Every finding on record at Berkley Care Center

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the upstairs kitchen. Specifically, the facility failed to:-Ensure dietary staff performed appropriate hand hygiene during meal service; and,-Ensure the rims of cups were not touched by staff when serving beverages. Findings include:I. Failed to ensure dietary staff performed appropriate hand hygiene during meal serviceA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 3/3/26. It revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)B. Facility policy and procedureThe Hand Hygiene policy and procedure, revised 10/28/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, The facility has adopted the CDC's (Centers For Disease Control And Prevention) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings for indications for hand hygiene that are generally consistent with the World Health Organization's 5 (five) moments for hand hygiene. Unless hands are visibly soiled, an alcohol-based hand rub (ABHR) is preferred over soap and water in most clinical situations. Associates perform hand hygiene (even if gloves are used) in the following situations:before and after contact with the resident; after contact with blood, body fluids, or visibly contaminated surfaces; after contact with objects and surfaces in the resident's environment; after removing personal protective equipment (gloves, gown, eye protection, facemask). Staff should wash hands with soap and water under the following situations as ABHR is not appropriate in these circumstances: before eating; after using a restroom; when their hands are visibly soiled (blood, body fluids); after caring for a resident with known or suspected C-difficile infection (CDI) or norovirus during an outbreak, or if endemic rates of CDI are high.C. ObservationsDuring a continuous observation on 2/24/26, beginning at 4:45 p.m. and ending at 6:19 p.m., the following was observed during the dinner meal service in the upstairs kitchen:At 4:45 p.m. dietary aide (DA) #1 entered the kitchen pushing the insulated food cart and immediately began unloading the food into the steam table. -DA #1 did not perform hand hygiene prior to unloading the food from the food cart into the steam table. At 4:53 p.m. DA #1 calibrated the food temperature thermometer and began uncovering the food. -DA #1 did not perform hand hygiene after calibrating the food temperature thermometer and prior to uncovering the food. At 4:55 p.m. DA #2 entered the upstairs kitchen area. DA #2 took over taking the temperatures of the food for DA #1 so DA #1 could go use the bathroom.-DA #2 did not perform hand hygiene upon entering the kitchen or prior to taking the temperature of the food. At 4:58 p.m. DA #1 came back from the bathroom. -DA #1 did not perform hand hygiene upon entering the kitchen. -At 4:59 p.m. DA #1 answered the telephone but did not perform hand hygiene afterwards. At 5:01 p.m. DA #2 moved the large trashcan by touching the lid, opened her energy drink and took a drink. -DA #2 did not perform hand hygiene after touching the lid of the trashcan and taking a drink of her energy drink. At 5:11 p.m. DA #1 washed her hands and then proceeded to touch her face. -DA #1 did not perform hand hygiene again after touching her face. At 5:12 p.m. DA #2 took the evening meal menu that was taped to the wall and hung it over the steam table where the uncovered food was on the serving line. -DA #2 did not perform hand hygiene after removing the evening menu from the wall and hanging it over the steam table. At 5:17 p.m. DA #2 answered the telephone but did not perform hand hygiene afterwards. At 5:20 p.m. DA #1 and DA #2 were told to stop serving because the mixed salad was not down to the correct temperature. At 5:37 p.m. DA #1 put her hands in her pockets and then touched her face. -DA #1 did not perform hand hygiene after putting her hands in her pockets and touching her face. -At 5:45 p.m. DA #1 and DA #2 were able to start serving again, however, neither DA #1 or DA #2 performed hand hygiene prior to resuming meal service. At 5:55 p.m. DA #1 answered the telephone, scratched the back of her neck and required prompting to perform hand hygiene afterwards. At 5:56 p.m. DA #1 finished washing her hands and then brought the paper towel that she had used to dry her hands and set it on the serving table while she waited for more sandwiches to be delivered. -At 5:58 p.m. DA #2 rested her forehead and forearms on the serving table while waiting for sandwiches to be delivered and did not sanitize her hands or the serving table afterwards. At 6:01 p.m. the upstairs kitchen ran out of plates and were still waiting on more sandwiches to be delivered. At 6:02 p.m. DA #1 and DA #2 began to load the food cart with dirty dishes while waiting for the plates and sandwiches. DA #2 touched her face and touched the beanie that she was wearing. DA #2 did not perform hand hygiene after touching her face and her beanie. At 6:03 p.m. The additional sandwiches were delivered to the upstairs kitchen.At 6:04 p.m. DA #1 and DA #2 were still loading the dirty dishes onto the cart when the additional plates were delivered. DA #1 and DA #2 resumed plating room trays for residents. -DA #1 and DA #2 did not perform hand hygiene after handling the dirty dishes and prior to resuming plating room trays. At 6:07 p.m. DA #2 leaned her forearms and forehead on the serving table and touched her face and hat.-DA #2 did not perform hand hygiene or sanitize the serving table. At 6:08 p.m. the registered dietitian (RD) sent DA #2 downstairs to the main kitchen and helped DA #1 finish plating the room trays. DA #1 began placing a small pile of used gloves and paper towels on the serving table while food was still being served. -The RD did not instruct DA #1 to remove the soiled gloves and paper towels from the serving table.-At 6:19 p.m. the last room tray was served and the pile of used gloves and paper towels was still sitting on the serving table. II. Failed to ensure the rims of cups were not touched by staff when serving beverages A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/3/26. It revealed in pertinent part, Single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food- and lip-contact surfaces is prevented. (4-904.11)B. Observations On 2/23/26 at 11:38 a.m. an unidentified staff member delivered a beverage to a female resident while holding the rim of the cup. On 2/23/26 at approximately 11:56 a.m. an unidentified staff member moved drinks on the table around by the rims of the cups so she could put the plates down for the residents. On 2/23/26 at approximately 11:58 a.m. another unidentified staff member was serving drinks to a resident by holding the rim of the cup. On 2/23/26 at 12:06 p.m. an unidentified staff member was moving drinks around by the rim of the cups getting them ready for room trays. III. Staff interviewsDA #3 was interviewed on 2/25/26 at 3:21 p.m. DA #3 said employees should wash their hands anytime they came into contact with a resident, handled anything that was raw or soiled and after they were finished pushing a cart. He said that staff should never touch the rim of a cup when they were serving beverages to residents. [NAME] (CK) #1 was interviewed on 2/25/26 at 3:25 p.m. CK #1 said employees should wash their hands all the time. He said hand hygiene should be performed whenever dietary switched tasks, came back to the kitchen after using the bathroom, when they were prepping food, after they touched their face and when they took their gloves off. The dietary manager (DM) was interviewed on 2/26/26 at 2:23 p.m. The DM said dietary staff should be washing their hands anytime they entered the kitchen, when they switched their gloves, when they went from touching dirty dishes to touching clean dishes, after touching their faces, when leaving the serving line and after touching the garbage bin. She said staff should not be touching the rims of cups or glasses when they were serving drinks to residents.

Based on record review and interviews, the facility failed to meet all requirements for the provision of hospice care for three (#3, #58 and #33) of three residents reviewed for hospice services out of 41 sample residents. Specifically, the facility failed to ensure hospice notes were readily accessible and the comprehensive care plan was developed with delineation of care responsibilities established between the facility and hospice for Resident #3, Resident #58 and Resident #33.Findings include: I. Facility policy and procedure The Hospice policy and procedure, revised 9/3/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part The facility provides hospice care under a written agreement and must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the long-term care (LTC) facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility must designate a member of the interdisciplinary team (IDT) to ensure hospice representatives are oriented to the facility and that the resident receives quality care in collaboration with the facility staff and the hospice staff. The designated IDT member facilitates communication between the facility and hospice and includes the resident's representative in decision-making. II. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic systolic congestive heart failure (when the left ventricle weakens and cannot contract properly, reducing blood flow to the body and backing up fluids to the lungs), hypertensive heart disease with heart failure, dementia and chronic respiratory failure with hypoxia (low levels of oxygen in the blood). The 12/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The assessment revealed she was dependent on staff for most of her activities of daily living (ADL) and mobility. The assessment indicated the resident was receiving hospice care services. B. Record review The February 2026 CPO documented Resident #3 was admitted to hospice care services on 9/2/25. -A review of the comprehensive care plan, initiated 9/12/25, revealed Resident #3 was receiving hospice care services, however it failed to include delineation of care responsibilities between the facility and hospice care services. A review of Resident #3's electronic medical record (EMR) revealed documentation of hospice recertifications for the resident and a hospice plan of care. -However, review of the resident's EMR failed to reveal documentation of routine hospice care visits provided to the resident. III. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnoses included chronic respiratory failure, pulmonary hypertension and anxiety disorder. The 2/13/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The assessment f revealed that Resident #58 needed substantial to maximal assistance with most of her ADLs. The MDS assessment did not indicate Resident #58 was receiving hospice care services. -However, the resident was admitted to the facility for respite care and was receiving hospice care services at home and at the facility (see record review below). B. Record review Review of Resident #58's EMR revealed she was receiving hospice care services upon her admission to the facility on 2/8/26. Review of her EMR revealed she was at the facility for respite care. A review of Resident #58's comprehensive care plan, initiated 2/9/26, revealed her hospice care plan was initiated on 2/24/26 (during the survey process), 16 days after her admission to the facility. Resident #58's hospice care plan failed to include a delineation of care responsibilities between the facility and hospice care services. IV. Resident #33 A. Resident status Resident #33, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included chronic obstructive pulmonary disease (a progressive, incurable lung disease primarily caused by smoking that restricts airflow, causing chronic shortness of breath, wheezing, and phlegm-producing coughs), depressive disorder, and chronic kidney disease (the long-term, progressive loss of kidney function, commonly caused by diabetes and high blood pressure). The 3/5/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required supervision for personal hygiene and dressing. The MDS assessment did not indicate the resident was receiving hospice services. B. Record review The February 2026 CPO identified resident #33 was admitted to hospice services on 4/1/25. A review of the comprehensive care plan, revised 4/16/25, revealed Resident #33 was receiving hospice care services, however, the care plan failed to include detailed interventions and a delineation of care services between the facility and the hospice care services company. A review of Resident #33's electronic medical record (EMR) revealed there were hospice notes uploaded on 4/22/25. -However, there were no other hospice notes uploaded in the resident's EMR until 2/25/26, during the survey. V. Staff interviews The hospice nurse practitioner (NP) was interviewed on 2/26/26 at 9:00 a.m. The hospice NP said hospice care staff would document in a binder when they visited a resident. She said the hospice staff would chart clinical documentation in their own electronic system, not the facility's. She said the hospice staff would document the physician's order changes in the facility binder, but they would additionally fax over the physician's orders to the facility. The hospice NP said from her understanding, the hospice company would fax over their clinical documentation weekly to the facility. LPN #4 was interviewed on 2/26/26 at 9:45 a.m. LPN #4 said each nurses' station had a hospice binder which was individual to each resident. She said the hospice binder told staff when hospice came to visit and told CNAs whether or not the resident got a shower. She said when hospice staff were inside the facility, they would give a quick report to nursing staff and would check with nurses before seeing the residents. LPN #4 said reports from hospice staff often described what medications residents were getting, whether or not the resident would receive a shower, and any other pertinent updates. LPN #4 was unsure whether or not there were full assessments located in the hospice binders. LPN #4 said staff could additionally look in the residents' EMRs, under the progress notes and the documents tab to view hospice notes. She said the hospice notes would tell staff what care was given to the hospice resident on each specific visit and whether or not there were any changes in condition. LPN #4 said it was important to see hospice notes in order to know what was going on with the residents and to provide appropriate care. She said it would be important to know whether or not a hospice resident had a change of condition or had increased pain. LPN #4 said medical records uploaded hospice documentation from the binders into the residents' EMRs. She said she assumed that each hospice company sent notes to social services or medical records and the notes were uploaded as they were received. Licensed practical nurse (LPN) #2 was interviewed on 2/26/26 at 9:51 a.m. LPN #2 said the facility had a binder that hospice staff would write in when they came to visit a resident. She said the hospice certified nurse aides (CNA) would document if they gave the resident a shower. She said most of the communication with hospice was done verbally. The social services director (SSD) was interviewed on 2/26/26 at 6:14 p.m. The SSD said she would create the hospice baseline care plan if a resident was admitted to the facility on hospice. She said she would also create the care plan for hospice care services when a resident was already a resident in the facility. She said a baseline care plan should be completed within 48 hours of admission. She said Resident #58's baseline care plan was not completed timely. She said it was important to have the baseline care plan completed timely because if something were to happen or change, staff would know who to inform for care coordination. The medical records director was interviewed on 2/26/26 at 6:58 p.m. The medical records director said he started working for the facility at the end of June 2025 or beginning of July 2025. He said his first priority when a resident was receiving hospice care services was getting records uploaded and making sure the documents were signed and completed before they were scanned into the EMR. He said the hospice care services companies would email him residents' records or the records that he requested from the hospice care services companies. He said the hospice care services companies would email him the residents' clinical documentation from their visits every week. He said if the hospice care services company did not email him residents' records, he would request the records from them. He said the records that they sent to him were the residents' progress notes, physicians' orders, care plans and anything that hospice might find important for the facility to know. -However, there was no clinical documentation found in the resident's EMRs during the survey (see record review above). The medical records director said he had recently found out that Resident #3 was receiving hospice care services. He said he found out about a week and a half prior to the survey. He said he had no knowledge or contact with Resident #3's hospice care services contact prior to a week and a half ago. He said he had to ask the admissions staff for all the residents receiving hospice care services. He said he was unsure of who was responsible for informing him if a resident was admitted to hospice care services. He said from a medical records standpoint, Resident #3's EMR was incomplete due to none of her hospice progress notes being uploaded. He said it was important to have her hospice notes uploaded because any hole in the record could cause delay in care or a lack of care for the resident. The medical records director said for Resident #33, he was not sure how often he received notes from the hospice care services company for him. The medical records director said he asked for the hospice services company's certification and when he received the certification, he also received the hospice notes for Resident #33 (during the survey). The director of nursing (DON) and the regional clinical resource were interviewed together on 2/26/26 at 7:25 p.m. The DON and the regional clinical resource said the facility and the hospice care services team communicated using the binder that was at the nurses' station. The DON and the regional clinical resource said that hospice staff would write in the binder describing what services were provided during a visit for each resident. The DON and the regional clinical resource said that the hospice care services companies would send the facility the resident's clinical documentation, and the medical records director would upload the documentation into the EMR. The regional clinical resource said the residents' hospice care plans should have a delineation of responsibilities between the facility and hospice. She said it was important to have a delineation of responsibilities so both the facility and the hospice care team would know who was providing what service for residents in order to provide the best care for the residents. The regional clinical resource said there should be clinical documentation from hospice in the residents' EMRs so facility staff knew what was being provided at each hospice and so the facility staff and the hospice care staff were on the same page.

Based on observations, 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 possible development and transmission of infectious diseases.Specifically, the facility failed to:-Ensure housekeeping staff cleaned and disinfected residents' rooms in a hygienic manner; -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents' rooms; -Ensure a urine spill in the dining room was cleaned and disinfected in an appropriate manner; and,-Ensure urinary catheter bags were stored in a sanitary manner in residents' rooms.Findings include:I. Failed to ensure housekeeping staff cleaned and disinfected residents' rooms in a hygienic manner and performed appropriate hand hygiene while cleaning residents' roomsA. Professional referenceThe Centers for Disease Control and Prevention's (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 3/2/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.The CDC/ Environment Cleaning Procedures (revised 3/19/24) was retrieved on 3/2/26 from https://www.cdc.gove/healthcare-associated-infections/hcp/cleaning-global/supplies-and-equipment.html#cdc_generic_section_6-3-4-personal-protective-equipment-for-environmental-cleaning.It read in pertinent part, Best practices for glove usage for cleaning: perform hand hygiene immediately before putting on gloves and directly after taking them off. When use of gloves is indicated, always change them between each cleaning session (routine cleaning of a patient zone under contact precautions, terminal cleaning of a general patient area).B. Facility policy and procedureThe Hand Hygiene policy, revised 10/28/25, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, Staff must perform hand hygiene (even if gloves are used) in the following situations: before and after contact with the resident; after contact with blood, body fluids, or visibly contaminated surfaces and. after contact with objects and surfaces in the resident's environment. C. Room cleaning observationsOn 2/25/26 at 8:54 a.m. housekeeper (HK) #1 was observed cleaning resident room [ROOM NUMBER], a double occupancy room. HK #1 performed hand hygiene with alcohol based hand rub (ABHR) and applied clean gloves. HK #1 collected a disinfectant spray bottle labeled from the housekeeping cart, entered the resident's room, went to the residents' bathroom and sprayed the toilet (both inside and out) and the wall grab bars. HK #1 began dusting in the residents' room. HK #1 started above the main entry door and worked counterclockwise through the room, dusting the dresser, the light fixtures above the sink area, the bathroom ceiling areas, the top of the inside and outside of the bathroom door, the window blinds, over the second resident's bed area, including the light fixtures and art work on the wall, over the curtain pull area, then over the first resident's bed, including her light fixtures and decor that was hanging. HK #1 finished her dusting above the oxygen concentrator by the main entry door to the room. HK #1 then proceeded to perform hand hygiene with ABHR, don a new pair of gloves and take a premoistened washcloth to wipe down the areas in the residents' room. She used the same cloth for both sides of the room.-HK #1 failed to use a different dusting device or cloth for each side of the residents' room. -Additionally, HK #1 continued to dust in the residents' living space after using the dusting device to dust in the residents' bathroom. At 9:13 a.m., HK #1 went to the housekeeping cart, performed hand hygiene, applied clean gloves and took the toilet brush and container from the cart. HK #1 went to the residents' bathroom and used the toilet brush to clean in and around the toilet bowl and toilet tank, including the surface of the toilet tank that was housed on the floor. Approximately one minute after cleaning all the toilet surfaces, she put the brush back into the toilet bowl, flushed the toilet and then tapped the toilet brush against the toilet seat. Droplets spread from the toilet brush onto the bathroom walls and floor. She shook the toilet brush five times and then put the brush back into the container. She took a rag and wiped down the surfaces of the toilet seat, the toilet tank and handrails and flushed the toilet again. -HK #1 failed to clean the toilet from cleanest to dirtiest areas when she used the toilet brush on the surfaces outside of the toilet bowl. -Additionally, when HK #1 hit the brush against the toilet seat to clear the excess solution and contaminated water from the brush, the droplets from the brush spread onto the bathroom walls resulting in cross contamination and the spread of germs.HK #1 went back to the housekeeping cart, put the toilet brush container into the cart and placed the used rag into a soiled bucket. She then removed her gloves, performed hand hygiene, and applied a new pair of gloves. She went back into the residents' room to mop. HK #1 completed cleaning the residents' room at 9:24 a.m.On 2/25/26 at 9:58 a.m. HK #2 placed her housekeeping cart outside room [ROOM NUMBER] and performed hand hygiene at the cart with ABHB. She applied a clean pair of gloves prior to entering the resident room. She collected a disinfectant spray bottle from the housekeeping cart and went into the resident's bathroom to spray down the toilet area including the toilet bowl, the toilet tank and under the toilet seat. She then closed the bathroom door, set a timer for ten minutes on a cellular phone and took the bottle of disinfectant back to the housekeeping cart.-HK #2 failed to change her gloves and perform hand hygiene after spraying the toilet with disinfectant and touching the lid of the toilet.Using the same gloves she used when touching the toilet lid, HK #2 took a dusting device out of her cart and proceeded to dust the top of the lighting fixture over the sink, the top of the bathroom door, the blinds and the radiator vents on the floor. She dusted the resident's doorway last before putting the dusting device back on the cart. -HK #2 did not change her gloves or perform hand hygiene after returning the dusting device to her cart.Using her same soiled gloves, HK #2 took a cleaning rag out of a container that was premoistened with a disinfectant solution. She went back into the resident's room and wiped the mirror and sink area, moving any personal items out of the way and then returning them when finished.-HK #2 did not change her gloves or perform hand hygiene prior to obtaining a cleaning rag out of the disinfectant solution and touching the resident's personal items. Without changing her gloves and using the same cleaning rag, HK #2 proceeded to wipe down the resident's bedside tray table surface, the bottom of the tray table area, the nightstand, again moving the resident's personal items out of the way to wipe underneath and then replacing them in their original spot, and finished with using the rag to clean the resident's dresser top. When she finished with the surface cleaning, HK #2 took the trash bag out of the trash container, disposed of it in the housekeeping cart and replaced the bag in the container. Without changing her gloves, HK #2 proceeded to sweep the resident's room, including the bathroom area, and gathered all the debris into her dust bin. The timer went off on the phone.-HK #2 failed to change her gloves or perform hand hygiene after removing the trash from the resident's room and prior to using the broom to sweep the resident's room and bathroom.HK#2 returned the broom and dustbin to the cart and took another premoistened rag from the cart and the toilet brush container. -HK #2 again failed to change her gloves or perform hand hygiene prior to obtaining another cleaning rag from the container of disinfectant solution.HK #2 returned to the resident's bathroom where she cleaned the toilet from top to bottom with the rag, including the top of the toilet tank, the toilet tank, the sides of the toilet tank, the flush handle, the underside of the toilet bowl and then the bottom area on the floor surface. She used the toilet brush to scrub under the toilet bowl rim and the toilet bowl. She flushed the toilet and squeezed the excess water from the scrub brush into the toilet tank. She then put the brush back into the container and took the rag and the container back to the cart.-HK #2 failed to change her gloves and perform hand hygiene after cleaning the toilet, which included squeezing the excess water from the soiled toilet scrub brush with her gloved hands. Wearing the same soiled gloves she had been wearing for the entire room cleaning observation, HK#2 took another premoistened rag from the disinfectant solution and went back into the resident's room. She began cleaning all the high contact areas, starting in the room first and then in the bathroom. She wiped the light switch, the bed remote, the call light, the mirror light switch, then the doorknobs to the bathroom, the hand rails in the bathroom, the emergency call light cord in the bathroom and then lastly the inside door knob of the bathroom door. She returned the rag to the dirty container and then took the mop handle from her cart. She opened a black storage container that was filled with a solution and had mop heads inside. Using her same soiled gloves, she picked up a mop pad, squeezed the excess water solution mix back into the container of solution where she retrieved it from and then attached the mop pad to her mop. -HK #2 failed to change her gloves and perform hand hygiene after cleaning the high contact surfaces in the resident's room and prior to obtaining the mop pad from the cleaning solution and squeezing the excess water from the mop pad back into the cleaning solution with her soiled gloves.HK#2 went to the resident's bathroom and mopped all areas behind and around the toilet bowl and then the floor, stopping at the bathroom/bedroom line. She took the used mop head pad to the cart, placed it in the dirty container and took out another clean mop head with her same soiled gloves. She followed the aforementioned procedure of squeezing the excess water back into the clean container. HK #2 finished mopping the resident's room, getting underneath the bed, underneath the night stand, under the sink area, and all along the floor surface of the area. She mopped backwards towards the resident's room door, where the last task she did was take another premoistened rag and wiped the doorknobs for the main door. She put the dirty rag into the dirty container, removed the dirty mop head, placed it in the same dirty container and then took off her gloves and performed hand hygiene. HK #2 completed cleaning the resident's room at 10:15 a.m.-HK #2 failed to change her gloves and perform hand hygiene throughout the entire room cleaning observation, cleaning the resident's entire room and bathroom with the same pair of soiled gloves throughout the process.HK #2 was observed a second time on 2/25/26 at 11:10 a.m., cleaning room [ROOM NUMBER]. HK #2 rolled the housekeeping cart to outside room [ROOM NUMBER] and performed hand hygiene at the cart with ABHR and applied a clean pair of gloves prior to entering the resident's room. HK #2 followed the same aforementioned process when cleaning room [ROOM NUMBER].-HK #2 failed to perform hand hygiene and change gloves after spraying down and touching the toilet seat, before and after cleaning high contact areas, before and after dusting, before and after taking the trash from the resident's room, before and after taking a new rag from the clean container, before taking a new mop head out of the solution container, before and after mopping and before cleaning high contact areas. -Additionally, HK #2 contaminated the clean mop bucket solution when excess water was squeezed from the mop pad with her soiled gloves. -HK #2 again failed to change her gloves and perform hand hygiene throughout the entire room cleaning observation, cleaning the resident's entire room and bathroom with the same pair of soiled gloves throughout the process D. Staff interviewsHK #1 was interviewed on 2/25/26 at 9:25 a.m. HK #1 said every resident room was cleaned daily in the same manner as she did during the observation (see observations above). The housekeeping supervisor (HKS) was interviewed on 2/26/26 at 1:45 p.m. The HKS said when new housekeeping staff were hired, he trained them personally on room cleaning. He said he created a housekeeping process sheet that was kept on each housekeeping cart, with one side written in Spanish and the other side written in English. He said it was his expectation that housekeepers followed that written cleaning process. The HKS said the dusting devices the facility used were not able to be disinfected, therefore housekeepers should not use them in residents' bathrooms. The HKS said he had specifically told staff the dusting devices were only to be used for room light fixtures and the window blinds. The HKS said he would set up a time to meet with management to discuss the purchase of disposable dusting devices.The HKS said housekeeping staff should be changing gloves at a minimum of three times during a room cleaning. The HKS said staff did not practice good infection control procedures when HK #1 hit the toilet brush against the toilet bowl and when HK #2 cleaned and completed an entire room cleaning with only one pair of gloves being used. He said staff would be trained specifically in infection control measures.II. Failed to ensure a urine spill in the dining room was cleaned and disinfected in an appropriate manner A. Professional referenceThe CDC's Environment Cleaning Procedures (revised 3/19/24) was retrieved on 3/2/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html#cdc_generic_section_6-4-5-spills-of-blood-or-body-fluids. It ready in pertinent part, For spills of blood or body fluids, wear appropriate personal protective equipment (PPE). Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules (if available) that are spread over the spill to solidify the blood or body fluid (all should then be disposed as infectious waste). Clean thoroughly, using neutral detergent and warm water solution. Disinfect by using a facility-approved intermediate-level disinfectant.B. Facility policy and procedureThe Housekeeping Services policy, revised 1/6/226 was received from the NHA on 2/27/26 at 3:54 p.m. It read in pertinent part, Blood/Body Fluid Spills: If there is a blood or body fluid spill or contamination, clean and disinfect the area immediately in a two-step process. [NAME] off the spill area to prevent contact, as well as accidental slips and falls. Clean and disinfect the spill as soon as possible. Confine the spill and wipe it up immediately with absorbent paper towels, cloths or absorbent granules and dispose of it as infectious waste. Clean the area with a facility-approved cleanser. 1:10 dilution of bleach may be used. Disinfect using a facility-approved intermediate-level disinfectant.C. Dining room observation and staff interviewA continuous observation of the dining room on the second floor to the left of the nurses' station was conducted on 2/24/26, beginning at 4:00 p.m. and ending at 6:55 p.m At 5:25 p.m. Resident #23 was seated at the first table of the dining room with two other residents.At 5:40 p.m. a puddle was observed underneath Resident #23's wheelchair. A strong urine odor was noted and additional urine was trickling out from the back of the resident's wheelchair. At 5:51 p.m. more urine was observed puddling under Resident #23's wheelchair. At 6:30 p.m. an unidentified male certified nurse aide (CNA) came into the dining room pushing a different resident in a wheelchair. He wheeled the other resident's wheelchair right through the puddle of urine, causing urine wheel marks on the floor. At 6:31 p.m. an unidentified nurse came into the dining room with a soiled linen bag and put Resident #23's sweater and towels that she had been sitting on in her soiled wheelchair into the bag. A male CNA then wheeled Resident #23 through the puddle of urine again, leaving urine wheel marks down the hallway to Resident #23's room.At 6:41 p.m. a laundry assistant entered the dining room with a broom and a dust pan and started sweeping the dining room.At 6:48 p.m. the laundry assistant began mopping the far end of the dining room. He then proceeded to mop up the urine from the floor before he finished mopping the rest of the dining room with the same mop.The laundry assistant was interviewed on 2/24/26 at 6:55 p.m. The laundry assistant said he changed the mop water but did not change the mop head. He said he only cleaned the dining rooms with that specific mop head and did not clean bathrooms with it, so he did not have to change the mop head.-However, the laundry assistant did not change the mop head after mopping up Resident #23's urine from the floor and prior to finishing mopping the rest of the dining room. D. Additional staff interviewThe HKS was interviewed on 2/26/26 at 5:00 p.m. The HKS said he was not aware staff did not properly mop up Resident #23's urine in the dining room. He said the expectation was the laundry assistant would sweep and then mop. He said he could not confirm if the laundry assistant used a disinfectant solution on the floor. He said by the time dinner was over, he and the housekeeping staff were already gone for the day.The HKS acknowledged the use of disinfectant was pertinent to infection control and prevention. He said moving forward, he would ensure the laundry assistant had access to disinfectant floor solution and he would have his staff use a different mop head for each dining room.III. Failed to ensure urinary catheter bags were stored in a sanitary manner in residents' roomsA. Facility policy and procedureThe Indwelling Urinary Catheter (Foley) Management policy, revised 6/27/23, was received from the NHA on 2/27/26 at 3:54 p.m. It read in pertinent part, Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. B. Urinary catheter observationOn 2/24/26 at 4:30 p.m. an interview was conducted in Resident #2's room. Observation during the interview revealed Resident #2 had her urinary catheter drainage bag hanging from the lower rail of the bed. The urinary catheter drainage bag was resting on the floor. On 2/25/26 at 8:17 a.m. a walk through observation revealed Resident #2's urinary catheter drainage bag hanging from the lower rail of the bed. The urinary catheter drainage bag was resting on the floor. C. Staff interviews CNA #1 was interviewed on 2/25/26 at 10:00 a.m. CNA #1 said urinary catheter drainage bags were emptied at least one time each shift, more if needed. She acknowledged urinary catheter drainage bags should never be touching the floor. At 10:14 a.m. CNA #1 observed Resident #2's urinary catheter drainage bag resting on the floor. CNA #1 immediately raised the resident's bed and adjusted the clip to bring the urinary catheter drainage bag off the floor. CNA #1 said the resident tended to lower her bed to the lowest position and that caused the urinary catheter drainage bag to hit the floor. CNA #1 said moving forward, the clip would be tighter so there wouldn't be any ability for the urinary catheter drainage bag to touch the floor. The director of nursing (DON) was interviewed on 2/25/26 at 6:15 p.m. The DON said her expectation was that all staff followed proper infection control policies and procedures. The DON said urinary catheter drainage bags should never touch the floor because of the high potential of contamination of germs. The DON said she was not aware that urinary catheter drainage bags were not being stored properly and she would use this as a learning experience and a good opportunity to provide staff with additional training related to urinary catheter drainage bags.

