Every finding on record at Berthoud Care and Rehabilitation

Based on record review and staff interviews, the facility failed to electronically submit complete and accurate direct care staffing information.Specifically, the facility failed to submit to the Center for Medicare and Medicaid Services (CMS) the Payroll Based Journal (PBJ) for the quarter (10/1/25 to 12/31/25) due to an unrecognized coding error.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/27/26 to 6/2/26, resulting in the deficiency being cited as past noncompliance with a correction date of 5/13/26.I. Record reviewThe CMS submission report, fiscal year quarter one, 2026 (10/1/25 to 12/31/25), revealed the facility failed to submit the required data for the quarter. A document titled PBJ final validation report was provided by the nursing home administrator (NHA) on 5/27/26 at 10:00 am. The report revealed PBJ information for fiscal year quarter two was submitted on 5/13/26 and was accepted.II. Facility's plan of correctionA document titled Process Improvement Plan, Payroll-Based journal Staffing Data Submission was provided by the NHA on 5/13/26 at 10:00 a.m. The plan documented the following:A root cause analysis was conducted after the rejected submission of quarter one PBJ information. It was determined the information was rejected due to a coding error attached to employee positions contained within the file. It documented the facility payroll vendor system was upgraded, resulting in an unanticipated increased length of time for the facility to review and validate data to be submitted and the facility was not notified of the increased time requirement. It documented the coding issue was not identified prior to the contracted service submission of the PBJ information and the investigation did not identify the coding error until several days past the submission deadline. The plan documented improvement goals with target dates, including the following:Ensure 100% of direct care staffing data is submitted accurately and on time each quarter, begin quarter two for 5/15/26 submission.Achieve zero discrepancies between PBJ records and payroll/agency source documents, by quarter three and quarter four, 2026.The facility will receive PBJ receipt of successful submission prior to the deadline, begin quarter two for 5/15/26 submission.The plan documented interventions which standardized the submission workflow including, Contracted service provider will provide preliminary PBJ report to facility to review and validate within 14 days prior to CMS submission deadline. Facility will review and validate preliminary report. Contracted service provider will submit PBJ report 10 days prior to submission deadline to allow for unforeseen errors and provide opportunity for facility to correct and resubmit. Contracted service will provide the validation of successful submission receipt to the facility.The plan documented the responsibility assignments for the PBJ information were to be submitted, including tasks of collecting staffing data, verification of data accuracy, reviewing agency documentation, performing pre-submission audit, submitting PBJ data to CMS, sending submission receipt to the facility and maintaining documentation.The plan documented data would be shared, findings would be reviewed quarterly and adjustments would be made based on outcomes at the facility's quality assurance performance improvement (QAPI) meetings.The documented plan to maintain long-term compliance included continued quarterly pre-submission validation, monitoring CMS updates to PBJ policy, and coordinating upgrades or changes to payroll and human resource systems allowing for review and verification of PBJ data in advance of the submission timeline, allowing for corrections if needed, and successful resubmission.III. Staff interviewsThe NHA was interviewed on 5/27/26 at 10:00 a.m. The NHA said the facility submitted data for the quarter to CMS prior to the submission deadline, however, the submission was rejected due to an issue with the data submitted.The facility's operations resource was interviewed on 6/2/26 at 4:18 p.m. The operations resource said the PBJ information for the quarter had to be submitted by 2/15/26. He said the data was submitted on 2/13/26 at 6:30 p.m., however, the submission was rejected by CMS on 2/14/26 at 12:46 a.m. The operations resource said the facility did not recognize the submission had not been accepted until 2/16/26. The operations resource said the submission was rejected because of a coding error for one of the facility's employees. The operations resource said the facility's payroll system changed in January 2026, which led to a coding error which was not recognized prior to submission, and this caused the PBJ information to be initially rejected. The operations resource said the facility had completed a process improvement plan to ensure consistent and timely PBJ quarterly submission and acceptance, and he said the PBJ information for the most recent quarter (1/1/26 to 3/31/26) was submitted on 5/2/26 and again on 5/11/26 and was accepted on time (see record review above). The operations resource said the facility's goal was to submit the PBJ quarterly information at least five days prior to deadlines to ensure adequate time to make corrections if not initially accepted.

Based on observation, interview, and record review, the facility failed to ensure an ongoing program of meaningful, structured activities was provided to meet the interests and physical, mental, and psychosocial well-being of three out of three units on weekends.Specifically, the facility failed to ensure activities were consistently provided on the weekends to meet the recreational needs of the residents.Findings include:I. Facility policy and procedureThe Activities policy, revised December 2024, was provided by the nursing home administrator (NHA) on 6/2/26 at 12:07 p.m. It read in pertinent part,It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate.Daily activities, including those on the weekends and holidays, are provided, as well as scheduled religious and social activities. II. Record reviewA review of the facility's April 2026 and May 2026 activity calendar revealed the following schedule of activities provided on Saturdays and Sundays: On 4/4/26 (Saturday):8:00 a.m. Daily chronicles;10:30 a.m Puzzle of the day;2:00 p.m. Snack cart;and 4:00 p.m. Fun on the run activity cart.On 4/5/26 (Sunday):8:00 a.m. Daily chronicles;10:00 a.m. Weekly devotional;1:00 p.m. Church service in the high peak dining room;2:00 p.m. Bingo; and, 4:00 p.m. Jigsaw puzzle.On 4/11/26 (Saturday):8:00 a.m. Daily chronicles; 10:30 a.m. Puzzle of the day;2:00 p.m. Drink cart; and,4:00 p.m. Fun on the run activity.On 4/12/26 (Sunday):8:00 a.m. Daily chronicles;10:00 a.m. Weekly devotional;1:00 p.m. Church service; 2:00 p.m. Bingo; and, 4:00 p.m. Tabletop activity.On 4/18/26 (Saturday):8:00 a.m. Daily chronicles;10:00 a.m. Coloring pages;11:00 a.m. Read current events;2:00 p.m. Snack cart; and,4:00 p.m. Fun on the run activity. On 4/19/26 (Sunday):8:00 a.m. Daily chronicles;10:00 a.m. Weekly devotional;1:00 p.m. Church service;2:00 p.m. Bingo and,4:00 p.m. Jigsawpuzzle.On 4/25/26 (Saturday):8:00 a.m. Daily devotional;10:30 Puzzle of the day;2:00 p.m. Drink cart;4:00 p.m. Fun on the run activity cartOn 4/26/26 (Sunday):8:00 am. Daily chronicles;10:00 a.m. Weekly devotional;1:00 p.m. Church service;2:00 p.m. Bingo; and,4:00 p.m. Table activities.On 5/2/26 (Saturday):8:00 a.m. Daily chronicles; 10:00 a.m. Coloring pages;11:00 a.m. Read current events;2:00 p.m. Coloring page;3:30 p.m. Daily puzzle; and,5:00 p.m. Dinner and a movie. On 5/3/26 (Sunday):8:00 a.m. Daily Chronicles;10:00 a.m. Daily affirmation;1:00 p.m. Church service;2:00 p.m. Bingo;3:00 p.m. Daily puzzle; and,4:00 p.m. Fun on the run activity cart.On 5/9/26 (Saturday):8:00 a.m. Daily chronicles;10:30 Puzzle of the day;11:00 p.m. One-on-one friendly visits;2:00 p.m. Snack cart; and,4:00 p.m. Fun on the run activity cartOn 5/10/26 (Sunday)8:00 a.m. Daily chronicles;10:00 a.m. Wish a mom happy mother's day;1:00 p.m. Church service;2:00 p.m. Bingo; and,4:00 p.m. Jigsaw puzzle.On 5/16/26 (Saturday):8:00 a.m. Daily chronicles;10:00 a.m. Weekend devotional;11:00 a.m. One-on-one friendly visits;2:00 p.m. Coloring page;3:30 p.m. Daily puzzle; and,5:00 p.m. dinner and movie.On 5/17/26 (Sunday):8:00 a.m. Daily chronicles;10:00 a.m. Veterans club;1:00 p.m. Church service;2:00 p.m. Bingo; 3:30 p.m. Daily puzzle; and,4:00 p.m. Fun on the run activity cart.On 5/23/26 (Saturday):8:00 a.m. Daily chronicles;10:00 a.m. Drink cart;11:00 a.m. Current events;1:00 p.m. Friendly visits;2:00 p.m. Coloring page; and, 3:30 p.m. Daily puzzle. On 5/24/26 (Sunday):8:00 a.m. Daily chronicles;10:00 a.m. Weekly devotional;11:00 a.m. one-on-one friendly visits;1:00 p.m. Church service;3:30 p.m. Daily puzzle; and,4:00 p.m. Fun on the run activity cart.On 5/30/26 (Saturday):8:00 a.m. Daily chronicle;10:00 a.m. Drink cart;11:00 a.m. Current events;1:00 p.m. One-to-one friendly visits;2:00 p.m. Coloring page; and,3:30 p.m. Daily puzzle. On 5/31/26 (Sunday):8:00 a.m. Daily chronicles;10:00 a.m. Daily affirmation;11:00 a.m. One-to-one friendly visits;1: 00 p.m. Church service; 2:00 p.m. Bingo; and,4:00 p.m. daily puzzle.-However, interviews with the residents and the receptionist, who worked on the weekends, revealed the activities calendar was not regularly adhered to (see interviews below).A request was made for the activity participation logs for the weekends in April 2026 and May 2026. However, the facility failed to provide the logs.III. Resident group interviewA group interview was conducted on 6/2/26 at 10:10 a.m. with five residents (#15, #24, #42, #46 and #50) who were identified as alert and oriented through facility and assessment. Resident #15 and Resident #24, Resident #46 and Resident #50 said they attended the resident council meetings regularly.Resident #42 said she was recently admitted and had not attended a meeting. Resident #15 said the weekends at the facility were incredibly long and boring. Resident #15 said there was absolutely nothing to do except sit in his rooms or the hallway. Resident #15 said the activity staff members left on Friday afternoon and did not come back until Monday morning.Resident #15 said that the sole activity assistant scheduled to work weekends left her employment on 1/1/26, and the facility had not replaced her. Resident #15 said that due to the lack of weekend activity staff, he occasionally had to call the numbers for Bingo himself in order for the residents to have a Bingo game on Saturdays and Sundays. The rest of the residents present at the meeting all agreed that the lack of activity staff on weekends affects the scheduled activities on the activities calendar. Resident #42 said she was admitted recently, but had noticed the lack of meaningful activities on the weekends.IV. Staff interviewsAA #2 and AA #3 were interviewed together on 6/1/26 at 2:15 p.m. AA #2 said she was a certified nursing aide (CNA) and recently began working in the activity department. AA #2 said she worked Monday through Friday. AA #2 said there were currently three activity staff members, which included the activity director who was on leave. AA #2 said there were only two staff members available to run activities at the moment, and both were off on the weekends.AA #3 said she was new to working at the facility. She said as far as she was aware, there was no activity staff scheduled for the weekend.The receptionist was interviewed on 6/2/26 at 12:55 p.m. The receptionist said she was scheduled Sunday through Wednesday for one week and Sunday through Tuesday the following week. The receptionist said her primary duty on Sundays was to manage and monitor the front desk. She said she also assisted residents with some activities. The receptionist said she assisted with passing the daily chronicles. The receptionist said that due to her front desk responsibilities, she struggled getting all the activities done and sometimes relied on the residents to engage in activities without a staff member. The NHA was interviewed on 6/2/26 at 12:33 p.m. The NHA said AA #1 managed and monitored the front desk and supported resident activities on the weekends. The NHA said he was unaware that Resident #15 felt obligated to call the Bingo numbers on weekends due to low activity staffing levels. The NHA said he would provide the last three months of activity participation logs for the facility.-However, the requested activity participation logs were not provided.

Based on observations, record review, and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for three residents (#62, #54, and #29) of six out of 42 sample residents.Specifically, the facility failed to ensure oxygen was administered according to physician's orders for Resident #62, Resident #54 and Resident #29. Findings include: I. Facility policy and procedure The Oxygen Administration, Storage, and Handling policy, dated July 2017, was received from the nursing home administrator (NHA) on 6/2/26 at 12:07 p.m. It revealed in pertinent part, It is the policy of this facility to promote Resident safety with oxygen administration. Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain medical gases shall be trained on the risks associated with their handling and use. II. Resident #62 A. Resident status Resident #62, age greater than 65, was admitted to the facility on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included critical illness myopathy (a disorder that causes severe muscle weakness and wasting), type 2 diabetes, congestive heart failure, hypertension, anxiety disorder, depression, restlessness, and agitation. The 3/31/26 minimum data set (MDS) assessment revealed the resident was cognitively intact, with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #62 received oxygen therapy and required substantial to maximum assistance with activities of daily living (ADLs). B. Observations On 5/27/26 at 10:14 a.m. Resident #62 was lying on her bed. She was wearing a nasal cannula connected to an oxygen concentrator set to 3 liters per minute (LPM). On 5/28/26 at 2:05 p.m. Resident #62 was lying in bed with her oxygen concentrator set to 3 LPM. On 6/1/26 at 9:20 a.m. Resident #62's oxygen was set to 3 LPM. On 6/2/26 at 11:25 a.m. Resident #62's oxygen was set to 3 LPM. C. Resident interview Resident #62 was interviewed on 6/1/26 at 5:14 p.m. Resident #62 said she did not know the liter flow she was receiving. Resident #62 said she was unable to reach the concentrator. She said the facility staff managed the liter flow of her oxygen. D. Record review Review of the June 2026 revealed the following physician's orders: Apply oxygen via nasal cannula at 2 LPM continuously to keep saturation above 90 percent, ordered 10/24/25. -However, observations revealed the resident's oxygen was set to 3 LPM (see observations above). The oxygen therapy care plan, revised 3/16/26, documented the resident had oxygen therapy related to congestive heart failure. Interventions included administering oxygen as ordered, monitoring for signs and symptoms of respiratory distress, and reporting to the medical director (MD). The care plan indicated the resident was to receive oxygen via nasal cannula at 2 LPM continuously to keep saturation at or above 90 percent. The vital signs record on 2/10/26 documented Resident #62's oxygen saturation at 95% on 3 LPM. The vital signs record on 2/19/26 documented Resident #62's oxygen saturation at 94% on 3 LPM. The vital signs record on 2/20/26 documented Resident #62's oxygen saturation at 93% on 3 LPM. The vital signs record on 3/21/26 documented Resident #62's oxygen saturation at 95% on 3 LPM. The vital signs record on 3/22/26 documented Resident #62's oxygen saturation at 94% on 3 LPM. The vital signs record on 5/27/26 documented Resident #62's oxygen saturation at 99% on 3 LPM. The vital signs record on 5/28/26 documented Resident #62's oxygen saturation at 99% on 3 LPM. The vital signs record on 6/1/26 documented Resident #62's oxygen saturation at 95% on 3 LPM. The vital signs record on 6/2/26 documented Resident #62's oxygen saturation at 95% on 3 LPM. -However, there was no documentation indicating the resident needed more oxygen based on the documented oxygen saturations (see observations above). III. Resident #54 A. Resident status Resident #54, age greater than 65, was admitted on [DATE]. According to the June 2026 CPO, Diagnoses included type 2 diabetes mellitus with diabetic nephropathy, depression, chronic respiratory failure with hypoxia (a condition where the body is consistently unable to maintain enough oxygen in the blood), dementia, and weakness. The 5/3/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. Resident #54 was receiving oxygen therapy and needed partial assistance with ADLs. B. Observations On 5/27/26 at 3:39 p.m. Resident #54 was sitting in her wheelchair in her room with a nasal cannula on and her oxygen was set to 2 LPM. On 5/28/26 at 1:24 p.m. Resident #54 was sitting in her wheelchair with her oxygen set at 2 LPM. C. Resident interview Resident #54 was interviewed on 5/28/26 at 1:24 p.m. Resident #54 said she had always been on 2 LPM of oxygen. Resident #54 said approximately one week ago, she was lying in her recliner when she suddenly felt a rush of oxygen. Upon opening her eyes, she observed two staff members in her room. Resident #54 said the staff informed her that her oxygen was set to 3.5 LPM when she asked them to check the concentrator. The resident said she had previously instructed staff members not to tamper with her oxygen flow, but that they did not listen to her requests. D. Record review Review of the June 2026 CPO revealed the following physician's orders: Apply oxygen via nasal cannula at 1 LPM continuous to keep saturation at or above 90%, ordered 3/4/23. The oxygen care plan, revised 3/10/26, revealed the resident had an altered respiratory status, difficulty breathing related to chronic respiratory failure. Interventions included monitoring for signs and symptoms of respiratory distress and reporting to the physician any increased respirations, decreased pulse oximetry, and increased heart rate. The care plan directed staff to administered oxygen via nasal cannula at 2 LPM continuously to keep saturation at or above 90% and providing oxygen as ordered. -However the physician's order dated 3/4/23 required 1 LPM of continuous oxygen via nasal cannula. (see physician order above). Oxygen settings: Via nasal cannula at 2 LPM continuous to keep saturation at or above 90 percent. The vital signs record on 4/11/26 documented Resident #54's oxygen saturation at 100% on 1 LPM. The vital signs record on 4/20/26 documented Resident #54's oxygen saturation at 100% on 1 LPM. The vital signs record on 5/2/26 documented Resident #54's oxygen saturation at 99% on 2 LPM. The vital signs record on 5/13/26 documented Resident #54's oxygen saturation at 98% on 2 LPM. The vital signs record on 5/27/26 documented Resident #54's oxygen saturation at 99% on 2 LPM. -However, there was no documentation indicating the resident needed more oxygen based on the documented oxygen saturations (see observations above). IV. Staff interviews Registered nurse (RN) #2 was interviewed on 6/2/26 at 11:25 a.m. RN #2 said oxygen was part of the resident's medication and must have a physician's order. RN #2 said Resident #62's physician's order was for 2 LPM and it was important to follow the physician's order due to Resident #62's diagnoses of chronic respiratory failure. RN #2 said Resident #54 had a diagnosis of chronic respiratory failure and required staff to monitor the use of oxygen and signs and symptoms of any adverse effects and report to the physician. RN #2 said she was not aware that Resident #54's oxygen order had been changed. RN #2 said she did not verify the amount of oxygen each resident was receiving on her shift. The director of nursing (DON) was interviewed on 6/2/26 at 11:40 a.m. The DON said the nursing staff were expected to document any change in oxygen flow rate and the rationale for the change in the residents' electronic medical records (EMR). The DON said the nurses were to verify the oxygen flow of each resident requiring oxygen therapy on their shift. The DON said oxygen was part of the residents' medications and that all physician's oxygen orders needed to be followed. The DON said that failure to follow the physician's order for oxygenation could result in health complications, such as respiratory failure, depending on each resident's condition. The DON said all nursing staff were trained to ensure respiratory compliance. She said however, she did not know why the staff failed to monitor compliance with physician orders. The DON said she would immediately provide education to the nursing staff. The physician assistant (PA) was interviewed on 6/2/26 at 1:22 p.m. The PA said prescribed oxygen was a medication, not a comfort measure. The PA said changing the flow rate outside of a physician's orders can have adverse consequences for a resident with respiratory illness. The PA said if a resident was found adjusting their own oxygen settings, staff should monitor them closely and ensure the equipment was set correctly. The PA said it was critical that the clinical staff thoroughly document every single episode of these encounters and immediately notify the provider. The PA said the resident's care plan should be updated to include interventions for staff to follow. IV. Resident #29 A. Resident status Resident #29, age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included COPD, chronic respiratory failure, emphysema, depression and heart failure. According to the 5/1/26 MDS assessment, Resident #29 had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS assessment identified Resident #29 was independent with eating, personal hygiene and dressing and required supervision for toileting and moderate assistance for showering. The assessment revealed the resident was receiving oxygen therapy. B. Observations and resident interview On 5/27/26 at 4:40 p.m. Resident #29 was sitting in her bed wearing a nasal cannula in her nose and connected to a room oxygen concentrator. The oxygen concentrator was set to an oxygen flow rate of 3.5 LPM. On 6/1/26 at 8:55 a.m. Resident #29 was lying in bed. The oxygen concentrator was set to an oxygen flow rate of 3.5 LPM. On 6/1/26 at 1:30 p.m. Resident #29 was sitting on the side of her bed. The oxygen concentrator was set to an oxygen rate of 3.5 LPM. On 6/2/26 at 9:35 a.m. Resident #29 was sitting in her bed. The oxygen concentrator was observed with certified nurse aid (CNA) #1 and was set to an oxygen rate of 4 LPM. CNA #1 then left the resident's room and was observed telling RN #1 that the oxygen level was set to 4 LPM. RN #1 told CNA #1 not to change Resident #29's oxygen setting at that time. -However, the physician's order for Resident #29's oxygen was for 3 LPM (see record review below). Resident #29 was interviewed on 6/2/26 at 9:45 a.m. Resident #29 said she had not turned the oxygen setting up on that day. Resident #29 said she sometimes turned the oxygen setting up, but she told staff when she did. C. Record review A review of Resident #29's respiratory care plan, initiated 1/3/24 and revised 3/16/26, revealed that Resident #29 had altered respiratory status and difficulty breathing related to COPD, chronic respiratory failure and emphysema. Interventions included administering medications as ordered, diagnostic testing as ordered, oxygen therapy, head of bed elevated when in bed, monitor and document changes in orientation, increased restlessness, anxiety, and air hunger, monitor for signs and symptoms of respiratory distress and report to the physician as needed, monitor for shortness of breath when lying flat and monitor and document abnormal breathing patterns. An updated respiratory care plan was provided by the DON on 6/3/26 at 5:10 p.m. (after the survey). The care plan included the addition that the resident chronically self adjusted oxygen in the room and was noncompliant with orders. The care plan did not include additional interventions. A review of Resident #29's May 2026 CPO revealed the following physician's order: Apply oxygen via NC (nasal cannula) 3 LPM every shift related to acute and chronic respiratory failure with hypercapnia (elevated level of carbon dioxide in the bloodstream), ordered 4/9/26 and discontinued 5/28/26, and an identical physician's order was renewed on 5/28/26. D. Staff interview RN #1 was interviewed on 6/2/26 at 9:38 a.m. RN #1 said she had not yet checked Resident #29's oxygen setting that day. RN #1 said Resident #29 sometimes changed the oxygen settings herself. RN #3 said the physician's order was for 3 LPM. RN #3 said the physician assistant was going to visit Resident #29 that day and RN #1 said she would talk with the physician assistant about the resident's oxygen settings when the physician assistant saw the resident. RN #1 did not change the oxygen setting.

