The nurse's station was located in the common area. On 9/29/2020 at 2:37 p.m., certified nurse aide (CNA) #4 she said she entered the facility from the shipping entrance at the back of the facility. She walked onto the long-term care portion of the facility to be assessed at the nurse's station. She said she wore eye protection and a surgical mask when entering the facility. On 9/30/2020 at 9:45 a.m., the social services director (SSD) said she entered the facility at the shipping entrance door and walked down the hallway on the long-term care portion of the facility passed several resident rooms, before she was assessed at the nurse's station. She said she wore a surgical mask and eye protection when she entered the facility. She said she completed the employee assessment form with a nurse. She said the nurse took her temperature and reviewed the form for completion and accuracy. On 9/30/2020 11:20 a.m., at CNA #5 said she entered the facility at the shipping entrance door. She walked through the hall leading from the fire doors, passed resident rooms, to the nurse's station before she was assessed on the long-term portion of the facility. On 9/30/2020 at 4:26 p.m., observations of resident rooms, on the hallway from the fire doors to the common area, located on the long-term care portion of the facility. -door to room [ROOM NUMBER] was open. -door to room [ROOM NUMBER] was open. -door to room [ROOM NUMBER] was open with the resident in the room with a staff member. The staff member wore the appropriate personal protection equipment (PPE). The door was signed for droplet isolation. -door to room [ROOM NUMBER] was open. -door to room [ROOM NUMBER] was open with the resident in the room. The door was signed for droplet isolation. -door to room [ROOM NUMBER] was partially open. On 9/30/2020 at 4:29 p.m., CNA #3 said she entered the facility at the shipping entrance and walked past several resident rooms on the long-term portion of the facility, to the nurse's station to be assessed. She said she completed the employee screening form and a nurse took her temperature and documented it on the form. She said the nurse reviewed the form for completeness. On 9/30/2020 at 5:23 p.m., the director of nursing (DON) said staff entered the facility at the shipping entrance located at the back of the facility and walked onto the long-term portion of the facility. She said staff wore a surgical mask and eye protection when they entered the facility. She said staff had to walk down a hallway, past resident rooms before they were assessed by a nurse at the nurse's station. She said she reviewed the employee assessment forms on a daily basis. -The DON said she preferred the staff enter the facility at the side entrance directly onto the long-term care portion of the facility. This entrance was near the nurse's station and did not require the staff to walk past resident rooms. She said she was unsure why the staff used the shipping entrance, instead of the side entrance. On 10/1/2020 at 10:30 a.m., the NHA said staff used the shipping entrance at the back of the facility to limit the number of entrance doors available for staff. He said staff wore surgical masks and eye protection when they entered the facility. He said staff had to walk past resident rooms before they were assessed at the nurse's station. He said the staff had been using the shipping entrance since 3/2020. VI. Additional interviews CNA #2 was interviewed on 9/30/2020 at 1:38 p.m. She said when she served meals to the residents, she would sanitize or offer hand hygiene to the residents prior to serving them. She said she would sanitize her own hands on the way out of the resident's room. She acknowledged she did not offer or perform hand hygiene with the resident prior to serving the meal. She said I did not want to act like I was always 100 percent (%) with hand hygiene because I was being observed because the truth is I am not always 100 %). She said she was afraid of accessing the residents bathroom to wash her hands because of the risk of exposing herself. She said she would ensure to perform and offer residents hand hygiene to residents going forward. On 9/30/2020 at 3:07 p.m., RN #1 was interviewed, she said she was an agency nurse. She said she did not receive hand hygiene training at the facility. RN #1 said she knew from her experience from haven practiced nursing for several years to wash her hands for 20 seconds when visibly soiled and also to use alcohol based hand rub (ABHR) till it was dry. She added that she was required to perform hand hygiene in between caring for residents, after toilet use, and when in contact with frequently touched surfaces. She agreed she did perform hand hygiene while she performed the activities described above. She said she did not know to perform hand hygiene when she did not make contact with the residents. She acknowledged however, that she had touched door handles when she opened and closed the doors leading into the residents rooms, and that she had held keys and touched her clothes multiple times which had now contaminated her hands and thus, necessitating that she performed hand hygiene. She said she would make amends going forward. Administrative interviews The director of nursing (DON)/ infection preventionist (IP) was interviewed on 9/30/2020 at 2:22 p.m. via telephone (phone number omitted). She went through an overview of the required steps of meal delivery. She said staff must knock on doors, announce themselves, encourage the resident to wear a face mask when staff was present, and ensure the meal card matched the meal and name of the resident to whom the room tray was delivered. The DON said residents should have received hand hygiene at time of meal delivery. She said residents should have been offered hand hygiene or had their hands wiped with sani-wipe to ensure that their hands were clean and free of contaminants when they ate their meal. She said staff should ensure to perform hand hygiene during meal delivery as needed and in-between residents. She said she would relay the concerns to the facility administration to ensure necessary training was provided. She said all residents in the isolation unit had a bin in their rooms for biohazard and a bin for linens. She said the dirty linens were collected in a dissolvable sugarbag. She said there was a bigger biohazard bin in the corner of the hallway which was used whenever laundry needed to be picked up. She said staff used the radio to communicate with the laundry department and informed them that an outside laundry (delineating the laundry was from an isolation unit) was ready for pick up. She said the laundry staff exited the building and walked around to avoid having direct contact with the isolation unit when they picked up the dirty linens from the isolation unit. She said the bags which contained the dirty linens from the isolation sat by the doorway so that laundry staff do not have to go into the isolation unit. She said laundry staff were to wear full personal protective equipment which included a gown, N95 mask, google and gloves. She said all staff caring for residents who tested positive for COVID-19 were to wear N95, face shield/ google, gown and gloves. She said when she called the agency staffer to request for nurses, she let the staffer know and to inform the agency nurse that they had an active case of COVID-19 in the building. She said she was at the facility the week before the survey and she left some N95 for whichever agency staff came in the facility. She said she left instructions with the on floor nurse (did not recall the name) to provide the agency nurse with N95. She said she was unsure whether the nurse acted as instructed. She clarified that seasoned or agency staff were not to wear surgical masks when they cared for residents who tested positive for COVID-19. She said the facility did not maintain a training/ inservices record on COVID-19 for the agency and seasoned nurses who cared for residents on the isolation unit because they wanted to avoid gathering of people in the same room. She said the assistant director of nursing (ADON) who was also the staff development coordinator (SDC) left in July, 2020. She had been unable to keep up with the task. She said nursing staff who worked in the COVID-19 unit should be screening themselves because they left through the back door; outgoing staff should be screening the incoming nursing staff and documenting in the COVID-19 screening form. She said it was important to have a log which recorded the temperatures and other symptoms of nursing staff who accessed the facility to ensure they did not record high on any of parameters which would warrant that the nursing staff be sent back home to prevent infecting or re-infecting residents. She said it was the duty of the nursing home administrator (NHA) to review the visitors checklist for the same reasons stated above. The NHA was interviewed on 10/1/2020 at 9:19 a.m. He said the facility had an abundance of N95 (did not know the exact figure). He said his understanding was that staff who had not been fit tested for N95 were not to use them. He said when nursing staff attended to a resident on isolation based precaution, they wore full PPE (gown, N95 mask, google and gloves). He said nursing staff who do not have N95 masks used the surgical face. He said nursing staff in the isolation unit screened themselves (outgoing shifts screened incoming shift). He said he was not aware that staff have not been following the procedure of having to screen themselves and completing the COVID-19 screening checklists. He acknowledged there was no COVID-19 checklist available in the isolation unit which documented the staff temperature and other required parameters to monitor for COVID-19. He said agency staff accessed PPE at the facility except for N95. He said he thought agency staff came in with their own N95. He said he was not able to guarantee the sanitary status of the N95 brought in by agency staff. He said it was important for staff to use N95 and advise residents to protect their faces when staff provided direct care to prevent staff from infecting residents and vice versa. The NHA was interviewed on 10/1/2020 at 11:44 a.m. He acknowledged he reviewed the visitors COVID-19 checklist. He said the problem with the checklist completed by visitors was that staff who was assigned the duty of screening visitors into the facility was not carefully reviewing to ensure the checklist was completely filled out to include documenting temperatures and answering all the yes and no questions as identified above. He said the consequence of the oversight was the potential of having an exposed person access the facility and infecting residents who were already vulnerable. He said he had been auditing employee COVID-19 checklists but had not audited the visitors checklist until survey. He listed home health, hospice, and oxygen delivery personnel as part the visitors who completed the checklists which were missing the identified information. The NHA said he had no evidence of training for the agency nurses before they were on the floor providing care. He said hand hygiene and isolation precaution measures were universal practice which he expected they (agency and seasoned staff) should have known. He acknowledged the four rooms on the isolation unit shared only one alcohol based hand rub (ABHR) dispenser. He said the lack of ABHR dispensers in individual resident rooms contributed to the missed opportunity for hand hygiene. He said his plan going forward was to train seasoned nursing staff and to do away with agency staff.