Based on observations, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene for one (#23) of four residents reviewed for services to maintain the highest practicable quality of life out of 41 sample residents.Specifically, the facility failed to ensure Resident #23 received timely incontinence care.Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADL) policy, dated 9/4/24, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.II. Resident #23A. Resident statusResident #23, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included nondisplaced fracture of the body of the right calcaneus (a break in the right heel bone where the bone pieces remain in proper alignment), type 2 diabetes mellitus (chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency leading to high blood sugar), chronic kidney disease (long term irreversible loss of kidney function) and unspecified obesity.The 1/23/26 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. The resident was dependent upon staff to help with toilet transferring and toileting hygiene. The MDS assessment identified that Resident #23 was frequently incontinent of urine and bowel.B. Resident interviewResident #23 was interviewed on 2/23/26 at 3:19 p.m. Resident #23 said sometimes she did not receive help with toileting assistance on time. She said she had to wait a long time to get to the bathroom and sometimes she had accidents because she had to wait too long for help. Resident #23 said she asked staff to put two briefs on her so the urine would be contained. Resident #23 said sometimes even with two briefs, urine would leak through to the outside of her pants. She said leaking through the two briefs would happen often but it was worse at night time. Resident #23 said sometimes staff tried to bring her to the dining room when they knew she was wet. Resident #23 said staff brought her food to her bedroom instead and then changed her once they were done with everything in the dining room or before they went home. Resident #23 said that made her feel terrible and she said she felt desperate.C. Observations On 2/24/26 at 5:40 p.m. Resident #23 was in her wheelchair in the dining room next to an unidentified certified nurse aide (CNA). Resident #23 had liquid underneath her wheelchair. There was an odor of urine coming from the area underneath her wheelchair.At 6:12 p.m. Resident #23 came out of the dining room. She was pushing herself in her wheelchair down the hallway toward her room and had sizable amounts of urine dripping from behind her wheelchair.At 6:33 p.m. the resident had wheeled herself into her room. Urine was dripping from her wheelchair onto the tile floor.At 6:44 p.m. CNA #1 and CNA #2 entered Resident #23's room with the sit-to-stand mechanical lift. The CNAs hooked Resident #23's sling to the sit-to-stand lift and brought the resident up to a standing position from the wheelchair. CNA #2 said the resident's wheelchair cushion had urine on it. The CNAs assisted the resident to bring her pants down. The resident was observed to have two briefs on. There was a strong urine smell in the room. Both of Resident #23's briefs were saturated with urine and were heavy. The CNAs cleaned up Resident #23 and put cream on her perineal area. A fresh brief and a fresh gown were put on the resident. Before exiting the room, CNA #1 wiped up the urine off of the floor.D. Record reviewThe ADL care plan, revised 3/7/19, revealed Resident #23 was incontinent and needed assistance for toileting and hygiene. Pertinent interventions included assisting Resident #23 with toileting.The bowel and bladder care plan, revised 5/13/22, revealed Resident #23 was incontinent and needed assistance for toileting and hygiene. Pertinent interventions included assisting Resident #23 with toileting, utilizing spanish speaking CNAs whenever possible, implementing good personal hygiene following any incontinence episode, and providing perineal care, to include barrier cream for skin protection. The urinary incontinence care plan, revised 3/7/19, revealed Resident #23 was incontinent related to diabetes mellitus, chronic pain, opioids, and incontinence. The pertinent interventions included a prompted toileting program upon arising, before and after meals and before bed. An additional intervention for assisting Resident #23 with toileting and perineal care as needed was initiated on 1/26/22.-The care plan did not include interventions to educate the resident on limiting the number of briefs that should be worn to prevent skin breakdown. Review of Resident #23's progress notes did not reveal that Resident #11 requested to wear two briefs. The progress notes did not identify that Resident #11 refused to be cleaned or changed more frequently.III. Staff interviewsCNA #1 was interviewed on 2/24/26 at approximately 6:50 p.m. CNA #1 said Resident #23 was wet with urine. She said it was important for the resident to be dry because if the skin was not dry, it could break down. CNA #1 said Resident #23 had two briefs on that day (2/24/26) because the resident wanted to play bingo both on the first and second floor. CNA #1 said that on days when the resident wanted to play bingo, the staff put two briefs on her. CNA #1 said that Resident #23 attended bingo that day at 2:00 p.m.Licensed practical nurse (LPN) #3 was interviewed on 2/25/26 at approximately 2:30 p.m. LPN #3 said staff came onto shift at 2:00 p.m. LPN #3 said that at that time, staff were supposed to change Resident #23. She said the goal was to change Resident #23 before she went to the dining room. LPN #3 said most residents that were in wheelchairs were supposed to be checked to ensure they were clean and dry before going to the dining room. LPN #3 said they worked as a team to ensure Resident #23 was clean, but CNAs most often helped change the residents. LPN #3 said residents should not wear two briefs because it affected skin integrity and the staff tried to protect the residents' skin. LPN #3 said if a resident requested to wear two briefs, she expected the CNAs to educate the resident on why it was not a good idea. LPN #3 said if the resident requested to wear two briefs, she would document that in the progress notes. The director of nursing (DON) was interviewed on 2/26/26 at 7:23 p.m. The DON said nursing staff were supposed to provide incontinence care per facility protocol or every two hours and as needed. The DON said nursing staff should put only one brief on residents. She said facility protocol was to put one brief on residents and if a resident requested more than one, nursing staff should educate the resident on the risks of wearing more than one brief. The DON said risks to wearing two briefs would include skin breakdown, irritation, redness and being overly wet. The DON said nurses could educate residents on risks and CNAs could remind residents about risks. The DON said staff should be documenting if a resident was requesting to wear two briefs. She said it could be documented in the care plan, nursing progress notes or behavioral notes. The DON said the facility recently edited the care plan to reflect that Resident #23 was requesting two briefs and that this was sometimes a preference of hers. -However, the electronic medical record (EMR) did not not reflect that Resident #23 was requesting two briefs or that this was the preference of Resident #23 (see record review above).

Based on record review and interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical records for two (#53 and #11) of two residents reviewed for advance directives out of 41 sample residents.Specifically the facility failed to:-Ensure Resident #53 and Resident #11's medical orders for scope of treatment (MOST) forms matched their physician's orders; and,-Ensure staff were able to locate the residents' MOST forms in order to follow the residents' choices for cardiopulmonary resuscitation (CPR).Findings include: I. Facility policy and procedure The Advance Directives and Advance Care Planning policy, reviewed [DATE], was received from the nursing home administrator (NHA) on [DATE] at 12:03 p.m. It read in pertinent part, Social services ensures that a copy of the advance directive is obtained for the resident's medical record and verifies that there is an appropriate physician's order in the resident's medical record as well. This review should focus on if the existing advance directives and advanced care planning match the current goals of care for the resident. The director of nursing (DON) or designee establishes a system to inform all direct care staff of the resident's DNR (do not resuscitate) status. II. Resident #53 A. Resident status Resident #53, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis (autoimmune disease of the central nervous system), dementia (disease that affects the brain), and lumbago with sciatica (chronic lower back pain involving the sciatic nerve). According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Record review Review of Resident #53's February 2026 CPO identified the resident's COR status (cardiac or respiratory - whether or not the resident wants resuscitation in the event their heart/breathing stops) was DNR (do not resuscitate), ordered on [DATE]. Review of Resident #53's MOST form (a form sent with the resident upon transfer or discharge to communicate advance directives/resident wishes), dated [DATE], documented the resident wished to receive cardiopulmonary resuscitation (CPR), full medical treatment and intervention and artificial nutrition. -However, the information documented on the form was last reviewed with the resident in [DATE] and did not match the [DATE] physician's order for DNR status (see physician's order above). Review of Resident #53's COR status care plan, dated [DATE], documented the resident's COR status was addressed during the meeting and noted the resident remained a full COR status. -However, the care plan was not updated to reflect the [DATE] physician's order which identified the resident's status changed to DNR. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 2:26 p.m. CNA #1 said was not sure where the MOST forms were located for the residents on the second floor. She said she was not sure how she would respond to someone if they asked what a residents' COR status was. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 2:40 p.m. LPN #1 said the code status of a resident could be found in one of two ways; either in the residents' electronic medical records (EMR), or in the green binder located at the nurses' station that housed the MOST forms. LPN #1 said it was important to ensure that both methods, the EMR and the MOST paper form, of indication were matching. LPN #1 looked at Resident #53's MOST form and the physician's order and said they did not match. LPN #1 said the nurses had the responsibility of ensuring a resident's MOST form was completed in case anything were to happen to the resident. LPN #1 said she was not sure how often the facility performed an audit to ensure the residents' MOST forms matched the physician's orders for resident's COR statuses. LPN #1 said she was fairly new to the facility and was still learning her role. She said she would ask her manager about the process and see to it that Resident #53's MOST form was revised to reflect the current physician's order for the resident's COR status. The DON and the regional clinical resource were interviewed together on [DATE] at 5:30 p.m. The DON said the nurses worked together, along with social services, to ensure the residents' MOST forms were completed upon admission to the facility. The DON said it was important to ensure physician's orders for residents' COR statuses matched the MOST forms so the residents' final choices for resuscitation were honored. The regional clinical resource said she did not know why Resident #53's MOST form did not match his physician's order for COR status. She said she would perform an immediate audit to ensure all residents' MOST forms and physician's orders had accurate and matching information for COR status. III. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included parkinsonism (a neurological disorder causing movement issues), type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) and contractures (the permanent, abnormal tightening of skin, muscles, tendons, or ligaments, causing joint rigidity, pain, and severely reduced movement). The [DATE] MDS assessment revealed the resident was unable to complete the BIMS assessment. According to the staff assessment for mental status, the resident's cognitive skills for daily decision making were severely impaired. The resident was dependent upon staff for personal hygiene, dressing, and assisting with eating. B. Record review Review of the facility's MOST form binder identified Resident #11 was a DNR status. Review of the electronic charting system identified Resident #11 as a full code. Review of the medication administration record (MAR) revealed Resident #11's code status was changed from full code (resident wanted all available life saving measures used to revive them if their breathing or heart stopped) to a DNR on [DATE] at 2:37 p.m., during the survey. C. Staff interviews CNA #4 was interviewed on [DATE] at 2:18 p.m. CNA #4 said in the case of an emergency, if a nurse had directed him to find the code status of a resident, he would check the online charting system on the wall. CNA #4 checked the charting system on the wall but said he could not find the code status there. CNA #4 said he would go to the computer charting system and check for the resident's code status there. CNA #4 checked the computer but could not find the code status of residents. CNA #4 then said he would instead ask another nurse for help and find out the code status for residents that way. LPN #3 was interviewed on [DATE] at 2:25 p.m. LPN #3 said nurses filled out the MOST forms with the residents and their families if needed. She said they completed MOST forms when residents were admitted to the facility or if the resident had a change of condition and wanted to change or update their MOST forms. LPN #3 said in the case of an emergency, staff should look in the MOST form binder for resident statuses. LPN #3 found Resident #11's code status in the MOST form binder where Resident #11's code status was a DNR. LPN #3 next looked in Resident #11's electronic charting system for her code status where the online code status documented the resident as a full code. LPN #3 said the electronic charting system was telling her Resident #11 was a full code and that was incorrect, because staff should always go off of the signed MOST form document in the binder. LPN #3 said the binder and the electronic charting system should show matching code statuses because staff would not want to make any mistakes with CPR. LPN #3 said medical records staff were responsible for ensuring code statuses matched in the binder and in the electronic charting system. LPN #3 said nursing staff were also responsible for ensuring the binder and electronic charting system code statuses matched because nurses helped residents fill out the code status and updated the MOST forms in the binder. She said after the MOST form was updated in the binder, that same nurse should then make sure the code status was correct in the electronic charting system as well. LPN #3 said social services, nurses and medical records staff worked together as a team to ensure everything was corrected.

Based on observations, record review and interviews, the facility failed to communicate effectively with the dialysis centers for two (#61 and #4) of two residents reviewed for dialysis out of 41 sample residents.Specifically, the facility failed to ensure dialysis communication forms between the facility and the dialysis center were thoroughly completed consistently for Resident #61 and Resident #4.Findings include: I. Facility policy and procedure The Hemodialysis Offsite policy and procedure, revised on 9/16/25, was provided by the nursing home administrator (NHA) on 2/27/2 at 3:54 p.m. It revealed in pertinent part, The facility assures that each resident receives care and services for the provision of offsite hemodialysis consistent with professional standards of practice, which includes: arrangements for safe transportation to and from the dialysis facility; ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments at a certified dialysis facility; and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility should provide immediate monitoring and documentation of the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications such as redness or edema. The care of the resident receiving dialysis services must reflect ongoing communication, coordination, and collaboration between the facility and the dialysis staff. The facility may wish to designate an associate to coordinate activities and communications with each dialysis facility with which they have arrangements to provide dialysis services. II. Resident #61 A. Resident status Resident #61, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included end stage renal disease (the irreversible loss of 85 to 90% of kidney function, where the kidneys can no longer support life), type 2 diabetes mellitus, blindness in one eye, and prior subdural hemorrhage (trauma-induced, accumulation of blood between the brain's outer covering and its surface). The 1/5/26 MDS assessment revealed the resident was unable to complete the BIMS assessment. According to the staff assessment for mental status, the resident's cognitive skills for daily decision making were severely impaired. Resident #61 required moderate assistance for dressing, bathing and personal hygiene. B. Record review Review of Resident #61's dialysis communications forms from 10/31/25 to 1/21/26. The forms consisted of a pre-dialysis assessment section, a section which gives information and assessment results during the dialysis treatment and a post-dialysis treatment assessment section. The pre-dialysis section was to be filled out by facility nursing staff and contained information about vital signs, lung sounds, assessment of the access site (the surgically created point on the body where blood was removed and returned during hemodialysis), whether or not the resident was on an antibiotic, whether or not a bruit (low pitched whooshing sound heard with a stethoscope over a fistula or graft indicating healthy blood flow through the vascular access site) or thrill (physical vibration or buzzing sensation felt with the fingertips over a vascular access site such as an arteriovenous fistula or graft) was present, and any medications or meals sent with the resident to the dialysis center. The dialysis center section of the communication form was to be filled out by dialysis staff. The section consisted of the dialysis center name, nephrologist (specialized physician who diagnoses and treats kidney diseases), vital signs taken, condition of the access site, whether or not a bruit and trill were present, type of vascular access site, and notes about amount of food consumed during the dialysis procedure. The post-dialysis center section was to be filled out by facility nursing staff and contained information about vital signs, lung sounds, assessment of the access site, whether or not the resident was on an antibiotic, whether or not a bruit and thrill were present, and whether or not there was a change of access site. Review of Resident #61's dialysis communication forms revealed the following: -The pre-dialysis center information was not filled out in its entirety on 12/5/25, 12/8/25, 1/5/26 and 1/19/26. The dialysis center information section was not filled out and was blank or nearly blank on 11/5/25, 11/21/25, 12/8/25 and 1/15/26. The post-dialysis section of the form was not filled out and was blank on 11/3/25, 12/1/25, 12/8/25 and 12/25/25. Review of Resident #61's progress notes, from 10/4/25 to 2/22/26, revealed no communication or documentation of phone calls from nursing staff to the dialysis center which indicated nursing staff contacted the dialysis center to retrieve the missing information from the dialysis appointments. C. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 2/26/26 at 12:13 p.m. LPN #4 said nurses filled out the top section of the dialysis communication forms before the resident went to dialysis. LPN #4 said the pre-dialysis section consisted of what the facility sent with the resident, the site assessment and the resident's vital signs. She said it was important to document whether or not there was a bruit or thrill before the resident left in order to make sure that the dialysis access site would work when the resident arrived at dialysis. LPN #4 said the dialysis center would fill out the middle section of the form and then facility nursing staff filled out the post-dialysis section of the communication form when the resident returned from dialysis. LPN #4 said the post-dialysis section consisted of the site assessment and other boxes nurses were supposed to fill out accordingly. LPN #4 said it was important to fill out the communication forms so that the facility and the dialysis center could properly communicate and to understand what changes were occurring with the resident. LPN #4 said if the dialysis center did not fill out their section of the form, the nurses had to call the dialysis center and get the information filled out. LPN #4 said if nurses had to call the dialysis center to fill out information on the form, it would be documented in the progress notes in the resident's electronic medical record (EMR). LPN #4 said the medical records department scanned the physical papers from the dialysis binders into the residents' EMRs under the document tab. LPN #4 said it was important for the dialysis center to fill out the post-dialysis weight value so that facility nursing staff could identify whether or not a resident would be at higher risk for falls upon return. She said that the more fluid dialysis pulled off of the resident, the more likely it was for the resident to be weaker. The medical records director was interviewed on 2/26/26 at 8:58 p.m. The medical records director said he scanned the dialysis communication forms from the dialysis binders into the residents' EMRs monthly. He said he began scanning them in October 2025 to the current day. The medical records director said he personally did not check the forms for completeness. He said nurses and the registered dietician looked at the documents for completion. III. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE] and re-admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, hypertensive chronic kidney disease, end stage renal disease (renal failure), dependence on renal dialysis, hemiplegia (paralysis) following cerebral infarction affecting left non-dominant side, amputation of left lower extremity and depression. The 12/4/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She used a wheelchair for mobility and required assistance from one staff member for toileting, personal hygiene, and transfers. The MDS assessment indicated the resident received hemodialysis (treatment to filter wastes and water from blood using an artificial membrane). B. Record review Review of Resident #4's February 2026 CPO revealed a physician's order for dialysis every Tuesday, Thursday, and Saturday, ordered on 6/1/24. Review of review of Resident #4's hemodialysis care plan, initiated 9/1/23, revealed the resident received hemodialysis. Interventions included encouraging the resident to go to scheduled dialysis appointments, observing and reporting signs and symptoms of renal insufficiency, including changes in level of consciousness, changes in skin turgor and changes in heart and lung sounds as needed (revised 12/1/25), observing and reporting bleeding, hemorrhage, signs and symptoms of infection or septic shock or peripheral edema as needed (revised 10/20/25) and assessing the resident's shunt site (abnormal direct connection between an artery and a vein) for bruit (swishing sound) and thrill (buzzing vibration) in the upper leg (revised 9/8/23). Review of Resident #4's dialysis communication forms revealed the following: -The dialysis center's section of the form was not completed on 1/13/26, 2/7/26, 2/17/26 and 2/26/26. -The post-dialysis section of the form, to be completed by the facility, was not completed on 2/12/16, 2/24/26 and 2/26/26. Review of Resident #4's progress notes did not include communication notes with the dialysis center. C. Staff interviews Registered nurse (RN) #1 was interviewed on 2/26/26 at 12:30 p.m. RN #1 said all the nurses were responsible for documenting on the dialysis communication forms RN #1 said the nurse on duty was responsible for documenting the pre-dialysis and post-dialysis sections of the forms. RN #1 said every time the dialysis center staff did not document the dialysis section, the facility nurses should call the dialysis center, ask for the information and update the dialysis communication form. RN #1 said it was important to keep the dialysis communication form updated so the next nurse could have an idea about the resident's condition after dialysis. RN #1 said the dialysis communication forms were not uploaded to the resident's electronic medical record (EMR), but were kept in a dialysis binder. The director of nursing (DON) was interviewed on 2/26/26 at 7:25 p.m. The DON said the nurses were responsible for calling the dialysis center if the dialysis center did not complete the dialysis section of the document. The DON said the pre-dialysis section of the form needed to be completed to determine the resident's status before the resident went to dialysis, including the resident's pre-dialysis weight and vital signs. The DON said the post-dialysis section of the form was equally as important for the nurses to document. The regional clinical resource was interviewed on 2/26/26 at 7:25 p.m. The regional clinical resource said she was not sure whether the nurses were documenting the dialysis communication forms and calling the dialysis centers each time the dialysis center staff failed to document in the dialysis section.