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 on one of three units, two out of two shower rooms and two of two soiled utility rooms.Specifically, the facility failed to:-Ensure housekeepers performed appropriate hand hygiene when cleaning residents' rooms;-Ensure drains were covered in two of two shower rooms;-Ensure that the biohazard trash was picked up; and,-Ensure the hopper (basin used for rinsing soiled clothes, emptying and rinsing bedpans) was clean.Findings include:I. Failed to ensure housekeepers performed hand hygieneA. Facility policy and procedureThe Infection Prevention and Control policy and procedure, revised November 2024, was provided by the nursing home administrator (NHA) on 5/27/26 at 4:00 p.m. It read in pertinent part, Staff and patient education is done to focus on risk of infection and practices to decrease risk. Universal precautions, handwashing and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment.B. ObservationsOn 6/1/26 at 10:38 a.m., housekeeper (HK) #1 was cleaning the bathroom in room [ROOM NUMBER]. She cleaned the inside of the toilet with a toilet brush and cleaned the outside with a rag and disinfectant. She then came out of the bathroom and went to her cart. She did not change her gloves or perform hand hygiene, she opened a few different compartments on her cart to put away cleaning supplies and put away her dirty rag. She then reached into the mop bucket where she had her mop heads soaking in the cleaner that she uses to mop the floor, using the same gloves that she used when she cleaned the toilet. She then mopped the bedroom floor, went back to the cart and took off the dirty mop head and put it in the dirty container on her cart. She did not change her gloves. She then reached in the clean bucket and pulled out a new mop head and mopped the bathroom. C. Staff interviewsHK #1 was interviewed on 6/1/26 at 10:49 a.m. She said she was not taught to change her gloves after cleaning the toilet. She said she probably should have changed them after cleaning the toilet. The infection preventionist was interviewed on 6/2/26 at 12:40 p.m. She said HK #1 should have changed her gloves after cleaning the toilet. II. Failure to have drain covers in shower roomsA. Professional referenceAccording to The Centers for Disease Control (CDC) Healthcare-Associated infections (2/6/26), retrieved on 6/4/26 from https://www.cdc.gov/healthcare-associated-infections/php/toolkit/water-management.html Recent evidence indicates sinks and other drains, such as toilets or hoppers, in healthcare facilities can become contaminated with multidrug-resistant organisms (MDROs). Because different types of bacteria may contaminate the same drain, drains can serve as sites where antimicrobial-resistant genes transfer between bacterial species.B. ObservationsOn 6/1/26 at 11:13 a.m., during a facility tour the following observations were made:-Shower room [ROOM NUMBER], the drain cover was missing, which left a hole in the floor that was approximately three inches wide. -Shower room [ROOM NUMBER], the drain cover was missing, which left a hole in the floor that was approximately three inches wide.C. Staff interviewsThe housekeeping supervisor was interviewed on 6/1/26 at 11:13 a.m. She said she was unsure of why the drain covers in the shower rooms were missing. She said she was unsure of how long they had been missing. The infection preventionist was interviewed on 6/2/26 at 12:40 p.m. She said the drains should be covered. She said with the drain covers missing it leaves an open hole in the floor and if a resident caught their toe in the drain hole they could get an infection. III. Failure to have biohazard trash picked up regularly and the hopper was cleanOn 6/1/26 at 11:13 a.m., during a facility tour the following observation was made:In soiled utility #1 there was a large pile of filled red biohazard trash bags piled on the floor. There were additional filled red biohazard bags on the counter of the room. The bags were varied in size and there were at least 10 bags. The hopper in soiled utility #1 was empty and clean. In soiled utility #2 the hopper had water in the bowl and there was a thick green film towards the bottom of the bowl and there was a thick brown film that was above the green film. B. Staff interviewsThe housekeeping supervisor was interviewed on 6/1/26 at 11:13 a.m. She said the biohazard company did not come the previous week, which was why there were so many bags. She said the bags should not be piled up. She said was unsure how long the bags had been in the room. She said that the maintenance employees were the ones who were responsible for cleaning the hopper. The maintenance director was interviewed on 6/2/26 at 11:03 a.m. He said he flushed the hopper weekly and he was aware that the hopper was dirty. He said housekeeping was responsible for cleaning the hopper. The infection preventionist was interviewed on 6/2/26 at 12:40 p.m. She said the hopper should be cleaned and maintained.

Based on observations, record review, and interviews, the facility failed to protect the residents' rights to privacy regarding mail delivered to the facility for one (#15) out of five residents reviewed out of 42 sample residents.Specifically, the facility failed to maintain residents' confidentiality by delivering mail opened.Findings include:I. Facility policy and procedureThe Resident Rights policy, revised May 2022, was received from the nursing home administrator (NHA) on 6/2/26 at 12:07 p.m. It revealed in pertinent part, It is the policy of this facility that all residents rights be followed per state and federal guidelines, as well as other regulatory agencies. The residents have the right to privacy in written communications, including the right to send and promptly receive mail that is unopened, and to have access to stationery, postage and writing implements at the resident's expense.II. Resident #15A. Resident statusResident #15, age greater than 65, was admitted to the facility on [DATE]. According to the May 2026 computerized physician's orders (CPO), diagnoses included an aneurysm of the iliac artery, acquired absence of the right foot, type 2 diabetes mellitus without complications, and adjustment disorder with mixed anxiety and depressed mood.The 5/13/26 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. B. Resident interviewResident #15 was interviewed on 6/1/26 at 10:00 a.m. Resident #15 said the facility failed to maintain the confidentiality of his mail. He said his incoming mail was delivered to him already opened on two separate occasions. Resident #15 said that one of the letters was from the social security administration addressed to him. He said the letter was delivered to him by the business office manager and it was already opened The resident said the business office manager brought the letter to his room and handed him the open envelope. Resident #15 said the business office manager said she opened it by mistake. Resident #15 said he felt his privacy was violated because his letters were personal and should not be opened before he received them.III. Staff interviewsThe business office manager was interviewed on 6/2/26 at 12:19 p.m. The business office manager said the front office receptionist received and sorted all of the incoming mail before it was transferred to her. The business office manager said that she accidentally opened Resident #15's letter from the social security administration. She said she opened the envelope before realizing that it belonged to a resident. She said she then delivered the opened mail to Resident #15. The business office manager said she should have checked before opening the envelope to prevent a breach of the resident's privacy. The business office manager said she did not report the incident to the NHA. However, she said she did offer an apology to Resident #15 at the time of the incident. The NHA was interviewed on 6/2/26 at 12:33 p.m. The NHA said he was just informed by Resident #15 about the concern regarding mail delivery. The NHA said the business office manager should have verified the addressee on the envelope before opening it. The NHA said he believed the mail had been opened by accident and therefore did not constitute a violation of the resident's rights. The NHA said he would immediately provide education for the staff who handle mail delivery.

Based on observations, record review and interviews, the facility failed to prevent misappropriation of property for one (#42) of five residents reviewed out of 42 sample residents. Specifically, the facility failed to prevent the theft of Resident #42's credit card, resulting in unauthorized charges and the theft of approximately $100.00 in cash by a staff member.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/27/26 to 6/2/26, resulting in the deficiency being cited as past noncompliance with a correction date of 5/20/26.I. Incident of failure to prevent misappropriation of property for Resident #42 On 5/13/26 at 9:30 p.m. the nursing home administrator (NHA) received a grievance from Resident #42's representative about unauthorized credit card charges on Resident #42's credit card statement, which occurred between 4/30/26 and 5/8/26. Additionally, $100.00 in cash was missing from Resident #42's wallet, which had been stored in her unlocked room cupboard. II. Facility plan of correction The corrective action plan the facility implemented in response to the incident of the misappropriation of property for Resident #42 by a staff member was provided by the NHA on 6/1/26 at 3:30 p.m. The corrective action plan documented the following:A. Immediate action The NHA initiated an internal investigation on 5/13/26 at 9:30 p.m. after Resident #42's family notified the facility of possible unauthorized transactions involving Resident #42's credit card and concerns regarding missing cash from Resident #42's wallet. The facility completed required notifications, including to management, the facility's ombudsman, Adult Protective Services (APS), and law enforcement. Resident #42 was immediately protected from further potential financial exploitation upon identification of the concern. Resident #42's credit card was deactivated by the family and the family removed Resident #42's wallet from her room. Resident #42 was assessed for psychosocial distress and ongoing safety concerns.Resident #42's care plan was updated to reflect increased vulnerability related to cognitive impairment and inability to manage finances safely.Facility staff obtained the transaction information from the family and reviewed the dates, locations, and amounts of the reported charges.The law enforcement investigation identified video footage reportedly showing a facility staff member, certified nurse aide (CNA) #2, utilizing Resident #42's credit card during a transaction at a store. This video was presented to the facility by a local sheriff on the morning of 5/19/26. CNA #2 was terminated from employment.B. Identification of other residents having the potential to be affected by the deficient practiceThe facility conducted interviews with all of the residents regarding concerns related to missing items, valuables and financial exploitation. Residents who reported keeping valuables in their rooms were offered the use of the facility safe and/or lock boxes for valuables. Families, power of attorneys (POA), resident representatives, and guardians of cognitively impaired residents were contacted as appropriate. The facility reviewed information from CNA #2's date of hire, which included all grievances for missing items, to track any trends. The facility documented no trends were identified. A full house audit was completed, which reviewed and updated resident property inventory records. All CNAs and nurses who worked on Resident #42's unit on 4/28/26, 4/29/26, and the morning of 4/30/26 were interviewed regarding direct care they provided to Resident #42 and if they had entered her room during their shifts. Beginning 5/19/26, the facility initiated an all-staff education regarding abuse prevention, misappropriation of resident property and abuse reporting. C. Measures or systemic changes to ensure the deficient practice will not recurThe facility completed a root cause analysis of the occurrence and reviewed practices related to resident valuables, financial protections, and reporting procedures. The facility documented ongoing monitoring and follow-up remained in place.The facility's social services director (SSD) would begin reviewing and updating the resident inventory information at the time of admission and quarterly, and would ask residents at the time of admission and quarterly if they had any valuables and wanted to request a lock box. The facility's plan included additional education to staff on misappropriation by the sheriff's department, which was scheduled on 6/12/26. The facility updated the admission packet provided to residents and representatives, including a resident inventory belongings list which identified the facility process for storage of resident valuables.D. Plan to monitor for sustained compliance The facility administration, or designee documented a plan to audit resident concerns and grievances related to missing property, valuables, and allegations of misappropriation weekly for 12 weeks to ensure concerns were promptly identified, reported, investigated, and addressed. Findings would be reviewed through the facility's quality assurance performance improvement (QAPI) process and additional interventions implemented as indicated. III. Facility policy and procedure The Abuse Prevention and Reporting policy, revised April 2024, was provided by the NHA on 5/27/26 at 4:00 p.m. It revealed in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation.Exploitation is taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.IV. Resident #42A. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included diabetes, chronic obstructive pulmonary disease, dementia, and generalized muscle weakness. The 4/15/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The MDS assessment revealed Resident #42 had lower extremity weakness, used a walker for mobility, required substantial assistance for personal care and bathing and had moderate difficulty with hearing and used hearing aides. B. Resident #42's representative interview Resident #42's representative was interviewed on 5/28/26 at 9:00 a.m. Resident #42's representative said Resident #42 had poor short term memory and did not remember any information about the incident of misappropriation. The representative said Resident #42 had her purse and wallet with her when she was admitted to the facility in the middle of April 2026, and these items were stored in an unlocked cupboard in her room. Resident #42's representative said his brother reviewed Resident #42's credit card statement and discovered unauthorized charges were made in an area that Resident #42 could not have made them, because she was living as a resident in the facility at that time. Resident #42's representative said he immediately acted and disabled the credit card and the credit card charges were reversed. Resident #42's representative said about $100.00 in cash also seemed to be missing from Resident #42's wallet. The representative said he reported the incident to the NHA on 5/13/26 and the NHA began an investigation. C. Record review The facility's investigation report was provided by the NHA on 6/1/26 at 3:15 p.m. and revealed the following: The facility's investigation of the incident was initiated on 5/13/26 after the resident's representative notified the facility of possible fraudulent activity involving Resident #42's credit card. The representative documented that on 5/12/26 multiple unauthorized transactions at gas stations and convenience stores, totaling $224.47, were discovered as having occurred between the dates of 4/30/26 and 5/8/26. The representative also informed the facility of Resident #42 missing $100.00 in cash. Resident #42's representative immediately deactivated the affected credit card to prevent additional unauthorized transactions and brought Resident #42's wallet to their family home. The investigation documented Resident #42 was interviewed by the NHA on 5/13/26 and reported she did not believe anything was missing and denied having concerns at that time. Resident #42 was interviewed a second time on 5/19/26 with her representative present, and she denied knowledge of missing items. The resident stated she felt safe in the facility and denied additional concerns regarding her care or belongings. All CNAs and nurses who were scheduled to work on the unit where Resident #42 resided, on 4/28/26, 4/29/26 and the morning of 4/30/26, were interviewed to determine whether they provided direct care to Resident #42 and/or entered her room during their shifts. No staff members reported observing valuables in the room, and all denied knowledge of or concerns regarding misappropriation of resident property.The facility's investigation revealed the alleged assailant, CNA #2, said she may have provided care to Resident #42 on 4/28/26, 4/29/26 and/or 4/30/26; however, she said she was not in the room for long periods of time. CNA #2 denied observing valuables, credit cards, money, or a wallet left out in Resident #42's room and denied knowledge of anyone taking valuables from Resident #42's room. CNA #2 denied having information regarding the reported missing debit card or money.On 5/19/26 the law enforcement investigation identified video footage reportedly showing a facility staff member, CNA #2, completing a transaction in a store using Resident #42's credit card during the timeframe of the reported unauthorized charges. CNA #2 was terminated from employment at the facility.The nursing care plan, dated 4/20/26, revealed Resident #42 was at risk for financial exploitation or misappropriation and loss of personal belongings related to cognitive impairment, intermittent confusion, impaired judgment, and inability to independently manage finances safely. Interventions included to encourage family involvement with management of resident finances/cards and monitor for/report concerns related to missing belongings, suspicious activity, or psychosocial distress.V. Staff interviews The NHA was interviewed on 6/2/26 at 10:00 a.m. The NHA said he became aware of the misappropriation incident involving Resident #42 on 5/13/26 at 9:30 p.m. when he reviewed the grievance document on his desk completed by the SSD that day. He said the form included the reported concerns from Resident #42's representative about unauthorized charges on Resident #42's credit card. The NHA said an investigation was initiated immediately and required notifications were made, including to Resident #42's representative, the police, APS and the facility's ombudsman. The NHA said all CNA staff and nursing staff, who were scheduled to work on the unit where Resident #42 resided on 4/28/26, 4/29/26 and the morning of 4/30/26, were interviewed to determine whether they provided direct care to Resident #42 or entered her room during their shifts. The NHA said CNA #2 had had a clear background check when she was hired at the facility in February 2026. The NHA said CNA #2 was interviewed on 5/29/26 during the investigation and she said she may have provided care to Resident #42 on 4/28/26, 4/29/26 and/or 4/30/26, but said she was typically not in the room for long periods of time. The NHA said CNA #2 denied observing valuables, credit cards, money or a wallet left out in Resident #42's room and denied knowledge of anyone taking valuables from Resident #42's room. The NHA said it was the video footage provided to the facility from law enforcement on 5/19/26 that confirmed CNA #2 was the staff member responsible for misappropriation of Resident #42's property. The NHA said CNA #2 was terminated from employment at the facility on 5/19/26. The NHA said he spoke with Resident #42's representative and informed the representative that the facility would reimburse the resident for the additional missing cash amount as a result of the incident. The NHA said the admission packet and the process for resident and representative discussion regarding resident valuables, and documenting resident valuables on admission had been updated in order to emphasize the facility's process more clearly regarding keeping residents' valuables in the facility. The NHA said all facility staff completed in-person education with the director of nursing (DON) since the incident to review abuse, misappropriation of property and mandatory reporting. He said the sheriff was scheduled to be at the facility on 6/12/26 to emphasize prevention of abuse and misappropriation and mandatory reporting requirements.

Based on observations, record review and interviews, the facility failed to ensure one (#29) of two residents reviewed for ancillary services, such as dental services, out of 42 sample residents received dental services timely.Specifically, the facility failed to arrange dental services for Resident #29 after she had a broken tooth.Findings include:I. Facility policy and procedureThe Dental Services policy, revised January 2026, was provided by the director of nursing (DON) on 6/2/26 at 12:42 p.m. It read in pertinent part, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g. taking impressions for dentures and fitting dentures. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. The dental needs of each resident are identified through the physical assessment and MDS (minimum data set) assessment processes, and are addressed in each resident's plan of care.II. Resident #29A. Resident statusResident #29, age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included chronic obstructive pulmonary disease (COPD, a lung disease), chronic respiratory failure, emphysema, depression and heart failure.According to the 5/1/26 MDS assessment Resident #29 had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS assessment identified Resident #29 was independent with eating, personal hygiene and dressing and required supervision for toileting and moderate assistance for showering.The MDS assessment revealed the resident had no dental issues.-However, Resident #29 had a broken tooth.B. Resident observations and interviewsOn 5/27/26 at 4:40 p.m. Resident #29 was sitting in her bed. Resident #29 said she had a broken tooth that was very sharp. The resident pointed to an upper left front tooth had a jagged edge and was short. Resident #29 said the tooth did not hurt at that time, but it hurt her mouth sometimes. Resident #29 said the tooth was broken months ago and she told staff about it. Resident #29 said no one had asked her if she wanted to see a dentist. Resident #29 said the broken tooth had made it more difficult to eat at times.Resident #29 was interviewed in her room a second time on 6/1/26 at 8:55 a.m. Resident #29 said the facility scheduled a dental appointment for her after they were notified of her broken tooth on 5/28/26. A sign on the wall in Resident #29's room revealed a scheduled dental appointment for Resident #29 on 6/4/26.C. Record reviewA physician progress note on 12/30/26 at 1:54 p.m. documented Resident #29 had broken her tooth on 12/29/26. It documented her pain was well controlled and the resident had no tooth pain at the time. The note documented a recommendation for the facility to arrange for a dentist to see Resident #29. The note documented the broken tooth was a left incisor (to the left of the front tooth).-However, there was no documentation revealing the facility scheduled a dental appointment to evaluate Resident #29's broken tooth.D. Staff interviewsThe social services director (SSD) was interviewed on 6/2/26 at 2:12 p.m. The SSD said she was not been aware of Resident #29's broken tooth. The SSD said the resident had not mentioned this to her. The SSD said she did not know why there was not follow up by the facility related to Resident #29's broken tooth. The SSD said the facility needed a way to communicate the information that was provided in the physician note about the broken tooth.The DON was interviewed on 6/2/26 at 2:12 p.m. The DON said if the physician did not write an order, she would expect the physician to communicate with staff about the need to follow up for a resident's broken tooth. The DON said she did not know who Resident #29 had told about the broken tooth, aside from the physician on 12/30/25, as no nursing staff were aware of the broken tooth. The DON said the facility's process included that she and the assistant director of nursing (ADON) reviewed physician notes on a continuous basis. The DON said she did not know why there was not a record of communication about Resident #29's broken tooth after the physician note was written on 12/30/25. The DON said after the facility was notified on 5/28/26 of Resident #29's broken tooth, a dental appointment was scheduled.

Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure the laundry area was free from multiple environmental and sanitary concerns; and, -Ensure clean and dirty storage were maintained in separate locations. Findings include: I. Facility policy and procedure The Infection Control for Housekeeping Services policy, revised January 2009, was provided by the nursing home administrator (NHA) on 6/11/24 at 9:10 a.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Equipment shall be maintained in a safe, sanitary condition. Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team. II. Laundry observations and interviews On 6/10/24 at 1:30 p.m. the facility's laundry area was observed with the maintenance supervisor (MS). The following was observed: -The exhaust fan in the soiled linen room was not on. The MS turned the switch and then said it was broken. The MS said he was not aware the fan was broken. The MS said he thought it must have not worked for some time because there was a significant amount of dust on the fan blades. -There was a hole in the ceiling approximately 12 inches by 20 inches located above a dryer; -There was a hole in the wall approximately three inches by 12 inches located directly below clean hanging clothes which were to be delivered to residents; and, -There was unfinished sheetrock and holes approximately six inches by eight inches each on either side of the door to the clean laundry area. A rodent trap was located near the door. The MS said he had not had time to repair the holes. III. Storage observations and interviews On 6/10/24 at 1:50 p.m., the Spartan unit soiled utility room was observed with the MS and the NHA. The following was observed: -A hopper toilet (a toilet/sink used to flush contaminants) in the corner of the room contained dark brown fluid with a hole in the ceiling directly above the toilet which dripped fluid. The NHA touched the ceiling and said it was wet and needed immediate repair. -A storage rack contained approximately 15 clean packaged gowns and 10 boxes of unopened gloves which were located next to four dirty linen and trash containers which contained soiled items. -Approximately six large trash bags were on the floor next to the dirty linen and trash containers. The MS said the bags contained clean isolation cart supplies. The NHA said the supplies should be stored in a different clean location. He said the clean supplies would be removed and disinfected. The MS was interviewed on 6/10/24 at 2:30 p.m. The MS said there were multiple areas which needed attention and he had not had time to assess or repair the ceiling in the soiled utility room. The infection preventionist (IP) was interviewed on 6/10/24 at 3:10 p.m. The IP said a soiled utility room should not contain clean items. She said she would not expect gowns and gloves to be stored in the soiled utility room. The IP said the isolation supplies should be stored in a clean area. B. Facility follow-up The Quality Improvement Action Sheet for Soiled Room Storage was provided by the NHA on 6/10/24 at 3:26 p.m. It read in pertinent part: All non-soiled items have been removed from the soiled storage room and either disinfected or discarded. Roof repair from the water leak has been temporarily fixed. Final drywall repair to be completed by 6/11/24.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#2 and #5) of five residents reviewed for edema care out of 30 sample residents. Specifically, the facility failed to: -Ensure physician orders were followed for the application and removal of elastic hose stockings (used to increase circulation, to prevent blood clots and reduce swelling) for Resident #2; and, -Ensure complete documentation of Resident #5's edema was completed accurately per physician order for Resident #5. Findings include: I. Facility policy The Edema Monitoring policy, undated, was provided by the nursing home administrator (NHA) on 6/10/24 at 9:00 a.m. It read in pertinent part Put on elastic hose as ordered, apply while in bed. II. Resident #2 A. Resident status Resident #2, age 75, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included respiratory failure, diabetes, heart failure, chronic ulcer (sore) of left thigh. The 2/29/24 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She required substantial assistance with showering and was dependent on staff for transferring, dressing upper and lower body and putting on and taking off footwear. B. Resident interviews Resident #2 was interviewed on 6/5/24 at 12:05 p.m. She said her left foot often swelled due to her diagnosis of diabetes. She said the nursing staff were supposed to put her socks (elastic hose stockings) on in the morning and take off at bedtime. Resident #2 said nursing staff had not yet put them on 6/5/24. Resident #2 was interviewed on 6/6/24 at 9:30 a.m. Resident #2 said nursing staff did not apply elastic hose stockings on 6/5/24 and had not yet applied elastic hose stockings on 6/6/24. Resident #2 was interviewed on 6/6/24 at 1:00 p.m., Resident #2 said nursing staff had not yet applied elastic hose stockings. Resident #2 was interviewed on 6/10/24 at 9:20 a.m. She said her elastic hose stockings had been on since the morning of 6/7/24. Resident #2 said a certified nurse aide (CNA) applied the stockings on 6/6/24 in the afternoon. She said the stockings were removed that night and then reapplied in the morning of 6/7/24. She said the stockings should have been removed at night on 6/7/24 and applied in the morning and removed at night on 6/8/24 and 6/9/24. C. Observations On 6/6/24 at 1:00 p.m. Resident #2's lower extremities were observed with CNA #1 which revealed there were no elastic hose stockings on the resident (see resident interview above). On 6/6/24 at 1:12 p.m. CNA #1 applied elastic hose stockings to Resident #2's lower legs. On 6/10/24 at 9:30 a.m. Resident #2 was observed with registered nurse (RN) #1 and revealed elastic hose stockings in place on Resident #2's lower legs. -According to Resident #2's interview, the elastic hose stockings had been in place since 6/7/24. D. Record review On 4/21/24 at 7:00 a.m., a physician order was initiated for Tubigrips or TED (thrombo-embolic-deterrent) hose (elastic hose stockings) for bilateral lower extremity edema management with directions to be placed in the mornings, removed at bedtime and left in place for no less than 12 hours and no more than 24 hours. A review of the task documentation (5/28/24 to 6/9/24) for application and removal of elastic hose stockings revealed nursing staff documented the application and removal of elastic hose stockings on 6/5/24, 6/6/24, 6/7/24, 6/8/24 and 6/9/24. -However, according to Resident #2's interview on 6/10/24, the elastic hose stockings were applied on the morning of 6/7/24 and had not been removed since they were applied. E. Staff interviews CNA #1 was interviewed on 6/6/24 at 1:03 p.m. CNA #1 said she was not sure if the elastic hose stockings were being used anymore because she had not seen them on Resident #2 in a few days. She said she should check with the nurse to see if they were needed. Licensed practical nurse (LPN) #1 was interviewed on 6/6/24 at 1:10 p.m. LPN #1 said she asked Resident #2 earlier if her stockings were placed and Resident #2 shook her head no. She said she misunderstood Resident #2 and thought the resident did not want them applied. The director of nursing (DON) was interviewed on 6/6/24 at 1:20 p.m. The DON said Resident #2's elastic hose stockings should have been placed and removed per the physician orders. She said staff should not document the stockings were placed and removed if the stockings were not put on. The DON said the elastic hose stockings helped to decrease Resident #2's edema. RN #1 was interviewed on 6/10/24 at 9:35 a.m. RN #1 said nursing staff documented Resident #2's elastic hose stockings were removed 6/7/24, 6/8/24 and 6/9/24. She said the incorrect documentation could have been due to agency staff working during the weekend. -According to Resident #2, the stockings were not removed 6/7/24, 6/8/24 and 6/9/24. The DON was interviewed again on 6/10/24 at 9:40 a.m. The DON said it was important to take off the stockings at night for circulation and comfort. She said she provided staff education to ensure elastic hose stockings were placed as ordered. She said based on the information provided, she planned additional staff education regarding documentation, application and removal of the elastic hose stockings. 47818 II. Resident status A. Resident #5 Resident #5, age 70, was admitted on [DATE]. According to the June 2023 CPO, the diagnoses included lymphedema (condition causing swelling in the body due to a buildup of fluid) and obesity (excessive fat deposits). The 5/29/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. She required maximum assistance with transferring and used a wheelchair for mobility. B. Observation During a continuous observation on 6/5/24 beginning at 10:00 a.m. and ending at 2:00 p.m., Resident #5 remained sitting up in her wheelchair engaging in independent and group activities. Resident #5's bilateral (both legs) edema was visible. Resident #5's legs appeared swollen, stretched and shiny. C. Record review The June 2024 CPO revealed a physician's order for staff to encourage Resident #5 to elevate her legs and observing for adverse signs and symptoms of edema, such as; increased swelling redness and complaints of pain or shortness of breath. Minus sign equaled no and positive sign equaled yes, ordered 6/2/24. (-=No +=Yes). -However, staff were not indicating - or + on the medication and treatment administration records (MAR/TAR). Staff were only documenting with a check mark which indicated something was administered. The fluid imbalance care plan, initiated on 9/22/22 and revised on 1/3/23, indicated Resident #5 had a potential for fluid imbalance related to edema with diuretic use. It indicated Resident #5 would remain free from symptoms including good skin turgor (skin's ability to change back to shape quickly after being pulled or pinched). Pertinent interventions included monitoring for worsening edema. D. Staff interviews and facility follow up CNA #2 and CNA #3 were interviewed on 6/6/24 at 1:44 p.m. CNA #2 and CNA #3 both said they were responsible for assisting Resident #5 to elevate her legs every shift and if Resident #5 declined the licensed nurses were notified. CNA #3 said Resident #5 declined to elevate her legs on a regular basis. RN #2 was interviewed on 6/6/24 at 2:00 p.m. RN #2 said Resident #5 was encouraged to elevate her legs every shift but Resident #5 declined on a regular basis. RN #2 said Resident #5 was encouraged to elevate her legs every shift because she had edema. RN #2 said it was important to monitor the swelling and redness to edema sites and report changes to the physician. RN #2 said monitoring for edema changes was documented in the MAR/TAR. RN #2 was unable to locate documentation for monitoring changes. RN #2 said the nursing staff should include supplemental documentation for monitoring Resident #5's edema and were not. The DON was interviewed on 6/6/24 at 3:00 p.m. The DON said she was informed by RN #2 of the supplemental monitoring not being documented correctly in the MAR/TAR for Resident #5 and the order was being rewritten so that all components of the order were visible when nursing was charting.

Based on observations, interviews and record review, 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 in three out of three units. Specifically, the facility failed to: -Ensure orientation for outside agency personnel regarding COVID-19 isolation precautions and donning/doffing of appropriate personal protective equipment; -Ensure an effective water management plan was in place; and, -Ensure residents' rooms were cleaned in a sanitary manner. Findings include: I. COVID-19 isolation precautions A. Facility policy and procedure The COVID-19 donning and doffing competency policy and procedure, initiated March 2020, and provided by the nursing home administrator (NHA) on 2/15/23 at 3:00 p.m. It revealed in pertinent part, Donning step 1-gown fully cover torso from neck to knees, arms to end of wrists, and wrap around the back, fasten in back of neck and waist; step 2-mask or respirator secure ties or elastic band at middle of head and neck, fit flexible band to nose bridge, fit snug to face and below chin, fit check respirator; step 3- goggles or face shield place over face and eyes and adjust to fit; step 4 -gloves extend to cover wrist of isolation gown. Standard precautions wipe down equipment between residents. Isolation precaution residents have designated equipment. B. Observations On 2/15/23 at 2:30 p.m. certified nursing assistant (CNA) #3 was observed entering a COVID-19 positive isolation room without donning personal protective equipment (PPE) and with a portable blood pressure/temperature/oxygen saturation monitor. COVID isolation precautions signs were observed on the door and a PPE cart was next to the door. After taking the resident's vital signs, CNA #3 left the room and observed the PPE cart next to the door. CNA #3 wiped the temperature probe and machine with sanitizing wipes and washed his hands at the sink. He did not remove or change his mask. CNA #3 then took the same portable blood pressure monitor and entered the resident room next to the COVID-19 isolation room. C. Staff interviews CNA #3 was interviewed on 2/15/23 at 2:30 p.m. He said that he was not aware the resident in the isolation room was COVID-19 positive. He confirmed he entered the COVID-19 positive room without donning PPE. He confirmed after he exited the COVID-19 positive room, he entered another resident's room to continue taking vital signs. He said it was his first day at the facility. The director of nursing (DON) was interviewed on 2/15/23 at 3:15 p.m. She said the facility did not provide orientation to outside agency personnel. She said she the previous shift should have informed CNA #3 which residents were under isolation precautions. The infection preventionist (IP) was interviewed on 2/15/23 at 3:30 p.m. She said the facility's current process did not include orienting outside agency personnel at the beginning of their shift on isolation precautions, use of PPE or the sanitization of equipment. She said that information should have been covered by their agency. She said the outside agency personnel should follow the information regarding isolation precautions and use of dedicated equipment posted on the residents' doors and CNAs would give a change of shift report on residents that were on isolation precautions. The nursing home administrator (NHA) was interviewed on 2/15/23 at 5:15 p.m. He said a binder was now created to orient outside agency personnel on isolation precautions and the use of PPE prior to the beginning of their shift. 38185 II. Failure to ensure the water management plan was effective A. Record review The Water Management plan was provided by the nursing home administrator on 2/14/23. It did not include documentation to indicate the control measures, how often the control measures were being conducted and the monitoring system for the control measures. It did not indicate a risk assessment had been completed. It did not indicate how the facility was ensuring the water management program was working and effective. B. Staff interviews The nursing home administrator and the maintenance director (MD) were interviewed on 2/16/23 at 5:12 p.m. The maintenance director said she was unable to locate the risk assessment within the facility's water management plan. She said the control measures included testing, however was unable to provide documentation that showed the control measures, how often the control measures were being conducted and a monitoring system. She said she was unable to determine if the water management plan was working or effective because the control measures had not been documented as completed and the facility did not have a monitoring system in place. III. Failed to ensure resident rooms were cleaned in a sanitary manner A. Facility policy and procedure The Proper Glove Usage policy and procedure, undated, was provided by the nursing home administrator (NHA) on 2/17/23. It revealed, in pertinent part, When cleaning a resident room, it is best practice to change gloves and rags in between cleaning the restroom and both sides of the patient room. When you clean the restroom, use one rag and one set of gloves, then discard the rag in dirty rags and remove gloves. Sanitize hands, put on new gloves, and grab a new rag to clean side B of the room. Once side B is complete, discard the rag and gloves, sanitize hands and then repeat for side A of the room. B. Observations On 2/15/23 at 2:20 p.m. housekeeper (HSKP) #1 was observed cleaning resident room [ROOM NUMBER]. With gloved hands, he grabbed a rag, soaked in disinfectant, from the housekeeping cart and entered the bathroom. He wiped the inside of the bowl first and with the same rag wiped the toilet handle, the bottom of the toilet, on the ground around the toilet and then the toilet seat. He used the toilet brush to scrub the inside of the toilet and then exited the bathroom. He returned to the housekeeping cart in the hallway, placed the rag in a dirty bin and put the toilet brush away. With the same gloved hands, he grabbed the broom and entered the room. He swept the bathroom and the debris into the dust pan. He emptied the dust pan, put the broom away, grabbed a mop pad (with the same gloved hands) and the mop handle and re-entered the room. He placed the dripped wet mop head on the floor of the bathroom and mopped the bathroom. He mopped into the window side of the room with the same mop head. He then picked up the mop, discarded the mop head into the dirty bin and put the mop away. He doffed his gloves and obtained alcohol based hand rub (ABHR) from the wall unit. He rubbed the ABHR on his hands for three seconds and grabbed a new pair of gloves. His hands were visibly wet with white residue from the ABHR in between his fingers. He had difficulty donning the gloves due to his visibly wet hands. He was only able to don the gloves to cover halfway up the palms of his hand with an inch of glove not utilized at the fingertips. He grabbed a rag, soaked in disinfectant and entered the room. He wiped down the sink and counter and then moved to the window side of the room. After cleaning the window side of the room, he moved to the other side of the room and began cleaning off surfaces with the same rag and same gloved hands. After disposing of trash from the room, he grabbed a mop pad, the mop handle and entered the room. He mopped the window side of the room and then the hallway side of the room. HSKP #1 put the mop back on the cart and moved to resident room [ROOM NUMBER]. He obtained ABHR from the wall unit, rubbed it in his hands for four seconds and then attempted to don gloves. His hands were visibly wet with white residue from the ABHR on his knuckles and in between his fingers. He was only able to put the gloves halfway up his palm. He grabbed a red rag, soaked in disinfectant, toilet bowl cleaner and a toilet bowl brush and entered the resident bathroom. The bathroom was a shared bathroom between two resident rooms. Using the red rag, HSKP #1 wiped the window sill, the toilet seat, inside the toilet bowl, the bottom of the toilet and the toilet handle. He then moved to the commode and wiped the top of the commode seat and then the commode handles. He then used the toilet brush to scrub the inside of the toilet bowl, grabbed the trash from the trash can and moved the commode back over the toilet, with the same gloved hands. He put the rag in the dirty bin and then doffed his gloves, obtained ABHR and rubbed it in for five seconds and attempted to don a new pair of gloves. He had visibly wet hands with white residue from the ABHR and was unable to get the gloves all the way past his palm. C. Staff interviews The maintenance director was interviewed on 2/16/23 at 5:12 p.m. He said ABHR should be used prior to cleaning the room and in between glove changes. He said the ABHR should be rubbed in for approximately 20 seconds or until it is completely dry. He said once it was dry, then gloves should be donned. He confirmed the ABHR was not effective if not used according to the manufacturer's instructions. He said new gloves should be donned after cleaning the bathroom and each side of the room. He said, in a shared room, each side of the room should be cleaned separately and the housekeeper should not share the rag between both sides of the room. He said the toilet should be cleaned from the top down starting with the tank, handle and then the seat. He said the seat should be cleaned last and once it was cleaned the rag should not be used to clean any other surfaces. He said he provided education with return demonstrations to all the housekeeping staff regarding glove usage and hand hygiene that day following the observation of HSKP #1.

Based on record review and interviews, the facility failed to ensure that five out of five certified nursing assistants (CNA) were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct yearly staff competencies for certified nursing assistants. Findings include: I. Record review The annual competency checklist was requested on 2/16/23 for certified nursing assistants (CNA) #4, #5, #6, #7 and#8. An annual competency checklist for 2022 was unable to be provided by the facility. II. Staff interviews The director of nursing (DON) was interviewed on 2/16/23 at 7:00 p.m. She said the facility had not completed competencies for the CNAs since she had become the DON (May 2022). She said there had been a recent change in nursing management, however she was unable to find documentation that competencies had been completed for 2022 for all CNAs that were employed by the facility. 38185

Based on observation, record review, and staff interviews, the facility failed to provide therapeutic and mechanically altered diets consistent with dietary orders for two (#51 and #66) of two out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #51 was served puree textured vegetables, which was ordered by the physician; and, -Ensure Resident #66 was served large portions, which was ordered by the physician. Findings include I. Facility policy and procedure The Food and Nutrition Services policy and procedure, last revised October 2021, was provided by the director of nursing (DON) on 2/17/23. It read, in pertinent part It is the policy of the facility that therapeutic diet shall be prescribed as necessary for each resident. A tray identification system is established to ensure that each resident receives his/her diet as ordered. Dietary staff will follow menu extensions while preparing and serving meals. II. Tray line observations Diner tray line service was observed on 2/15/23. The meal was ham and beans, mixed greens, broccoli, pureed vegetables, canned pineapple, and cornbread. A bistro menu was available for residents who did not want the main meal and consisted of tomato soup, cheese quesadilla, a hot dog, and a grilled cheese sandwich. Serving began at 4:40 p.m. The kitchen manager (KM) served all the meals, including the bistro menu requests. One dietary aide and the dietary manager (DM) stayed at the other end and assisted with the tray line and served the food to the residents. At 5:15 p.m. a tray for Resident #51 was prepared by the KM. She served the resident a regular textured diet, even though the tray card indicated the resident should be served pureed texture vegetables. The tray was passed on to the DM, she inspected the tray and placed the wrong order on the cart ready to leave the kitchen to be served to the resident. She did not observe that the vegetable was served in the incorrect texture. Upon prompting, the DM brought the tray back to the kitchen. The DM confirmed the tray was not accurate and contained regular-texture broccoli. She asked the KM to redo the tray, confirmed the correct texture of the vegetables, and placed it on the cart to be served. At 5:22 p.m. a meal tray with a large portion diet ordered indicated on the tray card for Resident #61 was dished up by the KM and passed on to the DM. The plate did not contain double portions, which was indicated on the tray card. The DM placed the tray on the cart to be served. Upon prompting, the DM confirmed the order was not accurate and gave it back to the kitchen for additional food items to be dished onto the plate. III. Resident #51 A. Resident status Resident #51, age 81, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnosis included unspecified dementia and dysphagia (swallowing difficulty). The 12/25/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance of one person for dressing and toileting and supervision for bed mobility, transfers, and eating. B. Record review The December 2022 CPO documented a dysphagia mechanical soft diet with puree vegetables. IV. Resident #61 A. Resident status Resident #66, age 81, was admitted on [DATE]. According to the January 2023 CPO, diagnosis included malnutrition. The 1/13/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required supervision with bed mobility, transfers, dressing, toileting, and eating. B. Record review The January 2023 CPO documented a regular diet and texture with large portions for his meals. The resident care plan, dated 1/13/23 and revised on 2/13/23, indicated the resident was at risk of malnutrition and unexpected weight loss. The interventions included large portions for meals. V. Staff interviews The dietary manager (DM) was interviewed on 2/15/23 at 5:40 p.m. The DM said Resident # 51 was assessed by a speech-language pathologist therapist who recommended puree vegetables for the resident. The DM said Resident #51 was ordered, by the physician, to be served pureed vegetables. She said Resident #66 was admitted with a high risk of malnutrition and had experienced weight loss. She said it was ordered by the physician that the resident be served large portions for meals. The director of nursing (DON) was interviewed on 2/16/23 at 6:49 p.m. The DON said diets were prescribed by the physician. She said all diets should be followed and served according to physician orders. She said she would ensure that periodic audits would be completed to eliminate any future occurrences.

Based on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for two (#41 and #45) of five residents reviewed out of 31 sample residents. Specifically, the facility failed to ensure a response to pharmacist recommendations from monthly medication regimen reviews for: -Resident #41 regarding the physician's recommendation to discuss the risk and benefits of the drug interaction of Tramadol, Trazodone, Bupropion, and Ativan (psychotropic and pain medications); and, -Resident #45 regarding the physician's recommendation to refer medication questions to the hospice provider. Findings include: I. Facility policy and procedure The Medication Regimen Review and Reporting policy and procedure, dated September 2018, was provided by the director of nursing (DON) on 2/17/23. It read in pertinent part: The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medication each resident receives is clinically indicated. Resident-specific medication regimen review recommendations and findings are documented and acted upon by the nursing care center and/or physician. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. II. Resident #41 A. Resident status Resident #41, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, bipolar disorder, end-stage renal disease, cognitive communication deficit, and chronic kidney disease. The 12/30/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of twelve out of 15. She required supervision and set-up help only with her activities of daily living (ADLs). B. Record review A review of the resident's medication administration record (MAR) and treatment administration record (TAR) revealed the resident had orders to receive the following medication: -Tramadol HCI tablet 50 milligrams, one tablet by mouth every six hours as needed for moderate pain. Ordered 12/7/22. -Trazodone HCI tablet 50 milligrams, give 0.5 tablets by mouth at bedtime for depression. Ordered 12/7/22. -Bupropion HCI tablet 75 milligrams, give 1 tablet by mouth two times a day for depression. Ordered 12/7/22. The 4/25/22 pharmacist medication regimen review reported a concern for Resident # 41 medication regimen. The recommendation indicated a concern with the use of Tramadol, Trazodone, and Bupropion which has two interactions with Tramadol. According to the report, these interactions increase the risk for death or ineffectiveness. The 6/21/22 pharmacist medication regimen review alerted the physician on the above concerns as Resident #41 had had three falls in three weeks. The report requested not to recommend Tramadol use in geriatrics due to unpredictable metabolism which increases the risk for death or ineffectiveness, serious drug interactions, and worrisome side effects. This was the second request, as the first time occurred on 4/25/22. The attending physician recommended on 6/28/22 the facility discuss the risk and benefits of these medications with the resident. III. Resident #45 A. Resident status Resident #45, age 66, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease and anxiety disorder. The 1/20/22 minimum data set (MDS) assessment revealed the facility was unable to conduct a brief interview for mental status (BIMS) as the resident was rarely/never understood. He required two-person physical assistance with his activities of daily living (ADLs). B. Record review A review of the resident's medication administration record (MAR), treatment administration record (TAR), and pharmacy recommendation note revealed the resident was receiving the following medications: -Cyclobenzaprine 5 milligrams, two times a day for muscle spasms. Discontinued 1/13/22 (see below). -Trazodone HCI 50 milligrams tablet, give 0.5 milligrams by mouth at bedtime for insomnia. Order date 7/14/22. -Celexa 15 milligrams tablets by mouth daily for depression. Order date 7/14/22. -Zyprexa 10 milligrams, by mouth every day for dementia.Order date 7/14/22. The 11/18/22 pharmacist medication regimen review for Resident #45 requested to not recommend Cyclobenzaprine for the elderly due to it causing sedation and requested for it to be evaluated and consider discontinuation. The attending physician's response on 12/19/22 indicated all medication requests and questions were to be referred to the hospice provider. -The facility had no records of any follow-up with the hospice provider. The Cyclobenzaprine was not discontinued until 1/13/22 by the hospice provider, which was more than a month later. IV. Staff interview The director of nursing (DON) was interviewed on 2/16/22 at 6:48 p.m. The DON said the facility had poor communication with the hospice care provider. She said scheduling appointments with the hospice care provider was difficult and the facility should have discussed the recommendations for Resident #45 with the hospice provider in a timely manner. The DON said she could not find any documentation of the facility discussing the pharmacy recommendations and the physician's request to discuss the recommendations with Resident #41.