Based on observations, interviews and record review, the facility failed to ensure infection control procedures were followed to prevent the possible cross-contamination of Coronavirus disease (COVID-19). Specifically, the facility failed to: -Follow isolation precautions with hand washing and sharps disposal; -Train all facility staff on infection control COVID-19; -Follow proper housekeeping protocols to prevent cross-contamination; and -Maintain proper cleaning standards and procedures. Findings include: I. Failure to prevent cross-contamination with isolation precautions, hand washing and sharps disposal A. Facility policy and procedure The Coronavirus Disease (COVID-19) interim policy, not dated, provided by the nursing home administrator (NHA) on 4/13/2020 at 10:00 a.m., read in pertinent part: The procedure for employees was to educate and re-educate and reinforce strong hand hygiene practices. The Isolation and Categories of Transmission-Based Precautions policy, revised date of October 2018, provided by the NHA on 4/13/2020 at 10:00 a.m., read in pertinent part: While caring for a resident, staff will change gloves after having contact with infective material. Gloves will be removed and hand hygiene performed before leaving the room. B. Observations and interviews Two resident rooms, #167 and #172, were observed on 4/13/2020 at 9:15 a.m. to be on contact and droplet isolation precautions. The doors were open to both rooms and a three drawer cart sat outside each room with personal protective equipment (PPE). Certified nurse aide (CNA) #1 was observed on 4/13/2020 at 10:33 a.m. to take a bag of linen and trash out of room [ROOM NUMBER] (isolation room). She had no gloves on and put the bags in the main trash bin in the supply room (not a biohazard container). She entered another resident's room (not an isolation room) and did not wash her hands after leaving the supply room. She was interviewed and said she put items from an isolation room into a biohazard container. She said the biohazard containers were on the next hallway over from room [ROOM NUMBER]. In the biohazard room there was one biohazard container and it was empty of any contents. She said she would put a biohazard container in room [ROOM NUMBER]. CNA #2 was observed on 4/13/2020 at 12:25 p.m. to deliver a meal tray to room [ROOM NUMBER]. She donned the gown that hung outside the door, put on gloves and goggles. When finished with her task she took off her gloves first, goggles second and gown last, and hung the gown back up on the door. The gown fell on the floor and she rehung the gown on the door. She left the room and did not wash her hands. A registered nurse (RN) was observed on 4/13/2020 at 12:35 p.m. to carry out a used needle (biohazard material) from room [ROOM NUMBER] (isolation room). She walked down the hallway to put the biohazard needle into the sharps container on the medication cart. She was interviewed and said she was in the isolation room and realized there was no sharps container to discard the used needle into. She said she was not trained on how to dispose of the sharps material in an isolation room. The director of nurses (DON) was interviewed on 4/13/2020 at 9:35 a.m. She said when a resident was in isolation the facility staff had to wear full personal protective equipment (PPE). She said she expected them to wash their hands before and after all cares and after glove use. She said all equipment should be in the isolation room and not taken out of the room without being put in a proper container first. She said there was a spread of infection when infection control measures were not followed. II. Failure to ensure coronavirus training was provided to all facility staff in a timely manner. A. Professional reference and staff training documentation According to the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memorandum Ref: QSO-20-09-ALL (2/6/2020) Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2019-nCoV): Train and Educate Healthcare Personnel: Provide HCP with job- or task-specific education and training on preventing transmission of infectious agents, including refresher training. Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment. On 4/13/2020 at 1:39 p.m., the staff development coordinator (SDC) provided a copy of the [MEDICAL CONDITION] in service, which was provided by the facility for staff on 3/3/2020, 3/17/2020, and 3/19/2020. The in-service revealed mandatory meetings for all nurses and CNAs for Coronavirus education. It contained: -[MEDICAL CONDITION]/evacuation; -Isolation precautions; -Admission precautions, contact and droplet precautions; and -Covid 19 spread. The sign-up sheets identified 37 staff members who attended the 2020-nCoV in-service. However, the facility had 67 current staff members according to the facility-provided staff list. B. Staff interview The SDC was interviewed on 4/14/2020 at 3:14 p.m. She said, I gave all of the department supervisors a hand out and they trained their own staff. She said all staff needed to be trained on Covid-19. She said she created educational sheets to train the staff and she would do that this week. She said the nursing home administrator would receive daily updates from the Center for Disease Control (CDC), Department of Health, and Center for Medicaid and Medicare Services (CMS). She said she talked to everyone often but did not document what was discussed or trained on. The SDC said the facility utilized agency nursing. She said they received their training from their agency. She said, We did inform them of our facility policies but I do not have any documentation showing this. She added, I will get an updated sign in sheet identifying all staff have been trained on Covid-19 immediately. She said a negative outcome would be a potential outbreak. She said the facility would get the training done this week. III. Failure to prevent cross-contamination during resident room cleaning A. Observations On 4/13/2020 at 12:10 p.m., housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER]. HSK #1 was cleaning four pillows on the bed. HSK #1 was spraying the disinfectant on each one of the pillows and immediately wiping the pillow without allowing time for the disinfectant to take effect. HSK #1 stated, Oh, I forgot to put my gloves on. She exited the resident room immediately and grabbed a pair of gloves from the top of her cart. She returned into the resident's room and proceeded to finish cleaning the pillows. HSK #1 moved to the mattress, which she sprayed with the disinfectant spray and wiped the mattress immediately. She continued to wipe the remainder of the room, spraying the area and wiping immediately, not following the disinfectant dwell time. She exited the resident's room. She did not wash or sanitize her hands during this process. HSK #1 left the room and grabbed her caddy of cleaners and returned into the resident room. She proceeded to wipe the resident's wheelchair following the same process as before of spraying and immediately wiping with the same rag. HSK #1 wiped the wheelchair wheels and foot pedals. She pushed the wheelchair to the corner of the room. She grabbed her caddy of cleaners and entered the resident's restroom. She sprayed the sink, the commode and other areas in the restroom and immediately wiped all areas. She exited the restroom and placed her caddy onto her cart. She removed her gloves and put on a new pair of gloves. She did not wash or sanitize her hand during this process. HSK #1 grabbed a mop pad from her cart. She rang the excess water from the mop pad. She reentered the resident room and dropped one mop pad on the floor by the window. She returned to the cart and grabbed a mop handle. She proceeded to wash the floor with the mop. She then entered the restroom and proceeded to wash the restroom floor. She finished mopping the floor with the mop working herself out to the doorway. She exited the room and pulled the mop pad off with her same contaminated gloved hands and placed the mop pad in the plastic bag. She removed her gloves and threw them into the trash on her cart. Throughout this entire process HSK #1 did not change her gloves or perform hand hygiene in between tasks while leaving the resident's room to take items from her cart. HSK #1 then walked over the linen closet in the hall and retrieved linens to make the bed. She returned to the room and proceeded to make the bed. She did not have any gloves on as she made the bed. She completed making the bed and completed the room. She did not wash or sanitize her hands before or after making the resident's bed and finishing the room-cleaning process. B. Staff interviews HSK #1 was interviewed on 4/13/2020 at 12:28 p.m. She said she would start cleaning the room from the large area to the restroom. She said she left the spray on for three minutes then wiped working her way out of the room. She said she would then mop the floor and then finish mopping the restroom. She said she used the same mop for both the room and the bathroom. The housekeeping supervisor (HS) was interviewed on 1/30/2020 at 1:16 p.m. The HS was told of the observation above. She stated housekeepers should start cleaning from the window out and the restroom should be the last thing to clean. She said they should use different rags for every task or area they were cleaning. She said the disinfectant dwell time should be three to four minutes and then wipe off the area. She said staff needed to change gloves between cleaning areas. She said after they came out of the bathroom they should either wash their hands or use hand sanitizer and then change to a new pair of gloves. She said they should change gloves after every new task especially after cleaning the restroom. She said the housekeeper should use two different mop heads when washing the large room floor and they needed to use another mop for the restroom. She said a negative outcome would be the spread of infections and potential for cross contamination.

Based on observation, record review and interviews the facility failed to provide care and services needed to attain/maintain the highest practicable physical, mental, and psychosocial well-being for one (#128) of two residents for non-pressure related skin issues out of 24 sample residents. Specifically the facility failed to: -Assess Resident #128's vascular wound on admission; -Follow physician orders for wound care and pain management before and during dressing changes; -Clarify the physician's orders for treatment of [REDACTED].>-Have necessary supplies on hand to provide wound care; and -Provide timely treatment to the wound. The failure to provide ointments, timely treatment and pain management with dressing changes resulted in an increase in pain and anxiety for Resident #128 not usually experienced during dressing changes. Finding include: I. Facility policy The wound care policy, revised in (MONTH) 2010, was provided by the director of nursing (DON) on 12/19/19 at 1:00 p.m. The policy read, in pertinent part, The purpose of these guidelines was to provide wound care to promote healing, verify that there is a physician's order for the wound care, and review the care plan to assess for any special needs of the resident . II. Resident #128 [NAME] Resident status Resident #128, age 86, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 12/16/19 minimum data set (MDS) assessment revealed the resident was cognitively intactt with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had varicose veins of lower right extremity with ulcers and encounter for change/removal of non-surgical dressing. B. Observations and resident interviews The resident was observed on 12/18/19 at approximately 9:45 a.m., seated in a recliner in her room. The resident had a gauze dressing on her right lower leg. The gauze had frayed edges and was discolored gray. An area approximately four inches by four inches was saturated with dry/crusted blood. Registered nurse (RN) #2 entered the room and administered medications to the resident. According to the Medication Administration Record [REDACTED]. The RN said specific instructions for where to apply the [MEDICATION NAME] were not included in the order so she did not administer the ointment. The resident told the RN the [MEDICATION NAME] ointment was to be applied to the wound on her right leg. She said she was in pain and described it as a five or six out of ten. The RN left the room to inform the DON about the [MEDICATION NAME] order. The resident said the dressing was supposed to be changed daily but no one had removed the dressing or looked at her wound since she was admitted on [DATE]. The resident was observed during a dressing change on 12/18/19 at 4:06 p.m. She sat in a recliner chair in her room with her legs elevated. The DON placed a chux cloth under the resident's right leg and began to remove the soiled and discolored dressing. The resident said she was nervous and anxious about the wound care. She grimaced in pain as the DON peeled the dry crusty gauze away from the wound. The dressing was stuck to the wound as the resident held onto her thigh for support. The resident said It hurts really bad and started crying. The resident said the dressing did not usually stick to the wound. She told the DON it was supposed to be changed daily but had not been changed since Sunday (12/15/19) in the hospital. The DON poured normal saline solution over the gauze and allowed it to soak in order to remove the dressing more easily. The wound was bright red, swollen and seeping with fluid. The resident continued to cry. The DON asked RN#2 if the resident could have pain medication. The RN retrieved some pain medication and administered it to the resident. Next, the DON applied [MEDICATION NAME] gel to the inflamed areas of the wound. The DON waited 10 minutes for the pain medication/ointment to take effect. At 5:22 p.m., the DON washed the wound with soap and water, rinsed it with normal saline and applied the clean dressings. Although the resident had an order for [REDACTED]. C. Record review 1. Care plans The care plan for skin integrity, initiated on 12/17/19, identified the resident had a venous ulcer (location was not identified). The resident's goal was to have no signs and symptoms of infection or worsening of skin alteration. Interventions included keep fingernails short to avoid scratching; keep hands and body parts free from excessive moisture; encourage fluid intake; encourage good nutrition and hydration to promote healing; monitor effectiveness of treatment as needed per weekly skin assessment; monitor and document location, size and treatment of [REDACTED]. to the MD (medical doctor); and, PT/OT (therapy). The care plan for pain, initiated on 12/17/19, identified the resident has the potential for pain related to PAD (peripheral artery disease) right lower extremity wounds and wounds on bilateral toes. The resident's goal was to not have discomfort related to side effects of [MEDICATION NAME]. Interventions included the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; administer pain medication as per orders; give 1/2 hour before treatments or care as needed; anticipate the resident's need for pain relief, provide pain interventions and follow up for effectiveness of interventions; evaluate the effectiveness of pain interventions; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results; impact on functional ability and cognition; and, monitor/record pain characteristics including quality (e.g. sharp, burning), severity (1 to 10 scale), anatomical location, onset, duration (e.g., continuous, intermittent), aggravating factors, and relieving factors. 