Based on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional standards or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#40) of two residents reviewed for trauma-informed care out of 41 sample residents. Specifically, the facility failed to ensure Resident #41 had a trauma-informed care plan which identified potential triggers that had the potential to re-traumatize the resident.Findings include:I. Facility policy and procedureThe Trauma-Informed Care policy and procedure, revised 1/6/26, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, Based on the comprehensive assessment of a resident, this facility ensures that residents who are diagnosed with mental disorder and psychosocial adjustment difficulty, or who have a history of trauma and/or post-traumatic stress disorder, receive treatment and services in accordance with professional standards of practice, and has a comprehensive person-centered care plan that reflects the resident's goals to eliminate or mitigate triggers that may cause re-traumatization of the resident. II. Resident #41A. Resident statusResident #41, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included acute on chronic diastolic congestive heart failure, major depressive disorder and post-traumatic stress disorder (PTSD). The 12/3/25 minimum data set (MDS) assessment revealed Resident #41 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #41 had no documented behaviors. The MDS assessment identified Resident #41 had a diagnosis of PTSD. B. Resident interviewResident #41 was interviewed on 2/23/26 at 10:59 a.m. Resident #41 said she had trauma from when her husband completed suicide in front of her. She said he had shot himself. She said gunfire sounds were a trigger for her. C. Record review-Review of Resident #41's comprehensive care plan revealed there was not a trauma-informed care plan focus for the resident. Review of Resident #41's electronic medical record (EMR) revealed her most recent trauma-informed care assessment was dated 10/21/25. The assessment revealed the resident experienced trauma when her husband shot himself in front of her and her daughter. -However, the assessment did not document any triggers for the resident that could lead to re-traumatization of the resident. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 2/26/26 at 1:40 p.m. CNA #3 said Resident #41 did not have any trauma or PTSD. She said the only time that she had seen Resident #41 cry or have any other emotions other than being happy or mad, was when one of her close friends had passed away. The social services director (SSD) was interviewed on 2/26/26 at 6:14 p.m. The SSD said she was the person who created the residents' care plans for trauma and PTSD. She said the care plans for trauma and PTSD should be created when she completed the trauma-informed assessment when the residents first admitted to the facility or if something was brought up to her after admission. The SSD said the trauma-informed care plans should consist of specific triggers and interventions for mitigating the triggers that could re-traumatize a resident. She said it was important for floor staff to know when a resident had a history of trauma or PTSD so that the staff could help prevent any triggers or re-traumatization. She said Resident #41 did not have her PTSD care planned because she said she did not have any triggers. She said if she had mentioned any triggers she would have care planned it immediately. -However, during an interview on 2/23/26, Resident #41 indicated gunfire was a trigger for her (see resident interview above).

Based on record review and interviews, the facility failed to ensure one (#17) of one resident out of 41 sample residents received dental services timely. Specifically, the facility failed to assist Resident #17 with finding another dental service that accepted his dental insurance.Findings include:I. Facility policy and procedureThe Dental Services policy and procedure, reviewed 9/3/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, The facility is responsible for assisting the resident in obtaining needed dental services, including routine dental services. The facility will provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident. Residents will be assisted with making appointments and arranging transportation to and from the dentist's office if necessary.II. Resident #17 A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic diastolic congestive heart failure, chronic kidney disease and atherosclerotic heart disease. The 12/4/25 minimum data set (MDS) assessment revealed Resident #17 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed that Resident #17 was independent with most of his activities of daily living (ADL), including oral hygiene. He needed assistance with showering and footwear. B. Resident interviewResident #17 was interviewed on 2/23/26 at 5:30 p.m. Resident #17 said he saw the dentist when they came to the facility and the dentist had recommended that he have a procedure done. He said the dentist came back and took some Xrays for the procedure. He said when he went to the appointment to have the procedure done, he sat in the waiting room for more than an hour and then he said he was told that the dental office did not accept his insurance. He said he had not heard anything about trying to go to a different dental office to have the procedure done. dent #17 was interviewed a second time on 2/24/26 at 10:30 a.m. Resident #17 said had pain on the lower left side of his mouth and said it felt like cavity pain. He said he remembered someone saying something about his wisdom teeth but he could not remember what they had said. C. Record reviewResident #17's ADL care plan, initiated 9/10/24 and revised 9/10/24, documented Resident #17 had a self-care performance deficit related to pain, decreased mobility, incontinence, medications, diuretics and decreased ADL functions. Interventions related to oral care revealed Resident #17 required assistance of one staff member with oral care. Resident #17's Kardex (staff directive tool) revealed he needed the assistance of one staff member for oral hygiene and to use a soft-bristle toothbrush. Review of Resident #17's electronic medical record (EMR) revealed a dental service note, dated 6/24/25. The note documented Resident #17 was seen for a consultation for a planned extraction of two teeth. The note documented the necessity of an external dental specialist for the procedure and Resident #17 would have to coordinate with the referred specialist to schedule the extraction. A health status note, dated 8/14/25 at 10:45 a.m., documented the dental office where Resident #17's oral surgery was scheduled to take place on 8/20/25 had called to let the facility know that they did not take Resident #17's dental insurance and Resident #17 would have to pay out of pocket. The note documented Resident #17 said to cancel the appointment and that he was not having tooth pain. A second dental service note, dated 9/5/25, revealed the dental provider discussed the need for Resident #17 to have his teeth extracted. The note documented that there was a scheduling issue when he was supposed to go in August 2025. The note documented that Resident #17 lost a broken tooth while brushing his teeth. The note documented the dental service would attempt to get a new referral as soon as possible. -However, there was no additional documentation to indicate the facility made further attempts to get a new appointment scheduled for Resident #17 for his oral surgery. III. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 2/26/26 at 8:43 a.m. CNA #3 said Resident #17 had never mentioned mouth or tooth pain to her. The social services director (SSD) was interviewed on 2/26/26 at 6:14 p.m. The SSD said she was the person who scheduled and coordinated ancillary services, including dental services. She said she was responsible for helping with coordinating any follow-up dental appointments. She said she was not aware that Resident #17's insurance was not accepted at his dental appointment for the oral surgery. She said she asked him how his appointment went and he had told her that he did not get anything done. She said she did not follow up with him any further. She said that in September 2025, the dental service company was going to refer Resident #17 for another dental appointment. She said she was unsure of why Resident #17 had not been seen or referred to another appointment.

Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for one (#36) of five residents reviewed for immunizations out of 41 sample residents. Specifically, the facility failed to ensure Resident #36 received pneumococcal immunization when consent was given.Findings include:I. Professional Reference According to the Centers for Disease Control and Prevention's (CDC) Pneumococcal Vaccination, revised 2/25/26, retrieved on 3/2/26 from https://www.cdc.gov/pneumococcal/vaccines/index.html, CDC recommends pneumococcal vaccination for all adults 50 years or older.II. Facility policy and procedureThe Vaccination of Older Adults policy, revised 1/28/25, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, Consents and declinations should be captured using an informed consent form for the vaccine.Education, assessment findings, administration, refusal or did not receive due to medical contraindications, and monitoring are documented in the resident's medical record. Update immunization record in the electronic health record. III. Resident #36 A. Resident statusResident #36, age greater than 65, was admitted to the facility on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses including acute kidney failure (sudden loss of kidney function), unspecified atrial fibrillation (rapid and quivering heartbeat) and chronic venous hypertension (elevated blood pressure in the leg veins).The 2/5/26 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 MDS assessment indicated the resident was not up-to-date with pneumococcal vaccination due to the vaccine not being offered by the facility.B. Record reviewReview of Resident #36's electronic medical record (EMR) revealed Resident #36 consented to receive the pneumococcal vaccine on 9/9/25, during her admission to the facility.-However, there was no documentation in the resident's EMR to indicate the pneumococcal vaccine had been administered to the resident.The facility obtained a second consent for the pneumococcal vaccine from Resident #36 on 12/28/25, however, the resident declined the pneumococcal vaccine at that time. IV. Staff interviewThe infection preventionalist (IP) was interviewed on 2/26/26 at 5:45 p.m. The IP said Resident #36 had consented to receive the pneumococcal vaccination on 9/9/25. The IP did not know why Resident #36 did not receive her pneumococcal vaccination from the date of initial consent 9/9/25 upon her admission to the facility.The IP said a second consent for the pneumococcal vaccine was obtained from the resident on 12/28/25, however, she said the resident declined at that time and she did not know why the resident declined the vaccination on 12/28/25. The IP confirmed Resident #36's EMR failed to provide documentation of attempts to administer the pneumococcal vaccination to the resident, education provided to the resident at time of the attempts and/or a reason why the resident chose to decline consent for the vaccination in December 2025.

Based on observation, interviews, and record review, the facility failed to assess and monitor an existing pressure injury for one (#50) of seven residents reviewed for wounds out of 32 sample residents and failed to take steps to prevent the resident's development of pressure injuries. Resident #50 who required hands on assisance from staff to complete activities of daily living such as toileting, bed mobility, dressing and personal hygiene and who was at high risk for developing pressure injuries developed facility acquired pressure injury. The resident's pressure injury was first discovered on 4/27/23 and started as a redness spread over the bony part of the resident's left hip. The wound care physician classified the wound as a trauma wound. There was no documentation in the resident's chart to identify what type of trauma caused the wound to develop other than the resident lying on the hip creating skin damage for pressure to the wound site. A note written by the facility's occupational therapist (OT) documented that the pressure injury was discovered on 4/27/23 after the resident had been sitting up in her wheelchair for an extended period. The injury was linked to the resident seating system and position in the wheelchair from the wheelchair components and the cushion putting pressure on the resident's left hip. Following the observation, the OT adjusted the resident's wheelchair seating system and the wound improved by 5/24/23 but emerged again a month later. On 6/28/23 the resident medical record revealed the wound to the resident left hip emerged again as an open wound measuring 1.3 centimeters (cm) in length by 2 cm in width by 2 cm in depth. The wound bed was covered with 100% slough (stringy yellowish dead skin). The facility physical therapist (PT) assessed the resident and recommended the resident lay off of her left side to facilitate wound healing to the left hip. Following this recommendation, the resident developed a pressure injury to the right hip (on 9/4/23). The wound was assessed as an unstageable pressure injury on the resident's right posterior (back) hip with full-thickness of the skin (extending beyond two layers of skin tissue) and tissue loss. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The PT reassessed the resident's seating system following the progression of the facility acquired pressure injuries and documented that the resident had had an inappropriate wheelchair and positioning program causing poor posture and skin related issues. The assessment documented that the resident required more frequent repositioning assistance to offload pressure from the left him with added side and back laying positions. The assessment documented that the resident had been tolerating the recommended repositioning; however, observations revealed the resident was not being respositioned as recommended (see observations below). The wound care physician (WCP) assessment of the pressure injuries reviewed the WCP believed the wounds were avoidable (see the WCP interview below). Interventions were not implemented consistently and observation of the resident's care revealed a lack of timely repositioning and staff not following the PT's recommendations to assist resident to offload pressure alternating from side to side and back lying on a frequent basis in order to promote healing the left hip wound and improved skin integrity. The facility failed to promote full healing of the wound and failed to prevent the formation of a second wound from worsening. The facility's failure to develop and implement timely and effective interventions led to the development of two unhealed pressure injury wounds one of which caused the resident severe pain. On 11/22/23, the pressure injury to the resident's left hip while healing persisted and measured 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. However, the pressure injury wound to the right rear hip, first observed 9/4/23, worsened from intact skin to an unstageable pressure injury measuring 1.2 cm in length by 1.2 cm in width by 0.1cm depth with a build-up of dead tissue and severe pain at the wound site. The wound required surgical debridement to remove dead tissue and progressed to a stage 4 pressure ulcer measured 1.2 cm in length by 1.2 cm that began to spread under the surface of the skin at the wound edges. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 12/7/23, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dark dead skin) may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy The Skin Integrity and Pressure Ulcer/Injury Prevention and Skin Management policy, reviewed 3/31/23, was provided by the nursing home administrator (NHA) on 11/30/23 at 1:26 p.m. It revealed in pertinent part, Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure, ulcer injury, complete, wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury, Advisory Panel) and WOCN (Wound, Ostomy, Continent, Nurse Society). A comprehensive skin inspection/assessment on admission and readmission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas, surrounded by edema; profound, redness, or induration; bogginess; and or discoloration. These signs possibly indicate an unavoidable stage three or four with slough, drainage, or even eschar within a few days. A risk assessment to Braden Scale, or Norton Scale determines the resident's. Risk of pressure injury development. The score is documented on the tool and placed in the resident's medical record using the appropriate form. Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include, but are not limited to; impaired/decreased mobility and decreased functional ability. Morbid conditions, such as end-stage, renal disease, thyroid disease, diabetes mellitus, or other end-of-life concerns. Drugs such as steroids that may affect wound healing. Impaired diffuse, or localized blood flow. A patient's refusal of some aspects of care treatment especially in multi-system organ failure, or end-of-life conditions. Exposure of skin to urinary and fecal incontinence. Under nutrition, malnutrition, and hydration deficit, edema and history of a healed injury. Measures to maintain and improve resident's tissue tolerance to pressure and implemented in the plan of care. All residents upon admission are considered to be at risk of pressure injury development due to medical issues requiring nursing care and related disease processes and illness or need for rehabilitation services. Upon admission and throughout stay at minimum distribution surface is in use with her and repositioning as needed with ADL care/assistance in care, if needed to include skin barriers, application as needed, preventative, wheelchair cushions, if indicated, etc. Skin inspections with particular attention to bony prominences. Skin cleansing with appropriate cleanser at the time of swelling and at routine intervals. Minimize skin exposure to incontinence using devices and skin barriers. Minimize injury due to shear friction through proper positioning, transfers, and turning schedules. Encourage PO food and fluid intake and improve residence, mobility and activity when potential exists. Measures to protect the resident against the adverse effect of external mechanical forces, such as pressure friction, and are implemented in the plan of care; reposition, at least every 2 to 4 hours, as consistent with overall patient goal and medical condition. Utilize positioning devices to keep prominences from direct contact and ensure proper body alignment protection/suspension if indicated. A distribution mattress surface is placed under the resident. When positioned in the wheelchair, the resident is to be placed on a pressure reduction device and repositioned. When positioned in a wheelchair consideration is given to postural alignment, distribution, weight, balance, and stability. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. III. Resident #50 A. Resident status Resident #50, age 75, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included Parkinson's, dementia with behavioral disturbances and major depressive disorder. According to the 11/10/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired and was unable to complete a brief interview for mental status (BIMS). She was dependent on one person with transferring and dressing. She required substantial assistance from one person with toileting, bed mobility, dressing, personal hygiene and eating. The resident was dependent on a wheelchair and needed moderate assistance with locomotion. The resident was at risk for developing pressure ulcers. The resident had unhealed pressure ulcers. The resident had one unstageable pressure ulcer. The pressure ulcers were not present at admission. B. Observations On n 11/27/23 Resident #50 was observed and revealed: -At 9:00 a.m. the resident was in her bed lying on her right side. -At 10:00 a.m. the resident was in her bed lying on her right side. -At 11:58 a.m. the resident was in her bed lying on her right side. On 11/28/23 Resident #50 was observed and revealed: -At 10:26 a.m. the resident was in her bed lying on her right side. -At 10:40 a.m. an unknown CNA went into the Resident #50's room but did not reposition her and the resident remained lying on her right side. -At 12:30 a.m. a unknown CNA went into Resident #50's room to help her roommate, but did not assist Resident #50 with any care. Resident #50 remained on her right side. -At 1:30 p.m. the Resident #50 remained on her right side. On 11/30/23 Resident #50 was observed and revealed: -At 9:00 a.m. the resident was in her wheelchair in the hallway. -At 12:00 p.m. an unknown staff member transported the resident, who was still up in her wheelchair to the dining room for lunch. -At 12:45 p.m. after the resident finished lunch, an unknown staff member transported the resident to her room and transferred her to bed using a hoyer (mechanical) lift. The staff laid her down on her right side. C. Record review According to the Braden scale (a scale to measure risk of developing pressure ulcers) dated 5/11/23 Resident #50 was at mild risk of developing pressure ulcers. According to the health status note dated 5/1/23 at 11 a.m., the resident had a new skin issue discovered on 4/27/23. The resident had redness spread over her left hip. The registered nurse (RN) on duty cleansed the skin and placed prophylactic (preventative) foam dressing on the left hip. A seating cushion that was previously placed for positioning the resident in the wheelchair was removed and OT had been working with the resident on positioning. OT removed a rigid lateral support (lateral trunk support) and adjusted lateral support so it would not rest on the bony prominence of her hip. According to a care management note dated 5/4/23 OT was discontinued due to the resident meeting all her wheelchair goals. According to the OT discharge summary dated 5/6/23 the resident received therapy between 3/15/23 and 5/6/23. The resident had been assessed by OT due to the resident being at risk for falling out of her wheelchair due to inability to sit up in the chair without leading to the left. The initial intervention for positioning was causing additional rubbing and pressure on the residents left hip. As a part of the assessment and treatment the OT made adjustments to preventing the support from rubbing against the resident's hip. According to an event note dated 6/28/23 the resident had an open area to her left hip on the bony prominence. The affected area had been padded with mepilex dressing for the past four weeks due to non blanchable redness (when the skin is unable to return to a normal pigment when pressed) that developed from using equipment to help her sit upright in her wheelchair. The resident was evaluated by the wound team. According to the wound observation tool dated 6/28/23 the resident acquired a new skin impairment on 6/28/23, on her left hip. The first observation revealed the resident's skin had epithelial tissue (normal healthy skin) present and granulation tissue (beefy red tissue an indicator that skin was healing) the wound had a small amount of serous drainage (normal clear yellow fluid an indicator of a healing wound). The wound measured 1.3 cm in length, 2.2 cm in width and 0.2 cm in depth. According to the wound note dated 7/5/23 the resident's left hip was identified as a trauma wound with a status of not healed. The wound measurements were 1.3 cm in length by 1.9 cm in width with no measurable depth with 100% slough. There was a small amount of serous drainage noted. The physician performed surgical debridement (procedure to remove dead tissue). Post debridement measurements were 1.3 cm in length by 1.9 cm in width by 0.1 cm in depth. According to the wound note dated 7/12/23 the resident had an unhealed left hip trauma wound. The wound measurements were 1.3 cm in length by 2.2 cm in width with no measurable depth.There was a small amount of sero-sanguineous (watery bloody) drainage noted. The wound bed had 95% eschar and 5% slough. There was no change noted in the wound progression. The left hip wound was still developing but not enough to allow for debridement. According to wound notes dated 7/19/23 the resident's left hip trauma wound and had received a status of not healed. The wound measured 1.5 cm length by 2.5 cm in width with no measurable depth. There was a small amount of serous drainage noted. Wound bed had 100% slough. There was no change noted in the wound progression. The wound was surgically debridement; post debridement measurements were 1.5 cm in length by 2.5 cm in width by 0.3 cm in depth. According to the PT evaluation and treatment plan dated 7/19/23 the resident had a pressure wound. The resident had poor posture, adverse effects to skin integrity and there was inconsistent use of hoyer lift. The resident's goal was to be able to sit in an upright position and transfer safely in the hoyer lift to decrease further risk of skin trauma. The PT assessment recommended making changes to the resident's wheelchair cushion. According to the wound note dated 8/2/23 the resident's left hip wound measured 1.7 cm in length by 2.4 cm in width with no measurable depth, muscle was exposed. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided with post debridement measurements of 1.7 cm length by 2.4 cm width by 0.3 cm. According to the August 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition resident every two hours and ensure offload of the left hip at all times every shift for wound on left hip, ensuring the resident was not laying on left hip until wound was resolved. Order dated 8/2/23 and discontinued 9/24/23. According to the wound note dated 8/9/23 the resident's left hip wound measurements were 2.5 cm in length by 1.3 cm in width with no measurable depth. Muscle was exposed and tunneling (occurs when a chronic wound has progressed to form an opening underneath the surface of the wound's edge) was present at a distance of 1.4 cm. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided. The post debridement measurements were 2.5 cm in length by 1.3 in cm width by 0.1 cm in depth. According to the PT evaluation and treatment plan dated 8/30/23 the resident's wheelchair was modified but continued to require monitoring for adverse effects. The assessment recommended that the resident be encouraged to lay on her side while in bed to alleviate pressure to aid with left wound healing but this resulted in a non-blanchable redness on the resident's right hip. The resident continued to require education on participants in a rotating program reposition and promote overall skin integrity. According to the comprehensive care plan focus for impaired skin integrity dated 8/24/23 the resident had a trauma injury wound. Interventions included providing treatment as ordered. Weekly skin checks in wound rounds. Air pressure mattress. Clean and dry skin after each incontinent episode. Encourage the residents to wear geri-gloves (non-compression, seamless knit material that contours to the body to protect thin, sensitive skin from tears, abrasions, and light bruising) as tolerated, to avoid skin tears on hands. Staff should make certain nails are trimmed. Added padding to the resident's wheelchair arms. Ensure the resident's hands on her lap when assisting her with ambulation. According to the altered skin integrity care focus dated 9/11/23 interventions included assisting the resident to reposition when in bed off of her back with the use of wedges, as tolerated, to prevent skin breakdown. According to an event note dated 9/4/23, the resident had a non-blanchable wound to the right hip bony prominence. The affected area was maroon in color. The resident had been laying mostly on her right side due to the wound on her left hip. The resident did not like to lay on her back to relieve pressure from both bony prominences. Affected area was cleansed with normal saline, skin prep and covered with mepilex dressing. According to wound notes dated 9/6/23, the resident developed an unstageable pressure injury on her right posterior hip with full-thickness skin and tissue loss. The pressure ulcer had received a status of not healed. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The wound bed had 100% epithelialization with obscured full-thickness skin and tissue loss. According to wound note dated 9/6/23 the resident's left hip wound measured 1.2 cm in length by1.5 in cm width by 1 cm in depth with undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) with a maximum distance of 2.3 cm. According to event note dated on 9/11/23,the resident had a non blanchable wound. The resident was sleeping and resting on an air mattress with order for staff to provide repositioning assistance and wound care treatment and dressing changes. According to the wound observation tool dated 9/13/23 the resident had an unstageable pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had slough tissue. The wound measurements were 3.0 cm in length and 5.0 cm in width According to the PT evaluation and treatment plan dated 9/20/23 the resident tolerated the position throughout the day with no adverse effects to the left hip wound. The resident tolerated a rotating positioning program in supine (on back) to promote overall skin integrity. The resident currently had an inappropriate wheelchair and positioning program. The resident needed a smaller wheelchair and to be repositioned more frequently. According to the September 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition the resident and offload bilateral hip as allowed every shift for skin management order dated 9/24/23 and discontinued 10/19/23. According to the PT discharge summary dated 10/2/23 the resident was discharged with a good seated and supine positioning with no worsening wounds. According to the pressure ulcer care focus dated 11/13/23 the resident had an unstageable pressure ulcer on her right hip. Interventions included administer medications and treatments, as ordered. Provide enhanced barrier precautions. Inform the resident and family of any new skin breakdown. Perform lab and other diagnostic work as ordered, report the results to the medical doctor and follow up as indicated. Observe and report changes in skin status; appearance, color, wound healing, sign of infection, wound size and stage of wound. Serve diet as ordered and monitor intake and record. According to the wound note dated 11/15/23 The resident had an unstageable pressure injury on her right, posterior hip with obscured full-thickness skin and tissue loss and had received a status of not healed. The wound measured 1.2 cm in length by 1.2 cm in width with no measurable depth, with undermining at a distance of 2.6 cm. There was a large amount of serous drainage noted. The patient reports a wound pain of level 0/10. The wound bed had 80%, granulation, 20% slough. The wound was surgically debrided, post debridement measurements were 1.2 cm in length by 1.2 cm in width by 0.1cm depth. According to the wound observation tool dated 11/22/23 the resident acquired a skin impairment on her left hip, due to trauma of equipment use on 6/28/23 (seating and transferring devices, see above). The left pressure wound was assessed to have been healing with granulation tissue (beefy red) the wound had serous and scan drainage. measurements were 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. According to the wound observation tool dated 11/22/23 the resident had a stage 4 pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had granulation and slough tissue . The wound measurements were, 1.2 cm in length and 1.2 cm in width with tunneling. IV. Staff interviews The wound care physician (WCP) was interviewed and observed on 11/29/23 at 1:20 p.m. while performing wound care on Resident #50's left hip. The WCP said the resident was admitted to the facility on [DATE], with a left hip trauma injury. The wound had been unstable. The wound had worsened and was now classified as a stage 4 pressure injury with tunneling and had a large amount of drainage. The WCP said the wound likely had severe colonization and was possibly an infection but he was unable to determine the severity of the infection because he was unable to see the bottom of the wound. The WCP said if the resident acquired the left hip wound at the facility then the wound on her right hip was avoidable. The wound doctor said the resident would not have acquired the right hip wound if she did not have the left wound. The WCP said the resident was positioned on the right hip because it was painful to lay on her left hip. The WCP said the resident should be repositioned supine (on her back) to avoid the wound's progression. The WCP said both wounds were stage 4. Registered nurse (RN) #1 was interviewed on 11/29/23 at 2:20 p.m. RN #1 said the resident's left hip trauma wound developed because the resident would propel herself in her wheelchair and would lean to the left side. RN #1 said the pressure ulcer on the right side developed because the resident was in pain and preferred to only lay on her right side. RN #1 said the resident should be positioned on her back to relieve pressure on both hips. RN #1 said the resident had wedge cushions on her bed to help the resident stay positioned on her back. Certified nursing aide (CNA) #1 was interviewed on 11/30/23 at 8:59 a.m. CNA #1 said if there was a change in skin condition the CNAs would report to the nurse and the nurses would report it to the resident's physician. CNA #1 said residents should be repositioned every two hours. CNA #1 said the residents in the facility should not have pressure ulcers if they were repositioned. CNA #1 said Resident #50 acquired pressure ulcers because she was not repositioned properly. CNA #1 said the resident initially had skin issues due to poor positioning in the wheelchair and because the resident was consistently laying on her left side due to not wanting to face the wall while in bed it made her wounds worse. CNA #1 said the resident's bed was facing the other way so now the resident was willing to lay on her right side. CNA #1 said the resident had bed wedges to keep her laying on her back and off her hips. CNA #1 said the other staff did not reposition the resident correctly; she knew this because she observed the other CNAs position the resident consistently on to her right side because the resident moved around when she was on her back. The director of nursing (DON) was interviewed on 11/30/23 at 12:06 p.m. The DON said if a change in the resident's skin was found the CNAs were to notify a nurse and the nurse would notify DON and start the risk management assessment documentation. The DON said residents who could not reposition themselves should be repositioned every two hours. The DON said Resident #50 had first developed a skin tear because she was not seated properly in her wheelchair and was leaning to the left causing friction. The DON said therapy staff put a wedge positioning cushion in place to prevent further skin issues but the resident did not tolerate laying on her back to offload pressure on her hips. The DON said the resident was not eating enough so she was at high risk of pressure ulcers. V. Facility follow-up On 12/1/23, the nursing home administrator (NHA) provided an addendum to the physician's 11/17/23. The addendum note dated 12/1/23 (after exit), documented the wound progress note demonstrates that the wound was unavoidable. The resident was combative during care and repositioning. -The note provided no other rationale about why the wound development was now determined to be unavoidable. Additionally, the WCP said during the interview that the resident's right hip wound was avoidable and would not be there if not for the left wound causing the resident pain and making her reluctant to off load pressure from the right hip and lay on her back.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in one of two medication storage rooms. Specifically, the facility failed to ensure vaccines and insulins (medications used to regulate blood glucose levels) were not stored in a dormitory style fridge. Findings include: I. Professional reference According to the Vaccine storage and Handling Toolkit retrieved on 11/30/23 from: https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf it revealed in pertinent part Do not store any vaccines in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units pose a significant risk of freezing vaccines, even when used for temporary storage. II. Facility policy and procedure The Storage and Expiration Dating of Medication, Biologicals policy, revised 7/21/22, was received from the nursing home administrator (NHA) on 11/30/23 at 12:50 p.m. It revealed in pertinent part, facility should ensure that medications and biologicals were stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. III. Observation On 11/30/23 at 9:19 a.m. the first floor medication room was observed to have a dormitory style refrigerator used to store vaccines and insulins. -The following insulin medications were stored in the refrigerator: three Trulicity pens, five Lantus pens, one Novolog pen, one insulin emergency kit containing one vial of each Lispro, Humalog, Humulin R and Lantus. -The following vaccines were stored in the refrigerator: eight Influenza quadrivalent 2023-2024 formula vials and 18 Prevnar 20 (vaccine for pneumonia) vials. -The freezer was observed with ice built up in and around the freezer compartment affecting the first shelf of the refrigerator. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 11/29/23 at 9:19 a.m. She said the freezer had a lot of ice built up around it and needed to be cleaned out. RN #1 said she did not believe the medications or vaccines in the refrigerator were compromised by the freezer or the ice build up. RN #1 said it was the responsibility of the night shift nurse to log temperatures and clean the medication refrigerators. The director of nursing (DON) was interviewed on 11/30/23 at 12:27 p.m. She said medication refrigerators were to be cleaned by nursing staff. The DON said medications and vaccines were not to be stored in a dormitory style refrigerator as they could freeze medication. The DON was not aware the first floor medication refrigerator was a dormitory style refrigerator and that it had a large amount of ice built up around the freezer. The infection preventionist (IP) was interviewed on 11/30/23 at 2:03 p.m. He said medications and vaccines should be stored at the manufacturer's recommendations. The IP was unaware there was a dormitory style refrigerator in use for medication/vaccine storage and said it should not be used as it was not good at regulating temperature within the compartment.