Based on interviews and record review, the facility failed to ensure two (#64 and #55) of two out of 31 sample residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #64 was provided psychosocial support after he had voiced difficulty in adjusting to his new level of care and admission to the facility; and, -Ensure Resident #55 was provided person-centered interventions to address the resident's behavior and provided continued psychosocial support. Findings include: I. Facility policy and procedure The Behavioral Health policy and procedure, revised January 2022, was provided by the nursing home administrator (NHA) on 2/17/23 at 2:26 p.m. It revealed in pertinent part, The interdisciplinary team (IDT) will ensure that residents who display or is diagnosed with mental disorder or psychosocial adjustment difficulty receives the appropriate treatment and services to attain the highest practicable mental or psychosocial well-being and will have an individualized plan of care that addresses the needs of the resident, based on the comprehensive MDS assessment of the resident. The plan of care will include non-pharmacological interventions and individualized, person-centered care approaches as well as trauma-informed approaches in accordance with resident's customary routines, with input from the resident and/or resident representative. The physician, in collaboration with the IDT team, will determine the appropriate psychiatric or psychological treatment or rehabilitative services needed. Treatment will be provided as ordered by the physician. II. Resident #64 A. Resident status Resident #64, age 70, was admitted to the facility on [DATE]. According to the February 2023 computerized physician orders (CPO) the diagnoses included post viral fatigue syndrome, dysarthria, anarthria, dysphonia (difficulty with speech), Parkinson's disease, repeated falls, and adult failure to thrive. The 1/18/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive intact with a brief interview for mental status score of 12 out of 15. He required extensive assistance with a two-person physical assist for transfers, dressing, toileting and bed mobility. It indicated the resident had mild depression with a PHQ-9 (patient health questionnaire) score of seven out of 27 indicating mild depression. B. Resident observations and interview On 2/13/23 at 5:17 p.m. Resident #64 was in his room sitting in a wheelchair eating from his dinner tray. He was watching his television while eating his dinner. He said was unhappy at the facility and there was nothing to do. He said he did not get visitors very often and he was tired of watching television. On 2/14/23 at 11:42 a.m. the resident was sitting in his wheelchair in his room. He said he was unhappy, bored and was unable to do anything because of an infection in his stool. He said the only thing he was able to do was watch television. Resident #64 was interviewed on 2/16/23 11:02 a.m. He said his goal was to move back to his apartment. He said he felt like he could not leave his room due to his medical condition. He said that he had nothing to do and no staff came by to do things with him or offer anything. He said he liked sports, especially baseball. He said he would really enjoy it if someone would come into his room and talk baseball with him. He said the only time he had any social interaction was when the staff entered the room to provide care. C. Record review The potential for adjustment issues care plan, initiated 1/16/23, revealed Resident #64 had a potential for adjustment issues due to his admission to the skilled nursing facility (SNF). The interventions included encouraging conversations with staff and other residents, providing the resident the opportunity to communicate his feelings regarding his admission, providing the resident the opportunity to communicate his feelings regarding attending group activities, and providing the resident situations in which he will have control over his environment and care delivery. The 1/16/23 social services summary documented the resident did not have any behavior or mood concerns. The activity care plan, initiated 1/20/23, revealed the resident had little or no activity involvement. It indicated the resident was unsure if he would participate in recreation while he was at the facility, as the resident wanted to focus on getting better. The interventions included establishing and recording the resident's prior level of activity involvement and interests by talking with resident, caregivers and family upon admission and as necessary. The 1/22/23 nursing note revealed the resident was very frustrated and said this is no way to live. The nurse said he had no plans to hurt himself and he would be monitored. The 1/23/23 behavior progress note revealed the resident was very frustrated with life and asked if the nurse could take him out and just let him freeze. He said it was hard since his life changed so much, recently. The 2/2/23 activity assessment identified his needs as he is eager to get back to his place and he wants to get better. It did not indicate what interventions would be put in place to address the resident's socialization needs. The activity participation log documented from 1/14/23 to 2/14/23 revealed that the resident was not provided any one-to-one activities. -A review of the resident's medical record did not reveal documentation of psychosocial support provided to the resident after he had voiced that he was having a difficult time since his admission to the facility and accepting his new level of care. -The facility failed to develop person-centered approaches to provide the resident with additional support and meet the resident's psychosocial needs. IV. Staff interviews The social services director (SSD) was interviewed on 2/16/23 at 5:47 p.m. She said she had spoken with Resident #64 after his behavior on 1/23/23. She said he had refused counseling. She said she had not offered the resident any other psychosocial support. She said she did not document this interaction in the resident's medical record. She said socialization helped Resident #64. She said the resident's brother and friends visited often. She said she had not documented any person-centered approaches to assist the resident with his difficulty in accepting his level of care or admission to the facility. She said the interdisciplinary team (IDT) had not discussed possible interventions for the resident. The director of nursing (DON) was interviewed on 2/16/23 at 6:52 p.m. The DON said during the care conference on 1/20/23, the resident had agreed to counseling. She said she was unsure if it was documented in the resident's medical record or if it had been arranged by social services. She confirmed the resident's plan of care did not document any psychosocial person-centered interventions to assist the resident in adjusting to his level of care or admission to the facility. The activity supervisor (AS) was interviewed on 2/16/23 at 6:23 p.m. She said she was not made aware of the resident's difficulty in adjusting to his admission to the facility. She said she was unaware the resident had made statements of wanting to freeze outside. She said, when she completed the resident's admission assessment, he was focused on physical therapy and wanting to get better to go home. She said she had not placed the resident on a one-to-one activity program. She said she was unaware the resident enjoyed baseball. She confirmed the resident would benefit from socialization from facility staff. She confirmed the resident should receive socialization from the facility staff, other than just when the staff entered his room to provide care. 47150 III. Resident #55 A. Resident status Resident #55, under the age of 65, was admitted on [DATE] and was readmitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included anxiety disorder due to known physiological conditions, a major depressive disorder with psychotic features and symptoms, mood disorder due to known physiological conditions with depressive features, moderate intellectual disabilities, cognitive communication deficit, and unspecified disorder of psychological development. According to the 12/30/22 minimum data set (MDS), the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required supervision with transfers, dressing, toileting, and personal hygiene. It indicated he did not have any behavioral concerns. B. Observations On 2/15/23 at 8:58 a.m., Resident #55 was observed leaving the dining room after eating breakfast. The resident's pants were soiled with urine. The resident was assisted by an unidentified staff member and returned to the dining area with new, clean pants. -At 9:52 a.m., the resident entered the dining room and filled a mug with water. He sat down on a chair. He sat down for approximately eight minutes, returned to his room, and then came back to the dining area with crayons. Upon returning to the dining room, he began drawing, however, he continued to pace back and forth between his room and the dining room. From 9:00 a.m. until 10:00 a.m., Resident #55 had gone between his room and the dining room seven times. -At 10:39 a.m. the resident paced back to his room and came right back to the dining area and continued drawing. -At 11:17 a.m. Resident #55 went back to his room. -At 11:18 a.m. he walked out of his room and went down the hallway, turned around, and walked right back to the dining room. -At 11:22 a.m. he paced back to his room and came out again in just a minute. He walked down halfway through the hallway and then returned to the dining room. -At 11:28 a.m. the resident paced back to his room and came out at 11:30 a.m., and then sat in the dining room. C. Record review The PASRR (pre-admission screening and resident review) care plan, revised on 5/10/22, documented the resident had both a major mental illness and an intellectual developmental disability. The interventions included providing the resident an evaluation to community integration, a day program, and continuing to monitor any manic episodes. The cognitive impairment care plan, revised on 8/31/22, documented the resident had impaired cognitive function and thought processes due to a diagnosis of dementia. The interventions included administering medications as ordered; communicating with the resident's family regarding the resident's capabilities and needs; engaging the resident in simple, structured activities that avoid overly demanding tasks; giving step by step instructions one at a time to support cognitive function; keeping the resident's routine consistent and providing consistent caregivers; and providing assistance with all decision making. The mood problem care plan, revised 1/10/23, documented the resident had a potential for a mood problem related to his major mental illness. It indicated the resident had a major depressive disorder with behaviors such as being sad and down, sad at his loss of independence, and had potential for verbal aggression. The interventions included administering medications as ordered; monitoring, recording, and reporting to the physician any acute episodes of feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleeping patterns and diminished ability to concentrate; and monitoring increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone and possession of objects that could be used as weapons. The behavior problem care plan, revised 1/10/23, documented the resident had a potential behavioral problem related to his intellectual developmental disability. It indicated the resident had a history of drinking fluids excessively, tried to get multiple mouthwash bottles and then drink them, and excessively drinking water to the point that he threw up on 2/9/22. The interventions included administering medications as ordered, anticipating and meeting the resident's needs, approaching the resident in a calm manner, continuing to monitor how much mouthwash was given, and explaining all procedures to the resident before starting and allowing the resident to adjust to changes. The 12/1/22 psychiatric progress note documented the facility staff had reported Resident #55 had been refusing some care including bed changes at night. It indicated the resident continued to be incontinent at night and typically soaked through his briefs and soiled the linen on the bed. The staff had reported he was not easy to redirect at night when needing to change his linen and had increased agitation and aggression. It indicated the resident said, They wake me up all the time at night and that he just wanted to sleep. The psychiatrist documented the resident had episodes of mania evidenced by perseveration on drinking water and pacing. The recommendations included one change of linen/briefs at night approximately 10:00 p.m. to 11:00 p.m. with evening medications and allow the resident to sleep through the night until awaken at approximately 6:00 a.m. -However, these recommendations were not included in the resident's comprehensive plan of care. The 12/2/23 nursing progress note documented at approximately 5:09 a.m., and certified nurse aide (CNA) entered Resident #55's bedroom to check on him. It indicated the resident was standing by his bed, soiled of urine. Resident #55 swung at the CNA with an open hand and yelled for her to leave the room. The CNA left the room and reported the incident to the nurse. -At 5:26 a.m. the CNA went back into Resident #55's room and changed the resident's soiled sheets while he was in the bathroom. Resident #55 followed the CNA down the hallway shouting I want my stuff back. The resident paced up and down the hallway, in and out of his room. -At 5:42 a.m. the resident continued to pace hallways and his bedroom and to and from the sink, drinking eight cups of water. The nurse called the physician and received an order to send the resident to the emergency department for evaluation and treatment. -At 11:45 a.m. the resident returned from the emergency department with a diagnosis of anxiety with a recommendation to start Lorazepam (anti-anxiety medication) and Seroquel (antipsychotic medication). The psychiatrist called the facility as Resident #55 was arriving back from the hospital and ordered Seroquel 25 milligrams (mg) every night. The 12/27/22 social service summary progress note documented Resident #55 had impaired decision-making and had a diagnosis of intellectual or developmental disability (IDD). He had an order for Seroquel and Lexapro (antipsychotic and anxiety medications) for the behaviors of refusal of care and anxiety management. -A review of the resident's electronic medical record on 12/14/23 did not reveal documentation that the resident had been provided additional psychosocial support to assist in determining the triggers for the resident's behavior. -The comprehensive care plan did not document person-centered, individualized interventions It did not also reflect the above interventions recommended by the resident's psychiatrist as the night staff continued to awaken the resident to offer incontinent care resulting in aggressive behaviors and refusal of care, as was documented in the nursing notes and within the staff interviews. The nursing progress note dated 12/12/22 documented at 1:10 a.m. that the nursing staff continued to offer incontinent care to the resident at night resulting in the resident yelling with an angry tone saying get out. The CNA tasks documented in December 2022 (between 12/2/22 to 12/31/22) the facility staff attempted to provide incontinence care to the resident on seven occasions during the night. D. Staff interviews Certified nursing aide (CNA) #2 was interviewed on 2/16/23 at 4:45 p.m. She said Resident #55 had behaviors and frequently refused care. CNA #2 said if the resident refused care, she would wait 10 minutes, come back and try again. She said Resident #55 would become agitated and angry when he was constantly being asked to change his clothing or bedding. The activity supervisor (AS) was interviewed on 2/16/23 at 6:05 p.m. She said Resident #55 has a diagnosis of intellectual or developmental disability. She said the resident used to participate in a lot of activities but did not anymore. The AD said the resident would become repetitive sometimes. She said leaving the resident alone and giving him a personal one-on-one task sometimes helped him calm down when he was anxious. The social services director (SSD) was interviewed on 2/16/23 at 5:45 p.m. She said Resident #55 had an intellectually disabled with obsessive-compulsive disorder. The SSD said she had identified some of the resident's triggers such as when the staff offered to change the resident multiple times. She said the resident would get really upset when the staff would ask him to change and then continued to ask him when he refused. She said part of the resident's manic episodes was pacing between his room and the common areas and drinking excessive amounts of water. She said when the resident was triggered, he would pace, become verbally aggressive, and drink water excessively. She said on 12/1/22, Resident #55 had probably been triggered because the CNA had entered his room after he yelled for her to leave and then changed his bedding without his permission. The SSD said she was responsible for developing the behavioral care plans. She said she was unsure of any person-centered interventions that assisted the resident when he became upset or was having a manic episode. The SSD said the resident had been seen regularly by a psychiatrist. She said she did not have time to read the psychiatrist's notes. She said she was unaware if the psychiatrist had developed any interventions to assist the resident in being triggered. She confirmed the resident's plan of care did not indicate any person-centered interventions to address the resident's behavior. The director of nursing (DON) was interviewed on 2/16/23 at 6:49 p.m. The DON said Resident #55 exhibited behaviors such as excessive drinking of water, agitation, pacing back and forth in the hallway, and refusal of care. She said sometimes the resident would get upset because the staff wanted to assist him with incontinence care. The DON said the facility struggled with the resident's incontinence care because of his refusals. She said part of the trigger for the resident's behavior was changing his bed sheets. She said the resident was frequently incontinent in bed and would get very upset when staff would change his bedding. She said the resident wanted a certain kind of sheet and a certain blanket. She said she believed that was what triggered the resident in early December 2022. She said she was aware of the recommendations made by the psychiatrist. She said she was not sure if those recommendations were documented in the resident's medical record or had been relayed to the facility staff. She said the comprehensive care plan should have person-centered approaches documented to assist the resident when he had exhibited behaviors. She said social services were responsible for developing behavioral care plans, but that the interdisciplinary team was able to update the interventions as needed.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#47) of two residents out of 31 sample residents. Specifically, the facility failed to ensure Resident #47's socialization needs were met by developing a person-centered activity plan. Findings include: I. Facility policy and procedure The Activity Documentation policy and procedure, revised January 2022, was provided by the nursing home administrator (NHA) on 2/17/23 at 2:26 p.m. It revealed, in pertinent part, It is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental and psychosocial well-being of the resident. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations. Cognitive impairment: smaller groups without interruption, one-to-one etc. II. Resident #47 status Resident #47, age 92 was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbance, bipolar disorder, psychotic disturbance, mood disturbance and anxiety. The 1/20/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance of one to two people with bed mobility, transfers, personal hygiene, toileting and dressing. It indicated it was important to the resident to have books, newspapers, and magazines to read, be around pets, keep up with the news, do things with groups of people, do her favorite activities, go outside to get fresh air when the weather is good and participate in religious services. A. Resident interview On 2/15/23 at 11:15 a.m. Resident #47 said she had nothing to do. She said she did the same thing every day. She said she was not invited to group activities and did not receive any individualized activities. B. Observations On 2/15/23 at 8:51 a.m. Resident #47 was observed laying in bed, sleeping. -At 9:12 a.m. Resident #47 was observed sitting in bed eating breakfast. The resident did not have a television nor was there music being played. There was no cognitive or social stimulation observed. -At 11:15 a.m. the resident was observed sitting up in bed. There were no meaningful activities provided for the resident. -At 1:28 p.m. Resident #47 was lying in her bed with her lunch tray in front of her. There were no meaningful activities observed. -At 2:26 p.m. the resident was laying in bed, asleep. -At 4:03 p.m. Resident #47 was observed sitting up in bed. There were no meaningful activities observed. C. Record review The 9/27/22 admission activity assessment documented the resident was interested in games, cards, trivia, BINGO, arts and crafts, drawing and painting. It indicated the resident's socialization plan was to encourage her to attend activities of choice and invite her to activities as tolerated. The activity care plan, initiated on 9/27/22, documented the resident was at risk for decreased socialization. It indicated the resident would benefit from small group settings. The interventions included communicating her activity interests to the health care team, introducing her to other residents with similar interests, inviting and encouraging the resident to attend activities with a low stimulation environment when available. The quarterly activity evaluation dated 12/23/22 documented the resident liked to watch people and attended group activities. It indicated the activity staff should continue to offer recreation to the resident. The one-to-one activity participation log documented the resident was provided one-to-one activities two times in November 2022, once in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. The social activity log documented the resident participated in social events three times in November 2022, once in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. According to the independent activity log, the resident watched television 10 times in November 2022, 10 times in December 2022, eight times in January 2023 and twice from 2/1/23 to 2/15/23. According to the entertainment activity log, the resident participated one time in November 2022, one time in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. III. Staff interviews The activity supervisor (AS) was interviewed on 2/16/23 at 6:23 p.m. She said Resident #47 was offered group activities but did not like to participate. She said the resident was a passive participant. The AS said Resident #47 did not watch television. The AS said they had attempted to paint with her but she was not interested. She said the resident was not part of an activity one-to-one program. She said the activity staff offered the resident music, however that was not regularly scheduled. She said she had not offered the resident to attend group activities.

Based on observations, record review and staff interviews the facility failed to provide services for one (#172) out 31 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #172's vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Professional reference Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 2/21/2023 at 10:17 a.m. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. Kizior, R. J., Hodgson, K. J. (2023). Metoprolol. Saunders Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. II. Resident #172 A. Resident status Resident #172, age 82, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included iron deficiency anemia related to blood loss, congestive heart failure and atrial fibrillation. The February 2023 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. He required the assistance of two people for bed mobility, transfers, personal hygiene dressing and toileting. B. Observations On 2/16/23 at 9:06 a.m. registered nurse (RN) #2 was observed dispensing a Metoprolol 25 milligrams (mg) tablet for Resident #172. RN #2 did not check the order for the blood pressure parameters or the record for the resident's most recent vital signs. RN #2 then administered the Metoprolol medication to Resident #172. C. Record review The February 2023 CPO documented a physician order of Metoprolol Succinate Extended Release 25 mg once a day for ventricular rate control in atrial fibrillation ordered on 2/9/23. The CPO did not document any vital signs parameters for the Metoprolol medication. The February 2023 medication and treatment administration record (MAR/TAR) documented the resident's vital signs should be checked every shift, initiated on 2/13/23. The first documented vital signs were on 2/13/23. The February 2023 vital signs summary revealed one blood pressure documented on 2/9/23, no blood pressures documented on 2/10/23 or 2/11/23, one blood pressure documented on 2/12/23, one blood pressure documented on 2/13/23, three blood pressures documented on 2/14/23 and one blood pressure documented on 2/15/23. III. Staff interviews RN #2 was interviewed on 2/16/23 at 9:15 a.m. She reviewed the Metoprolol physician's order and said there were no parameters ordered. She confirmed she did not obtain the resident's vital signs prior to administering the Metoprolol medication. She said she was unsure when the resident's vital signs had been last taken. Licensed practical nurse (LPN) #1 was interviewed on 2/16/23 at 10:00 a.m. She said blood pressure medication did not always have documented parameters. She said if the resident was outside of their baseline, she would contact the physician prior to administering the medication. She said the resident's vital signs should be taken and checked prior to administering blood pressure medications to avoid causing severe low blood pressure. The director of nursing (DON) was interviewed on 2/16/23 at 6:50 p.m. She said that blood pressure medication should be given as ordered by the physician. She said if there were parameters ordered for blood pressure medications, the physician should be notified if the resident's blood pressure was outside of parameters. She said if there were no parameters were ordered, the physician should be notified if the resident was outside their baseline. She said resident's vital signs should be taken prior to every shift.

Based on record review and interviews the facility failed to notify the physician timely for three (#4, #369 and #60) of three residents reviewed out of 42 sample residents. Specifically, the facility failed to notify the physician to notify of a resident change of condition for: -Resident #4 when blood pressure was out of parameters and the as needed medication was not administered as ordered; -Resident #369 when resident temperatures were elevated over 99.0 F, for three days; and, -Resident #60 with timely notification for lab results. Findings include: I. Facility policy The physician notification policy, revised August 2007, was received from the director of nursing (DON) on 11/9/21 at 1:10 p.m. It read in pertinent part: The policy of this facility is to promptly notify the resident's attending physician of changes in the resident's condition or status. The nurse supervisor will notify the resident's attending physician when there is a need to alter the resident's treatment. Except in medical emergencies, the notifications will be made within 24 hours of a change that occurred in a resident's condition or status. II. Residents A. Resident #4 1. Resident status Resident #4, age 73, was admitted [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/22/21 minimum data set (MDS) assessment revealed the resident had moderately impaired cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. 2. Record review The CPO documented the following orders: - [MEDICATION(S)] HCL 0.1 milligram (mg) tablets; give one (1) tablet, by mouth, two times a day for hypertension. Hold for systolic blood pressure (SBP) less than 105; start date 4/1/21. -[MEDICATION(S)] HCl 0.1 mg tablets; give one (1) tablet, by mouth, every 24 hours as needed for hypertension. Give for SBP greater than 190; start date 4/5/21. Review of the resident's medical record and medical administration records (MAR) from 6/1/21 to 11/4/21 revealed the Resident #4's SBP was greater than 190 on nine occasions; the as needed dose of [MEDICATION(S)] was not administered and the physician was not notified of the SBP result or the missed medication. Cross-referenced to F684 failure to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Staff interviews The assistant director of nursing (ADON) was interviewed on 11/8/21 at 1:05 p.m. The ADON said the resident's should have been notified if the resident SBP was over 190 and the medication was not administered as ordered. B. Resident #369 1. Resident status Resident #369, age 85, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 11/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had not received any or the recommended vaccinations for [CONDITION(S)]-CoV-2 COVID-19. 2. Record review Review of the resident medical record vital signs report from admission on 11/2/21 through 11/9/21 revealed the resident had an elevated temperature higher they the resident normal baseline temperature. Temperature vital signs records documented the resident had a temperature of 99.6 degrees F on 11/2/21, 99.5 degrees F on 11/3/21, and 99.5 degrees F on 11/4/21. Progress Notes failed to show documentation that the resident physician was notified of the resident elevated temperatures. There was no physician notification for three days (11/2/21, 11/3/21, and 11/4/21) of temperatures over 99.0 degrees F until brought to the facility's attention. Cross-referenced to F880 failure to monitor and quarantine an unvaccinated resident with potential COVID-19 symptoms. 3. Staff interviews LPN #2 was interviewed on 11/4/21 at 3:32 p.m. LPN #2 said if vital signs are out of range she would recheck. She said she would call the physician if there was a repeated temperature over 99.0 degrees F. RN #2 was interviewed on 11/4/21 at 3:39 p.m. RN #2 said she would call the physician if a resident had a repeat temperature over 99 degrees F. The clinical consultant (CC) was interviewed on 11/8/21 at 1:29 p.m. The CC acknowledged the CDC guidance, which would indicate that Resident #369 should have been placed in isolation as a precaution following more than two days of temperatures greater than99 degrees F. The CC said the resident's physician would be notified of the resident pattern of elevated temperatures for further guidance. C. Resident #60 A. Resident status Resident # 60 age 69 was admitted on [DATE]. The October 2021 computerized physicians orders (CPO) included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/13/21 minimum data set (MDS) indicated the resident was cognitively impaired for brief interview with a mental status score of 12 out of 15. He required an extensive two person mechanical lift for transfers. The resident was totally dependent for transferring, eating, bathing,toileting and personal hygiene. B. Record review The laboratory report indicated that a culture was obtained from the resident's wound on 9/10/21. The lab received the culture on 9/13/21, and sent the result of the lab test to the facility on [DATE]. The results of the culture test revealed a Heavy Growth of Staphylococcus aureus isolated.There was no record that the lab results had been sent to Resident #60's physician. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This dose ended on 10/1/21. -The antibiotic order was not ordered timely due to the physician not being notified of the lab result. The second prescription dated 9/30/21 was for [MEDICATION(S)] 750 mg every 8 hours intravenously. This dose ended on 10/4/21. A nursing note dated 9/30/21 indicated the writer called the pharmacy for the dosing of [MEDICATION(S)] for Resident #60 which was ordered on 9/28/21. The writer indicated that the physician notified the resident's family on 9/28/21 about the change in medication orders. C. Interview The director of nursing (DON) was interviewed on 11/9/21 at 11:29 a.m.She said there was no record that a lab culture result was sent to Resident # 60's physician. She said she spoke to the resident's physician today and he said he did not receive notification of the lab results until 9/28/21. He did not specify who notified him of those results. At that point he sent prescriptions to the facility and the pharmacy for Resident #60.