2. Physician orders The 12/16/19 admission orders [REDACTED] - (Home health agency) please do dressing changes (Tuesday/Wednesday/Friday) to RLE (right lower extremity) per (wound care physician) request to monitor for infection, wash RLE with soap and water to rinse wound with sterile normal saline. Dakins solution or H Chlor 12 0.125% soak x10 minutes to wound bed and then rinse with saline. To RLE: Apply saline moist [MEDICATION NAME] blue classic, cover with kerramax, remedy lotion and A&D (moisture barrier) to leg, [MEDICATION NAME] to peri-wounds and anterior ankle, ABD (large dressing) to shin, Cast padding and [MEDICATION NAME] G (stocking). Patient will be seen (Monday/Thursday) at OP (outpatient) wound clinic. - [MEDICATION NAME] 5% ointment apply topically daily. The (MONTH) 2019 CPO included orders: - Remove dressings and apply [MEDICATION NAME] ointment to wound beds, let sit in the wound bed for 10 minutes. Wash RLE with warm soapy water, rinse RLE with normal saline. Place Dakins soaked gauze on wound beds, let sit for 10 minutes. Rinse RLE with normal saline, pat dry. Apply A&D ointment and [MEDICATION NAME] ointment to periwounds and anterior ankle. Cut Hydraferra Blue to fit over wound beds and Soak Hydarferra Blue in normal saline. Cover with KerraMax. Place ABD pad to shin Wrap leg in cast padding, cover with surgigrip, order date 12/18/19. - H-Chlor 12 solution (an antiseptic) 0.125% apply topically to the wound bed every Tuesday, Wednesday and Friday for wound care, order date 12/17/19. - [MEDICATION NAME] ointment (a moisture barrier) 0.44-20.6 % apply topically to the wound and ankle on Tuesday, Wednesday and Friday, order date 12/17/19. - [MEDICATION NAME] 5% gel (a pain ointment) apply topically to the affected area daily (discontinued 12/17/19 and included in 12/18/19 wound treatment order-see above). The care plan for skin integrity, initiated on 12/17/19, identified the resident had a venous ulcer (location was not identified). The resident's goal was to have no signs and symptoms of infection or worsening of skin alteration. Interventions included keep fingernails short to avoid scratching; keep hands and body parts free from excessive moisture; encourage fluid intake; encourage good nutrition and hydration to promote healing; monitor effectiveness of treatment as needed per weekly skin assessment; monitor and document location, size and treatment of [REDACTED]. to the MD (medical doctor); and, PT/OT (therapy). The start date for wound care was changed from 12/17/19 to 12/20/19 because physician ordered ointments were not available (see DON interview below). 3. Nurses' notes 12/17/2019 - A nurse's note written at 6:51 a.m. documented the resident was at the facility for skilled services, wound management and strengthening. The note revealed the facility was waiting for medication from the pharmacy. The resident showed no signs or symptoms of discomfort and had no specific request. Concerns were for RLE wound previously treated during an earlier admission, awaiting wound products. - A nurse's written at 2:51 p.m. read, Concern persists about dressing change to RLE. 12/17/19 nurses' notes did not reveal the facility attempted to contact the pharmacy to try to expedite the delivery of supplies and or contact the physician to report the delay in treatment. 12/18/19 - A nurse's note written at 10:00 a.m read, Resident complains pain most at the RLE. Resident is alert and oriented time x2-3, c/o (complained of) pain most at the RLE, had [MEDICATION NAME] (pain medication) twice during the shift. States that it helped especially with the dressing changes. DON to change the dressing as per the order. Resident participating in PT/OT (therapy) during the shift. Transfer with maximum assist with the walker. Able to make her needs know and compliance to all the care medication. Resident resting well at the moment. Will continue to monitor. - A nurse's note written at 10:32 a.m documented the resident reported pain and received pain medication. The medication was ineffective, leaving the resident with pain described stabbing and was rated a six (out of 10 on a pain scale). - A nurse note written at 11:46 a.m. read, Call and fax the orders to the pharmacy for the wound care medications ([MEDICATION NAME], Dakins sol, and A&D) and reported that they will deliver by the end of the day. -A nurse note written at 12:20 p.m. documented an order for [REDACTED]. -A nurse note written at 4:41 p.m. noted the resident reported pain and received pain medication. The medication was ineffective, leaving the resident with pain described as a seven (out of 10). According to the nurse, The resident is in a lot of pain. - A nurse's note written at 4:42 p.m. documented the resident received PRN (as-needed) medication for pain experienced during the dressing change. 12/18/19 nurses' notes did not reveal the facility contacted the physician to report the delay in treatment or receive additional orders. 12/18/19 nurse's notes documented the resident experienced an increase in pain related to the wound on her right lower leg. 4. Admission data collection sheet The 12/16/19 nursing admission data collection sheet documented the resident had no history of skin issues but was admitted with a right lower leg laceration. The wound was not described or measured during the data collection process. A narrative included on the data collection sheet read, Covered wound, will be seen once the dressing is removed. D. Staff interviews The DON was interviewed on 12/18/19 at 10:30 a.m. The DON said she cancelled the original wound care orders on 12/18/19 because the ointments/solutions needed to complete the wound care were not available from the pharmacy. The DON said the resident did not receive wound care or a dressing change on 12/17/19 (Tuesday) and she was aware of that. She said the dressing change and wound care was moved to 12/20/19 because there were no previous orders for the facility to change the dressing. The medical records specialist (MRS) was interviewed on 12/18/19 at 2:53 p.m. The MRS said she typically ordered wound supplies whenever the DON gave her a request. She said the supplies for the resident's wound dressing were ordered on [DATE] and the turnaround time for delivery was generally two to three days. The nursing home administrator (NHA) was interviewed on 12/18/19 at 3:05 p.m. The NHA said the resident was seen by a wound clinic in the past. He said the resident was recently admitted to a hospital and was not provided with orders to return to the wound clinic upon discharge. The NHA said he called and rescheduled the resident to continue care with the clinic and she had an appointment on 12/19/19. He said he also called to clarify the wound orders for the facility to follow and was waiting for return call from the wound clinic. A technician from the pharmacy was interviewed on 12/18/19 at 3:29 p.m. The technician said the process was for new medication orders or revisions to be faxed over by the facility, filled by the pharmacy and sent out to the facility as soon as possible. The technician said pharmacy records indicated the resident's [MEDICATION NAME] solution was ordered and delivered to the facility on [DATE] and [MEDICATION NAME] ointment was ordered and delivered to the facility on [DATE]. The DON was interviewed on 12/18/19 at approximately 5:30 p.m. The DON said each new resident should receive a full skin assessment upon admission. She said, according to the 12/16/19 admission nursing assessment, the resident did not receive a full skin assessment upon her admission to the facility. She said she changed the start date for the wound care without notifying the physician because the facility did not have the supplies to complete the care. She said that did cause the dressing change to be delayed a few days. A nurse case manager from the wound clinic was interviewed on 12/19/19 at 8:35 a.m. The nurse case manager said the resident was seen by the clinic on a regular basis but was recently sent to the hospital. She said the resident's wound orders had been the same for awhile but she would have the physician see the resident and update orders with any changes. The nurse case manager said a delay in treatment and not having fresh dressings could cause the wound to heal slower than expected or to become infected.

Based on record review and interview, the facility failed to ensure nurse aides received required in-service training for three out of five nurse aides reviewed. Specifically, the facility failed to ensure the continuing competence training, no less than 12 hours per year, for three (#1, #2 and #3) certified nurse aides. Findings include: [NAME] Record review A review of nurse aide training records provided by the nursing home administrator on 12/18/19 revealed: - Certified nurse aide (CNA) #1, hire date (MONTH) 2000, completed three hours of in-service training between (MONTH) (YEAR) and (MONTH) 2019. - CNA #2, hire date (MONTH) 2014, completed three hours of in-service training between (MONTH) (YEAR) and (MONTH) 2019. - CNA #3, hire date (MONTH) 2014, completed three hours of inservice training between (MONTH) (YEAR) and (MONTH) 2019. B. Staff interviews The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 12/19/19 at 2:55 p.m. The NHA said he reviewed the sample of nurse aide training records. He said training was evident for newer nurse aides but the number of hours were not being met by nurse aides who were employed by the facility for more than a year. The DON said staff also received computerized training and the record of in-service should be easy to verify by printing a training report. The NHA acknowledged this practice but said there were no records to print for three of the nurse aides in the sample. He said the sampled nurse aides did not keep up with training and monitoring of staff training did not reveal the concern.

Based on record review, observations and interviews the facility failed to provide medications and/or biologicals, as ordered by the prescriber, to meet the needs of one (#128) of four residents reviewed for medication administration out of 24 residents. Specifically, the facility failed to obtain and administer physician-ordered medications in a timely manner to prevent treatment delays. Cross-reference F684, failure to provide timely wound care. Findings include: I. Facility policy The medication ordering policy dated (MONTH) 2019 was provided by the director of nursing (DON) on 12/19/19 at 1:00 p.m. The policy read, in pertinent part, The facility must provide pharmaceutical services that include procedures that assure the accuracy, acquiring, receiving dispensing and administering of all drugs and biologicals to meet the needs of the resident. II. Resident #128 [NAME] Resident status Resident #128, age 86, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 12/16/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had [MEDICATION NAME] degeneration, varicose veins of lower right extremity with ulcers and encounter for change/removal of non-surgical dressing. B. Record review The (MONTH) 2019 CPO included orders for: - [MEDICATION NAME] solution (eye drops) 0.2% apply to both eyes twice daily for [MEDICAL CONDITION], order date 12/16/19. - H-Chlor 12 solution (an antiseptic) 0.125% apply topically to the wound bed every Tuesday, Wednesday and Friday for wound care, order date 12/17/19. - [MEDICATION NAME] ointment (a moisture barrier) 0.44-20.6 % apply topically to the wound and ankle on Tuesday, Wednesday and Friday, order date 12/17/19. The (MONTH) 2019 CPO revealed the DON changed the start date for H-Clor 12 solution and [MEDICATION NAME] ointment on 12/17/19 at 3:23 p.m. from 12/17/19 to 12/20/19. Nurses' notes completed between 12/16/19 and 12/20/19 failed to reveal the facility contacted the resident's physician to change the start date from 12/17/19 to 12/20/19. A nurse's note written on 12/18/19 revealed a new request for H-Chlor 12 solution and [MEDICATION NAME] ointment was not sent to the pharmacy until 12/18/19 at 11:46 a.m. A nurse's note written on 12/18/19 revealed a new request for [MEDICATION NAME] solution was not sent to the pharmacy until 12/18/19 at 11:51 a.m. C. Resident interview The resident was interviewed on 12/18/19 at 9:15 a.m. The resident said she was suppose to have her wound dressing changed on Tuesday, 12/17/19. The dressing (including the use of biologicals) was not completed. D. Observation Registered nurse (RN) #2 was observed during medication administration on 12/18/19 at 9:57 a.m. An observation of the medication cart and interview with RN #2 revealed [MEDICATION NAME] solution eye drops (due at 8:00 a.m.), H-Chlor 12 solution and [MEDICATION NAME] ointment were not available for Resident #128. [MEDICATION NAME] eye drops were not administered. E. Staff interviews The DON was interviewed on 12/18/19 at approximately 11:24 a.m. The DON said the admitting nurse was suppose to verify the orders with the physician and then fax the orders to the pharmacy to be dispensed and delivered to the facility. She said the ointment/solutions from the pharmacy were delayed so she changed the order start date for H-Chlor and [MEDICATION NAME] to 12/20/19. She said the ointments/solutions were not available to complete the resident's wound care scheduled for 12/17/19. The DON said she did not know why the resident's eye drops were missed but the nurses knew to call the pharmacy for a refill when a medication was not available.