Based on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure the soiled linen laundry room exhaust fan was functional. Findings include: I. Observations An observation of the soiled linen laundry room was completed on 11/30/23 at 10:45 a.m. An exhaust fan was installed in the ceiling of the soiled linen laundry room. The fan was not audible and did not create air movement with the switch turned on. The fan was covered with thick gray and black debris. As a measure of checking the function of the fan, a small square of single ply toilet paper was placed against the vent. The exhaust fan was unable to hold the toilet tissue in place which indicated the fan did not function properly. -Soiled linen odors such as urine were observed during multiple observations in the soiled linen laundry room. The soiled linen laundry room exhaust fan was not functional. II. Staff Interview The environmental tour was conducted with the director of maintenance (DM) and the housekeeping director (HKD) on 11/30/23 at 10:46 a.m. The HKD said the exhaust fan had not worked in the soiled linen laundry room for the past [AGE] years. The DM confirmed the exhaust fan was not functional because he had shut it off from the main breaker three months prior to the survey because it was too loud and therefore he had to turn it back on to demonstrate it was functional during the survey. He said the fan had been serviced recently to ensure it was functional. -The DM attempted to turn on the fan from the main breaker, however, the fan did not turn on. -The DM was unable to provide documentation that the exhaust fan had been previously serviced. The DM said the ventilation fan should be in good working condition to protect staff from foul odors and ensure there was adequate airflow within the room.

Based on record review, observations, and staff interviews, the facility failed to ensure two (#54 and #4) of four residents reviewed for accident hazards out of 34 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of accidents. Resident #54 was admitted to the facility on [DATE] with a diagnosis and history of falls. The resident had four falls from 8/23/21 through 4/7/22. The facility failed to implement effective fall precautions with her risk of falling. On 4/7/22 the resident sustained a head injury following a fall which required hospital treatment. The interventions included educating the resident but also documented the resident was not always able to communicate her needs and that she forgot conversations held after a few minutes. The resident had a care plan to wear non-skid socks. During the survey from 8/8/22 to 8/11/22, the resident was observed walking the hallway in nylon material socks that were not non-skid. In addition, the facility failed to: -Transfer Resident #4 in an appropriate manner; -Ensure a tube feeding device was plugged into a medical electrical outlet power strip; and, -Ensure electric cord was clear of a water source. Findings include: I. Resident #54 A. Facility policy The Fall Management policy, revised 4/7/22, was provided on 8/16/22 at 3:53 p.m. via email from the nursing home administrator (NHA). It revealed in pertinent part, Purpose To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. Policy The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Unavoidable accident means that an accident occurred despite sufficient and comprehensive facility systems designed and implemented to: Identify environmental hazards and individual resident risk of an accident, including the need for supervision. Evaluate/analyze the hazards and risks and eliminate them, if possible and, if not possible, reduce them as much as possible. Implement interventions, including adequate supervision, consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice. All patients have fall indicators. Fall indicators are patient specific information that, when alone or combined with other fall indicators, create a potential for a patient to fall. B. Resident status Resident #54, age 81, was admitted on [DATE]. According to the August 2022 computerized physical orders (CPO), the diagnoses included Alzheimer's disease, adult failure to thrive, hypertension (high blood pressure), disorientation, dysphagia (difficulty swallowing), history of falls, and dementia with behavioral disturbances. The 7/16/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. The resident did not reject care from staff. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required limited assistance with transfers, and walking in the corridors. She was not steading moving from a seated to standing position. C. Record review A review of the facility fall investigations provided by the nursing home administrator (NHA) on 8/1/22 at 1:27 p.m. revealed Resident #54 fell four times. The resident had an injury during the fourth fall which required the resident to be sent to the hospital. A review of the four falls revealed in pertinent part: -The 8/23/21 fall report revealed the resident was found lying in the bathroom on her back, wearing only one non-skid sock. The report did not document any predisposing environmental, physiological, or situational factors that were documented on the fall investigation. The report did not contain any interventions that were put in place. The fall was unwitnessed. The resident was unable to give a description of the fall event. -The 12/18/21 fall report revealed a registered nurse (RN) assessed the fall but only revealed the resident was found on her right side. The report did not document where she was found at the time of the fall, what was the reason she fell , and no other predisposing environmental, physiological, or situational factors were documented on the fall investigation. The report did not contain any interventions that were put in place. The fall was unwitnessed. The resident was combative with staff during the fall assessment by the RN. The resident was unable to give a description of the fall event. -The 12/21/21 fall report revealed the resident was found on her left side on the floor. The report did not document where she was found at the time of the fall, what was the reason she fell , and no other predisposing environmental, physiological, or situational factors were documented on the fall investigation. The report did not contain any interventions that were put in place. The fall was unwitnessed. The resident was unable to give a description of the fall event. -The 4/7/22 fall report revealed Resident found lying face down with a chair on top of her, resident is alert but unable to tell what happened, small abrasion on forehead some bleeding noted. Resident was rubbing left hip and crying.The facility called an ambulance to transport the resident to the hospital. The report did not contain the location where the injury took place. The report documented there were no predisposing factors about the fall with injury. The resident was unable to give a description of the fall. -A follow up fall investigation report for the 4/7/22 fall, written on 4/14/22 (seven days after the fall) was provided by the facility nurse consultant (FNC) on 8/11/22 at 11:49 a.m. revealed in pertinent part, The event time was 3:00 a.m. The resident ambulates without assistance, able to transfer herself, has a history of falls. Resident was on the floor flat on her back, bleeding from the back of her head. Resident was then assisted to a sitting position, notice a deep laceration on her occipital (back of the head). Pressure dressing applied to stop bleeding. At 3:45 a.m. the resident started vomiting. Ambulance called and arrived at 3:53 a.m. The current interventions that were put in place at the time of the 4/7/22 fall were to Anticipate and meet the resident's needs. Assist with activities of daily living (ADLs) as needed, call light within reach. Educate the resident about safety reminders and what to do if a fall occurs. Provide activities that minimize the potential for falls while providing diversion and distraction. Provide appropriate footwear when ambulating non-skid socks provided. The 4/14/22 follow-up investigation had blank pages to the following questions: -Resident/family interviews and an interview of the resident who experienced the event with a list of questions and the resident's responses to be documented was left blank. The 4/14/22 follow-up investigation listed the falls for the past six months which were not included on the fall investigations revealed: -8/23/21 resident was face on floor in bathroom. The section documenting what new intervention was implemented after the fall was left blank. -12/18/21 resident was face of floor beside roommates bed. The section documenting what new intervention was implemented after the fall was left blank. -12/21/21 resident was found on (the) floor. The section documenting what new intervention was implemented after the fall was left blank. The fall care plan revealed the resident was at risk for falls related to diagnosis Alzheimer's dementia with decreased safety awareness, history of urinating in inappropriate places, history of falls. Interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred (4/11/22). Provide activities that minimize the potential for falls while providing diversion and distraction (added 7/16/21). Provide appropriate footwear when ambulating non skid-socks provided (added 3/28/21). Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (added 7/16/21). An additional care plan revised on 1/27/22 revealed due to the resident's severe cognitive impairment, education would require specific strategies. -The resident's fall care plan had not been updated when the resident fell on [DATE], 12/18/21 and 12/21/21. There was no documentation that the family was educated about safety reminders. The resident was not provided with activities (see activity director interview below). The resident to spend her day walking back and forth throughout the hallways unassisted with no staff reminders of safety/mobility device. The resident was observed not wearing non-skid-socks (see observations below). D. Observations On 8/8/22 and 8/9/22 from 9:00 a.m. until 4:30 p.m. Resident #54 was not wearing shoes. She was wearing red nylon socks which were not non-skid socks. She walked almost continuously from one end of the upstairs hallway to the other. She stopped to talk to residents, walked into her bedroom, and continued to walk without staff assistance. She did not use a walker, cane, or wheelchair while she walked. On 8/10/22 and 8/11/22 from 9:00 a.m. until 5:30 p.m the resident was lying on her bed, and she sat up for meals. Per staff interviews below, the resident often was up at night pacing and would sleep during the day. E. Interviews Licensed practical nurse (LPN) #1 was interviewed on 8/11/22 at 10:35 a.m. She said Resident #54 was up all night on 8/9/22. She said the resident often stayed up all night pacing and walking back and forth on the second floor and then she slept all day. She said the staff would offer her snacks to keep her occupied when she paced up and down the halls. She said the resident had on non-skid socks today. She said the resident had two pairs of socks in her closet. She said one pair of socks was non-skid and one pair of socks was not. She said she did not know if the red socks the resident wore yesterday were non-skid and she said those socks were not in the resident's closet. She said the resident was unable to put on her own socks. She said staff put socks on the resident daily. She said the resident did not prefer to wear shoes. She said the resident did not understand how to utilize her call light. She said due to the resident's mental status she did not understand directions very well. Certified nurse aide (CNA) #4 was interviewed on 8/11/22 at 11:20 a.m. She said Resident #54 was up again all night on 8/10/22. She said when the resident was up all night she paced the hallways and was in bed all the following day. She said Resident #54 walked the halls on the second floor almost everyday and all day. The activity director (AD) was interviewed on 8/11/22 at 11:30 a.m. She said Resident #54 did not attend activities. She said the activity department tried one time to give the resident a one-to-one visit but she declined. She said no other one-to-one attempts were made or given since the resident declined personal visits. She said the resident did not attend group activities often because it was hard for her to pay attention. She said the activity department did not put supplies in the resident's room to help the night staff utilize items when the resident was up all night. She said she would get supplies and put in the resident's room for the evening staff to use with Resident #54. The NHA was interviewed on 8/11/22 at 4:40 p.m. She said from what she remembered about Resident #54's fall on 4/7/22 and from reading the notes, the resident was up wandering most of the night. She said the resident was a fall risk. She said the resident was in her room, fell flat on her back on the floor, and had lacerations to the back of her head. She said the resident had Alzheimer's and dementia and had not declined in health. She said she was unaware of the resident wearing or having regular socks instead of non-skid socks. She said the interventions put in place for falls for Resident #54 would need to be reviewed and updated after the survey (the exit was on 8/11/22). II. Resident #4 A. Facility policy The Mechanical Lift policy, revised 7/22/21, was provided by the director of nursing (DON) on 8/10/22 at 6:23 p.m. It read in pertinent part: The purpose of the policy was to provide guidance when transferring a resident with a mechanical lift.It is important to train staff regarding resident assessment about the importance of safe transfers when using a mechanical lift to transfer a resident. Residents who become frightened during a transfer in a mechanical lift may exhibit resistance movements that can result in avoidable accidents. Communication with the resident during the transfer may help to reduce the resident ' s fear and avoid an accident. The facility will provide this kind of lift for the residents who are determined to need this type of transfer to meet their needs.The facility will ensure that two associates are present during the time of the transfer and that one of the associates is over the age of 18.The facility will use the Lippincott procedure for hoyer lifts and sit-to stand transfers. B. Resident status Resident #4, age 86, was admitted on [DATE]. The August 2022 computerized physicians orders (CPO) included a diagnosis of type 2 diabetes, chronic kidney disease, history of falling, localized [CONDITION(S)] and difficulty in walking. The 7/21/22 minimum data set (MDS) indicated the resident was cognitively impaired with a brief interview of mental status (BIMS) with a score of five out of 15. The resident required extensive assistance with toileting, sitting to stand, chair to bed transfer, dressing and bathing. C. Record review Transfer training documentation was received from the director of nursing (DON) one 8/10/22 at 6:23 p.m. It read: any mechanical lift requires two staff members when transferring a resident.The training sign off sheet contained 28 staff signatures, half of which took the training on 7/19/22 and the other half took the training on 7/21/22. The MDS functional status review dated 7/21/22 indicated the resident was totally dependent on the hoyer (mechanical) lift and needed a two person assistance with transferring, from sitting to a lying position and the resident was dependent on her wheelchair for mobility. The care plan detail was updated on 7/29/22. Resident #4 has an activity of daily living (ADL) self-care performance deficit. She has bilateral upper and lower extremity contractures.The resident has non weight-bearing status. A two person hoyer lift should be used for all transfers. D. Observations On 8/10/22 at 1:43 p.m., the resident was sitting in her recliner chair. Certified nurse aide (CNA) #5 and CNA #9 placed the hoyer mechanical lift sling around the resident. The sling criss crossed between her legs. When the CNA began to raise the lift. At 1:50 p.m., the director of rehabilitation (DOR) arrived into the room, after CNA #5 had requested her to come into the room. The DOR told the CNAs that a sit-to-stand lift would be used. She failed to look at the sling which was placed on the resident prior to changing the mechanical lift from a full hoyer lift to a sit to stand. CNA #9 said the sling for the sit-to stand lift was on top of the resident ' s closet. The sling was removed and placed behind the resident. The straps crisscrossed across her breasts. The straps were tight. CNA #5 began to use the lift and the resident was assisted into the standing position. The resident did not have her hands on the lift, and her arms hung down, as she was lifted. The resident called out that it hurt. The CNAs continued using the lift with the incorrect sling after the resident called out that it hurt and she was placed on the bed. The sling was removed. CNA #5 said the sling needs to be an extra large sling. CNA #5 looked at the sling which was used, and it was a medium. She said she would locate a large sling. At 2:06 p.m the DOR told the charge nurse that the sit-to-stand lift was the lift to use with her transfers from the bed to chair and vice versa, although she needed an extra large sling. E. Interviews The director of nursing (DON) was interviewed on 8/10/22 at 4:32 p.m. She said Resident #4 was supposed to be transferred by two staff in the hoyer lift instead the staff used a sit-to-stand lift. She said the staff used a medium sling when they should have used an extra large one. She said it resulted in extreme discomfort to the resident since the sling was too small. The director of rehabilitation (DOR) was interviewed on 8/11/22 at 5:30 p.m. The DOR, who was an occupational therapist assistant, said when she arrived at the room, the resident was complaining that the full mechanical lift sling was hurting her legs, so she said she made the decision to use the sit-to-stand lift. She said that in the past the sit-to stand lift was utilized for this resident. She did confirm that she did not assess the hoyer mechanical lift sling. She said the resident had been assessed for the sit-to-stand lift at an earlier date. She confirmed, she had not checked the sling which was in the room. The DOR said an extra-large sit-to-stand sling would be obtained. She said when the transfer happened, it was tight and squeezed her breasts. The DOR said having the right sling for the resident was important. III. Ensure tube feeding device was plugged into a medical grade power surge protector A. Observations On 8/8/22 at 10:36 a.m., Room 211 had a tube feeding device, which was plugged into a regular power strip. It was not a medical grade power surge. On 8/10/22 at approximately 4:00 p.m., the tube feeding device continued to be plugged into the non-medical power surge. B. Staff Interview The nursing home administrator (NHA) was interviewed on 8/11/22 at 7:00 p.m. The NHA said environmental plant rounds were completed weekly. She said it was to ensure the environment was safe. She said they had not identified the medical equipment that was not plugged into a medical grade power strip. She said the facility did have medical grade power strips and would replace it immediately. IV. Ensure electrical cord was clear of water source A. Observations On 8/8/22 at 2:30 p.m., room 216 had an electrical cord from the television which was observed hanging over the sink. The cord was plugged into a power surge protector, which was plugged in over the wardrobe closet. The power surge protector was not plugged into a ground fault circuit interrupter (GFCI). On 8/8/22 at 4:00 p.m., the cord was observed in the same position. B. Staff Interview On 8/8/2022 at 5:30 p.m., the nursing home administrator (NHA) was shown the electrical cord hanging over the sink. The NHA said, I missed that on my earlier round. The NHA asked the resident if she could unplug the television for a minute while she rerouted the electrical cord. The NHA immediately removed the cord from the power strip protector and plugged it into the GFCI outlet. The cord length still had the capability of hanging into the sink. The NHA said she would get some clips to ensure the cord was not close to the water source.