Based on observation, record review and interviews, the facility failed to consistently provide activities of daily living (ADL) support for four (#11, #21, #27, #56) of five dependent residents reviewed for ADLs out of 37 sample residents. Specifically, the facility failed to provide or offer showers according to the bathing schedule for Residents #11, #21, #27, #56. Findings include: I. Facility policy and procedure The Nursing Clinical Bath, Shower policy and procedure, revised January 2020, was provided by the nursing home administrator (NHA) on 11/9/21 at 10:37 a.m. It read in pertinent part, It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Residents have the choice between bed bath, shower, or bath. When residents admit please review the preference sheet with the resident. Complete a shower preference form. Residents may choose the days of the week they choose to bath or shower. Residents may choose their time that they can bathe or shower .Residents may change their preferences at any time during the stay. Nursing will upload preferences into the plan of care (POC) task. If a resident does not have a preference, the facility will utilize their default schedule. Facility is transitioned to electronic on bathing documentation. Facility is no longer using bathing sheets. II. Resident #11 A. Resident status Resident #11, age 71, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/5/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required limited assistance with dressing, and bed mobility with one person physical assistance. Supervision with one person physical assistance for transfers, toilet use, and personal hygiene. Bathing activity itself did not occur over the entire seven day MDS period so no functional status was listed. Preference was listed as very important to him to choose between a tub bath, shower, bed bath, or sponge bath. No rejection of care or other behavioral symptoms. B. Resident observations and interviews On 11/3/21 at 2:22 p.m. Resident #11 was seated on the edge of bed without pants on but wearing a shirt. His hair was oily and uncombed. He had a strong odor of urine and sweat. Resident #11 said he was bathed about one time per week. He said he preferred showers/baths two times per week. He said he does not ambulate but had help to transfer to his wheelchair. He said he can brush his own teeth with set up help. On 11/4/21 at 8:49 a.m. observed Resident #11 in bed sleeping. He had a strong odor of urine and sweat. On 11/4/21 at 2:45 p.m. Resident #11 was seated in bed without pants on but wearing a shirt, his hair was oily and uncombed. On 11/8/21 at 2:46 p.m. Resident #11 was seated in bed without pants on but wearing a shirt and a sheet over his legs. He had a strong odor of urine and sweat. C. Record review Care plan The care plan for ADL's, initiated 10/24/21, revealed ADL self care performance deficit. Interventions for bathing include requiring one person assistance with bathing two to three times a week per his preference in the evenings and as necessary. Care documentation The EMR task documentation completed by CNA's revealed Resident #11 prefers showers two to three times per week in the evenings. July 2021: Revealed zero bathing was provided from admission on 7/29/21 to 7/31/21. There were no refusals documented. August 2021: Revealed zero bathing was provided in the month of August from 8/1/21 to 8/31/21. There were no refusals documented. September 2021: Revealed three sponge baths were completed on 9/12/21, 9/22/21, 9/30/21 with total dependence; resident refusal on 9/24/21. October 2021: Revealed zero bathing was provided in the month of October from 10/1/21 to 10/31/21. There were no refusals documented. November 2021: Revealed one sponge bath was completed on 11/7/21 with total dependence (between 11/1/21 and 11/7/21). There were no refusals documented. Resident #11 had received a total of four baths, of any type, since admission on 7/29/21. Resident #11 should have received a minimum of 29 showers. He received four out of 29 scheduled showers since July 2021. Progress notes A review of progress notes failed to reveal the resident refused or was offered an opportunity to bathe/shower at another time, on another shift or on subsequent days until he was bathed. Preference sheet completed upon admission 7/29/21 revealed in pertinent part, Resident #11 would prefer a shower, in a chair, two to three days per week, depending on what is easier. Prefers to shower in the evenings before he goes to bed. III. Resident #27 A. Resident status Resident #27, age 72, was admitted on [DATE]. According to the November computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/30/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance with two person physical assistance for bed mobility, toilet use, and transfers. Dressing, and personal hygiene required extensive assistance with one person physical assistance. Eating required setup and supervision. Bathing activity itself did not occur over the entire seven day MDS period so no functional status was listed. Preference was listed as not very important to her to choose between a tub bath, shower, bed bath, or sponge bath. No rejection of care or other behavioral symptoms. B. Resident observations and interviews On 11/3/21 at 10:17 a.m. Resident #27 was in bed. Her hair was greasy and uncombed. She said the caregivers do not brush her hair or her teeth. She said the caregivers do not brush her teeth because she did not have any and they also did not clean her gums. Her fingernails had a brown colored matter under the nails. On 11/3/21 at 10:49 a.m. Resident #27 was in bed. She said she was mostly bed bound, but got up occasionally. She said the caregivers used a mechanical lift to get her up into a shower chair or wheelchair. She said she woke up at 7:00 a.m. and the caregivers cleaned her up and changed her at 10:30 a.m. She said she had to ask to have her hospital gown changed. She said the one she was wearing has been on for two days, and sometimes she wore the same one for three to four days. The gown, which had food stains and brown stains on the chest and neck area of the gown. She said she would prefer to have a new gown daily. She said she had a shower one to two times per week and that was her preference. She said she thought she had a shower last Saturday but was not sure. On 11/4/21 at 8:49 a.m. Resident #27 was in bed, her breakfast tray was finished. Her hair was greasy and uncombed. On 11/9/21 at 1:59 p.m. Resident #27 said on the days they changed her gown or gave her a bath or shower she felt good. She did not recall how often they did that for her. C. Record review Care plan The care plan for ADL's, initiated 9/21/21, revealed ADL self care performance deficit related to limited mobility. Interventions for bathing include to notify nurses immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. There was no other care plan related to shower or bathing preferences or assistance required. Care documentation The EMR task documentation completed by CNA revealed the residents' bathing preferences were not listed. The shower book kept at the nurses station revealed Resident #27's shower preference sheet (dated 10/28/21) indicating her preference of a shower, two times per week on Monday and Saturday in the evenings. August 2021: Revealed zero bathing was provided from admission on 8/23/21 to 8/31/21. There were no refusals documented. September 2021: Revealed two showers were provided on 9/2/21 at 4:59 p.m. and 9:46 p.m. with total dependence. The resident received zero other bathing in the month of September. There were no refusals documented. October 2021: Revealed zero bathing was provided in the month of October from 10/1/21 to 10/31/21. There were no refusals documented. November 2021: Revealed one sponge bath was provided on 11/7/21 with total dependence (between 11/1/21 and 11/7/21). There were no refusals documented. Resident #27 had received a total of three baths, of any type, since admission on 8/23/21. Resident #27 should have received a minimum of 22 showers. She received three out of 22 scheduled showers since August 2021. Progress notes A review of progress notes failed to reveal the resident refused or was offered an opportunity to bathe/shower at another time, on another shift or on subsequent days until she was bathed. There was no shower preference sheet completed upon admission on 8/23/21. III. Resident #21 A. Resident status Resident #21, age 79, was admitted [DATE]. According to the November 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/18/21 minimum data set (MDS) assessment indicated Resident #21 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance of one staff member for bed mobility, dressing and toilet use. She required extensive assistance of two staff members for transfers and required limited assistance of one staff member for personal hygiene. She required physical assistance of one staff member for bathing. She was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, when moving on and off the toilet and during surface to surface transfers. She had impairment of one side of her lower extremity and used a wheelchair for mobility. B. Resident interview Resident #21 was interviewed on 11/3/21 at 11:39 a.m. She said she was supposed to get a shower twice a week but it usually occurred about every 10 days because, they say they do not have enough help. She said she would feel so much better if I got my showers when I was supposed to. C. Record review Review of the November 2021 CPO indicated Resident #21 was to have spinal precautions with no bending, lifting or twisting, and she was to wear a lumbar brace when out of bed. The care plan initiated and revised on 11/8/21 indicated Resident #21 had an activities of daily living (ADL) self care deficit and required the assistance of one to two staff members. According to the shower preference sheet, signed by the resident, she requested showers on Sunday and Wednesday evenings. Review of the certified nurse aide (CNA) shower documentation since her admission in May 2021 revealed the following missed shower opportunities: -May 2021- She received one shower out of nine scheduled. -June 2021- It was documented she refused one shower, however there was no nursing documentation of the refused shower or of what alternatives were offered. She received three showers out of nine scheduled. -July 2021- She received two showers out of eight scheduled. -August 2021- She received one shower out of nine scheduled. -September 2021- She received five showers out of nine scheduled. -October 2021- She received two showers out of eight scheduled. -November 2021- She received zero showers out of two scheduled. IV. Resident #56 A. Resident status Resident #56, age 72, was admitted [DATE]. According to the November 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/8/21 MDS assessment indicated Resident #56 was cognitively intact with a BIMS score of 15 out of 15. He required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. He was dependent on one staff member for bathing. He had impairment on one side of his upper and lower extremities and used a wheelchair for mobility. B. Resident interview Resident #56 was interviewed on 11/3/21 at 3:56 p.m. He said he was supposed to get a shower two to three times a week but did not get them. He said he goes to [CONDITION(S)] on Mondays, Wednesdays and Fridays and would like a shower the day before those appointments because I just feel better if I am clean when I go. C. Record review The care plan, initiated 8/23/21 and revised 9/14/21, indicated Resident #56 had an ADL self care deficit related to left sided weakness and he required extensive assistance with bathing/showering. According to the 7/15/21 shower preference sheet signed by the resident he requested a shower two days a week in the mornings. Review of the CNA shower documentation since his July 2021 admission revealed the following missed shower opportunities: -July 2021- He received one sponge bath on 7/21/21 and one full bed bath on 7/25/21, out of eight scheduled showers. -September 2021- He received two showers and three sponge baths out of nine scheduled showers. -October 2021- He received four sponge baths out of eight scheduled showers. -November 2021- Documentation indicated the resident refused a shower on 11/3/21 however there was no nursing documentation of the refusal or what alternatives were offered. V. Staff interviews The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 11/9/21 at 9:21 a.m. They said showers were to be given per resident preference. They said they did not use a shower aide and showers were the responsibility of the CNAs. They said if a resident refused a shower the CNA was to encourage the resident throughout their shift to accept the shower. They were to document in the resident record that they refused and notify the nurse so she can investigate the reason for the refusal and offer alternatives. They said, In a perfect world the nurses were to document the refusal and what options were offered. The DON said her plan going forward was for all showers to be coordinated with the weekly skin checks so the nurses would be involved on shower days. They acknowledged the facility has had an issue with showers being given routinely and per resident preference for quite some time. CNA #5 was interviewed on 11/9/21 at 9:38 a.m. She said shower preferences were first determined at admission and can be updated monthly if needed. If the resident refused she would ask when they would prefer a shower and try multiple times. She said she would then document the refusal. She said she documents in the electronic medical record (EMR) task section. She documents how much help the resident needs and the type of shower or bath they received. CNA #4 was interviewed on 11/9/21 at 9:39 a.m. She said the CNAs were aware of when residents were to receive a shower by checking the shower binder at the nurses station. She said if a resident refused a shower they did not give it and they were to document it as refused in the computer and let the nurse know. She was unaware of how the nurse handled shower refusals. Registered nurse (RN) #1 was interviewed on 11/9/21 at 9:42 a.m. She said shower preferences and shower schedules were in a shower book. She said there was also a different body sheet for a CNA to fill out and give to the nurse if they notice a wound, sore or a scrape on the body. The CNA then documented the shower in the electronic medical record (EMR) in the task section. The CNA's record what kind of bath or shower and how much help the resident needed. She said refusals were also documented in the task section.

Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in two out of three units. Specifically, the facility failed to: -Place symptomatic resident in isolation (#369) -Change gloves from dirty to clean and perform hand hygiene during wound care with Resident #60, -Ensure residents hands were cleaned before meals, -Ensure shared equipment of blood pressure cuff was cleaned after use, and; -Ensure appropriate personal protective equipment (PPE) masks were worn properly in the facility. Finding include I. Facility policy The Infection Control Prevention and Control Program policy and procedure, revised 5/20/21, was provided by the nursing home administrator (NHA) on 11/8/21 at 12:56 p.m. It read in pertinent part, Residents who have signs and symptoms of COVID-19 must be tested . While test results are pending, residents should be placed on transmission-based precautions pending the results of testing. Facility will take appropriate action based on results once results are obtained. The Vital Sign Parameters policy and procedure was requested from the director of nursing (DON) 11/4/21 at 3:14 p.m. However, it was not provided during or after the survey. The hand hygiene policy, dated August 2014, provided by the nursing home administrator (NHA) on 11/10/21 at 4:00 p.m., read in pertinent part; The facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least sixty two percent alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents, and before handling clean or soiled dressings, gauze pad, etc.; before moving from contaminated body site to a clean body site during resident care, and after contact with blood or bodily fluids. The wound management policy revised 2017 as provided by the nursing home administrator (NHA) on 11/10/21 at 4:00 p.m., read in pertinent part; All treatments involving breaks in the skin require a clean technique, unless otherwise ordered by the physician. The cleaning and disinfection of resident care items and equipment policy, no date, was provided by the nursing home administrator (NHA) on 11/10/21 at 4:00 p.m., read in pertinent part; Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Center for Disease Control (CDC) recommendations for disinfection. II. Professional standards The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, (updated 9/10/21), retrieved on 11/11/21 from:https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Older adults with [CONDITION(S)]-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for [CONDITION(S)]-CoV-2 infection. According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings: Patients guidance, last reviewed: 3/15/16, retrieved on line 11/15/21 from: https://www.cdc.gov/handhygiene/patients/index.html Clean Hands Count for Patients. Patients should clean their hands: Before preparing or eating food. Before touching eyes, nose, or mouth. After using the restroom. After blowing their nose, coughing, or sneezing. After touching facility surfaces. According to the CDC, Hand Hygiene Guidance, last reviewed 1/30/2020, retrieved 11/10/21 online from https://www.cdc.gov/handhygiene/providers/guideline.html, recommendations for appropriate hand hygiene for infection control included in pertinent part: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient, -Before performing an aseptic task or handling invasive medical devices, -Before moving from work on a soiled body site to a clean body site on the same patient, -After touching a patient or the patient's immediate environment, -After contact with blood, body fluids, or contaminated surfaces, -Immediately after glove removal, Healthcare facilities should: -Require healthcare personnel to perform hand hygiene in accordance with CDC recommendations: -Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled, -Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered, -Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. III. Resident #369 A. Resident status Resident #369, age 85, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 11/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Eating required setup help and supervision. B. Resident observations and interview On 11/4/21 at 8:49 a.m. observed newly admitted , unvaccinated Resident #369. Resident was not initially in quarantine due to COVID-19 recovery and her vital records revealed the resident had a 99 degree Fahrenheit (F) temperature on 11/2/21, 11/3/21, and 11/4/21 (see record review below). There was no personal protective equipment (PPE) outside the door of Resident #369 room. Resident #369 said she went to therapy daily. On 11/4/21 at 3:11 p.m. Resident #369 was observed in the therapy gym/department. She was not wearing a mask and was not encouraged to do so. On 11/8/21 at 11:32 a.m. Resident #369 was observed in the therapy gym/department not wearing a mask and not encouraged to do so. C. Record review COVID-19 status-Review of resident profile reveals she was COVID-19 recovered 9/27/21. Review of immunization records indicates refusal of [CONDITION(S)]-COV-2 (COVID-19) (Dose one). Vitals Temperature-11/2/21 99.6 degrees F; 11/3/21 99.5 degrees F; and III. Resident #369 A. Resident status Resident #369, age 85, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 11/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Eating required setup help and supervision. B. Resident observations and interview On 11/4/21 at 8:49 a.m. observed newly admitted , unvaccinated Resident #369. Resident was not initially in quarantine due to COVID-19 recovery and her vital records revealed the resident had a 99 degree Fahrenheit (F) temperature on 11/2/21, 11/3/21, and 11/4/21 (see record review below). There was no personal protective equipment (PPE) outside the door of Resident #369 room. Resident #369 said she went to therapy daily. On 11/4/21 at 3:11 p.m. Resident #369 was observed in the therapy gym/department. She was not wearing a mask and was not encouraged to do so. On 11/8/21 at 11:32 a.m. Resident #369 was observed in the therapy gym/department not wearing a mask and not encouraged to do so. C. Record review COVID-19 status-Review of resident profile reveals she was COVID-19 recovered 9/27/21.Review of immunization records indicates refusal of [CONDITION(S)]-COV-2 (COVID-19) (Dose one). Vitals-Temperature-11/2/21 99.6 degrees F; 11/3/21 99.5 degrees F; and 11/4/21 99.5 degrees F Progress notes There was no physician notification for three days (11/2/21, 11/3/21, 11/4/21) of temperatures over 99.0 degrees F until brought to the facility's attention. (cross-reference F580, failed to notify the physician) Progress note (daily skilled note) on 11/3/21 (the very first progress note upon admission) revealed a vital sign temperature of 99.6 degrees F via the temporal artery route on 11/2/21 at 7:15 p.m. Vital signs do not show any fluctuations from baseline that require intervention(s). Progress note (daily skilled note) on 11/4/21 revealed a vital sign temperature of 99.5 degrees F via the temporal artery route on 11/4/21 at 12:10 a.m. Vital signs do not show any fluctuations from baseline that require intervention(s). The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Staff inteviews for isolation RN #1 was interviewed on 11/4/21 at 3:01 p.m. She said Resident #369 should be isolated if there was a fever to find the root cause and the nurse should call the physician. RN #1 said she did not know that Resident #369 had a fever so she did not call. The DON was interviewed on 11/4/21 at 3:14 p.m. She said if a resident had a fever it would be reviewed in the morning meeting. She said the nurse should notify the doctor when the temperature was over 100 degree F. She said she did not know the facility vital sign parameter ranges of when to call the physician. She said she gave the nurses the power to put the resident in isolation or not. LPN #2 was interviewed on 11/4/21 at 3:32 p.m. She said if vital signs are out of range she would recheck. She said she would call the physician if there was a fever over 99.0 degrees F. RN #2 was interviewed on 11/4/21 at 3:39 p.m. She said she would call the physician if a resident had a temperature over 99 degrees F. The infection preventionist (IP) was interviewed on 11/4/21 at 3:48 p.m. She said if a resident was COVID recovered and unvaccinated they need to wear a mask. She said she gave a report daily that they should wear a mask. It should be in the care plan to encourage residents to wear a mask. If you ask the resident and they refuse, they have a right to refuse. She said everyone should have vital signs taken two times per day. She said the nurses had been working on what the vital sign parameters were. She said she had a call out to the doctor to check. She said the nurses should phone the physician to follow up if a resident had a temperature. She said if the resident was on routine Tylenol or [MEDICATION(S)] the nurse would know to call the physician if they had a fever because the medications can lower fever symptoms. The IP and clinical consultant (CC) were interviewed on 11/8/21 at 11:36 a.m. She said if a resident came and had a temperature and multiple symptoms, like respiratory distress, she would call the physician. She said when she had looked at Resident #369 in bed, she had lots of blankets on. She said the nurses continued to monitor and the resident had no other symptoms. She said three days of fever was pretty normal for her. The CC was interviewed on 11/8/21 at 1:29 p.m. She acknowledged the CDC guidance which would indicate that Resident #369 should have been placed in isolation as a precaution following more than two days of temperatures >99 degrees F. She said she had not been familiar with this guidance prior. She said she had called to notify the physician after the third day of fever after it was brought to her attention. The rehab director was interviewed on 11/9/21 at 9:56 a.m. She said we try to offer masks to residents. She said we will still bring unvaccinated residents down to the therapy gym even if they refuse a mask but we try to have six feet of distance. She said she was not aware that Resident #369 had a temperature >99 degrees F on 11/2/21, 11/3/21, and 11/4/21. She said she had assumed that the nurses were monitoring. IV. Wound observations and hand hygiene Wound #1 left foot Registered nurse (RN) #1 was observed on 11/4/21 at 3:30 p.m. performing wound care for Resident #60. She collected the wound supplies, prepared the bedside table with a covering and put the supplies for the wound care on there. Resident #60 had a zip lock bag with his name on it specific to him with his wound supplies. Woundone was on his left foot. RN perform hand hygiene, donned gloves and removed the soiled dressing with scissors. She cleaned the wound with a wound spray. During the wound care she put her dirty gloved hand in her pocket to get her key out and handed the key to the director of nurses (DON) to go and get more supplies. The DON had bare hands and took the key. RN #1 continued to use the same gloved hands and dirty scissors to cut the sterile gauze and applied it to the wound. -She failed to change her gloves and perform hand hygiene in between dirty to clean processes. She also failed to clean the scissors used. Wound #2 right outer foot At 3:45 p.m. RN #1 performed wound care on the right foot. She took off the soiled dressing to the right foot with the same gloved hands from wound #1. She cleaned the wound and applied new dressings. -She failed to change gloves from dirty to clean and failed to perform hand hygiene in between wounds Wound #3 left hand At 3:55 p.m.RN #1 performed wound care on the left hand. She used the same scissors, cut off the gauze, cleaned the wound and applied a new dressing. She did not change her gloves and no hand hygiene was completed from dirty to clean. She doffed gloves at the end of this wound care and washed her hands in the sink. Wound #4 upper back At 4:00 p.m. RN #1 reached into her pocket and took out a pair of gloves. She donned the gloves and performed wound care to the upper back. She cleaned the wound and applied a new dressing using the same contaminated gloves. Wound #5 bottom At 4:15 p.m. RN #1 continued to go from wound #4 to wound #5 with the same gloves. There was no soiled dressing on this bottom wound. She cleaned the wound, touched the bed controls and reached into her pocket all with the same dirty gloves on. She cut the sterile dressing with the same dirty scissors and wore the same gloves and applied the dressing to the wound. -She failed to change gloves between dirty and clean procedures, failed to perform hand hygiene and failed to clean the scissors from dirty to clean processes. The scissors were placed back into the resident's wound supply bag used for him only. IV. Meals Observations on 11/3/21 at 12:10 p.m., revealed no hand hygiene offered to residents on the High Peak unit prior to the lunch meal. Observations on 11/4/21 at 8:42 a.m, revealed no hand hygiene offered to residents on the Spartan unit prior to the breakfast meal. -On 11/13/21 at 8:55 a.m. and 11:45 a.m no hand hygiene was offered to residents on the Spartan unit prior to breakfast and lunch meals. V. Blood pressure cuff observations RN #2 was observed on 11/4/21 at 9:28 a.m. to use the blood pressure vital machine equipment on three residents. She failed to disinfect the equipment before or after it was used on each resident. VI. Mask Observations Certified nurse aide (CNA) #1 was observed on 11/3/21 throughout the day to wear her mask underneath her nose. Resident was observed on 11/3/21 at 8:30 a.m. to leave the facility and he did not wear a mask. Several other residents were seen not wearing masks upon entering the facility. No encouragement from staff to have residents wear a mask. On 11/3/21 at 10:30 a.m. an unidentified staff member was seen walking with a resident in the hallway. Her mask was below her nose and the resident was not wearing a mask. Another unidentified resident passed them and he was not wearing a mask. There was also an unidentified male resident seated at the front entrance area not wearing a mask, with several other residents and staff walking near him. An unknown staff member was seen escorting a female resident down the hall in her wheelchair as well as an unknown male resident propelling himself in a motorized wheelchair, neither resident was wearing a mask. The staff members did not encourage the residents to apply masks. -At 10:34 a.m. an unidentified housekeeping staff member was seen on Spartan Street hall with her mask below her nose and two unidentified residents were in the hall near her, not wearing masks. She did not encourage them to apply a mask. -At 10:38 a.m. an unidentified male resident was seen propelling himself in a wheelchair on Spartan Street hall, his mask was below his chin. An unidentified staff member passed him and did not encourage him to raise the mask over his mouth and nose. -At 10:41 a.m. an unidentified certified nurse aide (CNA) was seen walking with a male resident down Spartan Street hall, the resident was not wearing a mask. Another unidentified staff member escorted a male resident to his room in his wheelchair, the resident was not wearing a mask. An unidentified male resident passed staff and other residents in his motorized wheelchair and he was not wearing a mask. Staff did not encourage the residents to apply masks. Licensed practical nurse (LPN) #1 was observed on 11/3/21 at 12:15 p.m. assisting residents at lunch and she wore her mask underneath her nose. On 11/4/21 at 9:20 a.m. multiple residents were seen throughout the facility not wearing masks. Many staff members interacted with them and did not encourage them to apply a mask. -At 11:47 a.m. an unidentified male resident was seen in the therapy gym working on a hand cycle machine, he was not wearing a mask, and the therapy staff did not encourage him to apply one. -At 11:56 a.m. two unidentified male residents were seen seated in the front lobby area talking with each other and neither was wearing a mask. Several staff members passed the residents and did not encourage them to apply masks. -At 12:59 p.m. two unidentified male residents were seen seated in the front lobby, neither were wearing masks. The nursing home administrator (NHA) and another staff member passed both residents and did not encourage them to wear a mask. The male resident in room [ROOM NUMBER] exited his room not wearing a mask. He talked to an unidentified nurse in the hallway that was standing next to her medication cart. He then proceeded down the hall to the front of the building. The nurse did not encourage him to apply a mask. Residents were observed at 1:35 p.m. to wear no masks in the common area near the dining room. -At 1:45 p.m. an unidentified male resident was seen seated at and using a hand cycle machine. He did not have a mask on. Another unidentified resident was seated behind him also not wearing a mask. Two therapy staff members were in the gym as well and one of them lowered her mask to talk to the resident. Neither staff member encouraged the residents to apply masks. -At 2:01 p.m. an unidentified therapy staff member was seen in the therapy gym working with a resident who was not wearing a mask. The staff member was standing in front of the resident with her mask below her chin tossing a balloon to the resident who held a pool noodle used to hit the balloon. The staff member did not raise her mask to cover her mouth and nose nor encourage the resident to raise her mask above her mouth and nose. -At 3:20 p.m. two unidentified female residents were seen in the therapy gym seated facing each other and neither resident was wearing a mask. Therapy staff did not encourage them to apply masks. An unidentified male resident was seen at the front desk talking to a staff member, he was not wearing a mask and the staff member did not encourage him to apply one. -At 3:49 p.m. three unidentified male residents were seen seated in the front lobby talking with one another, they were not wearing masks. The assistant director of nursing (ADON) walked past all three residents and did not encourage them to apply masks. On 11/8/21 at 8:45 a.m. an unidentified male resident was seen seated in the hallway across from the activity office, he was not wearing a mask. The activity director (AD) was in the hall talking to him, she did not encourage him to apply a mask. -At 8:51 a.m. multiple residents were seen returning to their rooms from the main dining room, none not wearing masks. One of the residents was escorted by a dietary staff member who did not encourage the resident to wear a mask. -At 10:15 a.m. an unknown staff member was seen exiting a residents room with the resident in a wheelchair. The resident was not wearing a mask and the staff member did not encourage her to wear one. She proceeded down the hall with the resident passing other staff and residents. VII. Nurse observations On 11/4/21 at 8:19 a.m. registered nurse (RN) #2 was observed during medication pass for Resident #21. The resident's oxygen tubing/cannula had fallen onto the floor. The RN picked the tubing up off the floor and replaced the cannula into the resident's nose. She did not clean the cannula or obtain a new one. -At 8:36 a.m. RN #2 obtained a blood pressure reading on the resident in room [ROOM NUMBER]-A. She placed the blood pressure cuff on the resident's bare upper arm. She then exited the room with the vital signs machine, and positioned the machine next to her medication cart. She did not clean the cuff after she obtained the reading and used the same blood pressure cuff on three other residents. VIII. Staff interviews RN #1 was interviewed on 11/4/21 at 4:30 p.m., she said she knew she needed to change her gloves and wash her hands when performing wound care for Resident #60. She said there was a potential for contamination because she did not wash her hands and changed her gloves. She had additional training today on hand hygiene. CNA #8 was interviewed on 11/8/21 at 11:53 a.m She said the residents had a choice to wear the masks or not. She said they encouraged the residents to wear the mask and to social distance but they refused. The director of nursing (DON) and the ADON were interviewed on 11/9/21 at 10:00 a.m. They said if a resident were to drop their oxygen cannula onto the floor the nursing staff were to replace the tubing and cannula with a new set. If it touched the floor it would be contaminated and should not be placed back into the resident's nose. They said when a blood pressure cuff was shared among multiple residents it should be cleaned with a disinfecting wipe after each use prior to being used on a different resident.The ADON said they used to have bags that hung on the vital signs machine that contained the disinfecting wipes for cleaning equipment after use, but she was unaware of what became of those bags and she acknowledged there were no disinfecting wipes with the machine. CNA #2 was interviewed on 11/9/21 at 10:20 a.m. She said the blood pressure cuff was cleaned after each use. She used the sani wipes. She said she knew how to clean the equipment from working in the field. CNA #3 was interviewed on 11/9/21 at 10:25 a.m. She said she used alcohol wipes to clean the blood pressure cuffs. She said to clean the vital tower in between resident use. RN #2 was interviewed on 11/9/21 at 11:10 a.m. She said she knew to clean the resident equipment with micro kill wipes every time it was used between residents. She failed to demonstrate cleaning equipment during observation above. The IP was interviewed on 11/9/21 at 11:35 a.m. She said hand hygiene occurred after resident cares, after changing gloves, and anytime there was a potential for contamination. She said blood pressure cuffs were cleaned when visibly soiled. She said unless the cuff touched the residents direct skin it did not have to be cleaned. She said residents were offered hand hygiene before meals and when they go to the bathroom. She said some residents refused to use the hand sanitizer. The masks were resident preference. The facility encourages the residents to wear them but they do not force them. She said residents who were unvaccinated wore them at all times outside of their rooms.

Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for two out of three resident units and hallways. Specifically, the facility failed to: -Ensure shower rooms were clean for resident use; -Ensure areas were free from odors and sticky floors in resident rooms and hallways; and, -Ensure satellite kitchen was in good repair. Findings include: I. Resident shower rooms A. Facility policy A policy related to housekeeping for shared resident areas and a home like environment for a clean and comfortable shower room experience was requested; no related policies or housekeeping procedure was provided. The Resident Rights document dated 10/4/16, was provided by the nursing home administrator (NHA) on 11/9/21 at 1:32 p.m., it read in pertinent part: As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. - Safe Environment. You have a right to a safe, clean, comfortable and homelike environment. B. Observations On 11/3/21 at 11:25 a.m. the resident shower room on the Mountain unit for where the majority of the residents were using for their bathing needs. The following was observed: -The shelving holding the resident ' s clean towels was soiled with a light brown/yellowish substance on the shelves and on the decorative hatching on the front facing of each shelf. -There was a large clump of grey hair sitting on the top shelf of the shelving unit holding the residents clean towels. -The sink was soiled with a dried gel like blue substance and was speckled with a black hair like substance substances. -There was a table next to the sink that was covered with a dried whitish substance. -There was a used green hairbrush on the table, full of grey and brown hair; the brush was not labeled for who it belonged to. -There was an unlabeled electric razor in the table; the razor was full of short hairs and the seams in the handle were caked with a whitish grey substance. -The flooring in the shower was scraped up and the scraped areas were soiled with a blackened substance. The grout in the shower was blackened and the floor had black stains over the entire surface. -There was a shampoo bottle in the shower that had a brow-dried substance on it. -There was debris on the floor including a used band aid, some plastic wrappers and a blue piece of plastic. -There was a computer table/rolling cart placed in the middle of the shower room. The shower room was observed a second time on 11/8/21 at 3:41 p.m. The following was observed: -The shelving holding the resident clean towels was still soiled with a brownish/yellow substance. -There sink was still soiled much as like described above, though less of the dried blue substance. -The green hairbrush was still on the table full of grey and brown hair. -The unlabeled electric razor was still in the same condition as described above. -The rolling computer cart was covered with used towels. -The floor was soiled with paper and plastic debris and dried blackened smudges. -The shower floor was in much of the same condition as described above plus there was a wad of used toilet paper by the drain and a large clump of a deep red substance on its surface. C. Resident interviews Resident #40 was interviewed on 11/3/21 at 11:20 a.m. Resident #40 said the facility had two shower rooms and the one by her room was not kept clean. Resident #40 preferred to use the shower on the rehabilitation unit when it was available despite the Mountain unit shower rom being closer to her room, because it was a nicer shower room and the housekeeper assigned to clean that room did a good job. Each time she took a shower in the shower room near her room, Resident #40 said she felt the need to clean the shower first; because the certified nurse aides (CNA) were always too busy to help her when she wanted a shower. Resident #40 said she sprinkled cleanser on the floor and then took a towel and scrubbed the surface running the towel over the surface with her foot. Other residents thank me for cleaning the shower room for them and leaving clean. Resident #18 was interviewed on 11/8/21 at 2:33 p.m. Resident #18 said the shower room was not cleaned well. D. Staff interviews CNA #2 was interviewed on 11/8/21 at 1:01 p.m. CNA #2 said she sanitized and cleaned the shower chair and shower surfaces after each resident use. The CNAs were also to remove any trash, soiled briefs, towels and clothing after assisting a resident with a shower. The housekeepers were responsible for cleaning the room daily. The maintenance director (MTD) was interviewed on 11/9/21 at 8:55 a.m. The MTD said he educated the housekeepers on cleaning the facility. The housekeepers were to use disinfectant with a one minute dwell time for best results. The housekeepers were to clean and disinfect the shower rooms daily. Housekeeper (HK) #1 was interviewed on 11/9/21 at 9:10 a.m. HK#1 said she cleaned the shower and the shower floors but the CNAs cleaned the equipment in the room and took out the linens and trash. The assistant director of nursing (ADON) was interviewed on 11/9/21 at 1:35 p.m. The ADON said the CNAs were expected to sanitize commonly used surfaces and spot clean the show room after each resident use and the housekeeping department was responsible to deep clean the room daily. The ADON was not sure who cleaned the shelving and tables in the shower room, and acknowledged the shelves holding the towels were dirty and should be replaced. II. Resident rooms and hallways A. Facility policy Facility policy was requested on 11/9/21 at 4:00 p.m. and not provided. B. Observations Observations on 11/4/21 at 12:08 p.m., revealed a strong odor of urine on the Spartan unit at the end of the hallway with 12 resident rooms. The floor in room 22 and 24 was sticky when walking on it by the bed and the sink area. There were no visual spills seen on the floor. There was a sign on room 24 that read; deep clean was scheduled for 11/4/21. Observations on 11/8/21 at 9:00 a.m., revealed a strong odor of urine on the Sparton hallway and the High peaks hallway. C. Staff interviews An additional environmental tour of the facility was conducted with the maintenance director (MTD) on 11/8/21 at 10:03 a.m. The MTD said he had a maintenance schedule to deep clean all the resident rooms. He said the floors were not properly waxed so they were more susceptible for odors and breakdown. He said the sticky floor was from liquid spills and because the wax was not on the floor it was more noticeable. He said he had not logged at each of the three nurses' stations where staff could write up a work order for any maintenance issue. He said he reviewed each of the logs the first thing each morning. He said staff verbally told him of any maintenance issues. III. Satellite kitchen On 11/11/21 at 4:00 p.m. the satellite kitchen was observed to have several maintenance issues. There were cabinet drawers and cabinet covers missing. The dishwasher had the cover to bottom missing with wires sticking out. There were holes in the wall above the refrigerator that measured approximately an inch in diameter. The tile on the floor in front of the sink was stained and some parts of the tile were loose and coming apart under the dishwasher. The handle to the door entrance to the kitchen was loose and in need of repair. There was an exposed metal strip on the corner edge of the gate entry, loose wall laminate near dishwasher, missing caulk around the sink, loose caulk at the top of the splash board adjacent to the sink countertop. The maintenance director (MTD) was interviewed on 11/11/21 at 4:15 p.m. He said the satellite kitchen had been in terrible condition since he started working there in January 2021. He said he threw out an old stove and microwave that did not work. He said the facility had new ownership as of 4/1/21.He said they had to purchase medication carts and medical supplies like wheelchairs, lifts and hospital beds. He said the company before them had taken all of the supplies with them. He indicated there was no money in the budget left to repair the kitchen. He said he would have more money in the budget in January 2022 to begin the remodel and repairs of the kitchenette.

Based on record review and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and that each resident received adequate supervision and assistance devices to prevent accidents for three (#2, #4 and #8) out of 13 sample residents. Specifically, the facility staff failed to: -Follow Resident #2's assessment requiring extensive assistance of two people with transfers and the use of a hoyer lift. -Properly assess, treat and follow up for residents after a fall for resident #4 and resident #8. The facility failed to transfer Resident #2, according to the resident assessment, for two staff members and the use of a hoyer lift, which resulted in the resident suffering a fall and a spiral fracture of her right leg. The fracture required surgical repair, a leg brace, and caused the resident unnecessary pain and discomfort. Cross reference F 657 Care plan revision, F725 sufficient nursing staff, and F865 Quality Assurance Findings Include I. Facility policy A. Fall Management Policy The Fall Management policy, revised 11/2017, was provided by the district director of clinical services (DDCS #2) on 8/12/19 at 2:00 p.m. It read in pertinent part: When a fall occurs, the resident is assessed for injury by the nurse. The nurse will enter the event into RiskConsole, complete an Incident/Accident report, complete the SBAR Communication Form and Progress Note, add the fall event to the 24-hour report, and initiate the interdisciplinary post fall review. The nurse communicates resident falls to the attending physician and the resident's representative. The nurse documents notification on the SBAR communication form and progress note. The nurse communicates the resident fall to the interdisciplinary team (IDT) through the 24 hour report. The nurse will discuss recommended interventions to reduce the potential for additional falls with the resident or resident representative and document in the care plan and progress notes. The IDT reviews all resident falls within 24-72 hours at the IDT meeting to evaluate circumstances and probable cause for the fall. The IDT will complete the post fall review. The IDT will discuss recommended significant changes to the care plan to minimize repeat falls with the resident or resident representative. The care plan will be reviewed and revised as indicated. Fall trending and analysis information is reported to the Quality Assurance and Performance Improvement (QAPI) committee. In the event a resident has a fall and it was determined they hit their head, or it can not be determined if they hit their head, the nurse initiates the following actions: All above items and neurological checks are completed and documented as instructed. B. Lift, Transfer and Repositioning Policy The Lift, Transfer, and Repositioning Policy, 2010, was provided by the DDCS #2 on 8/12/19 at 2:00 p.m. It read in pertinent part: The purpose of the policy read to provide guidance to facility staff regarding the process that must be undertaken to evaluate residents and implement a lift/transfer/repositioning protocol for those residents who are determined, through evaluation, to need assistance during transfers and repositioning. Each resident specific protocol will be implemented to ensure that the resident continues to reach his/her highest level of physical functioning while reducing the potential for employee injuries during the lifting/transfer/repositioning process. Residents identified as partial weight-bearing or non-weight bearing and needing assistance with lifts and transfers shall be lifted using an appropriate mechanical lift unless the resident or responsible party refuses the use of mechanical lifts or the use of mechanical lifts would be contraindicated for clinical or medical reasons. Facility Policy requires two staff members to assist when lifting with mechanical lifting devices. Staff will be required to educate residents and family members about the risks associated with refusing to utilize the lifts and clearly document that such education has occurred. The administrator and regional vice president are responsible and accountable for compliance with this policy .All department heads and senior facility management staff are responsible for becoming familiar with the policy and for implementing and monitoring compliance with the policy on a daily basis . Lift, transfer and mobility evaluations will be provided to residents who require such assistance based on their resident transfer evaluation, MDS assessment, and care plan interventions. II. Resident #2 A. Resident status Resident #2, age 79, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 7/22/19 minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for mental status score of 12 out of 15. She required extensive assistance of two or more staff members with mobility and transfers, and was totally dependent on staff for bathing. B. Record review a. Progress note On 7/9/19 at 10:50 a.m. a note read that the resident was being transferred by a sit to stand lift and that the resident's right knee buckled and she was lowered to the floor by the certified nurse aide (CNA). Her right leg was stuck under her left leg and upon assessment her right leg was internally rotated and the resident was in severe pain. The resident was transferred to the hospital via emergent transport. b. Facility investigation On 7/9/19 a facility investigation read that the resident fell while being transferred with a sit to stand lift due to incorrect use of the lift equipment and the lift equipment being operated by only one staff member instead of two in accordance with the facility policy. The investigation revealed that the two CNAs who each performed one person transfers for the resident with the sit to stand lift were agency staff and the resident insisted they both transfer her with only one staff member. The investigation report continued resident requires transfers by a full hoyer lift, though demands that the staff use a sit to stand lift and insists that only one staff member perform the transfers. c. Care plan The resident's care plan initiated on 10/12/18 and revised 1/23/19 did not indicate the resident's refusal to use the proper lift equipment, her insistence to be transferred only by one staff member, or any education was provided to the resident regarding the lift transfer policy or lift transfer safety. d. Additional progress notes On 7/15/19 at 9:21 a.m. a follow up note read that the resident would be using a full hoyer lift for transfers when she returned from the hospital and staff education had been completed and was ongoing regarding the facility lift and transfer policy. On 8/9/19 at 1:03 p.m. a care conference note read staff discussed with the resident and her daughter the lift that was required for the resident to use. The note read that the resident was unhappy about using the full hoyer lift and preferred the sit to stand, but the resident was to remain non-weight bearing. The note read the therapy department was attempting to find a full hoyer sling with an opening so the resident could use the toilet instead of the bedpan. Review of the resident record for since (MONTH) (YEAR) revealed no documentation of the resident being assessed to be appropriate for a full hoyer lift, her insistence to use the sit to stand lift against recommendations, her demands for one person assist with the sit to stand lift, or any education regarding lift transfer safety. Education was provided on 6/4/18 regarding safety related to the resident's preference to remain hooked to the sit to stand lift while in the bathroom. C. Resident interview Resident #2 was interviewed on 8/8/19 at 2:08 p.m. she stated when she fell she told both of the CNAs the sling was not hooked up correctly and she was going to fall, but they continued to transfer her. She stated the CNAs would always transfer her alone because there was never any other staff available to assist with the transfer. She stated since the fall, she has experienced increased pain as well as discomfort due to the leg brace and having to use a bedpan instead of the toilet for voiding which was not easy for her. She stated she was still transferred in the hoyer lift at times with only one staff member due to limited staffing. D. Staff interviews CNA #3 was interviewed on 8/8/19 at 5:00 p.m. and stated there had been times in the past CNAs transferred residents alone with lifts due to low staffing. She stated since the resident's fall, management had been more aggressive with training and ensuring two person transfers were occurring with mechanical lifts. She stated management staff had been trained on mechanical lift transfers to ensure more staff were available to assist. CNA #8 was interviewed on 8/8/19 at 5:30 p.m. and stated she was informed of the lift policy prior to working in the facility. She stated two people were required for all mechanical lift transfers. She stated she was not sure there were enough staff at all times to be able to always have two people for the transfers. CNA #9 was interviewed on 8/9/19 at 10:03 a.m. and stated she had been trained on the facility lift policy and knew two staff members were required for mechanical lift transfers. She stated she only worked the day shift where two staff members, including management, was easier to find, but stated on the evening/night shift when management was not in the building and there were only three nurses and three CNAs it would be more difficult. Licensed practical nurse (LPN #1) was interviewed on 8/12/19 at 11:00 a.m. and stated she would not be surprised if CNAs were transferring residents by themselves with mechanical lifts because there was not always enough staff. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on8/12/19 at 2:25 p.m. The NHA stated that the facility had always enforced the policy of two staff members assisting with mechanical lift transfers. He stated staff was re-educated and competencies were evaluated after the resident had fallen. He stated all staff, including management, were available to assist with mechanical lift transfers. He confirmed there was no documentation in the resident record related to her refusals of the hoyer lift or two person assistance, and that it should have been documented in assessments, nursing progress notes, and the resident's care plan. III. Resident #4 A. Resident status Resident #4, age 89, admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 7/18/19 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive function. She had difficulty focusing her attention and had disorganized thinking. She required extensive assistance of one person for activities of daily living. B. Record review a. Fall risk assessment According to the 7/16/19 Fall Risk Assessment the resident was a high risk for falls with a score of 12 with a score of 10 or higher indicating at risk. b. Care plan The care plan, last revised 12/23/18, revealed the resident was at risk for falls related to unsteady balance, poor safety awareness and cognitive status, side effects of medications, a history of falls, a fluctuation in strength and endurance and the resident reached for items on the floor. Interventions included: -Be sure call light was within reach and encourage to use it for assistance as needed; -Provide prompt response to all requests for assistance; -Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility; -Ensure appropriate footwear was being worn when ambulating or mobilizing in wheelchair; -Provide a safe environment; -Anti-tip to wheelchair; -Cushion to wheelchair to assist with positioning and pressure relief; -Encourage to seek assistance with reaching for items out of reach; -Encourage and assist to engage in activities of choice post meals; -Monitor for restlessness and then assist to toileting or bed as needed; -Place a scoop mattress; -Assist from the dining room after meal completion; and -Encourage and assist to engage in activities of choice post meals. c. Falls 1. 4/16/19 fall According to the 4/16/19 Situation, Background, Assessment, Recommendation (SBAR) Communication and Progress Note at 7:45 a.m., the resident leaned forward in her wheelchair and fell on the floor. The resident bumped her head on the floor and had a purple area noted to her right forehead. No other injuries were noted. This assessment was done by a licensed practical nurse (LPN). Review of the record revealed no documentation of a registered nurse (RN) assessing the resident after the fall. There was no documentation in the record to indicate this fall had been followed up by the interdisciplinary team (IDT). The care plan was updated on 4/16/19 to include: get up right before meals as resident tires easily. 2. 5/21/19 fall According to the 5/21/19 SBAR, the resident was observed by her roommate walking towards the bathroom. The roommate said the resident tipped backwards and fell on her bottom and stayed sitting up. Upon entering the room, the resident was sitting on the floor next to the bathroom. This assessment was done by an LPN. Review of the record revealed no documentation of an RN assessing the resident after the fall. According to the IDT Post Fall Review, signed by the director of nursing (DON) on 5/28/19, intervention recommendations were to monitor for injury, monitor and treat any complaints of pain and staff was to be educated to ensure that the resident was assisted up for meals. Review of the record revealed no neurological checks were done after this fall. Further review of the record revealed the resident was monitored for only 18 hours after the fall instead of the recommended 72 hours. The care plan was not updated with this fall or any interventions. IV. Resident #8 A. Resident status Resident #8, age 72, admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 7/24/19 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. He required supervision with set up assistance for his ADLs. B. Record review a. Fall risk assessment According to the 7/19/19 Fall Risk Assessment the resident was a high risk for falls with a score of 11. b. Care plan The care plan, initiated 3/30/19, revealed the resident was at risk for falls related to fluctuation in strength and endurance, potential side effects of medication usage, a history of falls, an unsteady balance and hallucinations with feeling of being unsafe. Interventions included: -Be sure call light is within reach and encourage to use it for assistance as needed; -Provide prompt response to all requests for assistance; -Provide education about safety reminders and what to do if a fall occurs; -Encourage to seek assistance with transfers, ambulation and for picking up items off floor or not within reach; -Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility; -Ensure appropriate footwear is being worn when ambulating or mobilizing in wheelchair; and -Provide a safe environment. c. Falls 1. 3/24/19 falls According to a 3/24/19 nursing note at 3:30 p.m. the resident was found with his hands on the side rail and on his knees in front of his bed. The resident was lifted up and given his walker. He had a skin tear to his left knee reopened from an injury prior to admit. The SBAR for this fall did not contain any information about the fall. It had vital signs taken at 7:28 a.m. documented along with notification to the resident's son at 3:00 p.m. and the physician at 2:29 p.m. According to the 3/24/19 SBAR written at 11:43 p.m. the resident was found on the floor. He stated he must have been dreaming. He was found on the floor next to the bed on his knees with his head down. He had scabs on his knees and forehead that reopened. According to the IDT Post Fall Review for the 1st fall on 3/24/19, intervention recommendations were for safety strips to be applied in his room. According to the IDT Post Fall Review for the 2nd fall on 3/24/19, intervention recommendations were for staff to ensure proper positioning in bed with every encounter. Review of the record revealed the care plan, initiated after this fall, did not include these interventions. 2. 4/15/19 fall According to the 4/15/19 SBAR the resident was starting to stand up from his bed and his slippers slid and he had to be lowered to the floor. According to the IDT Post Fall Review for this fall on 4/15/19, intervention recommendations were to apply safety strips next to the bed. (The same intervention recommended after the 3/24/19 fall.) The care plan was updated on 4/16/19 to include safety strips to the floor by the bed. V. Staff interviews LPN #3 was interviewed on 8/12/19 at 12:18 p.m. She said if a resident fell , she would make sure they were safe while the RN was notified. The resident was not to be moved until the RN completed a full head to toe assessment. She said notification needed to be made to the physician, family and supervisors. She said the nurse should document the fall and would continue to follow up and document for 72 hours. She said if the fall was unwitnessed or if the resident had a head injury, then neurological checks needed to be done. She said the IDT determined new interventions and should update the care plan. She said when safety strips were ordered, she would notify either maintenance or therapy to get them applied. She said the IDT was responsible to ensure the staff was aware of the interventions and to make sure the strips were put into place. Registered nurse (RN) #1 was interviewed on 8/12/19 at 1:38 p.m. She said when a resident fell she would assess them for injuries and then get them up if they were not injured. If they were injured, she said she would administer the appropriate first aid. She said she did a full head to toe skin assessment and pain assessment with every fall. She said an SBAR needed to be completed and the physician and family needed to be notified. She said if the fall was unwitnessed or if the resident had a suspected head injury, neurological checks needed to be initiated before the resident was ever moved. She said suggestions for interventions could be made by any of the nurses, therapy or management. She said all the falls and interventions were reviewed by the IDT. She said the care plan needed to be updated after every fall and could be updated by any nurse or therapy member. She said if safety strips were ordered, either maintenance or therapy would put them in place but it was the director of nursing (DON) or other managers to ensure it was done. The DON and district director of clinical services (DDCS) were interviewed on 8/12/19 at 2:57 p.m. They said interventions should be put into place immediately after the fall. They said all falls should be reviewed by the IDT within 72 hours after the fall to review the effectiveness of the interventions. They said the care plan should be updated after each fall with any new interventions. They said if an intervention for safety strips was recommended, it would be brought up to maintenance in the morning meeting and should be followed up on during the stand down meeting at the end of the day to make sure it was done.