Based on record review, observation and staff interviews, the facility failed to implement appropriate and timely interventions to ensure one (#21) of 34 sample residents received the necessary care and treatment to prevent the development of new pressure ulcers and promote healing. Specifically: The resident acquired a stage III pressure ulcer to left outer foot in 11/12. The facility failed to ensure treatment interventions were re-evaluated when the ulcer did not heal; since that time, the ulcer has not improved and no treatment changes had been requested or made. The findings include: A. Professional References According to U.S. Department of Health and Human Services, Clinical Practice Guidelines Number 15, pages 3-4 and 13: -A Stage III ulcer is defined as full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. -Pressure ulcer management should include the development of treatment plans, which are re-evaluated "as soon as any evidence of deterioration is noted" and if there is no evidence of healing within 2-4 weeks. Guideline recommendations for treatment include a complete history and physical examination [REDACTED]'s risks for additional pressure ulcers." "Slough is a yellow [MEDICATION NAME] tissue that consists of [MEDICATION NAME], pus, and proteinaceous material. Slough can be found on the surface of a previously clean wound bed and it is thought to be associated with bacterial activity... The accumulation of necrotic tissue or slough in a chronic wound is of major clinical significance, because it is thought to promote bacterial colonization and prevent complete repair of the wound .... " See: Enoch, S, Harding K, "Wound Bed Preparation: The Science Behind the Removal of Barriers to Healing," Wounds. 2003;15(7) at www.medscape.com. B. Resident #21 Resident #21, age 84, was admitted to the facility on [DATE]. According to the 1/13 Computerized Physician order [REDACTED]. The resident was hospitalized [DATE] to 11/21/12 for confusion and urinary tract infection. The most recent Minimum Data Set (MDS), dated [DATE], showed the resident had moderately impaired cognitive status. The MDS coded the resident as not rejecting any care. The resident required extensive assistance with mobility and transfers from the bed. The resident was coded as having a Stage III pressure ulcer. 1. History of Pressure Ulcers after Admission - Resident's Ability to Heal Review of the medical record showed the resident had a weekly wound documentation progress notes (WWD). The WWD revealed: -A wound to the left foot (bottom lateral) was discovered on 7/9/12. The wound was healed 1/7/13. -A "DTI" (deep tissue injury) pressure ulcer on left outer foot was discovered on 9/28/12 when her cast was removed from the resident's fractured left ankle. The ulcer was healed 1/7/13. -A stage II pressure ulcer was discovered on the resident's left buttock 12/27/12. This ulcer was healed 1/7/13. A physician telephone order dated 1/8/13 documented, "D/C (discontinue) treatment orders to left buttocks wound, Left outer foot wound (black area) and ball of Left foot d/t (due to) areas being healed." 2. Stage III Ulcer Left Foot - Facility Response - Failures in Facility Response a. Record Review In addition to the above ulcers, another ulcer, a Stage III ulcer, was discovered 11/16/12 on the resident's left foot. Review of the WWD progress notes, care plan and nurses' notes revealed: 11/16/12: On 11/16/12, the Initial Wound Evaluation read: 1 cm (length) X 1 cm (width) and 0.1 cm depth. The pressure ulcer was documented as a stage III on the left outer foot. The wound base documented 50% granulation and 50% slough. The WWD progress sheet documented, "In house acquired on 11/16/12." Although the WWD indicated the Stage III ulcer was discovered 11/16/12, a dietary progress note dated 11/14/12 read, "per DON (director of nurses) noted stage III P.S. (pressure sore) to left outer foot. She does not want the med pass. Will continue to encourage protein dense foods." Another dietary progress note dated 11/20/12 read, "labs 11/16/12: [MEDICATION NAME] 2.7 low ...protein needs 1.5 gm/kg 107 gm/day ...she still remain on a multivitamin." The resident was hospitalized for [REDACTED]. Review of the 1/13 computerized physician orders [REDACTED]." Review of the skin and WWD Progress Notes after the resident's readmission 11/21/12 to 1/17/13 revealed the facility failed to ensure treatment interventions were re-evaluated when the ulcer did not heal; since 11/21/12, the ulcer has not improved and no treatment changes have been requested or made. Specifically: 11/21/12: On 11/21/12 (date of readmission), the Wound Evaluation read: 1 cm (length) X 1 cm (width) and 0.1 cm depth. The wound base was documented as 50% granulation and 50% slough. The wound progress was documented as "improved," although see above, the measurements were the same as on 11/16/12. A dietary progress note dated 12/4/12, read: "...trying to incorporate protein into meal plan. Willing to try large meat portions ...re-draw serum [MEDICATION NAME] ..." However, there was no documentation in the record (reviewed 1/22/13) that the resident's [MEDICATION NAME] was redrawn. 12/6/12: On 12/6/12, the Wound Evaluation read: 1.3 cm (length) X 1.2 cm (width) and 0.1 cm depth. The wound base was documented as 50% granulation and 50% slough. The pressure ulcer had a scant amount of drainage, and the serous was brown and yellow. No odor. The wound progress was documented as improved although see above, the length and width of the ulcer had increased. On 12/12/12, almost three weeks after discovery of the third pressure ulcer, a care plan was initiated for "Skin breakdown in 3 areas on left foot, 2 areas related to cast." The goal was that the 3 areas would resolve without complication. Interventions included: Treatment as ordered; weekly skin checks; boots on when in bed; nutritional interventions as she will allow. 12/13/12: On 12/13/12, the Wound Evaluation read: 1.3 cm (length) X 1.0 cm (width) and 0.1 cm depth. The wound base was documented as 50% granulation and 50% slough. The pressure ulcer continued to be staged as a stage III pressure ulcer. The wound progress was documented as no change. On 12/18/12, the resident's care plan (see above) was reviewed. The plan was to 'cont(inue) interventions.' 12/20/12: On 12/20/12, the Wound Evaluation read: 1.5 cm (length) X 1.1 cm (width) and 0.1 cm depth. The wound base was documented as 50% granulation and 50% slough. The pressure ulcer had a scant amount of drainage, and the serous was brown and yellow. The wound progress was documented as no change. Although the resident's wound had not shown signs of improvement in the last four weeks, there was no documentation in the physician orders [REDACTED]. The care plan noted treatment reviewed and adjusted; however, review of the telephone orders revealed this treatment change addressed the left outer foot black area (resolved 1/7/13) and left ball of foot (resolved 1/7/13). The 12/12 CPO continued to read as above for the Stage III: "Cleanse left outer foot wound with wound cleanser, apply wound gel and border gauze daily." 12/27/12: On 12/27/12, the Wound Evaluation read: 1.4 cm (length) X 1.3 cm (width) and 0.2 cm depth. The wound base was documented as 50% granulation and 50% slough. The pressure ulcer had a moderate amount of drainage, and the serous was documented as bloody, brown and yellow. The wound had increased in length, width and depth from 12/20/12 (see above). There was no documentation the physician was notified regarding these changes or questioned about a treatment change. 1/5/13: On 1/5/13, the Wound Evaluation read: 1.5 cm (length) X 1.1 cm (width) and 0.2 cm depth. The wound base documented 50% granulation and 50% slough. The pressure ulcer had a scant amount of drainage, and the serous was documented as brown. The wound progress was documented as improved, although several of the wound's characteristics (see above) remained unchanged. The care plan was reviewed 1/8/13, documenting that wounds on left outer foot (DTI) and ball of left foot had resolved and to "continue treatment and interventions to Stage 3 on L(eft) outer foot." The 1/13 computerized physician orders [REDACTED].") 1/10/13: On 1/10/13, the Wound Evaluation read: 1.4 cm (length) X 1.1 cm (width) and 0.2 cm depth. The wound base documented 50% granulation and 50% slough. The pressure ulcer had a scant amount of drainage, and the serous was documented as brown and yellow. The wound progress was documented as improved. However, review of the WWD above revealed the wound characteristics remained unchanged since discovery 11/16/12, over seven weeks earlier. No treatment changes had been initiated since the ulcer was discovered. A 1/15/13 dietary progress note documented, "TO (telephone order) 1/8/13 to d/c current orders to left buttocks wound, left outer foot wound (black area) and ball of Left foot d/t (due to) areas being healed ....no updated labs to review ...still eats in room intakes can vary related to food choices and how she feels ..." The above dietary note failed to address the resident's Stage III ulcer that had not healed. 1/17/13: On 1/17/13, the Wound Evaluation read: 1.2 cm (length) X 0.9 cm (width) and 0 cm depth. The wound base was documented as 100% slough. The pressure ulcer had a moderate amount of drainage, and the serous was documented as brown and yellow. The wound progress was documented as stable, although the percentage of slough had increased from 50% to 100% (see reference above; "the accumulation of necrotic tissue or slough in a chronic wound is of major clinical significance, because it is thought to promote bacterial colonization and prevent complete repair of the wound ...."). b. Observations On 1/17/13 at 8:45 a.m., the resident's Stage III pressure ulcer on her left foot was observed: -The wound measured approximately 1.2 cm length (nurse unable to get exact measurement due to resident refusing to move her foot to allow measurements) 0.9 width and no depth. The wound bed was covered 100% in yellow slough. There was some drainage noted and there was no odor present. -During wound care, the registered nurse (RN) removed the resident's dirty dressing and then proceeded to clean the wound without washing her hands or changing her gloves. On 1/22/13 at 10:12 a.m., the RN acknowledged that she did not change her gloves between removing the dirty dressing and cleaning the wound. 3. Staff Interviews The RN who regularly measures and provides the wound treatments was interviewed 1/22/13 at 9:15 a.m. -The RN stated the current treatment order was clean with wound cleanser, apply wound gel and boarder gauze one time a day. She stated the measurements were taken once a week on Thursday. She stated that the wound had improved and stated the pressure ulcer was a circular wound bed with yellow slough at 100%. The RN said the ulcer did not look infected. The resident's physician was interviewed on 1/23/13 at 11:22 a.m. The physician stated that he could not remember the last time he had seen the pressure ulcer, but thought it had been a couple of weeks ago. (Review of progress notes reveal a note 1/7/13 noting 'ankle fx - wound healing.) He stated that the treatment used to be changed every two weeks. He stated he would talk to the Director of Nurses (DON), as she was the wound care expert, and he went by what she told him. The DON was interviewed on 1/23/13 at approximately 2:00 p.m. -The DON stated the pressure ulcer was discovered on 11/16/12 at a Stage III. The resident had previous pressure ulcers on her feet, although they have since healed. She stated that she observes the pressure ulcer once a week, although she had not had a chance to look at this past week. She stated she reviews the WWD weekly. -DON stated the last time she saw the wound the "whole wound bed was yellow." She described the yellow slough as "dead tissue." She stated the last time she saw the wound it was the 1.4 cm. X 1.1 cm X 0.2 cm. (See measurements above on 1/10/13) -The DON stated the treatment for [REDACTED]. She stated that the treatment would be changed if was necessary. She stated that she did not know if the treatment should be changed. She said wounds were reviewed monthly in the Quality Assurance meetings. The registered dietitian (RD) was interviewed, on 1/23/13 at 4:00 p.m. The RD stated that he was in the building weekly. He stated that he receives a wound report weekly. The last report he received was 1/4/13. -The RD stated that the resident had wounds on her foot from the cast that she was wearing (due to a fracture ankle). He stated the wounds had since healed, as his dietary progress note documented (see note on 1/15/13 above). -The RD said the resident had a low [MEDICATION NAME] back 11/12, so he suggested in his 12/4/12, note to have another [MEDICATION NAME] level drawn. However, he stated he suggested this, but he doesn't write orders. After reviewing the medical record, he determined there had not been follow-up on his suggestion. He said that if the resident had refused to have lab work, he would have documented it (and there was no documentation of a refusal). He said that the resident, although refusing health shakes, had agreed to have more protein such as extra meat servings. -The RD stated that he assesses the resident every time he sees her. He stated that he did not address the current pressure ulcer in his last note, as he addressed it when it was discovered. -The RD stated the resident was discussed in the Nutrition at Risk committee, which included her skin conditions, and weight. He said that her caloric needs and protein needs had not changed. The DON was interviewed again on 1/24/13 at 9:30 a.m. The DON stated that she wanted to clarify the resident's pressure ulcer history. She said the resident had a cast from a fractured ankle and when it was removed, a wound was found on the ball of her left foot. It was unstageable and it has since resolved. She also had one on her outer left foot, which was a deep tissue injury. It also resolved. The current pressure ulcer was correctly staged (III). She stated that the wound gel continued to be the current treatment. She stated that the RN who changed the dressing on 1/17/13 (see above) was nervous and that contrary to what the documentation and what she had stated at earlier in the interview on 1/23/13, the wound was not 100% slough, but remained at the 50%. 4. Follow-up The pressure ulcer was observed on 1/17/13 to have 100% slough. The physician observed the wound six days later on 1/23/13. The physician's progress note dated 1/23/13 read: "Pt (patient) seen to re eval(uate) her left foot wound. Pt denies presence of pain ...left foot 1.2 X 0.7 cm shallow wound lateral aspect pink granulation tissue of slough grey bed easily bleeds with tactile pressure...this appears to be slowing improving. It does not require manual debridement. I don't believe change in wound care is indicated ..."