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 disease and infection, including COVID-19 in two of two floors. Specifically, the facility failed to: -Ensure visitors and staff who entered into the facility through the front lobby, reception area, wore masks; -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; -Ensure resident bedrooms were cleaned with proper infection control techniques. The housekeeping staff wore the same gloves to clean rooms with double occupancy, and used the same cleaning rag throughout a double occupancy room; and, -Ensure proper personal protective equipment (PPE) were donned and doffed properly. Findings include: I. Facility policy The Infection Prevention and Control Program (IPCP) and Plan, revised 6/7/22, was provided on 8/11/22 at 8:30 a.m. by the director of nursing (DON). It revealed in pertinent part; Goals of the Infection Prevention and Control Program Monitor for any occurrences of infection and implement appropriate control measures. Identify and correct problems relating to infection prevention and control practices. Educate and train HCP (health care personnel), including facility-based and consultant personnel who provide care or services in the facility. Including consultants is important, since they commonly provide in multiple facilities where they can be exposed to and serve as a source of COVID-19. Reinforce adherence to standard IPC measures including hand hygiene and selection and correct use of personal protective equipment (PPE). Have HCP demonstrate competency with putting on and removing PPE and monitor adherence by observing their resident care activities. II. Entering the facility with no face covering A. Observation On 8/8/22 at 9:00 a.m. until 12:30 p.m. several staff and visitors entered the building through glass doors into the lobby receiving area where a receptionist sat. Multiple staff and visitors came in the building without wearing any masks, which included surgical or N95. The staff and visitors waited as necessary for their turn to use a screening machine for their temperature and to answer screening for COVID-19 questions. After the individuals finished their screening, they turned toward the receptionist desk and took a mask out of the mask box. Some individuals talked with the receptionist, other staff members, and family members without having on masks. The facility was currently in outbreak status. The receptionist did not ask for individuals to put on a mask before they entered the facility. There were no signs to inform people that the facility had a COVID-19 outbreak. (see interview below with nursing home administrator and nursing home consultant when they put up warning signs on 8/8/22 at 1:30 p.m.) B. Interviews The receptionist was interviewed on 8/8/22 at 10:00 a.m. The receptionist said when visitors or staff arrived at the facility, she would have them screen in and then they would get a mask out of the box. The nursing home administrator (NHA) and the facility nurse consultant (FNC) was interviewed on 8/8/22 at 1:30 p.m. while in the foyer putting up signage to notify individuals to put on masks due to a COVID-19 outbreak in the facility. The NHA said Don't mind us, we are just setting up the PPE (personal protective equipment) and signage. C. Facility follow-up On 8/8/22 at 2:30 p.m. the foyer area had a table with a basket of N95 masks and a note asking people to wear a mask due to a COVID-19 outbreak in the facility. The new signage posted up in the reception area revealed three signs which revealed: COVID-19 outbreak in the facility. Please stop at the receptionist desk for additional directions. Please remember to wear a mask during your visit. Do not enter if you are sick or required to self-isolate. Clean your hands before and after visiting, use soap and water or ABHR (alcohol based hand rub). There was also a stop sign put up on the glass in front of the receptionist. The yellow stop sign had written across it STOP HERE For Screening. III. Failure to ensure residents were offered hand hygiene before meals A. Professional reference The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes (updated 2/2/22), retrieved on 8/11/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, Educate residents and families through educational sessions and written materials on topics, including information about [CONDITION(S)]-CoV-2, actions the facility is taking to protect them and their loved ones from [CONDITION(S)]-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene.Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. B. Facility policy The Hand Hygiene for Residents, Families and Visitors policy, updated on 6/7/22, was received on 8/11/22 from the FNC read in pertinent parts, purpose to decrease the risk of transmission of infection by enabling residents to perform appropriate hand hygiene. Staff should encourage and assist the resident as needed to ensure proper hand hygiene through handwashing or the use of an alcohol-based hand rub. Hand washing should be offered/performed prior to the handling and/or consumption of food or drink C. Observations On 8/8/22 at 12:15 p.m., the second floor dining room was observed. The residents in the dining room were not offered hand hygiene prior to their meal being served. The tables did not contain any hand sanitizer gel or did not have small prepackaged paper towels pre moistened in a sealed package. -At 12:28 p.m., the trays were observed to be passed on the second floor to the rooms. An unidentified certified nurse aide (CNA) passed a meal tray to the resident in room [ROOM NUMBER]. However, she did not offer hand washing to the resident. On 8/10/22 at 6:00 p.m., CNA #9 was observed to pass an evening meal tray to a resident in room [ROOM NUMBER], the CNA did not offer hand washing to the resident prior to the meal being served. -At 6:05 p.m., CNA #10 served an evening meal to a female resident. She was not offered hand washing prior to her meal. D. Interview The NHA, the DON, and the (FNC) were interviewed on 8/11/22 at 1:30 p.m. The NHC said the residents were to be offered hand hygiene prior to the meals. She said staff had been trained, but it was constant training which had to occur. IV. Properly clean resident rooms A. Professional reference The Centers for Disease Control and Preventions: Healthcare-Associated Infections (HAIs) 4.1 General Environmental Cleaning Techniques was reviewed on 4/21/2020 and was retrieved on 8/18/22 at https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html. The document revealed, to clean from a clean area to a dirty area to avoid spreading dirt and microorganisms. Clean low touch surfaces before high touch areas surfaces. Proceed form high areas to lower areas (top to bottom) to prevent dirt and microorganisms from dripping/falling onto surfaces below thus contaminating already cleaned surfaces. Further, clean environmental surfaces before cleaning floors. Some common high touch surfaces were sink handles, bedside tables, call bells, door knobs, light switches, bed rails, wheel chairs, and counters where medications or supplies were prepared. B. Observations On 8/11/22 at 10:32 a.m. the housekeeping director (HSKD) and laundry assistant (LA) #2 cleaned a room where two residents resided on the second floor of the facility. LA #2 used one yellow cleaning rag to dust and wipe off areas for both residents in the room. She did not change rags or gloves during the cleaning process. She wiped down the two resident's dressers, both bedside tables, televisions, and the outside doorknob to the room with the same yellow rag. She took out of two trash cans the plastic bags which contained trash and put in clean trash bags while wearing the same gloves. She then went to the housekeeping supply cart in the hallway and brought into the room a broom, dustpan, and mop, again while wearing the same gloves. She then swept and moped the entire room. LA #2 wore the same gloves throughout the entire cleaning of the double occupancy resident room. The HSKD while wearing only one pair of gloves, sprayed the toilet with a chemical, went out in the hallway to set a timer for 10 minutes, washed the sink with a green rag, took out a trash bag from under the sink and replaced it with a new bag, grabbed a duster with a long handle to dust the walls and ceilings on both sides of the room, and the window blinds. He then used the same green rag and gloves to wipe off one dresser and the inside door knob of the entry door to the room. He then cleaned the toilet while wearing the same gloves. After he cleaned the toilet he changed his gloves. C. Interviews The HSKD was interviewed on 8/11/22 at 10:47 a.m. He said on 8/11/22 he was training LA #2 to clean resident rooms. He said he was trained to wear only one pair of gloves while he cleaned a resident's room. He said he was trained to only change gloves after the last task of cleaning a resident's room. He said the last cleaning task was cleaning the toilet. He said he cleaned the toilet last with a new cleaning rag, and then he changed his gloves. He said he then went into a new room with the clean gloves. He said he taught LA#2 to wear the same gloves throughout cleaning the residents room. The nursing home administrator (NHA) was interviewed on 8/11/22 at 4:29 p.m. She said she did not know where the housekeeping director received his infection control training. She said when cleaning a room she expected the housekeeping staff to change their gloves between each side of a resident's room. She said she expected the housekeeping staff to change gloves between cleaning bathrooms and resident's private areas. She said it was important to change gloves while cleaning for the safety of not spreading infections. She said the housekeeping staff could spread COVID-19 from resident to resident from not performing the correct infection control techniques. IV. PPE was donned and doffed properly 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 8/22/22 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf. It read in pertinent part, -PPE must be donned correctly before entering the patient area. -PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. -Face masks should be extended under the chin. -Both your mouth and nose should be protected B. Observations On 8/9/22 at 9:03 a.m. activities assistant (AA) #1 entered a resident's room [ROOM NUMBER] on the first floor. The room was marked for COVID-19 isolation and a three dresser drawer was outside of the door for the staff to put on PPE prior to entering the room. AA #1 entered the isolation room without putting on any PPE except the N95 mask that she was wearing. AA #1 did not put on gloves or a gown before entering the room. AA #1 held in her hand many activity calendars. AA #1 folded a blanket that was on the resident's bed while conversing with the resident. AA #1 exited the isolation room at 9:12 a.m. and used hand sanitizer. AA #1 entered another resident room [ROOM NUMBER] that was not on isolation with the same activity calendars to hand out. On 8/10/22 at 11:00 a.m., AA #1 was observed standing outside of room [ROOM NUMBER], whom was on droplet precautions. The AA #1 had a gown and gloves on, after leaving the room. The AA was looking at the four postings on the door, and then doffed the gown and gloves in the hallway and threw the gloves and gown into the trash can outside of the door. -At 6:05 p.m., the certified nurse aide (CNA) was observed to have the opened food cart, next to the isolation room [ROOM NUMBER] came to the door with no face covering and the CNA handed her the food tray. The CNA did not have any PPE on, as the tray was passed to the resident. C. Interview The FNC was interviewed on 8/10/22 at 6:30 p.m. The FNC said when a resident was on droplet precautions that meant the staff needed to wear full PPE. She said that included, gloves, N95 respirator mask, gown and eye protection. She said she would provide immediate education. The resident should be encouraged to wear a face covering. V. Facility training On 8/11/22 at 8:30 a.m. the DON provided the 4/27/22 inservice/training/education attendance record. The HSKD and LA#2 were not in attendance at this meeting. The training included donning (putting on)/doffing (removing) PPE for rooms on quarantine/droplet precautions, review of disinfecting equipment, and a review of hand hygiene practices. VI. Facility COVID-19 status The nursing home administrator (NHA) was interviewed on 8/11/22 at 4:29 p.m. The NHA said as of 8/8/22 the facility was in a current outbreak with COVID-19. The facility currently had four residents who were positive with COVID-19, and two saff with COVID-19 positive cases, which began on 6/23/22.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 26 of 53 resident rooms, six of six hallways. Specifically, the facility failed to ensure walls, baseboard cove, doors, floor tiles, and ceiling were repaired, painted and properly maintained: and failed to ensure resident's had clean bath linens. Findings include: A. Initial observations Observations of the resident living environment conducted on 8/10/22 at 3:00 p.m. revealed: Room #110: The bedside table had water damage with a two inch gap of saturated wood all the way around the table exposing the metal underneath. The wall underneath the television had four large nails sticking out of the wall. The resident did not have any towels next to her sink. Room #127: The heater vent behind the resident's bed was damaged from the bed being lifted and lowered. The four inch ceiling border along the top of the walls was missing throughout the entire room. The residents did not have any towels next to their sink. The heater vents next to room #127 and #126 were damaged and pulled away from the bottom of the heater. Room #122: The wall behind the resident's bed had a painted area approximately four feet long by three feet wide which had been repaired but not completed. The residents did not have any towels next to their sink. Room #118: The wall in the restroom had a painted area approximately 13 inches in circumference which had been repaired but not completed. Room #121: The wall behind the resident's bed had a painted area approximately four feet long and three feet high which had been repaired but not completed. The wall in the restroom had four painted areas approximately five inches in circumference which had not been completed. The wall underneath the sink had damaged sheetrock approximately 12 inches by 13 inches. The resident did not have any towels next to his sink. Room #211: The wall behind the resident's bed had damaged sheetrock from the bed being lifted and lowered. The residents did not have any towels next to their sink. Room #213: The baseboard cove approximately four feet long by four inches high was missing next to the resident's bed. The residents did not have any towels next to their sink. Room #212: The heater had a section approximately five feet long which was pulled away from the wall leaving a four inch gap. The wall next to the resident's bed had four deep scratches approximately six inches long. The wall behind the bed had approximately six deep scratches from the bed being lifted and lowered. The residents did not have any towels next to their sink. Room #210: The wall behind the resident's bed had deep scratches from the bed being lifted and lowered. The baseboard cove had a section approximately five feet long pulling away from the wall. The resident's dresser did not have a top drawer. The residents did not have any towels next to their sink. Room #209: The heater vent shield approximately eight feet long was laying on the floor and not attached to the heater. A section of floor tiles approximately four feet by five feet were damaged. The floor tiles were black with a one fourth inch gap around the whole area. The tile in the restroom had three holes approximately four inches in circumference. The restroom door had a hole approximately four inch by three in circumference. The residents did not have any towels next to their sink. Room #207: The heater vent shield approximately 15 feet long was laying on the floor and not attached to the heater. The wall underneath the clock had four large nickel sized holes. The baseboard cove next to the resident's bed was missing a section approximately five feet long. The transition strip at the door's entrance was too high. A section of floor tiles next to the sink were damaged and had black discolored areas. The residents did not have any towels next to their sink. Room #205: There was a large hole underneath the sink approximately 13 inches by 13 inches. The hole exposed all of the [MEDICATION(S)] chloride (PVC) pipe in the wall. The residents did not have any towels next to their sink. Room #204: There was a large corner piece approximately seven inches high and three inches wide which was broken. Room #203: The ceiling had three areas approximately six feet by six feet in circumference which had water damaged. All areas had brown rings around the edges and had peeling sheetrock. The residents did not have any towels next to their sink. Room #214: The wall next to the residents ' sink had an area approximately six inches high by two inches wide. Room #216: The resident was missing a privacy curtain approximately 12 feet long next to his bed. The 200 hall shower room was missing a corner piece next to the shower approximately four feet high and three inches wide. Room #224: The bedside table had water damage with a two and a half inch gap of saturated wood all the way around the table exposing the metal underneath. The resident's wall behind the bed had damaged sheetrock from the bed being lowered and lifted. The resident did not have any towels next to her sink. Room #226: The heater vent shield approximately five feet long was laying on the floor and not attached to the heater. The towel rack was falling off the wall. The resident did not have any towels next to his sink. Room #227: The foot board had been broken and was leaning against the wall. Room #223: The wall next to the sink had four dime size holes. The resident did not have any towels next to his sink. Room #221: The skid strips next to the sink were peeling off. There were no towels provided for the resident. B. Environmental tour and staff interview The environmental tour was conducted with the maintenance assistant (MA) and housekeeping supervisor (HS) on 8/11/22 at 10:46 a.m. The above detailed observations were reviewed. The HS documented the environmental concerns. The MA said the facility had been without a supervisor for several months. The MA said they had just hired a supervisor today and he would be starting soon. The MA said staff were supposed to fill out work orders but he mostly hears about problems through certified nursing aides (CNAs). He said staff had not been utilizing the work orders and hopes this will change with the new supervisor coming on board. The MA said he did not have any repair requisition requests for the above-mentioned. The HS said all of the residents get towels in the morning for their morning care such as washing up and their perineal care. He said the residents will use paper towels during the rest of the day. The HS said they have the towels in the closet and did have enough stock for the residents. Registered nurse (RN) #3 was interviewed on 8/11/22 at 1:49 a.m. She said CNAs provide towels to the residents in the morning and the residents would use paper towels the rest of the day. She said the residents should have clean towels in the cabinet but the CNAs would hand them out in the morning.

Based on observations, record review and interviews the facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities for two (#37 and #14) of two residents out of 34 sample residents. Specifically the facility failed to provide services to fix broken glasses for Resident #37 and #14. Findings include: I. Facility policy The Vision and Hearing Assistive Devices policy, revised 8/31/21, was provided by the director of nursing (DON) on 8/11/22 at 8:30 a.m. It revealed in pertinent part: Ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Assistive devices to maintain vision include but are not limited to, glasses, contact lenses, magnifying lens or other devices that are used by the resident. The facility will assist as needed with making appointments and arranging transportation to obtain needed services. In situations where the resident has lost their device, the facility must assist residents and their representative in locating resources, as well as in making appointments, and arranging for transportation to replace the lost devices. II. Resident #37 A. Resident status Resident #37, age under 70, was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/14/22 minimum data set (MDS) assessment revealed the resident was cognitively intake with a brief interview for mental status score (BIMS) of 15 out of 15. She wore corrective lenses, glasses. She needed extensive assistance with bed mobility, transfers, dressing, locomotion on and off the unit, and personal hygiene. She did not reject care from staff. B. Resident interview Resident #37 was interviewed on 8/8/22 at 2:11 p.m. She said the left arm of her glasses had been broken for a few months. She said a staff member put clear adhesive tape on the left arm of the glasses attached to the front glasses frame as a temporary fix for her glasses. She said it was annoying to have tape hold her glasses together. She said she asked for her glasses to get fixed but she never heard anything about the glasses getting fixed. C. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 8/10/22 at 12:57 p.m. She said the resident had tape holding the arm of her glasses to the front frame for a few weeks. She said she was not sure who would fix her glasses. She did not know if Resident #37 would be visited by an eye doctor, or if her family member would help get the glasses fixed. The social service director (SSD) was interviewed on 8/10/22 at 1:05 p.m. She said she was unaware the resident ' s glasses were broken and had tape on her glasses to hold the arm of the glasses to its frame. She said there was not an exact date set yet by the eye doctor to come and visit residents in the facility. She said the eye doctor hopefully would set a date to visit the facility in September 2022. She said she could help the resident with a few ideas to fix the glasses. She said she could go into the room and try to fix the glasses herself. She said she could also get the facility transportation to take her to an outside provider to get the glasses fixed. She said she could also request the eye doctor to come for an emergency visit to come in and fix the glasses. She said she would get the situation handled so that the resident did not have to wear glasses that were broken and held together by tape. III. Resident #14 A. Resident status Resident #14, age 78, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the minimum data assessment (MDS) dated [DATE] resident #14 adequately sees fine detail, including regular print in newspapers/books with use of corrective lenses. BIMs score 15/15. Uses Wheelchairs and 2 people assist with transfers. B. Resident interview Resident #14 was interviewed on 8/9/22 at 8:59 a.m. The resident said her glasses had been broken for months. She said she enjoyed reading the bible. She said it was difficult to read without her glasses. She said she currently reads by closing one eye and reading through one eye. She said she had to adjust with reading this way, as her glasses have been broken for awhile. C. Observations and interview On 8/9/22 at 8:58 a.m. the resident's eyeglasses were observed to have a lense missing and a crack down the right lower frame. On 8/11/22 at 3:00 p.m. the resident's eyeglasses were observed with certified nurse aide (CNA) #3 to have a lense missing and a crack down the right lower frame. She said the resident spent her time reading the bible and also doing crossword puzzles. She said the resident has said it was difficult without glasses. D. Record review The ocular progress note dated 5/11/22 states she received new glasses delivery. The ocular progress notes dated 6/21/22 showed the resident had an eye exam and that she had reported her broken and missing lens on her glasses. The care plan last updated on 6/25/22, identified the resident wore glasses and enjoyed reading the bible daily to meet her spiritual needs. E. Interviews The interim social service director (SSD) was interviewed on 8/11/22 at 10:51 a.m. The SSD said the resident was seen in June 2022 for an eye exam. The SSD said there was no other follow up after the June 2022 appointment.

Based on resident and staff interviews and record review, the facility failed to assist residents with either maintaining continence or ensuring appropriate treatment to restore continence to the extent possible for two (#14 and #46) of two residents reviewed of 34 sample residents. Specifically, the facility failed to offer and encourage Resident #14 and Resident #46 a toileting program to promote bladder continence. Findings include: I. Facility policy The Incontinence Management policy, revised 11/19/21, received from the nursing home administrator read in pertinent part, conduct a comprehensive, interdisciplinary review and assessment of the resident's continence status of admission, quarterly and with significant change of urinary function including factors that predispose the residents to the development of urinary incontinence and the use of indwelling catheter.Encourage the resident to void regularly for example every 2 hours, when the resident can stay dry, for two hours, increase the intervals by 30 min (minutes) everyday until achieving a 3-4 voiding schedule. II. Resident #14 A. Resident status Resident #14, age 78, was admitted on [DATE]. According to the August 2022 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data (MDS) assessment dated [DATE] showed the resident was cognitively intact with a score of 15 out of 15 on the brief interview for mental status. The MDS indicated the resident required assistance of two staff with transfers. The MDS showed the resident was not on a toileting program and she was frequently incontinent of urine. B. Resident interview Resident #14 was interviewed on 8/9/22 at 9:00 a.m. Resident #14 said she had urinary accidents while she waited for assistance to go to the bathroom. The resident said she was aware when she had to urinate. C. Record review The care plan revised 6/25/22 identified Resident #14 had urinary incontinence related to mobility and urgency. Pertinent interventions included the resident was to be checked and changed every two hours and as needed (PRN) with assistance The 8/5/22 evaluation for bowel and bladder training documented, a score 11 which indicated, she was a candidate for toileting, timed or scheduled voiding. -The medical record failed to show a voiding schedule was completed. D. Staff interviews Certified nurse aide (CNA) #11 interviewed 8/10/22 at 9:10 p.m. The CNA stated the resident called the staff to use the restroom. The CNA said the resident was able to void on the toilet. The facility nurse consultant (FNC) was interviewed on 8/11/22 at 2:40 p.m. The FNC said the resident was not on a voiding schedule. She said a three day bladder evaluation to determine an appropriate voiding schedule was not completed. II. Resident #46 A. Resident status Resident #46, age under 70, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was frequently incontinent of urine, and had occasional bowel incontinence. The resident did not reject cares. The seven day look back period documented that the resident received a total of 216 minutes of physical therapy. B. Resident interview Resident #46 was interviewed on 8/9/22 at 3:00 p.m. He said he preferred to go to a toilet to go to the bathroom instead of the staff changing his brief in his bed. He said staff did not want to put him in his wheelchair and take him to the bathroom. He said he felt it was easier for staff to just change him in his bed because he had a missing leg. He said he could use a toilet when staff would assist him into his wheelchair and then help push his wheelchair into his restroom. He said three times a week he went out of the facility to [CONDITION(S)] in his wheelchair. He said he felt since he could go out of the building in his wheelchair he could go to a bathroom and not use an incontinent brief. Resident #46 was interviewed again on 8/10/22 at 5:09 p.m. He said no staff took him to the bathroom today or yesterday. He said he stayed in bed and the staff changed an incontinent brief that he wore instead of helping him to the bathroom. He said he wished the staff would help him into his wheelchair and take him to the bathroom. He said, I don't understand why they cannot do this for me. C. Record review The 5/4/22 evaluation for bowel and bladder training revealed the resident was always mentally aware of his toileting needs, and he was always continent of bowel and bladder. The training scored the resident at a four, which put him into the good category for individual training. Resident #46's comprehensive care plan initiated on 5/6/22 and revised on 6/26/22 revealed the resident had bowel incontinence and was to be assisted with toileting as needed. The 8/4/22 evaluation for bowel and bladder training revealed the resident was always mentally aware of his toileting needs, and he was never continent of bowel and bladder. The training scored the resident at a nine which indicated he was a candidate for toileting, timed or scheduled voiding. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 8/11/22 at 10:08 a.m. She said Resident #46 could not go to the bathroom on his own. She said the staff tried once but he did not do it again since that one time the staff tried. She said the staff changed his brief in his bed and assisted him there. She said the staff never assisted him to the bathroom because it was too hard for the resident. The director of nursing (DON) was interviewed on 8/11/22 at 2:40 p.m. She said when a resident was admitted into the facility a bowel and bladder assessment would be done. She said the facility would do a three day study, 72 hours, to determine if a resident needed assistance for a toileting and hygiene program. The assessment provided a score that helped determine if a resident could be put on a program. She said Resident #46 had a score that indicated he was a good candidate for a bowel and bladder training program. She said the facility would provide the program for him. The facility nurse consultant (FNC) was interviewed on 8/11/22 at 2:45 p.m. She said Resident #46 scored a nine on his latest evaluation for bowel and bladder. She said that made him a candidate for a bowel and bladder program. She said the facility only did two days of the three day required study for a toileting program. She said three days were required to complete a voiding program to get a proper evaluation to help the resident. She said the facility would fix the situation and implement a program for him immediately.