Based on record review and staff and resident interviews, the facility failed to ensure [MEDICATION NAME] and hypertension medications were ordered and administered in a timely manner to prevent missed doses for three (#1, #5 and #8) of seven sample residents. Specifically, the facility failed to ensure timely reordering of [MEDICATION NAME] resident #5. The resident missed three doses and experienced symptoms of withdrawal, including pain at a 10 out of 10 level, sweating, nausea, and diarrhea. Additionally, the facility failed to ensure timely reordering of [MEDICATION NAME] for resident #1. The resident missed two doses. The resident experienced mild pain. The facility further failed to ensure timely reordering of [MEDICATION NAME] for resident #8. The resident missed one dose. The findings included: I. Facility Process The facility's pharmacy policy for medication refills, as provided on 12/15/17, indicated the following in pertinent part: -- Medications could be ordered electronically through the pharmacy's electronic re-ordering system. -- If the medication was not due for refill yet, the refill request would not process. -- Narcotics required a reauthorization from the physician for refills. Registered nurse (RN) #1 was interviewed on 12/14/17 at 4:05 p.m. She stated that when a resident was getting low on medication, about a week away from being out, she would reorder their medication. She stated she attempted to check all of her residents' medications at the end of her shift to see what medications needed to be reordered. She stated it is every nurse's responsibility to reorder medications. She stated there are two ways to reorder medications in the facility. The first way to reorder was using the system in point click care (PCC), the computerized charting for the resident. She stated when you used the system in PCC you could click on the reorder button, but sometimes that did not work. She stated the other way to reorder medication was by faxing in the request to the pharmacy. She stated when she ran out of a medication she would make a note in the resident's Medication Administration Record [REDACTED] -The RN stated if she ran out of a medication that was needed by the resident immediately, she called the pharmacy and got an authorization to get access to the emergency medication kit. She stated there was a list of the available medications in the emergency medication kit in every narcotics book located at every nurses' station. The RN said the e-kits included most narcotic medications. RN #2 was interviewed on 12/14/17 at 4:07 p.m. She said she had been directly employed by the facility for approximately a month and prior to that had worked in the facility as an agency nurse. She said the facility did frequently have difficulties with running out of medications, which she said was a result of the agency nurses not knowing when to reorder or how to do so efficiently. She confirmed she had not been certain of the facility's medication ordering or pharmacy policies when working as an agency staff nurse. -The RN said staff were to reorder medications when the supply was down to a few days' worth of medication. She said staff could order through a button on their computer, but that the button would not work if the refill was not listed as due in the pharmacy's system. She said it was each nurse's responsibility to ensure refills were ordered timely. -The RN stated that her cart occasionally ran out of medication, but said it was less frequent on that cart than on some of the other carts because both herself and the day shift nurse were directly employed by the building and had received training on how and when to order medications. She said she and her counterpart conducted informal checks for each other, but said she was not aware of any auditing program to double check medication ordering. -The RN said when the cart ran out of a medication, the nurse was supposed to contact the pharmacy and tell them she needed the medication stat and call the physician for guidance to see if the medication could be held or a similar medication administered. She said if the medication was a narcotic, it was usually available from the e-kit. She said she had to fax the pharmacy and obtain an authorization number to access the kit, and then could obtain the medication. She said the narcotics e-kit contained both [MEDICATION NAME] and those could be obtained with confirmation from the pharmacy as long as there was a physician's orders [REDACTED]. RN #3 was interviewed on 12/14/17 at 4:17 p.m. She said she worked as an agency nurse in the facility. She said she would reorder medications when the medication was not available in the cart. She said she usually called the pharmacy to request the medication and they were usually able to deliver it on their next run to the building. -She said the cart she worked on ran out of medication one to two times a week. She said when this happened, she needed to call the pharmacy to try to obtain the medication as quickly as possible. She said she could not divert medication from another resident, so if the medication was not urgent she would wait for the pharmacy to arrive. When prompted, the RN confirmed she could access the e-kit for some medications, and confirmed that most narcotics were available with an individual access code that could be obtained from the pharmacy. The staff development coordinator (SDC) was interviewed on 12/14/17 at 4:52 with the nursing home administrator (NHA), director of nursing (DON), assistant director of nursing (ADON), and district clinical directors (DCD) #1 and #2. -The SDC said medications were reordered through a link between the facility's electronic medical records system and the pharmacy's system. She said nurses could simply push a button on their screen to reorder the medication. She said the facility's nurses had been instructed to notify nursing management if they were unable to order a medication. -The SDC said medications should be ordered when the card was down to the last column and that the nursing staff should not wait until the last dose or when the medication was out to re-order. She said if a medication did run out, staff should inform management and attempt to obtain the medication from the pharmacy on their next run, and if the medication was an urgent one, such as a pain medication or an antibiotic, it might be available through the e-kit. -The SDC said facility staff were trained on the medication ordering procedures. She stated if the agency staff had questions about the medication ordering process, the management could answer their questions. -Regarding the facility's system for auditing, DCD #1 said a report could be generated of missed doses to trigger a review of why medications were missed. However, none of the staff present were aware of a proactive audit of medication ordering prior to the residents missing a medication. -The NHA and DCD #2 stated they would check in with the agency nurse on the floor to ensure she was aware of how and when to order medications. II. Resident failures A. Resident #5 1. Professional references a. The Food and Drug Administration (FDA) label for [MEDICATION NAME] sulfate, accessed via https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/ 7s004lbl.pdf (12/19/17), indicated the following in pertinent part: -Chronic use of [MEDICATION NAME] can lead to dependence, which involves the manifestation of withdrawal symptoms after stopping use of the drug. -Withdrawal is characterized by the manifestation of symptoms, including muscle pains, chills, restlessness, and sweating following the removal of the medication. Additional symptoms, such as nausea, vomiting, diarrhea, and anxiety, were also noted as being present. -As a general rule, chronic [MEDICATION NAME] users should be tapered off the medication rather than having administration abruptly stopped. b. According to Drugs.com, https://www.drugs.com/condition/opiate-withdrawal.html (12/28/17), the following medications are used for treatment and prevention of withdrawal symptoms: [MEDICATION NAME], Robaxan, [MEDICATION NAME], Methadose, Methocarbomel, Dolophine, [MEDICATION NAME], and [MEDICATION NAME]. c. The Food and Drug Administration (FDA) label for [MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME]), accessed at https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/ 8s053lbl.pdf (12/28/17), indicated the following in pertinent part: -The on label use for [MEDICATION NAME] is relief of moderate to moderately severe pain. There is no indication for use in the prevention or relief of symptoms caused by [MEDICATION NAME] withdrawal. 2. Resident status and physician orders Resident #5, age 66, was admitted to the facility on [DATE]. According to the December 2017 physician orders [REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 of 15. She had received scheduled and as needed (PRN) medications for pain during the assessment period, but was not in pain at the time of the assessment. A computerized physician order [REDACTED]. 3. Record Review A review of the resident's Medication Administration Record [REDACTED] The resident received her scheduled 8:00 a.m. dose of [MEDICATION NAME] 11/2/17. The administration scheduled for 11/2/17 at 1:00 p.m. was not given. The MAR indicated [REDACTED]. The administration scheduled for 11/2/17 at 8:00 p.m. was not given. The MAR indicated [REDACTED]. The nursing note related to the scheduled administration, written on 11/2/17 at 9:13 p.m., indicated the medication was not on hand and an authorization from the physician was pending. The administration scheduled for 11/3/17 at 8:00 a.m. was not given. The MAR indicated [REDACTED]. The nursing note related to the scheduled administration, written on 11/3/17 at 9:32 a.m., indicated the medication was not on hand and the nurse had notified the nurse practitioner, resident's family, and the pharmacy. A review of the nursing notes and MAR indicated [REDACTED]. The [MEDICATION NAME] was demonstrated as effective. A review of the nursing notes and MAR indicated [REDACTED]. A situation, background, assessment, recommendation (SBAR) evaluation note dated 11/3/17 at 9:00 a.m. indicated the resident presented with severe pain (10 out of 10), sweating, heavy breathing, nausea, and diarrhea. The note indicated the nurse was concerned the resident might be in withdrawal from the MS Contin. The note indicated the nurse practitioner was notified and the resident was prescribed a stat 15 mg dose of MS contin, and 10 mg [MEDICATION NAME] to be administered every hour for withdrawal symptoms. The resident also received an administration of [MEDICATION NAME], an administration of [MEDICATION NAME], and an administration of [MEDICATION NAME]. After the first hourly administration of [MEDICATION NAME], the resident was noted to be resting quietly. A review of e-kit requests provided by the facility demonstrated the kit was accessed on 11/3/17 at 9:45 for the resident with an order for [REDACTED]. No other ekit requests were made. 4. Resident and staff interviews The resident was interviewed on 12/14/17. She said she had pain from [MEDICAL CONDITION] arthritis and [MEDICAL CONDITION]. She stated that she received multiple scheduled pain medications to manage her pain and they were generally effective. She described severe breakthrough pain that was alleviated through additional PRN medications. -The resident did not recall specific concerns about the administration of her pain medications during the interview. Registered nurse (RN) #2 was interviewed on 12/14/17 at 4:07 p.m. She said at the time of the incident above, she had been employed as a temporary agency staff and had worked the cart for the resident. She said that while directly employed staff were well trained in how to order medications and what steps to take when medications ran out, the agency staff were not well versed in these procedures. -Regarding resident #5, the RN confirmed the medication had run out and that as documented in the nursing notes, a physician authorization had been needed to obtain a refill. She confirmed the resident had experienced nausea, severe pain, and sweating. On 12/14/17 at 4:52 p.m., the staff development coordinator, (SDC), director of nursing (DON), assistant director of nursing (ADON), nursing home administrator (NHA) and both district compliance directors (DCD #1 and #2) were interviewed. -The SDC confirmed it was not facility practice to wait until the last dose to reorder medications because it could result in the resident not having the medication available, especially if additional steps were needed to fill the medication. -The SDC said if the facility ran out of a medication, the nurse was to call the physician for guidance and attempt to obtain the medication from the pharmacy on the next run. She said for medications that would be needed right away, including pain medications, the nurse should call the pharmacy to access the e-kit, provided that there was an order. -Regarding resident #5, staff confirmed the medication appeared to be waiting for physician confirmation of the refill. DCD #1 was interviewed on 12/15/17 at approximately 12:00 p.m. She confirmed by observation that the [DIAGNOSES REDACTED]. B. Resident #1 1. Resident status and physician orders Resident #1, age 78, was admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The 9/27/17 annual minimum data set (MDS) assessment documented the resident was cognitively intact as evidenced by a brief interview for mental status (BIMS) with a score of 13 out of 15. According to the MDS, the resident was on a scheduled pain medication regimen. According to the CPOs the resident had an 8/7/17 order for [MEDICATION NAME] HCI tablet 50 MG, one tablet by mouth three times a day scheduled at 8 a.m., 4 p.m., and 10 p.m., for pain. 2. Record Review A review of the resident's December 2017 Medication Administration Record [REDACTED]. The missed doses were the resident's 10 p.m. dose on 12/10/17 and his 8 a.m. dose on 12/11/17. A review of the December 2017 nursing progress notes revealed the resident was not given the ordered [MEDICATION NAME] because the facility had run out of the medication. Regarding the resident's missed 10 p.m. dose on 12/10/17, the nursing progress note indicated the facility was waiting for the medication to be delivered from the pharmacy. When the resident's 8 a.m. dose on 12/11/17 was missed, nursing progress notes indicated the medication was still not in the facility, but that the medication would be delivered on 12/11/17 by the pharmacy. According to the 12/11/17 nursing progress note the resident had to request [MEDICATION NAME] for mild pain. According to the resident's December 2017 vitals summary, his pain level on 12/10/17 at 8:45 p.m. was three out of 10. His pain level on 12/11/17 at 9:28 a.m. was three out of 10. See staff interviews above regarding facility process and expectations for medication ordering and availability. C. Resident #8 1. Resident status Resident #8, under age 55, was admitted to the facility on [DATE]. According to the physician orders [REDACTED]. According to the minimum data set (MDS) assessment dated [DATE] the resident was alert and oriented with a brief interview for mental status (BIMS) score of 15 of 15. 2. Resident interview Resident #8 was interviewed on 12/15/17 at 9:40 a.m. He stated the facility had run out of his [MEDICATION NAME] on 10/31/17 and he had missed his regularly scheduled dose. He said this was a common concern in the facility, with a medication running out approximately every two weeks. The resident attributed this to the procedures when the medications were checked in. He said when the nurses did not check the drugs in right, they were not able to reorder them using the computer system, which was how they usually did it. He said when they could not order through the electronic computer system, they had to call the pharmacy on the phone. He said because the nurses were busy, they sometimes forgot or just did not have the time to call the pharmacy and that as a result, residents ran out of medications. See staff interviews above regarding facility process and expectations for medication ordering and availability.