Based on observations, record review and staff interviews, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being for one of ten sample residents (#2) and one supplemental sample resident (#11), in accordance with the comprehensive assessment and plan of care. Specifically: -The facility failed to manage resident #2's pain during wound care; -The facility failed to ensure resident #2 and resident #11 were appropriately positioned in their wheelchairs. The findings include: I. Wound Care A. Facility Expectations with Wound Management and Pain Control The Palliative Wound Management Guidance policy was reviewed and read in pertinent part, "According to the National Pressure Ulcer Advisory Panel, pressure ulcer development in individuals receiving palliative care is never going to be able to be eradicated due to the multiple risk factors and organ system failure that the individual experiences. Even though individuals receiving palliative care are at high risk for skin breakdown and healing is often not a realistic goal, it is important to continue to implement preventative and treatment interventions as appropriate and in accordance with the individuals' wishes." "Goal of Palliative Wound Management - The overall goal of palliative wound management are comfort and minimizing the extent or impact of the wound, without the intent of healing. -Pressure Redistribution..Pre-medicate the individual 20-30 minutes prior to repositioning as appropriate, observe the individual choices in repositioning and position of comfort. -Comfort is the primary goal; therefore comfort may supersede prevention causing the individual to have a single position of comfort. Utilize appropriate support surfaces in the bed and wheelchair to provide comfort as well as improve pressure redistribution, avoid lying or sitting directly on a pressure ulcer whenever possible or per the individual's wishes, protect bony prominences and utilize positioning devices.. -Monitor the ulcer in order to continue to meet the individuals' goals, such as comfort, pain control, and management of odor and drainage.." The Guidelines for Pain Management of Wounds was reviewed and read in pertinent part, "..If consistent with treatment plan, provide opioids and/or non-steroidal anti-[MEDICAL CONDITION] drugs 30 minutes prior to dressing changes or procedures and afterward.. Topical Management of pain (allow for adequate time to take effect, may require greater then 15-30 minutes)..Provide time out periods during the dressing/procedure, utilize lift or transfer sheet to minimize friction and shearing forces, avoid positioning the individual on the ulcer as appropriate..position changes.." B. Failure to manage resident #2's pain during wound care Resident #2, [AGE] years old, was admitted to the facility on [DATE]. According to the [DIAGNOSES REDACTED]. 1. Resident Status According to the 12/6/11 Minimum Data Set (MDS), the resident had short and long-term memory impairments with severe cognitive impairment in daily decision-making. There were no behaviors reported. The resident was on a scheduled pain regimen and also received prn (as needed) medications. Non-medication interventions were utilized for pain. The resident was unable to participate in an interview regarding pain. Two stage II unhealed pressure ulcers were identified as new for the resident. The resident was admitted to hospice services on 1/11/12 with a [DIAGNOSES REDACTED]. Review of the (pertinent) 1/27/12 resident care plans identified the resident had cognitive impairment function and impaired thought processes. The resident had chronic pain related to arthritis. -Staff was directed to anticipate the resident's need for pain relief and respond immediately to any complaint of pain/discomfort. The resident demonstrated a communication problem and staff should anticipate and meet her needs. Staff was directed to monitor for physical/nonverbal indicators of discomfort or distress and follow-up as needed. -The resident was identified with pressure ulcers and staff was directed to follow facility policies/protocols for the prevention/treatment of [REDACTED]. The 11/29/11 pain evaluation revealed the resident was in pain with repositioning and transfers, and was not reluctant to verbalize or express pain. The Abbey Pain scale showed a score of six, indicating mild pain and chronic in nature. -The resident exhibited mild vocalization with movement such as whimpering, groaning or crying. -The resident exhibited moderate pain with facial expressions such as looking tense, frowning, grimacing, or looking frightened. -The resident exhibited mild pain with behavioral changes, physiological changes and physical changes. On this document, staff wrote, "pain when transferred, repositioned, pt. will moan, pt. will grimace, frown." A note written by the physician on 1/19/12, "Statement of concern: Regarding her weight loss and wound, I believe she is reaching the end of her life. She suffers from advanced dementia with severe impairments in functional ability. She is essentially non-ambulatory. She has been continent of bowel and bladder. She is dependent on all cares. We tried to manage her pain as best we can and tried to optimize her nutrition as best we can. Despite these efforts, her condition continues to deteriorate. I believe her weight loss and the presence of her wound is unavoidable, given the end-state nature of her disease and the fact she is reaching the end of her life. I think ongoing measures to keep her comfortable and preserve her dignity are in order. More aggressive care for these problems would be contrary to her previously stated wishes." Review of the monthly nursing summaries, from 12/26/11 through 2/8/12, revealed the resident had frequent pain at a moderate level. The resident demonstrated facial expressions and moaning, and demonstrated protective body movements or posture changes to indicate she was in pain. The pain was located in the coccyx area. On 2/1/12, the physician orders [REDACTED]." Nursing staff could also administer [MEDICATION NAME] 325 mg every four hours as needed for mild to moderate pain, two tablets. The resident received the [MEDICATION NAME] at 10:00 a.m., 4:00 p.m., 10:00 p.m. and 4:00 a.m. Review of the February 2012 medication records revealed the resident received one dose of Tylenol on 2/17/12 for pain. The resident was squirming/grimacing. After the administration, the resident was not grimacing. Review of the physician orders, written 2/17/12, directed staff to change the resident's dressing to her stage IV coccyx wound daily and as needed. There were no orders to pre-medicate as indicated in the above policy. Review of the 2/25/12 skin assessment indicated the resident's wound progressed to a stage IV pressure sore on the coccyx (which would mean an open area down to the bone). Review of the weekly wound documentation indicated the resident did not have pain associated with the wound. Review of the February pain assessments, completed on a daily basis, indicated the resident did not have any complaints of pain. 2. Even though nursing documentation reported the resident did not have pain, observations during wound care revealed the resident demonstrated objective signs of pain. More specifically: On 2/28/12 at 3:00 p.m. observations of wound care for resident #2 were conducted. The licensed practical nurse (LPN) positioned the resident on her right side with the assistance of a certified nurse aide (CNA). -The LPN removed the old dressing, revealing a deep open wound at the resident's coccyx area. The wound was clean with minimal drainage noted on the old dressing. The wound opening was deep; therefore, the bottom of wound bed was not visible. -During the observations, when the LPN sprayed wound cleanser directly into the wound bed, the resident attempted to withdraw from the nurse, pulling her buttocks forward and drawing away from the nurse. At that time the nurse said, "I know it's cold (resident name), I'm sorry." The LPN wiped the residual cleaner from the wound site, and stated she planned to repeat using the cleanser, stating, "That's just me, I'm obsessive." The resident again attempted to withdraw her buttocks away from the nurse. -Following the cleanser, the LPN applied wound gel deep inside the wound with a cotton tipped swab applicator. When she removed the applicator, she stated, "I was off the last four days, and it's evident the tunneling has increased." The resident again attempted to withdraw from the nurse, pulling her buttocks away from the nurse's probing. -The LPN then instructed the CNA to pull the resident's buttocks apart further, stating that she needed the resident to be positioned so she could, "sprinkle the powder directly into the wound bed." The resident again withdrew her buttocks, pulling away from the nurse. At that time, the LPN said that she typically pre-medicated the resident prior to the wound care, because it was painful; however, she said the resident had just recently received a dose of [MEDICATION NAME] and therefore, she could not give her anything until later. The LPN stated the facility was "really big on pain management." -The LPN then proceeded to introduce the alginate rope into the resident's wound, applying notable pressure to insert and pack the dressing into the wound bed. The resident again withdrew from the nurse, attempting to pull her buttocks away from the nurse. The LPN stated, "I know it hurts, (resident name) we're almost done." Review of the physician's orders [REDACTED]. The LPN reiterated and stated to the resident that she knew the resident was in pain and hurt during the dressing changes, and that she could have medication shortly after the procedure was done. On 2/29/12 at 10:21 a.m., the resident's physician (also the facility medical director) was interviewed. -He stated it had been difficult to treat the resident regarding pain. He said the resident frequently exhibited facial grimacing, "even on a good day." He said they had not been able to correlate any of the facial grimacing to pain. He said she would verbalize "Ou(ch)" which correlated with care. -He said that based on feedback from the staff and his clinical following of the resident, the frequency of the [MEDICATION NAME] was increased, and seemed to be helping her. Although, he further stated, even with the increase in pain medication, there was no evidence of any changes in her grimacing. "That's the way she is, part of her dementia." -He further stated he was all for keeping the resident comfortable, though he did not want her to become oversedated. The physician was then informed of the observations of the resident repeatedly attempting to withdraw and pull her buttocks away during wound care. In addition, during the observations, the resident was positioned on her left side facing the wall and visualization of the resident's back side was made from standing behind her. Therefore, her face/facial expressions were not readily visible during the observations above. During the interview, the physician stated that physically exhibiting signs of withdrawing her buttocks away from the nurse while she was probing inside the wound bed, could be a portrayal of pain. He said that made sense and stated they would address coordination of wound care with pain management, perhaps specifically ordering pain medication an hour or so prior to the wound care. II. Positioning A. Resident #2 See Resident #2's admitted and [DIAGNOSES REDACTED]. 