Based on record review and interviews, the facility failed to ensure residents who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#54 and #33) of three residents out of 34 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #54 and Resident #33. Findings include: I. Census and Conditions demographic The 8/8/22 Census and Condition form documented that 62 total residents resided at the facility. The form further documented there were 16 residents with a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Professional reference The Gerontologist (February 2018), retrieved from on 8/22/22: https://academic.oup.com/gerontologist/article/58/suppl_1/S1/ 59?login=true The Alzheimer's Association Dementia Care Practice Recommendations included the following foundations for person-centered care: 1. Know the person living with dementia. It is important to know the unique and complete person, including his/her values, beliefs, interests, abilities, likes, and dislikes-both past and present. This information should inform every interaction and experience. 2. Recognize and accept the person's reality. It is important to see the world from the perspective of the individual living with dementia. Doing so recognizes behavior as a form of communication, thereby promoting effective and empathetic communication that validates feelings and connects with the individual in their reality. 3. Identify and support ongoing opportunities for meaningful engagement. Engagement should be meaningful to, and purposeful for, the individual living with dementia. It should support interests and preferences, allow for choice and success, and recognize that even when the dementia is most severe, the person can experience joy, comfort, and meaning in life. 4. Build and nurture authentic, caring relationships. Persons living with dementia should be part of relationships that treat them with respect and dignity, and where their individuality is always supported. This type of caring relationship is about being present and concentrating on the interaction, rather than on the task. It is about 'doing with' rather than 'doing for' as part of a supportive and mutually beneficial relationship. 5. Create and maintain a supportive community for individuals, families and staff. This allows for comfort and creates opportunities for success. 6. Evaluate care practices regularly and make appropriate changes. III. Facility policy The Behavioral Health Management policy, revised 5/9/22, was sent via email by the nursing home administrator (NHA) on 8/15/22 at 3:27 p.m. It revealed in pertinent part, To promote resident safety, attain highest practicable mental/psychosocial well-being and reduce behavior related events. Providing behavioral health care and services is an integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's behavioral health needs. Highest practicable physical, mental, and psychosocial well-being is defined as the highest possible level of functioning and well-being, limited by the individual's recognized pathology and normal aging process and is determined through comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental, or psychosocial needs of the individual. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptomology and rates of progression. The facility must provide necessary behavioral health care and services which include: a. Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. b. Ensuring direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. c. Providing an environment and atmosphere that is conducive to mental and psychosocial well-being. d. Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's wellbeing. Provide resident/responsible party and staff education as needed. IV. Resident #54 A. Resident status Resident #54, age 81, was admitted on [DATE]. According to the August 2022 computerized physical orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/16/22 minimum data set (MDS) assessment revealed the resident was not assessed for a brief interview for mental status score. The resident did not reject care from staff. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required limited assistance with transfers, and walking in the corridors. She was not steading moving from a seated to standing position. B. Observations On 8/8/22 and 8/9/22 from 9:00 a.m. until 4:30 p.m. Resident #54 was not wearing shoes. She was wearing red nylon socks which were not non-skid socks. She walked almost continuously from one end of the upstairs hallway to the other. She stopped to talk to residents, walked into her bedroom, and continued to walk without staff assistance. She did not use a walker, cane, or wheelchair while she walked. On 8/10/22 and 8/11/22 from 9:00 a.m. until 5:30 p.m the resident was lying on her bed, and she sat up for meals. Per staff interviews below, the resident often was up at night pacing and would sleep during the day. C. Record review The 3/7/19 comprehensive care plan and revised on 1/27/22 (over six months ago) revealed, The resident Has impaired cognitive ability impaired thought processes with dementia. She is often able to communicate her daily preferences, however at times she will say she doesn't know what she wants. She is unable to differentiate staff from non-staff, does not know the location of her room, has poor safety awareness, for example, she frequently hugs strangers and will follow anyone encouraging her to go with them. She is at risk for changes in mood and behavior with dementia. She does not utilize [CONDITION(S)] medications. The resident has potential to be physically and verbally aggressive towards others (related to) dementia, History of harm to others, poor impulse control. She moved rooms due to negative interaction with former roommate. (Resident) often misinterprets the environment and actions of others (related to) cognitive impairment (dementia). She may yell at staff or raise her fist at them when irritated. Interventions: Allow extra time for resident to respond to questions and instructions. Ask yes/no questions in order to determine the resident's needs. Communicate with family regarding residents capabilities and needs. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Give the resident as many choices as possible about care and activities. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Provide activities that minimize the potential for falls while providing diversion and distraction. -There was no activity one-to-one review log for the year. (see activity director interview below). The July 2022 and August 2022 individual resident daily participation record was provided by the AD on 8/11/22 at 11:20 a.m. It revealed in pertinent part, -July 2022: the resident was documented for 31 days to actively read almost daily, participated in trivia three times, and five times took supplies from a cart. There was no indication of what was on the cart that the resident took. The resident was documented as refused or unable to participate in all other group activities 128 times. -8/1/22 to 8/10/22: the resident was documented to actively read daily. The resident took supplies off the supply cart four times. There was no indication of what was on the cart that the resident took. The resident did not participate in any group activities. The resident was documented as refused or unable to participate 30 times. The 7/17/22 quarterly activity participation note revealed, Activity staff will continue to invite and encourage resident to attend all group activities of potential enjoyment when able but will respect her decision to decline. Resident still prefers to participate in independent activities and small group activities. She has a copy of the New Testament in her room in order to meet her spiritual needs. D. Interviews The social service director (SSD) was interviewed on 8/10/22 at 12:02 p.m. She said she was the interim SSD until the facility could hire a permanent social worker. She said she was unaware Resident #54 had a sister that she could call and get a history about the resident so that she could understand how to work with her. She said she was unaware that Resident #54 had a son in a different state. She said Resident #54 walked back and forth throughout the halls either in the daytime or the evening. She said the facility did not have a special dementia unit. She said she did not provide dementia care for Resident #54. She said she did not have a role in participating in therapeutic recreational activities for those with dementia care needs. Licensed practical nurse (LPN) #1 was interviewed on 8/11/22 at 10:35 a.m. She said Resident #54 was up all night on 8/9/22. She said the resident often stayed up all night pacing and walking back and forth on the second floor and then she slept all day. She said the staff would offer her snacks to keep her occupied when she paced up and down the halls. Certified nurse aide (CNA) #4 was interviewed on 8/11/22 at 11:20 a.m. She said Resident #54 was up again all night on 8/10/22. She said when the resident was up all night she paced the hallways and was in bed all the following day. She said Resident #54 walked the halls on the second floor almost everyday and all day. She said that was about all the resident did except for sleeping and eating. The activity director (AD) was interviewed on 8/11/22 at 11:20 a.m. She said the only dementia training she had was what she watched on the computer. She said she started as the new AD last October (2021). She said neither Resident #54 or Resident #33 were on a one-to-one activity program for dementia care. She said the facility did not have a one-to-one program in the facility for the residents and for any residents with dementia. She said if someone refused a visit she did not try again, she did not document refusals, or try new ideas with someone. She said she did not contact the family to learn what Resident #54 would like. She said we did not do family visits on the phone or on a computer tablet with a family member for Resident #54 so that she could talk or see her family. She said Resident #54 refused a one-to-one visit one time from the activity department and the activity department never asked or offered that to the resident again. She said the facility did not try a different approach after the resident declined to do a one-to-one with her. She said Resident #54 primarily paced up and down the hallways. She said the resident may stop in a group but she did not have the attention span to participate. She said the resident was up awake often through the night walking the hallways and then she slept all day. She said she did not give any activity supplies for the evening staff from the activity department in the event Resident #54 was up all night. She said she would put together supplies for the evening staff to be able to do something with Resident #54. She said the activity department invited Resident #54 to groups but she usually declined. V. Resident #33 A. Resident status Resident #33, age 67, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data (MDS) assessment dated [DATE] brief interview for mental status (BIMS) score of zero out of 15, which indicated the resident had cognitive impairment. The MDS coded the resident required extensive assistance with activities of daily living. B. Observations Throughout the survey between 8/8/22 through 8/11/22 the resident wandered the hallways of the second floor. The resident did not have any meaningful activity. Observations were as follows: On 8/8/22 at 11:00 a.m., the resident walked aimlessly throughout the second floor. The resident did not have any meaningful activity, or did not receive any socialization. -At 12:26 p.m., the resident was assisted with eating by an unidentifed certified nurse aide (CNA). The CNA was sitting next to the resident and assisting her with eating her meal, she failed to interact with the resident during the meal. On 8/9/22 at 2:33 p.m., the resident was walking hallways independently with no direction. She had no meaningful activity. -At 2:57 p.m., the resident entered other resident rooms. -At 3:31 p.m., the resident continued to wander aimlessly throughout the second floor. She continued to not have any meaningful activity. -At 4:49 p.m., the resident got her foot caught under the hoyer (mechanical) lift while walking. There were no staff around. She was heard calling out softly. Licensed practical nurse (LPN) #1 and the facility nurse consultant (FNC) assisted the resident. LPN #1 said, Mama. Let's go to bed or sit down. The resident was up walking within a minute of sitting and staff were conversing amongst themselves and the resident was not provided redirection. The resident then ambulated down the hall and around the corner. On 8/10/22 at 8:36 a.m., the resident was sleeping in the dining room. She had food in front of her and one 120 cc of juice in front of her, however, there were no staff in the dining room. -At 2:48 p.m., the resident continuously walked hallways with no direction, or offer of meaningful activity. C. Record review The care plan revised 6/24/22 revealed the resident was at risk for falls with interventions to provide activities that minimize the potential for falls while providing diversion and distraction. Assist residents with obtaining and displaying personalized decor in her room to assist in providing a home like environment. Will be provided with leisure materials for independent activities such as radio, CD, arts/craft supplies and visual art books as needed. When the resident displays behaviors (wandering into other rooms, disturbing, declining assistance with care) distract with activities. The care plan identified the resident had cognitive deficits and was difficult to understand. She had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Pertinent interventions included, cue, reorient and supervise as needed and allow extra time for the resident to respond to questions and instructions. The care plan identified when the resident displaying behaviors (wandering into other rooms, disturbing, declining assistance with care) distract with activities. D. Staff interviews The activity assistant (AA) #2 was interviewed on 8/11/22 at 8:40 a.m. AA #2 said the resident spent her day walking the hallway. AA #2 said the activity department provided one-to-one activities for some residents [MEDICATION(S)] 10-20 minutes daily. She said the activity director (AD) assessed what the residents liked to do. The social service director (SSD) was interviewed on 8/11/22 at 10:51 a.m. The SSD said to meet dementia care residents' needs staff needs to listen to them and redirect them. She said staff tried their best to avoid agitating the residents.

Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was not five percent or greater for observed medication administration. Specifically, the facility had a medication error rate of 6.9%, which was two errors out of 29 opportunities for error. Findings include: I. Professional standard According to Perry, Potter and Ostendorf, (copyright 2017), Fundamentals of Nursing (ninth edition), page 614, it read in part, Safe drug administration involves adherence to prescribed doses and dosage schedules. Follow the medication administration policies of your agency about the timing of medications to ensure that you administer medications at the right time. II. Facility policy The General Dose Preparation and Medication Administration policy and procedure, effective revised on 1/1/22, was provided by the facility nurse consultant (FNC) on 8/11/22 at 6:15 p.m. It included in pertinent part, facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. Facility staff should only prepare medication for one resident at a time. III. Medication error observations and interviews Licensed practical nurse (LPN) #4 was observed preparing and administering medications for Resident #43 on 8/10/22 at 11:48 a.m. The resident's order was for [MEDICATION(S)] 9000 units, give one tablet by mouth three times a day for lactose intolerance.The LPN dispensed one tablet into the medication cup. The bottle of [MEDICATION(S)] stated that three tablets were needed to make a dose of 9000 units. Registered Nurse (RN) #1 was observed on 8/11/22 at 4:22 p.m. She pre-poured and prepared medications for Resident #164. She then proceeded to place one cup with medication (not labeled) and placed it into the medication cart drawer. RN #1 said she acknowledged she dispensed the medications early for Resident #164 and said it was not normal practice to pre-dispense medications for residents. RN #1 was able to identify the medications as [MEDICATION(S)] (gastrointestinal agent), zinc (trace element), and senna (stimulant [MEDICATION(S)]). LPN #3 was interviewed on 8/11/22 at 5:39 p.m. She said nurses should not pre-pour medications. LPN #3 said it was important to ask residents first to make sure they were ready for their medications to be prepared and to be taken. The director of nursing (DON) and FNC were interviewed on 8/11/22 at 6:00 p.m. They said pre-pouring medication was not allowed in the facility because it increased the risk of medication errors.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two medication carts and one storage room. Specifically, the facility failed to ensure: -Medication or treatment carts were locked when the licensed nurse was not present; -Topical medications were labeled; -Topical medications were not stored on nurses desk; -Food was not stored in the medications storage areas; and, -Disinfectant was kept separate from medication. Findings include: I. Facility policy and procedure The General Dose, Preparation and Medication Administration, dated 1/1/22,, provided on 8/11/22 at 6:15 p.m. from the facility nurse consultant (FNC) read in pertinent part, Facility staff should not leave medication or chemicals unattended. Facility should ensure that all medication carts are always locked when out of sight or unattended. The Storage and Expiration Dating of Medications, Biologicals policy, revised 1/1/22, was provided by the director of nursing (DON) on 8/9/22 at 2:13 p.m. read in pertinent part, Facility should ensure that all medications and biologicals including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medication and biologics are stored. Facility should ensure that test reagents, germicides, disinfectants and other household substances are stored separately from medications.Section 6 Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions. II. Observations On 8/8/22 at 2:41 p.m. the first floor treatment cart was found unlocked. On 8/9/22 at 3:34 p.m. the second floor north medication cart was left unlocked with the keys in lock. There was no licensed nurse at the cart, or at the nurses station. Several residents were around the cart area. Licensed practical nurse (LPN) #1 left the cart unlocked and unsupervised for three minutes. On 8/11/22 at 12:32 p.m. the second floor north medication cart was found unlocked and unattended. LPN #1 returned three minutes later. At 12:05 p.m., the second floor south medication cart had the following: -Oxivir TB wipes found next to [MEDICATION(S)] (stool medication) in cart; -The Drug buster (container used to destroy medications) was next to the Tums; -[MEDICATION(S)] topical roll on (used for pain relief) found in cart with no name or date of opening; and, -[MEDICATION(S)] topical powder had no label or open date. At 12:24 p.m. the medication room on the second floor had personal items found in the room that included water cups and styrofoam food containers with food in it on the counter. At 12:07 p.m. LPN #1 retrieved Biofreeze topical cream for a resident that was located on the nurses station and not locked away from residents. III. Interviews LPN #1 was interviewed on 8/9/22 at 3:34 p.m. The LPN confirmed she left the medication cart unlocked and unattended. She said the medications were to be kept locked at all times when medications were not being administered. LPN #1 was interviewed on 8/11/22 at 12:18 p.m. The LPN confirmed the [MEDICATION(S)] roll was not labeled or dated. She said medications should be labeled. The DON and the FNC were interviewed on 8/11/22 at 2:30 p.m. The DON and the FNC said the medication carts needed to be kept locked when unattended. The FNC said they had started education with the nurses to ensure the carts were locked. The FNC said food or drinks should not be kept in the medication room.

Based on record review, observations and interviews, the facility failed to ensure that the resident environment remained as free from accident hazards as possible and that each resident received adequate assistance to prevent accidents for one (#1) of four sample residents. Specifically, the facility failed to ensure that the temperature of hot soup, heated in a microwave and served in the resident's room, was appropriate for resident safety and that resident #1 was adequately assisted to prevent spilled hot soup which caused second degree burns on this resident's left upper arm and side. The findings include: Facility policy and procedures The facility's Incident Management policy, undated, provided by the Nursing Home Administrator (NHA) on 11/29/16 at 4:05 p.m. indicated: -the facility identifies residents at risk for incidents and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence. -each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risk for incidents. -the resident environment remains as free of accident hazards as is possible, The facility attempts to provide and environment that is as free from hazards over which the facility has control. The facility's Microwave Food Safety procedure, undated, was submitted after survey exit, by the NHA on 12/5/16 at 2:05 p.m. and indicated: -rotate food throughout the cooking process; cook to at least 165 degrees and allow food to stand for two minutes before serving to allow the internal temperature to be achieve through out the product and to allow food product to cool down to appropriate temperatures. Check the internal temperature of the food in several places. Serving temperatures for coffee, soups, hot beverages should never exceed 155 degrees. References According to the Burn Foundation Safety Facts on Scald Burns. www.BurnFoundation.org <http://www.BurnFoundation.org>, Web, <http://www.burnfoundation.org/programs/resource.cfm?c=1&a=3>, (December 2016) : Hot liquids burn like fire. Over 500,000 scald burns occur annually in the United States. The two highest risk populations are children under the age of 5 and adults over 65 .Coffee, tea, soup and hot tap water can be hot enough to cause serious burn injury .Most scald injuries can be prevented. Hot water causes third degree burns in: .in 1 second at 156º .in 2 seconds at 149º .in 5 seconds at 140º .in 15 seconds at 133º. According to the Consumer Product Safety Commission (CPSC) Safety Alert: Avoiding Tap Water Scalds, Publication 5098, 03/2012, <https://www.cpsc.gov/s3fs-public/5098.pdf> : The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five . Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Resident #1 Resident #1, age 72, was admitted [DATE]. According to the 11/16 face sheet, [DIAGNOSES REDACTED]. According to the 11/5/16 minimum data set (MDS) assessment, the resident had intact cognition with a brief interview of mental status (BIMS) score of 13 out of 15. She required assistance of one staff for bed mobility, dressing, grooming and toilet use; assistance of two staff for transfer. She used a manual wheelchair for ambulation. Thermal burn 9/21/16 Review of the resident's clinical record revealed that she had second degree burns on her left upper arm, approximately 7 cm by 10 cm, and on her left side, approximately 5 cm by 7.5 cm, after hot soup spilled on her while she was in her room in bed on 9/21/16. The clinical record documented: The situation, background, assessment and recommendation (SBAR) communication form, completed on 9/21/16, documented that blisters formed on left arm and left side of abdomen; resident sustained [REDACTED]. The resident reported no pain. The nursing progress notes on 9/21/16, entered at 9:32 p.m., documented: -Resident was alert and able to make needs known. During the early hours of the shift, the CNA reported to the nurse that the resident sustained [REDACTED]. Immediately went to her room to do assessments, blisters observed to left arms well as part of abdomen. CNA gave her soup at 1:30 p.m. and reminded resident not to eat it yet and call for assistance to eat due to resident in bed. Resident tried to reach it and spilled it to her left side. Resident denied any pain due to left side paralyzed. Redness noted, scant serosanguinous drainage, some are opened, some are still closed. Burn noted on left arm and on the abdomen with a measurement of 5 cm x 7.5 cm x 0 cm depth. Physician and family notified, with new orders. Reinforced resident to ask for help and reminded CNA to check temperature before serving. Nursing progress notes also included daily charting to monitor burns from 9/21/16 until 11/4/16, with no signs of infection, until healed. The care plan was updated on 9/21/16 for burn on left arm and left side of abdomen, with treatment as ordered started on 9/21/16 and staff education on 9/21/16 - 9/22/16. The care plan, as of 11/29/16, also included: -resident requires assistance with activities of daily living (ADLs) related to [DIAGNOSES REDACTED]. -resident is at risk for falls related to [DIAGNOSES REDACTED]. According to the 8/5/16 minimum data set (MDS) assessment, the resident had impaired cognition with a brief interview of mental status (BIMS) score of 11 out of 15. She required extensive assistance of one staff for bed mobility, dressing, grooming and toilet use; assistance of two staff for transfer. For eating, she was assessed as limited assistance with one person physical assist. According to the 11/5/16 minimum data set (MDS) assessment, the resident had intact cognition with a brief interview of mental status (BIMS) score of 13 out of 15. She required assistance of one staff for bed mobility, dressing, grooming and toilet use; assistance of two staff for transfer. For eating, she was assessed as independent with setup help only. The nursing monthly summaries dated 9/4/16 and 10/13/16 indicated that the resident needed assistance with eating, she ate in the dining room and needed set-up help for meals. Observation On 11/29/16 at 12:10 p.m. in the second floor dining room, at 12:55 p.m. in the hall, and at 1:20 p.m. in the resident's room, the resident was observed to keep her left arm still, rested on her lap, and did not move her left arm or her left leg. She was observed to use her right hand and right arm to feed herself, while seated in her wheelchair at a dining room table. The staff assisted her with meal set-up, with three nursing staff members providing supervision in the dining room. She was observed to use her right hand and her right leg and foot to self-propel her manual wheelchair from the dining room, down the hall and into her room. On 11/29/16 at 12:20 p.m. in the satellite serving kitchen for the dining room, the hot food items on the steam table did not include soup or any hot liquids for that meal. The microwave had a sign posted on the front, dated 9/21/16, with instructions to check the temperature of any food or beverage heated in the microwave. A thermometer was attached to the front of the microwave, next to the sign. This sign noted: - Attention - All and any liquids or foods that are microwaved must have the temperature checked. There is a food thermometer beside the microwave that must be used prior to serving residents food/liquids after being warmed in microwave. When warming up liquids and food in microwave: - Heat first 30 seconds, stir and check temperature, If need to be warmer, microwave for another 30 seconds, stir then check temperature. All liquids and foods should be served between 135 to 145 degrees. Coffee cups are insulated, so the take longer to cool. When reheating leftovers or resident's personal food, it should be heated to 165 degrees, then cooled to 135 degrees. Resident Interviews Resident #1 was interviewed on 11/29/16 at 1:20 p.m. She said that she spilled hot soup on herself while she was lying in bed, and she had a burn on her left arm and her left side. She recalled that when the certified nurse aide (CNA) delivered the hot cup of soup and placed it on her over-bed table, the CNA told her it was very hot and she should wait until it cooled, and that she should call for help when needed. She did not recall how long she waited, but she reached for the soup and it spilled on her, but she did not feel any pain, since her left side was not sensitive due to her stroke. She said that she did not know it caused blisters until another CNA came in later to help her get out of bed. She reported that the physician came in the next day to check the burns, and that they were healed. Physician Interview The primary care physician (PCP) was interviewed on 11/29/16 at 3:50 p.m. He stated that he had seen the resident's burns on 9/23/16, confirmed that the resident had second degree burns on her left arm, approximately 7 cm by 10 cm, and on her left side, approximately 5 cm by 7.5 cm, for which he ordered treatment. He said that he recently saw the resident on 11/22/16, and the burns were healed. Staff Interviews The Dietary Aide (DA) was interviewed on 11/29/16 at 12:45 p.m. She stated that hot beverages and soup that are prepared in the kitchen for service during meals are always checked for maximum serving temperature of 155 degrees. If a resident ordered soup from the always available menu, the dietary staff heated a single-serving soup in a cup in the microwave in the main kitchen, and checked the temperature. The hot soup or hot beverage would be sent to the resident floors when it was 155 degrees or less. But if a resident requested hot soup between meals, there were cans of single-serving cups of soup on the resident floors for the CNAs to heat in the microwave on the 2nd floor. CNA #1 was interviewed on 11/29/16 at 1:45 p.m. She stated that she was the first one to discover the resident's blisters on 9/21/16, at approximately 3:45 p.m., when she was helping the resident get out of bed, and saw the spilled soup on the resident's clothes. She said that the resident reported no pain. She reported the burn to the nurse immediately. She stated she cared for this resident regularly, and that the resident eats in the dining room, but was not feeling well that day; therefore the resident was in bed when she received the soup. CNA #2 was interviewed on 11/29/16 at 1:45 p.m. She stated that she cared for this resident regularly, and was aware that the resident needed assistance for meals. She confirmed that after the burn occurred, all staff were trained on safe microwaving of hot liquids and safe temperatures. LPN #1 was interviewed on 11/29/16 at 12:45 p.m. He said that the resident has left-sided weakness and [DIAGNOSES REDACTED], and needed assistance and set-up help for meals. The unit manager registered nurse (UMRN) was interviewed on 11/29/16 at 12:45 p.m. She stated that the resident had second degree burns on her left arm and side that were monitored and treated daily until healed on 11/4/16. She confirmed that all staff were educated on 9/21/16 after the burn occurred on safe temperatures of microwaved foods and beverages. The Cook (CK) was interviewed on 11/29/16 at 3:50 p.m. He stated that hot beverages and soup that are prepared in the kitchen for service during meals are always checked for maximum serving temperature of 155 degrees. Homemade soup is only on the menu approximately twice per month. But residents can choose from four flavors of single-serving canned soup anytime. If a resident ordered soup from the always available menu during meal service, the dietary staff heated a single-serving soup in a cup in the microwave in the main kitchen, and checked the temperature. The hot soup or hot beverage would be sent to the resident floors when it was 155 degrees or less. But if a resident requested hot soup between meals, there were cans of single-serving cups of soup on the resident floors for the CNAs to prepare by heating in the microwave. The NHA was interviewed on 11/29/16 at 2:45 p.m., 3:50 p.m. and 5:30 p.m. She stated the after the burn occurred, the staff was educated later that day on safe microwave use. An investigation was conducted, with staff and residents interviewed. She stated that the CNA heated a cup of soup in the microwave on the 2nd floor, and did not check the temperature of the hot soup before placing it on resident #1's over-bed table, while the resident was lying in bed. The CNA placed the cup of hot soup within reach of the resident, and told the resident to wait until it cooled. She stated the resident did need assistance with eating, and the CNA should not have placed the hot soup within reach of the resident until a staff member was able to be in the room and assist the resident. The new procedure, dated 9/21/16, was written, posted on the microwaves and all staff were trained on 9/21/16 and 9/22/16. The NHA confirmed no additional training or follow-up monitoring had been conducted after the incident on 9/22/16.

Based on record review and interview, the facility failed to ensure one of 18 residents (#7) received the necessary care and services to attain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to ensure the [MEDICAL CONDITION] medication [MEDICATION NAME] was administered and monitored as ordered by the physician. Cross-reference F333. The findings include: Resident #7 was originally admitted to the facility on [DATE], with readmission on 3/18/08. [DIAGNOSES REDACTED]. According to the quarterly minimum data set (MDS), dated [DATE], the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating her cognitive ability was slightly impaired. The resident required supervision for all activities of daily living, except for personal hygiene, for which she was independent. Record Review The resident's care plan pertaining to [MEDICAL CONDITION] was last updated, on 3/2/12, and included the following approaches: "administer anti-convulsant medication as ordered - [MEDICATION NAME]; protect from injury during witnessed [MEDICAL CONDITION]; monitor for any [MEDICAL CONDITION] activity and notify MD; labs per orders - report abnormal results to MD." Review of resident #7's record revealed that in January 2012, the resident was receiving [MEDICATION NAME] 100 mg (milligrams) for [MEDICAL CONDITION] three times daily. The record included documentation that the resident experienced a fall, on 2/6/12, and that, because of the fall, the physician ordered lab work for the resident on that day. Her [MEDICATION NAME] result was 22.3, indicating a high level of [MEDICATION NAME] in her blood (normal reference range is 10.0 - 20.0). A new telephone order, dated 2/7/12, read, "Hold [MEDICATION NAME] today (2/7/12) and tomorrow (2/8/12). Start [MEDICATION NAME] 100 mg po (by mouth.) Recheck [MEDICATION NAME] level 2/16/12." On 2/16/12, the resident's [MEDICATION NAME] level was 9.0. Another telephone order, dated 2/22/12, was documented by a nurse as follows: "[MEDICATION NAME] 200 mg PO (by mouth) every other day to alternate with 300 mg PO every other day. (Give 100 mg PO every am and alternate [MEDICATION NAME] 200 mg and 300 mg every other day in eve(evening). Recheck [MEDICATION NAME] level in two weeks (3/7/12)." On the order, the nurse wrote lines through both the 200 mg and 300 mg values. "100 mg" was written above the original 200 mg value. "200 mg" was written above the original 300 mg value. According to a laboratory report, dated 3/9/12, the resident refused the blood draw for the [MEDICATION NAME] level on 3/9/12. (This report was not in the resident's chart; rather it was faxed to the facility from the medical laboratory on 5/29/12 upon request.) There was no documentation in the resident's record indicating the reason for the refusal, or that other attempts were made to obtain a [MEDICATION NAME] result. There was also no documented evidence the resident's physician or family members were aware she had refused the blood draw on 3/9/12, and that the resident's [MEDICATION NAME] level was not being monitored as ordered. Review of the resident's February 2012 medication administration record (MAR) revealed that starting 2/22/12, resident received [MEDICATION NAME] 100 mg every morning, and [MEDICATION NAME] 100 mg and [MEDICATION NAME] 200 mg alternating every other evening. However, the March, April, and May 2012 MARs indicated the resident received [MEDICATION NAME] 100 mg every morning, and [MEDICATION NAME] 200 mg and [MEDICATION NAME] 300 mg alternating every evening. From 3/1/12 through 5/8/12, resident #7 was given 100 mg of [MEDICATION NAME] each day above the ordered amount of [MEDICATION NAME]. The resident's record contained no other [MEDICATION NAME] lab result until 5/8/12. On 5/8/12, the physician ordered lab work to be completed because resident #7 was experiencing "altered mental status," as documented by the physician on the order. The resident's [MEDICATION NAME] level on 5/8/12 was 27.9, which was documented on the report as a critical high level. On 5/9/12, the physician changed the [MEDICATION NAME] order to: "D/C current [MEDICATION NAME] orders; [MEDICATION NAME] 100 mg PO BID (twice daily); Hold [MEDICATION NAME] on 5/9/12 and 5/10/12. Recheck [MEDICATION NAME] on 5/16/12." Physician's Progress Notes, written by a Nurse Practioner student, and co-signed by the physician, was dated 5/10/12 and included the following documentation: "elevated [MEDICATION NAME] - stopped. . . Altered mental status resolved withholding [MEDICATION NAME]." The nurse practitioner wrote another progress note on 5/17/12, which read, "Resting in bed, A & O (alert and oriented) to self, place, and month. . . [MEDICATION NAME] level 17.3 on 5/15." Interviews On 5/29/12 at 3:30 p.m., resident #7's January through May 2012 telephone orders, physician recapitulation orders, and MARs, pertaining to [MEDICATION NAME] were shown to the Assistant Director of Nursing (ADON) and the Executive Director (ED). On 5/30/12 at 12:30 p.m., the ADON and ED reported they had reviewed the resident's record, and the ADON acknowledged there was a discrepancy between the order for [MEDICATION NAME], as reflected on the telephone order, dated 2/22/12, and the [MEDICATION NAME] that was given to the resident, from 3/1/12 through 5/8/12, as reflected on the MARs. The ADON confirmed that the [MEDICATION NAME] order written on the telephone order was different from the [MEDICATION NAME] order which was documented on the MARs. The ADON explained that the resident's [MEDICATION NAME] order should have been clarified by the nursing staff on 2/22/12 and re-written. The ADON stated, "Orders shouldn't be crossed out." The ADON further acknowledged there was no evidence the physician had been notified when Resident #7 refused to have her blood drawn on 3/9/12, as ordered, to determine her [MEDICATION NAME] level. The ADON verbalized the facility should have notified the physician and family of the refusal and documented the refusal in the resident's chart. When asked why the physician was not notified, the ED stated, "We don't have an answer." On 5/30/12 at 2:45 p.m., resident #7 was interviewed. When asked why she refused the blood draw, on 3/9/12, the resident answered through an interpreter, "I was feeling horrible that day. I asked them to come back in two days . . . I have no problem giving my blood. I know it's necessary." The resident verbalized she was unsure if staff came back two days later to obtain her [MEDICATION NAME] level.

Based on record review, staff and family interviews and observations, the facility failed to ensure the environment for one (#1) of 18 sample residents was free from accident hazards. Specifically, resident #1 had a history of [REDACTED]. Cross-reference F333. Findings include: Sample resident #1, a [AGE] year-old male, was admitted to the facility, on 4/18/12, with [DIAGNOSES REDACTED]. He had previously been an inpatient at a local hospice and family requested he go to a skilled nursing facility after a 15 day (3/21 through 4/4/12) hospitalization for seizure activity so severe he was intubated (and extubated) three times. He did return to the inpatient hospice, from 4/4/12 through 4/18/12, at which time he was transferred to the facility for skilled care and hospice was to be provided at the facility. He was not in the facility long enough to have a Minimum Data Set. According to his temporary care plan he required the assistance of at least one staff member for all ADLs (Activities of Daily Living) which included transfers, ambulation, dressing, personal hygiene and dressing. He had a Foley catheter and an internal colostomy, as well as an internal porta-cath in left chest wall. Record Review/Fall Risk Per a facility Fall Risk Assessment, initially completed, on 4/20/12, (two days after he was admitted ), resident #1 was scored as a 24. The facility form instructed; a score greater than 10 makes the resident a High Fall Risk. He did sustain a fall at the facility, on 4/24/12. His fall risk assessment was recalculated and he then had a score of 26. Medication Error A significant medication error was made upon admission, regarding his Dilantin (aka phenytoin) due to a transcription error. It was not discovered until the resident became lethargic and would not eat or drink and then had a fall out of bed, on 4/24/12. The Fall On 4/24/12 resident #1 was found on the floor. His tab alarm was sounding. Resident stated he was dizzy and rolled off the bed. Upon admission, the facility knew the resident had been in the hospital for 15 days, during which he had been intubated and extubated three times due to the severity of his seizures. Staff Interviews The NHA (Nursing Home Administrator) and the DON (Director of Nursing - whose last day at the facility was 5/27/12 or thereabouts) were interviewed, on 5/22/12 at approximately 3:45 p.m., about the resident's fall. When asked what they had put in place (based on his history of seizures and previous falls) the DON stated that all new admissions were issued tab alarms for their beds and wheelchairs (if applicable). She also stated he had a hi/lo bed (as all residents in the facility had). After the fall (where he was found on the far side of the bed under the window), his bed was placed up against the wall, a fall mat (aka landing strip) was placed on the near side as well as up against the wall (to protect him should he seize). They obtained wedges to help him from rolling out and make him aware of where the edge of the bed was. Two days after the fall he was moved closer to the Nurses' Station and he received a bariatric bed with a specialty mattress, which then allowed for bolsters. On 5/24/12, after a phone interview with the complainant, the NHA and the DON were again interviewed. When asked if based on resident #1's history (falls, seizures, lung and colon cancer with metastasis to the brain) were all appropriate preventative measures put in place upon admission, she stated, "In hindsight, no." The replacement DON was interviewed on 5/30/12. While he was not there when resident #1 was residing at the facility, he had become familiar with resident #1 and his fall. He stated that he would have put all of those safety measures in upon admission. He also acknowledged that the significant medication error most likely did contribute to the fall. Outcome Record review showed a change in the resident's mental status (described by family as sleepy and confused), decreased appetite and thirst levels. He also, according to his wife, started having jerky movements in his hands (which, historically according to her, signified seizures were coming). He was also documented to have blurred vision, after receiving three times as much Dilantin as was originally ordered for five consecutive days. While there was originally no injury reported, he did complain of pain at a 0-3 level immediately after the fall. Four days later, on 4/28/12, the pain (in his left knee - resident was found lying on his left side on the floor) was described as a 10/10 by the resident. Even after receiving pain medication, he still rated his pain at an 8/10. He then suffered a series of seizures that led to him being transferred to the ER. Record Review Review of the entire medical record was done on 5/22 and 5/23/12, for resident #1 and showed that he had confusion, involuntary jerky movements (per family) of his hands, lethargy, sleepiness, slurred speech, and unsteadiness. Out of the 15 possible signs listed below resident #1 had at least six of those, and upon admission to the ER he arrived unconscious. The signs of Dilantin overdose include the following: ? Coma ? Confusion ? Fever ? Involuntary, jerky, repeated movement of the eyeballs ([DIAGNOSES REDACTED]) ? Lethargy ? Low blood pressure ? Nausea ? Sleepiness ? Slow or slurred speech ? Staggering gait or walk ? Swollen gums ? Tremor ? Unsteadiness ? Uncoordinated movements ? Vomiting According to: Osborn H. Phenytoin and fosphenytoin toxicity. In: Tintinalli J, et al. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004:chap 178. Update Date: 2/6/2012 Updated by: Eric Perez, MD, St. Luke's / Roosevelt Hospital Center, NY, NY, and Pegasus Emergency Group (Meadowlands and Hunterdon Medical Centers), NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. URL of this page: http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm

Based on record review, staff and family interviews, the facility failed to ensure they administered medications in a manner to prevent significant medication errors for two of 18 sample residents (two of three taking [MEDICATION NAME]). Specifically, resident #1 was given three times the amount of [MEDICATION NAME]/[MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) he was supposed to receive and resident #7's [MEDICATION NAME] orders were not clarified, resulting in the resident experiencing an elevated [MEDICATION NAME] level and change in mental status. The facility failed to follow and clarify the physician's orders [REDACTED].#7 had a change in mental status. Further investigation into the cause of the fall and the change in mental status led the facility to determine they had made a significant medication error. Cross-reference F323 and F 309. Findings include: 1. Sample resident #1, a [AGE] year-old male, was admitted to the facility, on 4/18/12, with [DIAGNOSES REDACTED]. He had previously been an inpatient at a local hospice and family requested he go to a skilled nursing facility after a 15 day (3/21 through 4/4/12) hospitalization for [MEDICAL CONDITION] activity so severe he was intubated (and extubated) three times. He did return to the inpatient hospice, from 4/4/12 through 4/18/12, at which time he was transferred to the facility for skilled care and hospice was to be provided at the facility. He was not in the facility long enough to have a Minimum Data Set. According to his temporary care plan he required the assistance of at least one staff member for all ADLs (Activities of Daily Living) which included transfers, ambulation, dressing, personal hygiene and dressing. He had a Foley catheter and an internal [MEDICAL CONDITION], as well as an internal porta-cath in left chest wall. Record Review/Fall Risk Per a facility Fall Risk Assessment, initially completed, on 4/20/12, (two days after he was admitted ), resident #1 was scored as a 24. The facility form instructed that a score greater than 10 makes the resident a High Fall Risk. He did sustain a fall at the facility on 4/24/12. His fall risk assessment was recalculated and he then had a score of 26. Medication Error A significant medication error was made upon admission, regarding his [MEDICATION NAME] (aka [MEDICATION NAME]) due to a transcription error. It was not discovered until the resident became lethargic and would not eat or drink and then had a fall out of bed, on 4/24/12. -The initial orders for resident #1 (transfer orders from inpatient hospice) read as follows: [MEDICATION NAME] ([MEDICATION NAME]) 100 mg, 3 capsules at bedtime. That would have been 300 mg each day. -The History and Physical form, completed by the physician and signed, on 4/20/12, listed: [MEDICATION NAME] 100 mg TID (three times a day). That still would have been 300 mg each day. -The last Physician's Progress Note (prior to having been transferred to the facility), dated 4/15/12, and listed: [MEDICATION NAME] 300 mg qhs (each night at bedtime) -The "Admittance Sheet", written and signed by a facility RN (Registered Nurse) on 4/18/12 read: [MEDICATION NAME] 100 mg p.o. TID=3 tabs. NOTE: TID= three times a day not three tabs. -The initial MAR (Medication Administration Record) showed that as of the day he was admitted to the skilled nursing facility, on 4/18/12, he was given the following dose: [MEDICATION NAME] 100 mg=Three tabs (300 mg) PO TID. The doses were scheduled at 6 a.m., noon and 8 p.m. He was given 900 mg three times a day, when he should have been given 300 mg a day. That error in dosing continued through 4/24/12. The resident was described as being lethargic and he fell out of his bed, on 4/24/12. He was given an additional 600 mg per day, except on 4/18/12 and 4/24/12, when he received 300 mg per day. The resident received 3000 additional mg. Cross-reference F323. -There was a Telephone Order (T.O.) written on 4/24/12 that read: "Hold [MEDICATION NAME] 300 mg TID X 2 days. Resume [MEDICATION NAME] 100 mg p.o. (by mouth) every hs (bedtime). Recheck [MEDICATION NAME] level on 4/26 and 4/29)." -On 4/25/12 there was another T.O. that read: "D/C (discontinue) CMP/[MEDICATION NAME] level 4/26. CMP/[MEDICATION NAME] level tonight, per family request." -On 4/26/12 another T.O. read: "Start [MEDICATION NAME] 100 mg p.o. BID (twice a day)" That order was started 4/26/12 when he received 100 mg at bedtime, then 100 mg on 4/27/12 at 8 a.m. The evening dose was not signed off nor was there any explanation as to why that dose was not given. He received 100 mg at 8 a.m. on 4/28/12, and then was discharged to the ER later that day at the family's request. Lab Results The following [MEDICATION NAME] levels were drawn for resident #1: -On 4/23/12 the [MEDICATION NAME] level was High at 21.6. The therapeutic Reference Range is 10.0-20.0 (Those results were called into the facility on [DATE] at 4:14 a.m.) -On 4/25/12 the [MEDICATION NAME] level was 15.5 - within normal limits. His [MEDICATION NAME] had been on hold since he fell on [DATE]. (Those results were called into the facility on [DATE] at 3:02 a.m.) -After the resident was sent to the ER, a [MEDICATION NAME] level drawn on 4/28/12 at 9:25 p.m., was Low at 4.5 Interviews The NHA (Nursing Home Administrator) and the DON (Director of Nursing - whose last day at the facility was 5/27/12 or thereabouts) were interviewed, on 5/22/12 at approximately 3:45 p.m., about the resident's fall. They both at first denied any knowledge of that. On 5/24/12, after a phone interview with the complainant, the NHA and the DON were interviewed again. At that time they stated there had been a medication error (which they referred to as a "Transcription Order"). But denied there was any outcome to the resident. However, when reviewing the facility investigation into the medication error (on their Incident/Accident Report) under the section that read: "Full description of Incident/Accident" the facility documented "[MEDICATION NAME] ordered 100 mg 3 tabs daily. Transcribed TID (three times a day)." The physician response, "[MEDICATION NAME] level ordered, [MEDICATION NAME] dose on hold, till result obtained." That [MEDICATION NAME] level drawn 4/24/12 was 21.6, which was High. Professional Standards Per the State Operations Manual (SOM), in regard to F333 (Significant Medication Error) ... "Drug Category-if the drug is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especially important with a drug that has a Narrow Therapeutic Index (NTI) (i.e. a drug in which the therapeutic level is very close to the toxic dose). Examples of drugs with NTI are as follows: Anticonvulsant: [MEDICATION NAME] ([MEDICATION NAME]) ..." Per Mosby's Nursing Drug Reference, 2010, pages 864-866 ... ". . . Dosage for [MEDICAL CONDITION] . . . Adult: . . . maintenance dose 300-400 mg/day, max 600 mg/day . . . Side effects/adverse reactions: CNS (central nervous system): Drowsiness, dizziness, [MEDICAL CONDITION], paresthesias, depression, suicidal tendencies, aggression, headache, confusion, slurred speech. CV (cardiovascular): [MEDICAL CONDITION] (low blood pressure), ventricular fibrillation. GI (gastrointestinal): nausea, vomiting, constipation, anorexia, weight loss . . . Precautions: allergies [REDACTED]. . ." Outcome Record review showed a change in the resident's mental status (described by family as sleepy and confused), decreased appetite and thirst levels. The resident received three times as much [MEDICATION NAME] as was originally ordered for five consecutive days and fell out of bed on 4/24/12. While there was originally no injury reported, he did complain of pain at a 0-3 level immediately after the fall. Four days later the pain (in his left knee, and resident was found lying on his left side on the floor) was described as a 10/10 by the resident. Even after receiving pain medication, he still rated his pain at an 8/10. When he arrived at the hospital, he was unconscious. See ER record below. Electronic Nursing Notes The electronic note was documented as having been made in the computer at 10:17 p.m., after the resident was discharged to hospital ER. Due to his complaint of knee pain (especially left knee) the facility nurse had called the hospice nurse. The hospice nurse gave an order to "Increase [MEDICATION NAME] to 0.5 ml-1.0 ml every hour PRN (as needed), give two doses, if no change, call back. Two doses given as ordered, resident stated no change, still pain 10/10. Call placed again to (name of) hospice. Spoke to (name of phone triage hospice nurse) stated that Hospice RN is coming on her way. Resident's wife came in to visit and is sitting at bedside. And she called my attention to the fact that the resident is having [MEDICAL CONDITION]. This nurse went in and witnessed resident having [MEDICAL CONDITION] takes 8 mins long and interval for 15 min, second is 5 mins and third is 6 mins. Safety precaution implement and wife on bedside, hospice nurse came in at approx 8:00 p.m. and stay with patient and family." The overnight RN made the following entry at approximately 11:58 p.m.: "At approximately 8:30 p.m. hospice nurse called to request transport of resident to (name of) hospice. Family called (911) to request transport of resident to hospital. Transport paramedics arrived at 9:00 p.m. Family left to accompany resident when transported. Reported to this nurse that both parties agreed to transport to (name of) hospice." NOTE: The NHA could not explain why it was not documented that the resident was transferred to the hospital. She stated it was perhaps a miscommunication at change of shift (10-10:30 p.m.) as he was gone when the shifts changed. Neither she nor anyone else at the facility, could explain the difference in the length of [MEDICAL CONDITION] time reported to the ER. Also of note, resident #1 had not had any [MEDICAL CONDITION] since he was discharged from the hospital in March 2012. emergency room Report The resident was transferred to the same hospital he had previously been at for [MEDICAL CONDITION]. The record was received and reviewed. It revealed the following: "Visit Date/Time: 4/28/12 21:14 (9:14 p.m.) ...from NH (nursing home) for [MEDICAL CONDITION] X 4 today. Last [MEDICAL CONDITION] reportedly lasted 76 minutes. Pt. given 5 mg IM Versed and 5 mg IV [MEDICATION NAME] by EMS. No [MEDICAL CONDITION] activity upon arrival. Pt. unconscious, valid DNR/DNI (Do Not Resuscitate/Do Not Intubate) with pt. airway patent. Pt. on 15L NRB (non rebreather) ... ESI (emergency services indicator): 2 (ED-High Risk/Unstable)." [MEDICATION NAME] Overdose [MEDICATION NAME] is a medicine used to prevent [MEDICAL CONDITION]. Overdose <http://www.nlm.nih.gov/medlineplus/ency/article/ 7.htm> occurs when someone accidentally or intentionally takes more than the normal or recommended amount of this medication. Poisonous Ingredient ? [MEDICATION NAME] Where Found ? [MEDICATION NAME] ? [MEDICATION NAME] Symptoms The symptoms vary, but may include: ? Coma <http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm> ? Confusion <http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm> ? Fever <http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm> ? Involuntary, jerky, repeated movement of the eyeballs ([DIAGNOSES REDACTED]) ? Lethargy ? Low blood pressure ? Nausea ? Sleepiness <http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm> ? Slow or slurred speech ? Staggering gait or walk ? Swollen gums <http://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm> ? Tremor ? Unsteadiness <http://www.nlm.nih.gov/medlineplus/ency/article/ 9.htm> ? Uncoordinated movements ? Vomiting Outlook (Prognosis) The outlook depends on the severity of the overdose: ? Mild overdose: Supportive therapy alone may be all that is needed. Recovery is likely. ? Moderate overdose: With proper treatment, the patient usually makes a complete recovery within 24 to 48 hours. ? Severe overdose: If the patient is unconscious or vital signs <http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm> are abnormal, more aggressive treatments may be necessary. It may take 3 to 5 days before the patient wakes up (becomes conscious). However, unless there are complications, long-term effects and deaths are uncommon. Death usually occurs as a result of liver failure. References Osborn H. [MEDICATION NAME] and [MEDICATION NAME] toxicity. In: Tintinalli J, et al. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004:chap 178. Update Date: 2/6/2012 Updated by: Eric Perez, MD, St. Luke's / Roosevelt Hospital Center, NY, NY, and Pegasus Emergency Group (Meadowlands and Hunterdon Medical Centers), NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. URL of this page: http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm 2. Resident #7 was originally admitted to the facility, on 1/5/06, with readmission on 3/18/08. [DIAGNOSES REDACTED]. Record Review Review of resident #7's record revealed that in January 2012, the resident was receiving [MEDICATION NAME] 100 mg (milligrams) for [MEDICAL CONDITION] three times daily. The record included documentation that the resident experienced a fall, on 2/6/12, and that, because of the fall, the physician ordered lab work for the resident on that day. Her [MEDICATION NAME] result was 22.3, indicating a high level of [MEDICATION NAME] in her blood (normal reference range is 10.0 - 20.0). A new telephone order, dated 2/7/12, read, "Hold [MEDICATION NAME] today (2/7/12) and tomorrow (2/8/12). Start [MEDICATION NAME] 100 mg po (by mouth.) Recheck [MEDICATION NAME] level 2/16/12." On 2/16/12, the resident's [MEDICATION NAME] level was 9.0. Another telephone order, dated 2/22/12, was documented by a nurse as follows: "[MEDICATION NAME] 200 mg PO (by mouth) every other day to alternate with 300 mg PO every other day. (Give 100 mg PO every am and alternate [MEDICATION NAME] 200 mg and 300 mg every other day in eve(ning). Recheck [MEDICATION NAME] level in two weeks (3/7/12)." On the order, the nurse wrote lines through both the 200 mg and 300 mg values. "100 mg" was written above the original 200 mg value. "200 mg" was written above the original 300 mg value. Review of the resident's February 2012 medication administration record (MAR) revealed that starting 2/22/12, resident received [MEDICATION NAME] 100 mg every morning, and [MEDICATION NAME] 100 mg and [MEDICATION NAME] 200 mg alternating every other evening. However, the March, April, and May 2012 MARs indicated the resident received [MEDICATION NAME] 100 mg every morning, and [MEDICATION NAME] 200 mg and [MEDICATION NAME] 300 mg alternating every evening. From 3/1/12 through 5/8/12, resident #7 was given 100 mg of [MEDICATION NAME] each day above the ordered amount of [MEDICATION NAME]. The resident's record contained no other [MEDICATION NAME] lab result until 5/8/12. On 5/8/12, the physician ordered lab work to be completed because resident #7 was experiencing "altered mental status," as documented by the physician on the order. The resident's [MEDICATION NAME] level on 5/8/12 was 27.9, which was documented on the report as a critical high level. On 5/9/12, the physician changed the [MEDICATION NAME] order to: "D/C current [MEDICATION NAME] orders; [MEDICATION NAME] 100 mg PO BID (twice daily); Hold [MEDICATION NAME] on 5/9/12 and 5/10/12. Recheck [MEDICATION NAME] on 5/16/12." Physician's Progress Notes, written by a Nurse Practioner student, and co-signed by the physician, was dated 5/10/12, and included the following documentation: "elevated [MEDICATION NAME] - stopped,,,Altered mental status resolved withholding [MEDICATION NAME]." Interviews On 5/29/12 at 3:30 p.m., resident #7's January through May 2012 telephone orders, physician recapitulation orders, and MARs, pertaining to [MEDICATION NAME] were shown to the Assistant Director of Nursing (ADON) and the Executive Director (ED). On 5/30/12 at 12:30 p.m., the ADON and ED reported they had reviewed the resident's record, and the ADON acknowledged there was a discrepancy between the order for [MEDICATION NAME], as reflected on the telephone order, dated 2/22/12, and the [MEDICATION NAME] that was given to the resident, from 3/1/12 through 5/8/12, as reflected on the MARs. The ADON confirmed that the [MEDICATION NAME] order written on the telephone order was different from the order which was documented on the MARs. The ADON explained that the resident's [MEDICATION NAME] order should have been clarified by the nursing staff on 2/22/12 and re-written. The ADON stated, "Orders shouldn't be crossed out."