1. Resident status The 12/6/11 Minimum Data Set, documented in pertinent part that the resident had short and long-term memory impairments with severe cognitive impairment in daily decision-making and was totally dependent on two staff members with Activities of Daily Living (ADLs). Review of the (pertinent) 1/27/12 resident care plans identified, in pertinent part, that the resident had limited physical mobility and was dependent on staff for ADL needs. Review of the 11/29/11 Braden scale for predicting pressure sore risk indicated a score of 'one' with mobility and friction/shearing. The score of 'one' indicated the resident was completely immobile in bed and required moderate to maximum assistance in moving. The resident would frequently slide down in bed or chair, requiring frequent repositioning with maximum assistance. 2. Failure to Properly Offload and Reposition On 2/28/12 at 2:45 p.m., in preparation for wound care, a LPN and CNA were observed to position resident #2 on her right side. They moved the resident, up and closer to the side of her bed, by sliding her body over the mattress. Following the completion of the wound care, peri care was provided, an adult brief was placed on the resident, she was dressed in sweat pants and placed on top of another incontinent pad. During this procedure, the LPN and CNA were again observed to slide the resident across the mattress (using the bottom bed sheet). On 2/29/12 around 7:55 a.m., resident #2 was observed sitting in the dining room. The resident's buttocks had slid down and forward in the chair, so the resident was sitting on her sacrum and her hips were shifted laterally and to the left of center in the chair. -The Director of Nursing (DON) was asked to observe the resident at this time. The DON acknowledged the resident was not sitting properly to ensure the coccyx area was off loaded. The resident was brought to her room. A CNA familiar with the resident stated the resident slid forward and down in her wheelchair to move off her buttocks and this was constant whenever she was up in the chair. -Staff then repositioned the resident back in the chair for optimal offloading. A few seconds later, the resident was observed to independently shift her buttocks forward in an attempt to move off her buttocks area a few times. The CNA commented, "that is why she is the last one up and the first one to lie down." With the DON present, the CNA stated hospice had provided this cushion for the resident and commented her positioning was much better than it was before (hospice services were initiated on 1/11/12). On 2/29/12 at around 1:15 p.m., the resident was observed up in the wheelchair (after lunch, staff had wheeled the resident into the common area). The resident had shifted her hips and bottom forward in the wheelchair about 1/4" from the back of the wheelchair (not effectively offloading the area). Another CNA approached the resident and commented, "she slides forward in her chair because her bottom hurts." Staff brought the resident to her room to lie down in bed. Observations were made of the resident's wheelchair at this time. The back of the wheelchair cushion was noted to have a cut out "V" pattern in the middle of the cushion. The tip of the "V" was 5 - 3/4 inches forward from the back of the wheelchair (about 1/4 way from the back of the wheelchair). The area right in front of the "V" was slightly raised, creating an indentation (increase area of pressure/wear and tear) of the resident's sitting posture and forward sliding. B. Resident #11 Resident #11 was admitted to the facility on [DATE]. Diagnoses, according to the face sheet, included [MEDICAL CONDITION] and subdural hematoma. 1. Resident status The 9/12/11 and 12/6/11 Minimum Data Set (MDS) assessments revealed the resident was dependent on staff for all care, mobility and postioning. Review of 2/12 computerized physician's orders [REDACTED]. The 2/11/12 comprehensive care plan identified, in part, the resident had a deficit in self care performance due to the subdural hematoma and [MEDICAL CONDITION]. The goal was for the resident to maintain her current level of function, total dependence on staff through the review date. Interventions included: - One to two staff participation with transfers, repositioning and turning in bed, - Weekly skin inspection, observe for redness, open areas, scratches, cuts, discolorations and report changes to the nurse, - Total dependence on staff to provide a bath twice weekly and as necessary, - One staff participation to dress, - Requires total assistance of one staff to eat. A second problem identified the resident had limited physical mobility related to the subdural hematoma and [MEDICAL CONDITION]. The goal was for the resident to maintain her current level of mobility, a high back wheelchair with trunk postioning pad and one person assist to move wheelchair through the review date. Interventions included: Resident is totally dependent on staff for locomotion. High back wheelchair, trunk positioning pad. 2. Failure to ensure proper positioning Observations of the resident, in her high back wheelchair, were conducted at various times throughout the survey from 2/27/12 - 2/29/12. More specifically: -On 2/27/12 at 8:37 a.m., during dining observations, the resident was observed seated in her wheelchair at the table. A staff member was feeding her. The resident was leaning towards her right side, with her head resting on the edge of the positioning pad. Her right arm was hanging over the side of the armrest and on top of the wheel. The staff member was not observed to attempt to reposition the resident to an upright position or move her arm from the wheel. -On 2/27/12 at 12:08 p.m., the resident was observed in the dining room. The resident was leaning towards her right side, with her head resting on the edge of the positioning pad. Her right arm was hanging over the side of the armrest and on top of the wheel. The staff member was not observed to attempt to reposition the resident to an upright position or move her arm from the wheel. -On 2/28/12 at 10:00 a.m., the resident was observed in the TV/activity area, seated in a circle with other residents. She was leaning towards her right side and her right arm was hanging over the side of the armrest and on the wheel of the chair. Throughout the activity, multiple staff members were in the area including, CNAs and activity staff. However, staff was not observed to attempt to reposition the resident or move her arm from off of the wheel. -On 2/28/12 at 12:15 p.m., a staff member was observed feeding the resident in the dining room. The resident was leaning towards her right side with her right arm hanging over the armrest resting on the wheel of her chair. The staff was not observed to attempt to reposition the resident or move her arm from the wheel. -On 2/28/12 at 12:35 p.m., the resident was observed seated in the same position as described above. -On 2/29/12 at 11:58 a.m., the resident was observed in the dining room. She was leaning towards her right side, slumped slightly forward and her head was at the edge of the positioning pad. Her right arm was hanging over the side of the armrest on top of the wheel. While staff assisted the resident during the meal and fed her, they were not observed to reposition the resident or her right arm. -On 2/29/12 at 1:15 p.m., the resident was observed seated in the TV/activity area. Even though a cushion had been added and was observed positioned in between the resident's right hip and the side of the wheelchair, her right arm was hanging over the side of the armrest of the chair and on the wheel. Staff was not observed to attempt to reposition the resident's arm or provide any type of device to assist in helping to keep her arm off the wheel. On 2/29/12 at 8:08 a.m., during breakfast, the resident was observed seated upright in her chair, with her head and neck positioned appropriately in between the postioning pad. A family member was observed feeding the resident with one hand, and the family's other hand was up underneath the resident's right arm, holding onto her right hand. The family was interviewed at the time and stated they came in every day to visit with and help feed the resident. On 2/29/12 at 10:50 a.m., the director of rehabilitation was interviewed. -She said typically, therapy conducted quarterly screenings on residents, in conjunction with the quarterly MDS assessments. She said in order to determine if a resident needed therapy intervention, the therapists obtained resident information from the MDS, the activities of daily living (ADL) log, word of mouth from the staff and/or from observations. -She said they used the MDS "a lot" and compared it to the previous assessment to determine if a screening was needed; although she said residents could be seen sooner than the three month time frame if needed. -She further stated when therapy did screen a resident, the screening form was maintained in therapy notebooks and not the resident's medical record, because a screening was not part of the permanent medical record. The director stated the resident's last therapy screening was done in 12/11, and said therapy had been working with the resident "on and off" over the years. She said they would make recommendations for adaptive equipment if that was needed, and not necessarily add the resident to their caseload. Or, she said they made recommendations to the family for various positioning aides/devices to assist the resident. She said therapy would meet with families and make recommendations for various items, however, "They (families) can follow or not do it." She said the resident's family had not been complaining; rather, the therapy department frequently went to the family with recommendations. When the director was informed that facility staff were not observed to attempt to reposition the resident's arm or assist her to a more upright position throughout the survey, she offered no comments. As of the survey exit the afternoon of 2/29/12, no therapy documentation or other information regarding the resident's positioning had been provided.

Based on observations, record review, staff and resident interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four (#4, #5, #6 and #8) of 10 sample residents. Specifically, the facility: -Failed to ensure pain was managed adequately for residents #4 and #5; -Failed to appropriately manage sliding scale insulin per physician order [REDACTED]. -Failed to follow physician orders [REDACTED]. Findings include: FAILURE TO ENSURE PAIN WAS ADEQUATELY MANAGED: A. References According to The Merck Manual of Geriatrics, Third Edition; Merck, 2000; pages 386, 389 and 391: "Identification of pain and [DIAGNOSES REDACTED]. Usually, it also requires supplemental use of rapid onset short-acting drugs, especially for breakthrough pain..." 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..." 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 pain assessment tools for older adults: "Patients' self report is the most reliable measure of pain intensity as there are no biological markers of pain. Simply worded questions and tools, which can be easily understood, are the most effective, as older adults frequently encounter numerous factors, including sensory deficits and cognitive impairments..." According to "Fundamentals of Nursing," by Harkreader & Hogan, 2nd Edition, (2000), page 411, "After administering a medication to a client, chart it immediately on the medication administration record (MAR) or computerized medical record." According to "Clinical Nursing Skills & Techniques," by Perry & Potter, 5th Edition, (2004), page 449: "After administering a drug, record the following information on the MAR (Medication Administration Record) or other appropriate form . . . signature and title of nurse administering drug." Review of the Pain Assessment/Documentation Guidelines for Licensed Nurse form, provided by the facility, documented in pertinent part: "Initial Admission Assessment: -Completed on the Health & Service Assessment (page 3/6) -Include on initial assessment ACCEPTABLE PAIN LEVEL -Guest Preferences section include: NON-PHARMACOLOGICAL INTERVENTIONS as identified by the resident to help manage pain ... may include: 1. Cold 2. Positioning 3. Massage 4. Music 5. Other (require documentation in back of MAR) -Pain medication orders on admission should include medication, dose, route, frequency, type of pain being treated --Residents w/ (with) PAIN PUMPS / IV meds etc should have alternative therapy ordered along with use of PUMP Ongoing Assessments: -Will be completed daily via resident interaction and documented on the MAR using the PAIN SCALE 0-10 or Non Verbal Scale as appropriate -Review of the Daily Log q (every) shift w/ DNA (Designated Nursing Assistant) for any new resident c/o of Pain -PRN PAIN MED use will be INITIALED on the Front of the MAR w/ supporting PAIN ASSESSMENT documented on the BACK of the MAR --PRN Documentation will include: 1. Pain rating premedication 2. Type & Location of pain 3. Non- Pharmacological Intervention 4. Reassessment of Pain Post medication w/ rating (0-10) ** should be documented no later than 2 HRS post medication** -Routine Medication are to be administered per MD (medical doctor) order and include daily assessment of pain to ensure that pain med regimen is appropriate -Monthly / Weekly assessments should include a review of the residents use and or need for PRN (as needed) / routine pain medication daily Pain Reassessments: -Will be completed as a NARRATIVE IDT NOTE and include but not be limited to a. Onset / Duration / Location / Severity of pain b. Identify Alleviating factors - Non Pharmacological interventions c. Acceptable pain level as identified by the resident d. Possible causes along w/ aggravating factors & accompanying s/s (signs/symptoms) e. Determine appropriate pain medication as ordered by the MD f. If no pain medication is ordered Notify the MD & obtain an Order g. Update ICSP to reflect new changes and identified alleviating aggravating factors -Completed QUARTERLY & with SIGNIFICANT CHANGE IN STATUS -Significant changes: will include but not be limited to 1. Initiating a new routine pain medication 2. Increased and more frequent use of PRN Pain meds that warrant reassessment to establish need for ROUTINE MEDICATION." B. Resident Data 1. Sample resident #4, [AGE] years old, was admitted to the facility on [DATE] with diagnoses, per face sheet and [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) information available. Review of care plans for the resident documented that he required limited to extensive physical assistance from one staff member for most activities of daily living, including ambulation, transfers, dressing, toileting and bathing. Review of a care plan for pain documented that the resident was to be monitored "for effectiveness of pain management program throughout the day." The care plan documented the resident's acceptable level of pain as a 3 (the facility used a pain rating scale of 0-10), and documented non-drug interventions as "reposition ice/heat." Additional approaches included: -"Monitor pain level each shift -Medication as ordered -Notify physician as needed." Review of a care plan for medications documented the resident was to receive medications as prescribed and monitored for side effects. Review of a care plan for support services documented the resident was to participate in physical and occupational therapy. Review of hospital records revealed the resident had a total knee arthroscopy on 1/06/11. Review of the initial Skilled Nursing Health & Services Evaluation/Assessment, dated 01/09/11, documented the resident had burning and sharp pain occasionally and rated it a 6/10, where zero was no pain and ten was the worst possible pain. The acceptable pain threshold was listed as 3/10. The pain site was documented as surgical incision on his right knee. Grimacing was marked as a non-verbal sign/symptom of pain for this resident. Review of the January 2011 Medication Administration Record (MAR) on 1/11/11 documented the resident had the following pertinent medications ordered: -[MEDICATION NAME] 5 mg tab, 1-2 tabs (5-10 mg) orally every four hours as needed for pain. -Tylenol 325 mg, 2 tabs orally every four hours as needed for temperature greater than 100 degrees. According to the MARs, the resident did not have any orders for routine pain medication. The MAR also revealed documentation of the pain assessments every shift. According to the January 2011 MAR, the resident's pain was assessed as: --1/10/11 -6-2 shift: 4 -2-10 shift: 0 -10-6 shift: initials documented, not pain assessment rating 01/11/11 -6-2 shift: 4 -2-10 shift: 5 -10-6 shift: 5 01/12/11 -6-2 shift: 5 C. Observations and Interviews The resident was observed in his room on 01/11/11 at 12:46 p.m., lying in his bed with the head of the bed elevated. The resident explained he had just arrived at the facility earlier that week after a total knee replacement. Observation of the resident revealed he was wearing shorts and his right knee was extremely swollen with multiple staples along a surgical incision. His knee was elevated on the bed, but not elevated by a pillow or other device and no ice was observed. The resident stated his pain was currently a 6/10. He also stated that it frequently took more than an hour to get pain medications when requested. The resident explained that he did not have an order for [REDACTED]. The resident also stated that the facility would bring ice if he asked for it, but he stated he didn't think to ask for it often. The MARs for resident #4 were reviewed at 12:52 p.m. on 1/11/11. The narrative on the back of the MAR revealed the resident had received one [MEDICATION NAME] tab (5 mg) at 8:20 a.m., on 1/11/11 with a decrease in pain (no pain scale ratings were documented) at 9:00 a.m. Record review and observation revealed the nurse was passing medications to resident #4's hall (nurse #1) did not administer any pain medication during the lunch time. The resident was observed on 1/11/11 at 1:34 p.m. Earlier observations revealed he ate lunch in his room, lying on his bed. At 1:34 p.m., the resident was observed visiting with his wife while receiving a muscle stimulator therapy (TENS) treatment on his right knee. The resident verified therapy staff had not asked him what his pain level was when they attached the TENS unit, and stated his pain was currently a 6/10. "The medicine only lasts about two hours." The resident stated the [MEDICATION NAME] worked in approximately 20 minutes and reduced his pain down to a 3/10, "I can tolerate that." The resident confirmed an acceptable pain level was 3/10. Nurse #1 was interviewed on 1/11/11 at 1:37 p.m., and stated she asked the resident in the morning how his pain was and he reported he was in pain so she gave him one [MEDICATION NAME]. The nurse stated, "Then I just medicate him if he asks." The nurse was unaware that the resident's current pain was a 6/10 or that his pain approximately one hour prior had been a 7/10. According to the MARs, the resident did not receive any routine lunchtime medications. The nurse verified she did not ask the resident to rate his pain more than one time per shift. The resident was interviewed on 1/11/11 at 2:40 p.m. He stated the TENS treatment helped and his pain was now a 5/10. He stated the nurse had not been in to rate his pain or offer him pain medication since early that morning. "You watch, it'll be a long time before they come ... you have to ask and ask ... wait and wait." The resident was observed on 1/11/11 at 3:50 p.m. He was lying on his stomach on his bed with his right leg hitched up at the hip and his right knee slightly bent. The resident appeared to be resting, although he was somewhat restless and continuously made small body adjustments. The resident was observed walking in the hall with a front-wheeled walker (FWW) and a therapy staff on 1/11/11 at 5:24 p.m. Nurse #1 was interviewed on 1/11/11 at 5:26 p.m., and stated she had not given the resident any pain medications since being notified of the resident's pain rating by the surveyor at 1:37 p.m., because she could not find the MARs in the med book. The Director of Nursing (DON) was interviewed on 1/11/11 at 5:33 p.m. and stated she expected a pain rating to be done each shift and then expected nurses to check with residents every time they were in the resident rooms to determine if they were in pain and if they had a need for PRN (as needed) pain medication. According to the DON, the residents should not have to ask for pain medication. If they did ask, they should not have to ask again. The DON reiterated that nurses should be checking with the resident about pain throughout the day. Review of the MARs showed the resident received two tabs (10 mg) of [MEDICATION NAME] at 5:55 p.m. on 1/11/11; however, there was no pain rating documented at the time of administration, per the reverse side of the MARs. According to this documentation on the MARs, the resident's pain was decreased to "4/10 at (illegible writing/unknown time)." The MARs also documented another dose of two tabs (10 mg) of [MEDICATION NAME] was administered at 11:00 p.m. on 1/11/11 with an additional notation that read, "2400 (12:00 a.m.) eff (effective) sleep." Review of the MARs on 1/12/11 showed the resident had received two tabs (10 mg) of [MEDICATION NAME] at 7:40 a.m. The resident was interviewed on 1/12/11 at 9:06 a.m. He had just finished his breakfast and was lying in bed with the head of the bed elevated. The resident appeared uncomfortable and was shifting in bed, grimacing and guarding. The resident stated his pain was a 5/10 and had not really improved since he had received his morning medications. He stated that no one had asked him how his pain was after the [MEDICATION NAME] administration earlier in the morning. Nurse #1 was interviewed on 1/12/11 at 9:12 a.m. and stated she gave the resident pain medication at 8:00 a.m., at which time the resident had rated his pain as 5/10. The nurse stated she had not had a chance to check on the resident's pain again since she administered the pain medication. When asked about medications for breakthrough pain, the nurse reviewed the MARs and then stated the resident had no other pain medications except the [MEDICATION NAME]; adding the only other options were non-pharmacological interventions. When asked about the Tylenol order, which, according to the back of the MARs, had been administered twice on 1/10/11 by nurse #1 for pain, the nurse stated, "Oh, yes, I could use that for pain breakthrough." The nurse stated that the facility's standing orders allowed Tylenol administration for temperature or pain. The nurse was notified of the 9:06 a.m., resident interview where he stated his pain level was still a 5/10; the nurse stated she would check on him and give him Tylenol. The DON was interviewed at 9:29 a.m. on 1/12/11 and stated she was concerned that the resident's current pain medication regimen was not effectively managing his pain. The DON was not certain whether the cause of the resident's pain was due to breakthrough pain or getting behind on the pain when the medication was not administered regularly. The DON stated, "There will be med changes." The resident was seen by his physician at approximately 10:00 a.m. on 1/12/11, per Interdisciplinary Progress Notes (IDPN). Review of the 1/12/11 IDPN documented, in pertinent part: " ...Pain control fair. The Oxy IR ([MEDICATION NAME]) is effective, but doesn't last long enough. Therefore, start [MEDICATION NAME] ER (extended release) bid (twice daily); continue to use [MEDICATION NAME] IR for breakthrough pain ..." The Nursing Home Administrator (NHA) and DON were interviewed on 1/12/11 at 3:04 p.m. The DON stated that her expectation of pain management was that nurses should be calling the physician if a resident's pain was not being controlled. The resident was interviewed on 1/12/11 at 4:12 p.m., and stated he felt much more comfortable after administration of his new pain medication, with a pain rating of 2/10. The resident stated he felt relieved now that the new [MEDICATION NAME] was [MEDICATION NAME] longer and knowing he had the other [MEDICATION NAME] available for breakthrough pain. The resident was resting on his bed and appeared more comfortable than in previous observations. The resident was interviewed on 1/13/11 at 9:01 a.m., and was observed sitting on the edge of his bed rubbing his right knee continuously and grimacing. The resident stated his current pain level was 6/10. The resident stated he had received "a mess of pills" earlier that morning. The facility was notified of the above-stated observations and interviews at approximately 9:40 a.m. According to the back of the MAR, the resident was administered one tab (5 mg) of [MEDICATION NAME] at 10:10 a.m. for breakthrough pain; the resident was also given an ice pack for his knee. The medication nurse (nurse #2) was interviewed on 1/13/11 at 12:06 p.m., and stated she had been in the resident's room four times that morning, but did not specifically ask the resident about his pain with every interaction. Per nurse #2, the most important thing to do for residents in pain was to "recheck, recheck, recheck." 