Based on record review, observations and interviews, the facility failed to ensure adequate treatment and services to promote healing or prevent new sores from developing for two (#1, #2) of 16 sample residents. Specifically, the facility: --failed to complete timely and thorough documented pressure sore assessments, --failed to ensure physician orders were in place to treat resident #1's pressure sore, --failed to ensure an appropriate care plan was in place for resident #1's pressure sore, --failed to provide adequate encouragement for relieving pressure to resident #1's coccyx during the day, and --failed to ensure removal of the padded full body sling when transferring resident #2 to her cushioned wheelchair. The failures contributed to the worsening of resident #1's pressure sore from stage II to stage III. The findings include: 1. FACILITY SKIN CARE POLICY According to the Policy section of the Evaluations, Screenings, and Assessments from the facility's Pressure Ulcer Care Guide, "At the time of admission, each resident is evaluated for special needs related to skin care. Additionally, all residents receive a weekly skin integrity check performed by licensed personnel. Skin should be checked daily... On a weekly basis, an in-depth assessment is performed and recorded on the Pressure Ulcer Status Record in the resident's medical record. Each resident's pressure ulcer description is listed on the Weekly Pressure Ulcer Tracking Report, which is submitted to the Executive Director, Director of Nursing, and the NIP Committee. The NIP Committee records in the resident's medical record any changes determined by the committee." According to the Procedure section of the Treatment Orders from the facility's Pressure Ulcer Care Guide, "1. After observation/evaluation of the affected skin area, the physician is notified. As appropriate, the physician writes a treatment order that includes at least the following: --Site of wound --Name of cleanser --Name of ointment --If debridement is necessary and what type --Type of dressing --Number of times to perform the treatment/duration of treatment --Dietary intervention The physician order is followed, as are the manufacturer's instructions for use for each product ordered. After completing each treatment, each dressing is dated and initialed. 5. The treatment is documented on the Treatment Administration Record." According to the Policy section of the Assessment and Monitoring of Healing from the facility's Pressure Ulcer Care Guide, "Pressure ulcers are assessed and monitored once a week to determine if the treatment plan is working or should be re-evaluated. Frequency of monitoring may be indicated for resident who are at risk for complications secondary to impaired skin or tissue integrity. In addition... if a wound cannot be assessed (i.e., it is covered with necrotic tissue), the wounds are monitored and assessed daily and with each dressing change. With each dressing change, the pressure ulcer is observed for developments that may indicate the need for change in treatment such as: --Wound deterioration or improvement. --More or less exudate. --Signs of infection. The physician, resident, and family/caregiver are kept informed of the progress toward healing. The resident is reassessed if the ulcer does not show signs of healing as expected. --1-3 weeks for most partial-thickness acute wounds and Stage II pressure ulcers. --2-4 weeks for most full-thickness wounds." According to the Procedure section of the Assessment and Monitoring of Healing from the facility's Pressure Ulcer Care Guide, "Document your findings. Include a narrative description of the wound, including its physical characteristics, in the medical record to avoid miscommunication or misinterpretation. The description should include: --Location --Stage --Size --Tissue types --Wound bed and periwound condition --Exudate --Presence or absence of granulation or [MEDICATION NAME] --Necrosis/eschar --Odor --Wound edges --Tunneling --Undermining/sinus tracts --Slough --Presence or absence of pain (If present, documentation includes whether it is being adequately controlled.) --Type of wound (pressure-related vs. non-pressure related) Note: Never backstage a wound." According to the Other Documentation section of the Assessment and Monitoring of Healing from the facility's Pressure Ulcer Care Guide, "--Chart observations and assessments on the flow sheet weekly. --Document significant findings or changes in the interdisciplinary/nurses' notes. --Document physician notification." 2. Resident #1 Resident #1, who was [AGE] years old, was originally admitted to the facility, on 10/19/11 and was re-admitted on [DATE]. According to the resident's current face sheet, his current [DIAGNOSES REDACTED]. a. Resident Status According to the 10/25/11 Minimum Data Set (MDS), resident #1 had two stage II pressure sores, was cognitively intact, was occasionally incontinent of bladder, required limited to extensive assistance of one or two staff members for activities of daily living (ADLs), had no range of motion limitations, experienced a fall in the previous month, and experienced a fall with major injury since admission to the facility. According to the 11/3/11 MDS, resident #1 had one stage II pressure sore, had some memory problems, was frequently incontinent of bladder, required limited to extensive assistance of one or two staff members for activities of daily living (ADLs), had limited range of motion on one side of lower extremities, experienced a fall with a fracture in the previous month. Even though the resident's stage II pressure sore was documented on both of the MDSs, review of the care plan revealed no documented evidence a care plan was initiated for the pressure sore. There was a care plan problem/need initiated, on 10/20/11, for being "@ high nutrition risk r/t (related to) dx (diagnosis) FTT (failure to thrive) w/BMI (body mass index @ (less than) 16. He requires a modified diet r/t chew/swal(low) problems. He has decreased skin integrity (Stage II decub (pressure sore) - mid back on admit. He also has abnormal nutrition related labs." However, there were no approaches for treatment or assessment of the pressure sore. b. Record Review Review of the Braden Scale for Predicting Pressure Sore Risk revealed the resident was assessed "at risk" on 10/19/11, 10/28/11, 11/5/11 and 11/11/11. He was not at moderate, high or very high risk for developing pressure sores. According to the 10/19/11 nurse's note, resident #1 was admitted at 5:30 p.m., from the hospital after being found on the floor at home by his neighbor. His height was documented as 5 feet 9 inches, and his weight was 104 pounds. His "skin turgor is poor. Coccyx two open areas 0.2 x 0.2 (cm) covered (with) Replicare till further orders obtained. Resident is skin (and) bones." There was no documented evidence the second area was assessed as it was not described, not measured and did not reveal the location. There was no documented evidence a physician's order was obtained for the use of Replicare at that time. According to the 10/19/11 Initial Data Collection Tool/Nursing Service, the resident had two stage II pressure sores: one mid-back without measurements and one on the coccyx measuring 0.2 x 0.2 cm. Review of the physician's 10/19/11 admission orders [REDACTED]. The 10/19/11 physician's telephone order at 6:30 p.m. was for barrier ointment to coccyx every shift and as needed (PRN). Review of the 10/11 Treatment Administration Record (TAR) revealed, even though there was no physician's order for Replicare, the Replicare dressing was in place on 10/19/11. Review of the laboratory results for the specimen collected, on 10/19/11, revealed resident #1's [MEDICATION NAME] level was low at 8.5 mg/dl (reference range 17.5-36.0). According to the 10/20/11 nurse's note at 2 p.m., Replicare was applied to the coccyx wound. However, there was no documented evidence of a physician's order for its use and no evidence the wound was appropriately assessed. The 10/20/11 physician's telephone order was for, 1) 4 ounces Med Pass 2.0 twice daily between meals orally, 2) discontinue multivitamin, 3) add pre-[MEDICATION NAME] to 10/20/11 lab draw if possible, and 4) multivitamin with minerals for 30 days. According to the 10/21/11 nurse's note at 1:30 p.m., "dressing to coccyx intact with Replicare and (no) s/s (signs/symptoms) of infection noted." However, there was no documented evidence of a physician's order for its use and no evidence the wound was appropriately assessed. According to the 10/21/11 nurse's note at 8 p.m., "coccyx Replicare intact (no) c/o (complaints of) pain." However, there was no documented evidence of a physician's order for its use and no evidence the wound was appropriately assessed. According to the 10/22/11 nurse's note at 5:50 a.m., "Replicare to coccyx." However, there was no documented evidence of a physician's order for its use and no evidence the wound was appropriately assessed. Review of the 10/11 Treatment Administration Record (TAR) revealed, even though there was no physician's order for Replicare, the Replicare dressing was replaced on 10/22/11. The Weekly Skin Integrity Data Collection revealed the 10/22/11 skin assessment with an "old" "open area" to the resident's coccyx without measurements or specific description. According to the 10/22/11 nurse's note at 9 p.m., the resident "c/o coccyx pain & wants donut cushion in his w/c (wheelchair). RN (registered nurse) to inform therapy." However, there was no documented evidence the wound was appropriately assessed. According to the 10/23/11 nurse's note at 4:30 a.m., "dressing intact to coccyx." However, there was no documented evidence the wound was appropriately assessed. According to the 10/25/11 nurse's note at 10:30 a.m., the resident fell and was transferred to the hospital. There was no evidence the resident's skin was assessed prior to the transfer. Review of the 10/11 Treatment Administration Record (TAR) revealed, even though there was no physician's order for Replicare, the Replicare dressing was replaced on 10/25/11. According to the 10/28/11 readmission nurse's note at 3 p.m., the resident had a "coccyx stage II (pressure sore). Replicare placed. Site is small in size 0.2 x 0.2 cm (with) abrasion type wound @ top." However, there was no documented evidence of a physician's order for use of Replicare and no evidence the wound was appropriately assessed. According to the 10/28/11 Initial Data Collection Tool/Nursing Service, the resident weighed 116.6 pounds, and had one stage II pressure sore without measurements on his coccyx. Review of the physician's 10/28/11 admission orders [REDACTED]. The resident was to receive a weekly skin assessment every Saturday evening. The 10/28/11 physician's telephone order at 3 p.m., was for barrier ointment to buttocks every shift and PRN. Review of the 10/11 Treatment Administration Record (TAR) revealed, even though there was no physician's order for Replicare, a Replicare dressing was in place on 10/28/11. According to the 10/29/11 nurse's note at 6 a.m., "Replicare to coccyx replaced." However, there was no documented evidence of a physician's order for its use and no evidence the wound was appropriately assessed. The 10/29/11 physician's telephone order at 11:25 a.m., was for house supplement 120 cc three times daily between meals, dietary evaluation and treatment, and Prostat 30 cc orally every day. Review of the physician assistant's (PA) 10/29/11 visit note revealed no evidence of assessing the resident's coccyx wound. The "integumentary" documentation read, "Positive for surgical scar. Negative for pruritis or rash." The exam of the skin documentation read, "poor turgor; unable to visualize the L (left) hip today." Review of the FastCair New Rental FAX CONFIRMATION revealed a "dermafloat LAL 36 x 80 sys" was installed for resident #1 on 10/29/11. According to the 10/29/11 nurse's note at 8 p.m., the resident was "on air mattress." However, there was no documented evidence the wound was appropriately assessed. The Weekly Skin Integrity Data Collection revealed the 10/29/11 skin assessment with no documented evidence of a pressure sore, rather "red" coccyx. According to the 10/30/11 nurse's note at 5 a.m., the resident had "Replicare to coccyx. Remains on air mattress." However, there was no documented evidence the wound was appropriately assessed. According to the 10/31/11 nurse's note at 2:30 a.m., "air mattress in operation." However, there was no documented evidence the wound was appropriately assessed. According to the 10/31/11 nurse's note at noon, "Replicare applied to coccyx with barrier cream to buttocks." However, there was no documented evidence of a physician's order for the use of [REDACTED]. Review of the 10/11 Treatment Administration Record (TAR) revealed, even though there was no physician's order for Replicare, the Replicare dressing was replaced on 10/31/11. Review of the physician's 10/31/11 visit note revealed no evidence of assessing the resident's coccyx wound. The "integumantary" documentation read, "Positive for surgical scar. Negative for pruritis or rash." The exam of the skin documentation read, "unable to visualize the L (left) hip today." According to the 10/31/11 nurse's note at 11:15 p.m., the resident was "monitored for safety - position." According to the 11/1/11 nurse's note at 8 p.m., "coccyx Replicare intact." However, there was no documented evidence of a physician's order for its use and no evidence the wound was appropriately assessed. According to the 11/2/11 nurse's note at 11:40 p.m., "Replicare to coccyx." However, there was no documented evidence of a physician's order for the use of [REDACTED]. Review of the physician's 11/2/11 visit note revealed no evidence of assessing the resident's coccyx wound. The exam of the skin documentation read, "warm and dry." The 11/3/11 physician's telephone order at 11:30 p.m., was to check pre-[MEDICATION NAME] and add Magic Cups with lunch/dinner. Review of the laboratory results for the specimen collected on 11/3/11 revealed resident #1's [MEDICATION NAME] level was low at 8.2 mg/dl (reference range 17.5-36.0). The 11/4/11 physician's telephone order at 10 a.m., was for "Replicare to coccyx every 3 days and PRN and clean wound with wound cleanser." Review of the 11/11 TAR revealed the coccyx wound was cleaned with wound cleanser and covered with Replicare on 11/4/11. According to the 11/5/11 nurse's note at 10 a.m., resident #1 was with "therapy today when RN noticed open areas @ coccyx; 3 open areas measuring wound #1 0.3 x 1.7 cm, wound #2 1.9 x 1.5 cm & wound #3 1.0 x 0.6 cm; necrotic tissue noted; painful to touch; 5/10 (pain rated at a 5 on a scale of 0-10 with zero being no pain and 10 being unbearable); called (physician) & left a message... Santyl applied to the affected area & cover (with) dry drsg (dressing." There was a half sheet of scrap paper with the resident's 11/11 TAR, dated 11/5/11, with the resident's name that had the same measurements as above and another measurement of "redness: 9 cm x 5 cm." The 11/5/11 physician's telephone order at 10 a.m., was for "Apply Santyl to wound; put (illegible) & cover (with) dry dressing (change every) day & PRN." The Weekly Skin Integrity Data Collection revealed the 11/5/11 skin assessment with a "new" "open area" to the resident's coccyx without measurements or specific description. According to the 11/5/11 nurse's note at 8 p.m., "coccyx drsg in place... refused to go back to bed after meals. RN advised resident to limit sitting in w/c (secondary) to open areas @ the coccyx area; resident still refused to go to bed." According to the 11/5/11 nurse's note at 11:20 p.m., "coccyx dressing intact/clean." Review of the 11/11 TAR revealed Santyl was applied and covered with a dry dressing on 11/6/11. According to the 11/6/11 nurse's note at 2 p.m., "resident repositioned to his side when in bed; drsg @ coccyx intact." According to the 11/6/11 nurse's note at 7 p.m., "coccyx wound drsg intact; resident repositioned to his side when in bed." According to the late entry 11/6/11 nurse's note for 11 p.m., "dressing change to coccyx - no c/o voiced." However, there was no documented evidence the wound was appropriately assessed. Review of the 11/11 TAR revealed Santyl was applied and covered with a dry dressing on 11/7/11. According to the 11/7/11 nurse's note at 1 p.m., "wound dressing change on coccyx, and (no) s/s of infection noted... encouraged to lie in bed to get the coccyx off pressure." However, there was no documented evidence the wound was appropriately assessed. The 11/7/11 physician's telephone order at 3:40 p.m., was for "(1) Pt (resident) to lie on Derma float air mattress when in bed (secondary) to stage II to coccyx. (2) Administer Pro-stat 30 cc PO (orally) daily to promote wound healing. (3) PT/OT (physical therapy/occupational therapy) to assess wc (wheelchair) cushion for appropriateness." According to the 11/7/11 nurse's note at 3:50 p.m., "called (physician's) office & spoke (with) nurse in regards to stage II to coccyx. Orders ok'd to obtain LAL (pressure relieving) mattress for pt, start him on pro-stat, & have PT/OT eval for different cushion." The 11/8/11 physician's telephone order at 11:30 a.m., was for "Cleanse coccyx wnd (wound) (with) wnd cleanser, apply Santyl to slough area. Cover (with) foam drsg (dressing). Change daily until healed." Review of the 11/11 TAR revealed Santyl was applied and covered with a dry dressing twice on 11/8/11. According to the 11/8/11 nurse's note at 1:30 p.m., "coccyx wound dressing changed this morning and yellow slough noted and (no) drainage." However, there was no documented evidence of an appropriate wound assessment. Review of the physician's 11/8/11 visit note revealed no evidence of assessing the resident's coccyx wound. The exam of the skin documentation read, "warm and dry." The 11/8/11 physician's order at 8:15 p.m., was for dietary to evaluate and treat for low pre-[MEDICATION NAME]. According to the 11/8/11 nurse's note at 8:20 p.m., the resident was seen by the physician's assistant (PA) "today, new order received for lab(oratory) draw and for dietary to eval(uate) & tx (treat) (secondary to low) [MEDICATION NAME] level and skin issues, dietary notified." According to the 11/8/11 nurse's note at 8:30 p.m., the resident "c/o pain @ 2000 (8 p.m.) to buttocks. [MEDICATION NAME] one PO (orally) given @ 2000 also scheduled bid (twice daily)." According to the 11/8/11 nurse's note at 11 p.m., "coccyx dressing intact - resting quietly in bed watching TV." Review of the 11/11 TAR revealed Santyl was applied and covered with a dry dressing on 11/9/11. According to the 11/9/11 nurse's note at 11 p.m., "coccyx wound increasing in size - dressing (changed)." However, there was no documented evidence of an appropriate wound assessment. Review of the 11/11 TAR revealed the coccyx wound was cleansed with wound cleanser, Santyl was applied to slough, and it was covered with foam dressing twice on 11/9/11. According to the 11/10/11 nurse's note at 1:10 p.m., "Wound to coccyx measures 2 x 2 cm (L x W) x 0.3 cm in depth. Physician notified of wound getting worse at 1:00 p.m. Secretary stated she would get msg (message) out & someone would call back. Pt received [MEDICATION NAME] as appetite stimulant. Appetite remains poor. He has LAL mattress in place as well as Rojo cushion in place to w/c. Supplements in place. Nursing states he takes his time & does drink them. Dietician increased Prostat today. Current orders are Santyl with foam dressing to be changed daily. Will ask PT to look at wound today as it may need mechanical debridement. Message left on voicemail of (family member) at 1:10 p.m. in regards to wound. Currently awaiting call back. Will continue to monitor." The 11/10/11 physician's telephone order at 1:10 p.m., was for "please monitor percent of supplement taken on MAR (Medication Administration Record). Notify RN or physician if pt refuses." According to the 11/10/11 nurse's note at 1:50 p.m., "wound to coccyx dressed and slough noted, cont(inue) to use Santyl, encouraged resident to lie on his side, but he refused and said that he learned that pressure is good for wound healing, that they taught him that when he was in the Army. Will cont(inue) encouraging him to relieve pressure off his coccyx, air mattress on (illegible)." Review of the 11/11 TAR revealed the coccyx wound was cleansed with wound cleanser, Santyl was applied to slough, and it was covered with foam dressing on 11/10/11. On 11/10/11 the facility initiated the Pressure Ulcer Status Record for the resident's pressure sores. This was the only documented wound round assessment of the resident's pressure sores. There were three forms initiated for the three pressure sores on 11/10/11. One form revealed an unstageable pressure sore requiring debridement on the resident's coccyx with 100% necrotic tissue measuring 2 x 2 x 0.3 cm with a small amount of drainage, positive for odor, yellowish-gray color, no tunneling, open area with 100% slough, deteriorated response to treatment, and positive for coccyx pain. The second form revealed a stage II pressure sore on the coccyx not requiring debridement, with no necrotic tissue, measuring 0.5 x 1.2 x 0.1 cm with a small amount of drainage, no odor, pink/red color, no tunneling, crescent moon shape open area with no change in response to treatment and positive for coccyx pain. The third form revealed a stage II pressure sore on the coccyx not requiring debridement measuring 0.5 x 0.4 x 0.1 cm with a scant amount of drainage, no odor, pink/red color, no tunneling that appeared as a small open area with no change in response to treatment. The 11/10/11 physician's telephone order at 4 p.m., was for "Foley cath(eter) (secondary) to Stage II to coccyx." According to the 11/10/11 nurse's note at 11:20 p.m., "Foley inserted last shift. Dressing to coccyx." Review of the 11/11 TAR revealed the coccyx wound was cleansed with wound cleanser, Santyl was applied to slough, and it was covered with foam dressing on 11/11/11. According to the 11/11/11 nurse's note from wound rounds at 3:30 p.m., "Pt continues to have circular wound at coccyx region unstageable at this time. There is a pink area surrounding area of slough which is an improvement from yesterday. IDT (interdisciplinary team) recommends continuing Santyl to debride sloughed area & remove source of pressure. Air mattress in place as well as Rojo cushion. Pt educated to stay on side. He voices that he'd rather be on his back. Education done on why pressure should be removed from source. Pt has small moon-shaped wound above & to the left of larger coccyx wound. He also has smaller wound developing beneath larger wound. Though no s/s infection present to smaller wounds, larger wound contains slough (with) darkened area in wound bed. There is a foul odor present. Therapy will adjust Rojo cushion in center to further reduce pressure to area. (Pt has been found off-setting pressure in w/c which may be causing additional pressure.) (Physician) was notified on 11/10/11. Orders received to place Foley catheter (secondary) to wound & RD notified to assess for the need for supplements. Will continue to monitor." Review of the Resident/Family Education Assessment & Interdisciplinary Flow Record revealed the physical therapist provided instruction to the resident and a family member, on 11/11/11, on wound management, pressure reduction, side-lying and weight shifts. The resident has some understanding of basic information, was accepting of the information and had decreased cognition. According to the 11/11/11 nurse's note at 8 p.m., "coccyx drsg C/D/I (clean/dry/intact). Less red & inflamed since FC (Foley catheter) inserted." Review of the 11/11 TAR revealed the coccyx wound was cleansed with wound cleanser, Santyl was applied to slough, and it was covered with foam dressing on 11/12/11. The Weekly Skin Integrity Data Collection revealed the 11/12/11 skin assessment with an "old" "open area" without a location, without measurements and without a specific description. Review of the physician's 11/12/11 visit note revealed no evidence of assessing the resident's coccyx wound. The exam of the skin documentation read, "warm and dry." According to the 11/12/11 nurse's note at 11:50 p.m., "Dressing to coccyx intact/clean." Review of the 11/11 TAR revealed no evidence the dressing was changed on 11/13/11, as ordered. Review of the 11/11 TAR revealed the coccyx wound was cleansed with wound cleanser, Santyl was applied to slough, and it was covered with foam dressing on 11/14/11. c. Observations Resident #1 was observed, on 11/14/11 at 9:27 a.m., in his room seated in his wheelchair. A dermafloat air mattress was on his bed. He was working with a speech therapist. According to the 11/14/11 nurse's note at 1:45 p.m., "buttock wound with slough, and dressing change this morning." However, there was no documented evidence of a thorough wound assessment. Resident #1 was observed seated in his wheelchair in the main dining room, on 11/14/11 at 5:50 p.m. When his food was served he ate independently with encouragement from a staff member. Review of the 11/11 TAR revealed the coccyx wound was cleansed with wound cleanser, Santyl was applied to slough, and it was covered with foam dressing on 11/15/11. However, there was no documented evidence of a thorough wound assessment. Resident #1 was observed, on 11/15/11 at 11:15 a.m., in his room seated in his wheelchair. He was working with a staff member. Review of the 11/11 TAR revealed the coccyx wound was cleansed with wound cleanser, Santyl was applied to slough, and it was covered with foam dressing on 11/16/11. Resident #1 was observed on 11/16/11 at 9:10 a.m., in his room seated in his wheelchair. The resident was interviewed at this time, but was not a reliable historian. d. Interviews/Observations The resident's nurse was interviewed, on 11/16/11 at 10:20 a.m. She said resident #1 currently had an open area on his coccyx and she already did the dressing change, but she could show it to me. The Assistant Director of Nursing was interviewed, on 11/16/11 at 1:40 p.m. She stated the blank spot on the TAR for the pressure sore treatment on 11/13/11 meant "technically that it wasn't done, but the nurse could've done it and just not documented." The ADON said she would look at the resident's record and provide the evidence of wound assessments and treatments. However, when the evidence was provided, it only contained the information already listed above. Resident #1 was observed, on 11/16/11 at 3:35 p.m., in his room seated in his wheelchair, telling staff he would stay in his wheelchair. Resident #1's pressure sore was observed with staff, on 11/16/11 at 4:15 p.m. Referring to his coccyx, the resident said, "like having a jack knife there all day long. It's the worst I've ever had." The resident had one stage III pressure sore measuring 2.3 x 1.6 cm from outer edge to outer edge with 95% slough, tunneling 1.4 cm at 12 o'clock, and tunneling 1.1 cm at 2 o'clock. The edges were pink. The center was yellow and there was undermining all the way around the wound. The wound was surrounded by blanchable redness measuring 7.5 x 5.0 cm. 3. Resident #2 Resident #2, who was [AGE] years old, was originally admitted to the facility, on 4/3/08 and re-admitted on [DATE]. According to the resident's current face sheet, her current [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED]. a. Resident Status According to the 9/18/11 Minimum Data Set (MDS), resident #2 had no current pressure sores, was cognitively impaired, was always incontinent of bladder, was totally dependant on one or two staff members for activities of daily living (ADLs), had bilateral range of motion limitations in upper and lower extremities. b. Record Review Review of the Braden Scale for Predicting Pressure Sore Risk revealed the resident was at very high risk on 6/16/11 and 7/8/11, and was at high risk on 9/19/11 and 11/7/11. Review of the 11/11 Computerized Physician Orders (CPOs) revealed the following orders related to skin care/pressure sores: --6/20/11 LAL mattress due to history of pressure ulcers. --3/15/11 Pt to be on up/down schedule as follows: up as close to breakfast as possible, down after breakfast, up before lunch, down after lunch, up before dinner, down after dinner. --5/30/11 weekly skin assessment on Tuesday. --7/11/11 hip air orthosis while in bed only, no footrests on wheelchair due to pressure/tone issues. --6/20/11 protective ointment to buttocks after every incontinent episode. Review of the physician's 11/7/11 telephone order revealed to (1) apply [MEDICATION NAME] to open area on right buttock, change every 3 days, and (2) monitor dressing and buttock every shift until healed. Review of the resident's current care plan revealed a problem was added on 4/10/08 that the resident was at risk for skin breakdown related to decreased mobility and incontinence. The approaches included using a Hoyer lift for transfers, up/down schedule after meals, LAL mattress in place related to history of pressure ulcers, float heels when in bed to offload pressure and Isch Disch custom cutout seat cushion to w/c. Further review of the resident's current care plan revealed a problem was added on 11/7/11 that the resident had an open area to the right buttock. The approaches included the dressing change was to be done every three days, skin protective ointment to bottom, monitor bottom every shift until healed, reposition every two hours while in bed and must be put to bed after each meal. According to the 11/7/11 nurse's note at 1:45 p.m., the physician and family member were "notified of open area found on (right) buttock this shift. Treatment orders implemented. Supervisor notified. All assessment completed." According to the 11/7/11 nurse's note at 9:45 p.m., "dressing in place to the open area on (right) buttocks. (No) s/s of pain or discomfort noted." According to the 11/8/11 nurse's note at 2:30 a.m., "dressing to buttocks open area is intact. (No) s/s infection noted." According to the 11/8/11 nurse's note at 1 p.m., "Drsg to open area to bottom intact. Repositioned (every) 2 (hours) and as needed this shift. Air mattress functioning properly." According to the 11/8/11 nurse's note at 9:58 p.m., "Drst to open area to (right) buttock applied. (No) s/s of infection or other complication to the area. Air mattress functioning normal. Pt repositioned." Review of the Weekly Skin Integrity Data Collection form revealed on 11/8/11 the resident had an "old open area (right) buttock." According to the 11/9/11 nurse's note at 2:55 p.m., "Resident cont(inues) wound care to open area on buttocks. (No) s/s infection notes. Dressing is intact. Resident turned every 2 (hours)." According to the 11/9/11 nurse's note at 1:15 p.m., "Dressing to bottom changed this shift. Area cleansed with wound cleanser." According to the 11/9/11 nurse's note at 10:15 p.m., "open area on (right) buttock drsg intact. (No) s/s of infection or any other complication. Pt repositioned every 2 (hours)." According to the 11/9/11 nurse's note at 11:50 p.m., "dressing to buttocks. (No) s/