2. Sample resident #5, [AGE] years old, was admitted to the facility on [DATE] with diagnoses, per face sheet and [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) information available. Review of care plans for the resident documented that she required limited physical assistance from one staff member for activities of daily living such as ambulation, dressing, toileting, and bathing; she was independent with bed mobility, transfers, and grooming. Review of a care plan for pain documented the resident was to be monitored "for effectiveness of pain management program throughout the day." The care plan documented the resident's acceptable level of pain as a 5 (the facility used a pain rating scale of 0-10), and documented non-drug interventions as "ice packs." Additional approaches included: -"Monitor pain level each shift -Medication as ordered -Notify physician as needed." Review of a care plan for support services documented the resident was to participate in physical therapy. Review of 12/30/10 Interdisciplinary Progress Notes (IDPN) revealed the resident was admitted [DATE] with a [DIAGNOSES REDACTED]. Review of the initial Skilled Nursing Health & Services Evaluation/Assessment, dated 12/30/10, documented the resident had aching, throbbing, and radiating pain almost constantly and rated it a 6-7/10, where zero was no pain and ten was the worst possible pain. The acceptable pain threshold was listed as 5/10. The pain site was documented as back, hip, and surgical incision. Irritability and decreased mobility were marked as a non-verbal signs/symptoms of pain for this resident. Review of the January 2011 Medication Administration Record (MAR) on 1/11/11 documented the resident had the following pertinent medications ordered: -[MEDICATION NAME] 5/325 mg 1-2 tabs orally every four hours as needed for mild to severe pain; discontinued 1/04/11. -[MEDICATION NAME] 5/325 mg two tabs orally every four hours scheduled for back pain; order start date 1/04/11. The MAR also revealed documentation of the pain assessments every shift. According to the January 2011 MAR, the resident's pain was assessed as zero on each shift (three times a day) from 1/11-1/12/11. Review of IDPN recorded entries documenting the resident's pain was controlled. However, the following entries also addressed pain, in pertinent part: -01/04/11: " ...Cont (continue) to receive pain meds. Pain med recently increased ..." -01/07/11: " ... Asked if I (nurse) could be sure to wake her for the 0400 dose or she will have increased pain." -01/09/11: " ...C/o (complaint of) pain in L (left) hip and back 4/10 ..." -01/10/11: "Resident asked for scheduled meds at midnight ..." -01/11/11: " ...Pain control helps with sched (scheduled) pain meds. Order recv'd (received) during NP (nurse practitioner) rounds for increase in [MEDICATION NAME] ..." D. Observations and Interviews The resident was observed and interviewed on 1/11/11 at 12:31 p.m. She was lying on her back in bed, flexing, pointing, and shifting her left foot. The resident stated her pain was currently a 7/10 because her pain medication only lasted two hours and she could only receive it every four hours. The resident stated it took more than an hour at times to receive her pain medication after requesting it, "They need to come by more often." The resident was observed in therapy at 1:29 p.m. on 1/11/11. The resident was interviewed on 1/11/11 at 2:42 p.m., and stated her pain level was 5.5/10. She also stated that her acceptable pain level was 0/10, "I see no reason why it can't be zero." The resident was observed shifting in bed and moving her left leg and foot back and forth. The resident was interviewed on 1/11/11 at 3:50 p.m., and stated that her pain level was a 5/10. She stated, "I think I am due for more pain medicine at 4 (p.m.). We'll see how they help." The resident also stated that she was having breakthrough pain and was discouraged about that. The resident was again observed shifting in bed. The resident was interviewed again on 1/11/11 at 5:11 p.m., and stated she had received her 4:00 p.m. pain medication and her pain level was currently a 4/10. "It's not as low as I'd like, but it's better." The resident seemed calmer and less fidgety than in earlier observations. The medication nurse (nurse #1) was interviewed on 1/11/11 at 5:26 p.m. When asked how resident #5's pain was managed, nurse #1 stated the resident had an order for [REDACTED].?" The nurse then looked for the resident's MARs in the med book; she located the MARs for resident #5's roommate, reviewed them, then stated that she did not see an order for [REDACTED].#5's MARs. She turned to the appropriate place in the med book and announced, "Here it is!" However, the MARs were not present in the med book. The nurse then stated, "I don't know where they went. They're gone now!" When asked if they were present at 4:00 p.m. when she administered the resident's routine [MEDICATION NAME], she stated, "Oh yes!" When asked if she signed off on the MAR when she administered the resident's routine [MEDICATION NAME] at 4:00 p.m., she again stated, "Oh yes!" The nurse also stated she had administered an anxiety medication to the resident at 4:00 p.m. and signed it off on the MAR. As the resident's medical record was being reviewed at 5:31 p.m. on 1/11/11, the January 2011 MARs were found misfiled in the chart; the 4:00 p.m. routine [MEDICATION NAME] was not signed off on the MAR, nor was the anxiety medication, both controlled substances. The DON was notified at 5:33 p.m. Review of the MARs on 1/12/11 at approximately 8:30 a.m., revealed the resident had a new order to discontinue the routine [MEDICATION NAME] 5/325 mg order and add [MEDICATION NAME] 10/325 mg one tab orally every four hours around the clock; the order date was 1/11/11 and the first dose administered was 1/12/11 at 8:00 a.m. When asked about the medication change, the resident stated, "What did they change it to?" and stated she had not been aware the medication administered earlier that morning had been a new dose. The resident was interviewed on 1/12/11 at 9:04 a.m. She was lying in bed and stated she was looking forward to exercising with therapy and stretching her leg and back. She stated her pain was currently a 4/10. The DON was interviewed on 1/12/11 at 9:29 a.m., and stated the nurse practitioner had been in to see the resident the previous night and had seen that the resident was nearing the maximum allowed dose of Tylenol (Tylenol is a component of [MEDICATION NAME]) so had "increased the oxy component." Review of the IDPN, written by the MDS Coordinator on 1/12/11, documented, "Review resident's pain management. Interviewed resident related to pain. Resident states that she is in pain almost constantly. She describes pain as between 4 to 7, when I request specific she stated 5 and a half. I recorded 6 explaining we did not do a half that we could put in the computer. Following the interview I asked if she had lost any sleep in the last 5 days, she stated no, I get a sleeper @ (at) night. Resident states that ice and positioning help with pain. She stated that she would like to have pain med every two hours. Dr. orders dated 1/11/2011 show her primary increased her pain meds ...Resident stated that the pain is better than last week." The resident was interviewed again at 4:11 p.m. on 1/12/11 and stated the new pain meds were "good, but still not [MEDICATION NAME] four hours." The resident also stated that upon reflection, she had mis-spoke to "that other lady" about waking up from pain; the resident stated that she did regularly wake up around midnight and 4:00 a.m., because she needed her pain medication. The resident requested to speak with nursing staff regarding her acceptable pain level, as she again stated that her acceptable pain level was zero and not five, as documented in her medical record. Another medication nurse (nurse #3) was interviewed on 1/12/11 at 5:00 p.m. She stated that if pain medications were not effective and the resident was still in pain, staff should offer non-pharmacological interventions such as repositioning. According to the charge nurse, the resident should always be re-checked one hour after medication or non-pharmacological interventions to determine if the pain had lessened, resolved, or stayed the same. If the resident continued to be in pain then nursing staff should call the physician that same day; per nurse #3, the charge nurse should also be notified immediately. She continued to state that if nothing came of the physician and charge nurse notifications, nursing staff was to contact a supervisor. FAILURE TO APPROPRIATELY MANAGE SLIDING SCALE INSULIN PER PHYSICIAN ORDER 1. Sample resident #8, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses, per face sheet and [DIAGNOSES REDACTED]. Review of a 9/03/10 Minimum Data Set (MDS) documented the resident was independent with cognitive skills for daily decision making and required the extensive physical assistance of 1-2 staff members for most activities of daily living. Review of care plans documented that the resident had a [DIAGNOSES REDACTED]. Review of a care plan for medications documented the resident was to receive medications and be monitored for side effects. Review of the January 2011 Computerized Physician order [REDACTED]. -"RFS (rapid finger stick) fasting (6:00 a.m.) and at 1700 (5:00 p.m.) and call if below 60 or above 400." Order date 8/29/10 -"[MEDICATION NAME] R 100 units/ml insulin for> [MEDICATION NAME] R Per sliding scale 0-150= 0 units 151-200= 2 units 201-250= 4 units 251-300= 6 units 301-350= 8 units 351-400= 10 units Over 400= 12 units and call MD (medical doctor)" Order date 7/07/10. Review of the December 2010 MARs revealed the following errors: -12/07/10 - 5:00 p.m. BS (blood sugar) = 195 - Should have received 2 units; received 0 units. -12/21/10 - 5:00 p.m. BS = 172 - Should have received 2 units; received 0 units. Review of the November 2010 MARs revealed the following errors: -11/11/10 - 5:00 p.m. No BS taken -11/14/10 - 5:00 p.m. No BS taken -11/28/10 - 5:00 p.m. BS = 164 - Should have received 2 units; received 0 units. -11/30/10 - 5:00 p.m. BS = 166 - Should have received 2 units; received 0 units. Review of the October 2010 MARs revealed the following errors: -10/01/10 - 6:00 a.m. BS = 179 - Should have received 2 units; received 0 units. Review of the diabetic policy provided by the facility documented in pertinent part: -"The person performing this procedure (RFS) should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if the resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc. 7. The signature and title of the person recording the data." The DON was interviewed on 1/13/11 at 2:17 p.m. She stated she reviewed all of the previous month MARs for accuracy. She stated she did not know of any sliding scale or RFS errors for resident #8. FAILURE TO ENSURE COMPRESSION STOCKINGS (TED HOSE) WERE APPLIED, PER PHYSICIAN ORDER A. Reference: According to "Clinical Nursing Skills & Techniques," by Perry & Potter, 5th Edition (2004), on pages 842-843: "Elastic stockings help reduce . . . blood stasis and venous wall injury. They promote venous return by maintaining pressure on superficial veins to prevent venous pooling, thereby reducing the risk of clot formation in the lower extremities. When applying the stockings, slide the sock over client's foot, being sure that the toes are covered. Make sure the foot fits into the toe and heel position of the sock. If toes remain uncovered, they will become constricted by elastic and their circulation can be reduced." 1. Review of sample resident #4's (see information above) medical record revealed an order for [REDACTED]. Multiple observations of the resident (see above) on 1/11/11 and 1/12/11 revealed the resident was not wearing TED hose. The resident was interviewed on 1/12/11 at 4:12 p.m., and stated that he was supposed to be wearing TED hose every day and take them off at night. The resident stated he wanted to wear them, but his wife had taken them home to wash and he had not had any other pairs to wear for at least two days. The resident stated he had asked the facility for another pair, but they had told him there were none available for his use. The DON was interviewed on 1/12/11 at 4:26 p.m., and stated the facility had extra TED hose available for resident use and stated she would obtain a pair for resident #4. The DON acknowledged that she was unaware the resident had not been wearing his physician-ordered TED hose. The resident was observed again on 1/13/11 at 9:01 a.m. The resident was sitting on the edge of his bed, wearing shorts and no TED hose. The resident again acknowledged he knew he was supposed to be wearing the TED hose. He did not remember any staff coming in to speak with him about a replacement pair of TED hose, although the DON had stated the previous day she would obtain a pair for him (see above). The resident verified he was not wearing any TED hose or other compression stockings and had not done so for at least three days. The resident stated his wife should be bringing the laundered TED hose back sometime that day. A Certified Nurse Aide (CNA), who worked with the resident regularly was interviewed on 01/13/11 at approximately 9:30 a.m. She acknowledged she was unaware resident #4 had a physician's orders [REDACTED].