Based on observations, interviews, and record review, the facility failed to ensure all staff was trained in procedures necessary to emergently evacuate one of 28 sample residents (#14). Specifically: The facility failed to create and train staff on a specialized evacuation protocol to accommodate the special needs of resident #14 in the case of an emergency. The resident required the use of a bariatric bed and was unable to transfer independently. The resident's bed could not fit through the doorway to her room and her only wheelchair was not always operational. Further investigation revealed staff was not aware of the protocol to evacuate residents with special needs, could not identify and/or clarify a procedure to evacuate resident #14, and instructions on how to evacuate the resident were not in the facility's emergency manual. The facility's failure to ensure staff was prepared to safely evacuate resident #14 in the case of an emergency created a situation of immediate jeopardy with the potential for serious harm. The findings included: I. IMMEDIATE JEOPARDY A. Findings of Immediate Jeopardy Observations, staff interviews and record review revealed the facility failed to have a plan to evacuate resident #14 in the event of an emergency, failed to educate staff on such a plan, and failed to communicate such a plan to all staff. These failures created a situation of immediate jeopardy for serious harm. On 6/30/14 at 3:47 p.m., the corporate nurse consultant (CNC), and the director of nurses (DON) were informed these facility failures created a situation of immediate jeopardy for serious harm. (At that time, the DON stated another resident (resident #91) had been identified by the facility as unable to get out of bed and, therefore, like resident #14, would have to be evacuated in an emergency in her bed.) B. Plan to Remove Immediate Jeopardy 1. On 7/1/14 at 2:41 p.m., the facility presented a plan to keep resident #14 as well as facility-identified at risk resident #91, safe. The plan was as follows: Residents identified at risk -Resident #14 -Resident #91 The facility floor plan has been reviewed and updated to include methods for transferring the residents below, based on individual need, in the case of an emergency. Resident #14 - transfer from bed - move bed in lowest position, use 4 staff members (at a minimum) slide resident utilizing bed linen to floor on to a fall mat, protecting head with pillow, pull resident to safety out nearest door. Two (2) staff will stay with the resident while moving to provide safety until resident is in a safe location. During a simulated practice this process took less than 5 minutes. If resident is up in wheelchair 1 person can transport resident out door to safety. The facility will provide a bariatric, manual wheelchair for use during an evacuation. Care plan has been updated on 7/1/14 to reflect the special evacuation needs of this resident. At time of emergency if in bed this resident would be evacuated last if in wheelchair second. Resident #91 - disconnect [MEDICAL CONDITION], take tube feeding and ambu bag with resident and 1 staff member to move resident via bed to safety out nearest door. Care plan has been updated on 7/1/14 to reflect the special evacuation needs of this resident. At time of emergency this resident would be evacuated last. Staff from every department then was educated regarding the individual plans for these two residents and an emergency evacuation transfer simulation will take place on 7/1/14 that will assure that the plans work smoothly and efficiently for these residents. Residents with the potential to be at risk Reviewed the plan of care of each resident to determine whether the resident has special needs, such that an individualized plan for transfers is necessary for those residents identified. An emergency preparedness plan was established for residents with special needs and for residents in the general population. The method of transfers (was) mapped on the facility floor plan so that staff has clear guidance on how to move residents in the event of an emergency. Care plans and care cardexes were updated to reflect additional interventions in the event of an emergency. Care plans and cardexes will be reviewed and updated, as necessary, quarterly, annually and with change of condition. Systemic Changes All newly admitted residents will be evaluated by the IDT (interdisciplinary team) during the admission process to determine whether they have special needs that would require individualized plans for transfers in the event of an emergency. Members of the interdisciplinary team will collaborate to develop such transfer plans for each identified resident. Care plans and care cardexes will be updated to reflect individual transfer plans and will be identified on the facility floor plan and a copy of the individualized transfer plan will be posted inside the residents' closet door(s). The floor plan will be located in the red Operations 6, Emergency Preparedness Manual, under the tab marked floor plan emergency routes. The floor plans will be updated by the DON/designee with each admission and/or significant change. These floor plans will be located at each nurses' station in the red emergency binders. Employees will be educated on these admission needs. Staff was educated by the DON/designee beginning on 6/30/14 regarding Evacuating Residents with Special Needs. Education included ensuring the following: The registered nurse in the facility will take charge of the evacuation process until the administrator / DON arrives to assume responsibility. Evacuation will take place in accordance with facility Emergency Preparedness policies and procedures. As per, Evacuation/Shelter-in-Place policy, Priority of Movement residents will be evacuated in the following order. . Ambulatory residents 2. Residents using wheelchair and walkers 3. Residents who are bedridden residents. Such transfer will be done using emergency lifts and transfers 4. Residents requiring special precautions. The NHA (nursing home administrator) or designee will provide additional education to the charge nurses regarding the above evacuation process. Newly hired charge nurses will receive this training upon hire. Staff will remain in their designated area unless reassigned by someone in authority (charge nurse, NHA, DON, etc.). Local authorities will assume overall command of emergency situations when they arrive on the scene. District and Division staff will respond, as needed, and will assist with emergency evacuation. The Administrator or Director of Nursing will contact local authorities (fire and police departments) for assistance, where necessary. Bariatric Residents: - transfer from bed - move bed in lowest position, use 4 staff members slide resident utilizing bed linen to floor protecting head with pillow, pull resident to safety out nearest door. If resident is up in wheelchair 1 person can transport resident out door to safety. Residents with Trachs: - Disconnect [MEDICAL CONDITION] (if present), take tube feeding (if present) with resident and 1 staff member to move resident via bed to safety out nearest door. Newly hired employees will receive this training during general orientation to the facility. This education will include a return demonstration of moving someone from bed to floor. Procedures will be reviewed with current staff periodically during drills using the procedures for evacuating residents with special needs. The NHA or designee will track and trend evacuation drills, admission evaluations and ongoing evaluations of current residents with special evacuation needs, floor plan updates, current staff and newly hired staff education. The facility QAPI (Quality Assurance) committee met on 7.1.14 to review and approve this plan. The QAPI committee will meet daily until the findings or immediate jeopardy are removed. Thereafter, during the monthly meeting any identified trends will be shared with the QAPI committee. The committee will evaluate the effectiveness of the plan and make recommendations for improvement. " C. Removal of Immediate Jeopardy On 7/1/14 at 4:00 p.m. the immediate jeopardy was removed based on review of the facility's updated floor plan and emergency manual and resident #14's care plan. However, deficient practice remained at an E level (potential for more than minimal harm at a pattern) based on the facility's systematic failures identified during survey 6/23/14 - 7/2/14, including the lack of floor plans that mapped residents' transfer needs, the lack of information on addressing residents' specialized needs in the emergency manual, as well as the lack of staff training on emergency evacuations upon hire and periodically thereafter. Review of the employee training record revealed that the last training had occurred more than a year prior in 4/13. Employee interviews confirmed that an RN who had been employed by the facility for two months at the time of survey had not been educated on the facility ' s emergency and evacuation protocols. II. Resident #14 Resident #14, age 47, was readmitted to the facility on [DATE]. The resident's face sheet, dated 6/20/14, indicated the resident suffered from [DIAGNOSES REDACTED], a condition in which the spine is not completely formed and causing exposure of nervous tissue. The resident's face sheet also indicated that the resident was morbidly obese. The resident's most recent Minimum Data Set ((MDS) dated [DATE], indicated that the resident weighed 411 pounds at the time of the assessment. The MDS also indicated the resident required two or more staff to assist her in bed mobility (moving around in her bed) and transferring (moving from her bed to her wheelchair/chair to bed), and that she was impaired in the mobility of both her lower extremities. 1. Record Review Record review demonstrated resident #14 required additional assistance during an evacuation based on her size, mobility limitations, and low trunk strength. Record review also demonstrated that, although the facility had equipped each nursing station with red binders containing emergency and evacuation protocols, the facility failed to develop a specific plan to address the special needs of resident #14, as required by their policies. As a result, the information needed to quickly and safely evacuate resident #14 in the case of an emergency was not readily available. Specifically: - The resident's vital sign and weight flow sheet indicated that her most recent weight, taken on 6/5/14, was 379.5 pounds. - The resident's most recent transfer evaluation, dated 6/2/14, indicated that the resident was unable to bear weight, and she was unable to sit on her bedside without full back support. -The resident's most recent side rail safety assessment indicated that the resident experienced problems with balance and poor trunk control. - The resident's care plan for Activities of Daily Living (ADLs), dated 6/2/14, stated the resident required extensive assistance for ADLs. The care plan also contained a note, dated 4/24/14, which read the resident refused to get up at times. - The resident's care plan for transferring, dated 6/2/14, stated the resident required the use of a Viking lift plus two person assist for transfers due to [DIAGNOSES REDACTED] and weakness. - The facility's emergency protocols, last revised in June 2012 and copied at the facility on 6/30/14, stated that bariatric residents constituted a special needs population requiring individualized evacuation plans in the case of evacuations. - The facility's emergency protocols, last revised in June 2012 and copied at the facility on 6/30/14, contained a section titled, "Evacuation of Bariatric Residents." The section read, "After admission of a bariatric resident, the administrator should mark the location of the resident's room assignment on the floor plan ... determine whether or not the resident can be evacuated while in bed. If not, identify a method of transferring the resident that will allow for safe evacuation ...Determine the number of employees that will be required to help in the evacuation of each bariatric resident ...identify a specific number (of) employees assigned to assist in evacuation of residents based on the pre-determined number." - The facility's Tornado Plan stated that residents in the west hall "are to be placed from the Social Services office down to the tee (unclear in copy) in west hall." - The facility's red emergency protocol binders, as examined on 6/30/14 at 11:30 a.m., did not contain specific instructions for the evacuation of resident #14, nor did the binders contain a marked floor plan to assist staff in locating resident #14's room. 2. Observations - On 6/24/14 at 2:34 p.m., resident #14 was observed lying in her bed inside her room. The bed was wider than a normal bed intended for use by bariatric residents, and was equipped with a grab bar. - On 6/30/14 at approximately 11:00 a.m., a bariatric bed identical to resident #14's bed was measured to have a width of 48 inches. The doorway to resident #14's room was measured to have a width of 44 inches. - On 6/30/14 at 1:55 p.m., the DON and corporate nurse consultant (CNC) were observed viewing the floor plan, which was posted above the facility's fire alarm panel. The floor plan did not contain a mark denoting resident #14's room, or any specific instructions regarding her evacuation needs. 3. Interviews Interviews with resident #14 and the staff revealed that the resident was frequently confined to her bed due to set times when staff was available to help her transfer, and also because her wheelchair was frequently broken. The interviews also revealed that the staff had not been trained regarding specific steps needed to safely evacuate resident #14 in the case of an emergency. Finally, the interviews revealed miscommunication around which division was responsible for updating the evacuation protocols and providing training to staff. Specifically: - On 6/24/14 at 2:34, resident #14 was interviewed. The resident stated she is unable to get out of her bed on her own, and she requires the assistance of staff to get out of her bed and into her wheelchair. The resident stated that the staff did not always get her out of bed in the morning and, when that happened, she would be in bed all day. - On 6/30/14 at 10:00 a.m., the resident was interviewed. The resident stated she would not be able to get out of her bed today because her wheelchair had broken. The resident stated she did not know how long it would take for the chair to be fixed, but in the past, it had taken multiple weeks for the chair to be fixed. The resident stated that she could not use another chair because she would fall out. As a result, she would be unable to leave her room until the chair was fixed. -On 6/30/14 at 12:30 p.m., the maintenance director (MD) was interviewed. He said he had been employed at the facility for approximately 3 months. The MD stated that he was not in charge of the red emergency books. He stated that he had not completed an evacuation; however, fire drills occurred monthly. The MD stated that the bariatric beds were not able to fit through the doorway; he stated the beds were too big and not all the beds, including resident #14's, collapsed. The MD stated that if staff cannot get a resident out in case of emergency, then their door is closed and resident remains in the room. The MD stated that he had not been trained on the emergency red books. - On 6/30/14 at approximately 12:45 p.m. the DON was interviewed. The DON stated the MD is in charge of the red emergency books. She stated that a trial evacuation of residents had not been attempted in the past year. She stated resident #14 is unable to get out of bed alone and is a bariatric resident. - On 6/30/14 at 12:24 p.m., registered nurse (RN) #2 was interviewed. She had been employed at the facility for one year. RN #2 stated she had received fire safety and emergency evacuation training. The RN said that in the event of a fire, she would look at the fire alarm panel to determine the location of the fire. She would page all staff to the location and would evacuate all residents in the area of the fire to a location behind the nearest set of fire doors. The RN stated that the evacuation would proceed based on the resident's proximity to the location of the fire. The RN stated residents that were in bed would be wheeled out in bed, but was unable to describe how she would evacuate a resident in a bariatric bed. She said she would need to check and answer that question later. The RN followed up at 12:28.p.m. and stated that the facility would use a drop and drag method for a bariatric resident, and stated that staff would lower the bed as close to floor as possible and lower the resident to the floor with a sheet and exit the resident in this way. However, the RN was not able to specify the number of staff required to evacuate resident #14 in this way. - On 6/30/14 at 12:34 p.m., RN #1 was interviewed. The RN stated she had been employed at the facility for two months and had not received training on the facility's emergency protocols. The RN stated that in the case of an emergency, she would expect everything she needed to know to quickly implement the appropriate emergency protocol to be in the red emergency binder. The RN stated that in the event of an emergency, she would evacuate bed-bound residents in their beds, because there would not be time to transfer residents into their wheelchairs. However, the RN also confirmed that if the facility were to evacuate, resident #14's bed would not fit through the door of her room. The RN stated that she assumed they would have to "drop and drag" resident #14, and stated that she didn't know exactly how many staff would be required to evacuate the resident using this method. - On 6/30/14 at 12:36 p.m. housekeeper #3 was interviewed. The housekeeper stated she had received fire safety and emergency evacuation training. She stated the facility conducts fire drills every month, with the last drill being in May. The housekeeper stated that in the case of an emergency, she would close the resident door after checking the resident and would go to the nurse for any concerns or questions. The housekeeper stated that if the resident were immobile, she would ask the nurse for direction. - On 6/30/14 at 12:42 p.m., the Physical Therapist (PT) was interviewed. The PT stated that she had received fire safety and emergency evacuation training. The PT stated the facility did fire drills almost every month, but that she did not know when the last drill had occurred. The PT stated that if the facility had to evacuate, the residents would be taken past the fire doors. The PT confirmed that resident #14's bariatric bed was not able to get through the doorway to her room, and stated that they would have to use a lift to get the resident into a wheelchair. - On 6/30/14 at 1:35 p.m., CNA #4 was interviewed. She said she had been employed at the facility over a year. The CNA stated she had received fire safety and emergency evacuation training once since employment but she did not remember the evacuation for a bariatric resident being covered. The CNA also stated that she did not think resident #14's bed would fit through the door of her room. The CNA stated she "honestly had no idea how (staff) would evacuate (resident #14)" if there was a fire and she was in bed. - On 6/30/14 at 1:45 p.m. the DON and the CNC were interviewed. The DON and CNC, by observation, confirmed that the facility's emergency evacuation protocols required for all rooms containing residents with special needs to be marked on a floor plan of the facility. The DON and CNC, by observation, also confirmed that the red emergency binder did not contain a floor plan at all; the floor plan was located on top of a cabinet by the front nurses' station and the DON and CNC observed that resident #14's room was not highlighted. Moreover, there were no instructions regarding a special evacuation protocol for the resident. The DON stated that they would immediately correct the floor plan so it would be usable in the case of an emergency and place copies in the red emergency binders. The DON and the CNC both stated that it was not acceptable to just close the door and leave the resident in the room during an evacuation. Both stated they would expect all staff to know that. - On 6/30/14 at 2:10 p.m. and again at 2:20 p.m., CNA #1 was interviewed regarding use of lifts. The CNA stated that there were approximately 6-7 residents on West wing and 3-4 residents on East wing who required the Viking Hoyer lifts in order to transfer. The CNA stated that there were 2 regular Viking Hoyer lifts, and 1 specialized Viking Hoyer lift that could be used for bariatric residents. The CNA stated the Bariatric Viking Hoyer was required for resident #14 as she exceeded the weight limit for the other 2 regular lifts. However, the CNA stated that the lift was not assigned to any specific resident and it was utilized for other non-bariatric residents if the 2 regular lifts were being utilized. - On 7/1/14 at 10:46 a.m. the Business Office Manager (BOM) was interviewed. The BOM stated that she served as resident # 14's ambassador, meaning that she was the resident's primary staff contact for any issues or concerns at the facility. The BOM stated resident #14's wheelchair broke frequently and that it was currently broken. She stated that she had contacted the manufacturer of the chair for maintenance and they had informed her that it would take three weeks before they could fix the chair. The BOM stated that what usually broke on the resident's chair was a hydraulic lift that allowed for the chair to tilt in space. She stated the chair had to be tilted when resident #14 was sitting in it; otherwise, her feet hit the wheels. She stated that she was unaware of a manual wheelchair that could accommodate the resident, and stated the PT would have to assess the manual wheelchairs for positioning and suitability. - On 7/1/14 at 3:19 p.m., the PT was interviewed about resident #14's wheelchair. The PT stated resident #14's chair was specifically designed to accommodate her size, as well as to tilt in space so resident #14 could safely sit in it. The PT also stated that the resident's wheelchair would sometimes break due to her weight, and that it is currently broken. She stated that it would not be safe for resident #14 to be placed in a manual wheelchair, because the resident lacked the trunk strength to hold herself upright. The PT stated that she had done research to try to find a tilt in space manual chair that could accommodate resident #14's size so the facility would have a back up chair, but that she had not been able to find one. The PT also clarified that if there were an evacuation and resident #14's chair was broken, they would not be able to transfer her into a chair to evacuate. The PT stated that they would have to drop her to the floor and drag her out on bedding and then wait for a gurney.

Based on observations and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two of 37 sample residents (#9 and #12). Specifically, the facility failed to ensure: -Resident #9's witnessed fall resulting in a fracture was thoroughly investigated. -Medication carts were locked when nursing staff were not within sight of the cart. -Resident #12 had appropriate implementation of interventions after multiple skin tears. The findings include: I. Failure to Investigate Falls A. Facility Policy On 10/4/12 at 3:00 p.m., the Nursing Home Administrator (NHA) provided the Facility Practice Guidelines on Fall Management (revised 2/2010). The guidelines (Fall Event) documented, in pertinent part: 1. When a fall occurs assess the resident for injury. 2. The Licensed Nurse will complete: Incident/Accident Report (Briggs), 24-hour Report (Briggs) and Initiate the Interdisciplinary Post Fall Review. 3. Communicate all resident falls to the attending physician and the resident's family and document on the Interdisciplinary Post Fall Review form. The licensed nurse documents family/responsible party and physician notification on the Interdisciplinary Post Fall Review form and places the completed form in the Nurse's Notes section of the Medical Record. 4. The nurse will communicate the resident fall to the IDT via the 24-Hour Report (Briggs). 5. The IDT will review all resident falls within 24-72 hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. 7. The IDT then modified and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. The RCS Assignment Sheets/Care Kardexes are updated as appropriate. B. Resident #9 On 6/12/07 this female resident ([AGE] years old) was admitted to the facility. The Face Sheet documented the resident had the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented the resident was moderately impaired for cognitive skills for daily decision-making. The resident had both short- and long-term memory problems. The resident was totally dependent on staff (2+ physical assist) for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident was totally dependent on staff (2+ physical assist) for locomotion on and off the unit. The resident has a traumatic brain injury and non-Alzheimer's disease. The resident received occupational therapy. 1. Record Review Review of a Fall Risk Evaluation, dated 8/16/12, documented a score of 15 indicating high risk. The Care Plan for Activities of Daily Living, dated 8/16/12, documented the resident required total care utilizing two staff members. Review of an Interdisciplinary Post Fall Review, dated 9/4/12, documented at 1645 (4:45 p.m.) the resident had a witnessed fall and sustained two bruises to the left leg: one below the knee and one to the left shin. The location of the fall was in the hallway; the resident was sitting in a shower chair. The family was notified at 1945 (7:45 p.m.), three hours after the fall. The physician was notified at 2325 (11:25 p.m.), seven hours after the fall. The summary documented that staff would now be using a Broda Shower Chair to provide more support for the resident. The back of the form was blank. A Change of Condition form, dated 9/4/12 at 2240 (12:40 p.m.), documented the resident had a witnessed fall with two bruises to the left leg (bruise to the lower left knee and to the left shin). The back of the form documented the resident had two bruises to the left leg, one below the left knee and the second one to the left shin. Cold compresses were applied. Nurse's Notes did not provide any documentation for the entire day of 9/4/12. Nurse's Notes, dated 9/5/12 at 0330 (3:30 a.m.), documented the resident continued on initial follow up from a witnessed fall on 9/4/12. The resident complained of knee pain: as needed Tylenol was given with good effect. The resident was able to make all their needs known. PTO, dated 9/5/12 at 1000 (10:00 a.m.) documented the resident was to have, "x-ray left knee stat for complaint of pain." A Mobile X-Ray Service form, dated 9/5/12 at 1:05 p.m., documented the resident sustained [REDACTED]. "This does not appear to be a pathologic process. Mild osteoporosis was evident. A joint effusion and soft tissue swelling are present." PTO, dated 9/5/12 at 1400 (2:00 p.m.), documented to "set up appointment with Orthopedic Center (name) for left knee fractures." An Incident/Accident Investigation Follow Up, dated 9/5/12, documented the resident was being transported from the shower room in a shower chair by two CNAs. "CNA was turning corner, wheel caught and resident tipped forward out of shower chair in the hallway." Summary of Investigation read, "Resident fell forward out of shower chair while being transported from shower room by two CNAs. X-ray done on 9/5/12 and was positive for fracture. New order for an orthopedic appointment: received. Sent to (named hospital) to evaluate and treat on 9/6/12 as orthopedic clinic could not take her: got splint from hospital. Recommendations were, "Broda Chair for all showers. Monitor for pain. Broda Chair for showers related to inability of resident to bend lower extremity. Broda Chair related to contractures." The back of this form was blank. A Pain Evaluation - Change of Condition form, dated 9/5/12, documented [DIAGNOSES REDACTED]. The evaluation also documented at this time the resident was unable to answer any questions. Nurse's Notes, dated 9/5/12 during the (6-2 shift), documented, "Resident continues on initial follow up for witnessed fall on 9/4/12. Resident complains of pain despite Tylenol given when moving the resident for activities of daily living. The left knee was bruised and slightly swollen. Notified the Nurse Practitioner and received new order for Ultram three times a day for fourteen days. This order was called in stat. Resident did not complain of further pain and at 1300 (1:00 p.m.) the resident was in bed resting. The resident denied any needs at this time." Nurse's Note, dated 9/5/12 at 1540 (3:40 p.m.) documented the x-rays were positive for a fracture. A call was placed to the family and awaiting a return call. "Received new orders for orthopedic office visit: waiting for an appointment to be in a couple days. No complaint of pain voiced." Nurse's Note, dated 9/5/12 at 2150 (9:50 p.m.), "No call back from the resident's family. No indications of pain noted: scheduled pain medication given. Resident was resting in bed." A Care Plan for falls, dated 9/5/12, documented the resident was at risk for falls (9/4/12), "will have assist of two with transport to and from shower (9/4/12). Broda Shower (chair) to be used for resident (9/5/12)." A Care Plan for pain documented, "fracture of left knee (9/5/12): administer analgesics as ordered and implement pain management flow sheet." An in-service report, dated 9/5/12, documented resident #9 was to be showered in a Broda Shower chair and not the regular shower chair due to contractures. However, one of the CNAs involved in the fall with the resident was the only signature on the back of the form. Another in-service report, dated 9/5/12, documented resident #9 was to be showered in a Broda Shower chair and not the regular shower chair due to contractures. There were twenty staff signatures on the back of that report. PTO, dated 9/6/12 at 9:48 a.m., documented, "Transport to (named hospital) non-emergency for evaluation and treatment of [REDACTED]. A Nurse's Note, dated 9/6/12 during the 6-2 shift, documented, "Resident given routine Tylenol for temperature. Resident transported to emergency department (named hospital) for evaluation and treatment. Resident's son was notified and will meet resident at the hospital. Resident to follow up with orthopedic (clinic) in a few days. Resident transported non-emergency. A Nurse's Note, dated 9/6/12 at 1345 (1:45 p.m.), documented, "Spoke with emergency department nurse, resident in a splint and new orders given for Percocet." A Nurse's Note, dated 9/6/12 at 1410 (2:10 p.m.), documented the resident returned from the hospital. The Care Plan, dated 9/6/12, documented the resident had a potential for decline related to the recent left tibia/fibula fracture. "Use left leg brace secondary to fracture." Nurse's Notes, dated 9/7/12, documented the Interdisciplinary Team met to review the fall, staff education was done, and the resident was to use the Broda Shower Chair only for baths. Nurse's Notes, dated 9/14/12, documented the Interdisciplinary Team met to review the resident for falls. "Staff continues to use Broda Chair for showers. Continue to follow and monitor." The Pain Evaluation, dated 9/20/12, documented the following pertinent answers for the following questions: -Have you had pain or hurting at any time in the last five days? (yes); -How much of the time have you experienced pain or hurting over the last five days? (frequently); -Over the past five days has the pain made it hard for you to sleep at night? (yes); and -Location of pain? (broken left leg). Physician's Telephone Orders (PTO), dated 10/2/12, documented, "Transport to (named hospital) on 9/6/12 for evaluation of fracture tibia/fibula: resident unable to sit in wheelchair. . On 10/2/12 at 3:15 p.m., the resident was observed lying in a low bed with her eyes open, saying, "Help" over and over. The resident stated she did not remember breaking her leg. On 10/2/12 at 4:10 p.m., the Director of Nursing (DON) stated the facility did not have any written documentation provided by the two Certified Nurse Aides (CNAs) involved in the accident with the resident. The DON provided an In-Service Report dated 9/5/12 for one on the CNAs. The report documented the resident was to be showered in the Broda Chair, not the regular shower chair, due to contractures. The DON stated the other CNA left the facility quickly and was not able to be in-serviced. On 10/2/12 at 4:18 p.m., the Regional Clinical Director (RCD) stated CNAs were not allowed to make written statements according to corporate policy. The RCD stated the one CNA did not work anymore shifts at the facility and did not return any facility phone calls. On 10/2/12 at 4:45 p.m., the DON provided statements from one CNA and a floor nurse, both involved in the incident. The two statements were from phone conversations with the DON and the two staff members. The statements were written by the DON. The DON stated the statements were located in the Investigation Book. The statement by CNA #1 documented on 9/5/12, "We were wheeling resident back after shower; came around corner and chair stopped. The resident fell forward and CNA #2 (named) caught the resident's top half and helped resident to the floor. Got nurse (named) to assess and lifted her up with Hoyer lift to bed." The phone statement to the DON, from the nurse, (named) documented on 9/5/12; "I was at the medication cart and saw girls take resident out of the shower. An aide came and stated the resident fell out of the shower chair. The resident was on the floor on her back when I saw her. The aide stated she assisted the resident to the floor and lifted her with the Viking lift. An assessment was done by me (nurse) no complaint of pain, very small bruises to knee and an ice pack was applied. Started neurological assessments and faxed doctor all that stuff." The statement did not document any ranges of motion or extremity positioning. On 10/2/12 at 5:00 p.m., the DON stated there was no other documentation on this fall. The DON stated CNA #1 was pushing the shower chair and CNA #2 was in front of the shower chair holding the resident's legs. The shower chair stopped, unsure if a wheel hit anything but it just stopped. The resident came out of the shower chair (consider it a fall) and her knee hit the floor. "It is unknown if the shower chair turned wrong or if it hit a wall corner. CNA #2 was already scheduled to quit after this shift." No disciplinary action was administered for either CNA. On 10/3/12, the Registered Nurse (RN) who assessed the resident after the fall on 9/4/12, provided detailed documentation (dated 10/3/12) on the backside of the Change of Condition form, as a late entry for 9/4/12, 29 days after the fall. The Change of Condition form documented, "While this nurse was passing medications, I glanced to see the resident was being transported in a shower chair from the shower room. I noticed they went around the corner; left toward the television room. I was on my way to administer medications when a CNA told me the resident had fallen. I saw the resident on the floor supine. I told the CNA to get the vital cart, assistance and lift. I asked what happened. The CNA informed me she was wheeling the resident from the shower room and after she turned the corner the resident started leaning forward. The CNA further stated she knew she was not going to be able to stop her from falling forward. She stated she hurried to catch her as she fell forward from the front to help her ease to the floor. The CNA said she (resident) landed on her left leg but did not hit her head. I assessed ranges of motion which was limited per resident baseline. I saw two areas on the left leg that resembled abrasions/rug burns. No bruising was noted other than a small area where the abrasion/rub burn was located. The resident denied pain, vital signs were within normal limits and ranges of motion were within normal limits. The total lift was obtained and with an assist of three persons the resident was moved from the floor to the resident's bed with the total lift. A cold compress was placed on the resident's left leg and knee. The physician was notified via fax and the family was called and a message was left to call the facility. The resident's son returned the call and I spoke with the resident's son (named)." On 10/3/12, the facility provided a MDS (dated 10/3/12) correction (thirty-six days later), for the previous MDS dated [DATE]. The facility acknowledged the MDS Coordinator had made an error and the following corrections were now accurate for the Activities of Daily Living Assistance section: - locomotion on unit was total dependence with support of one person physical assist; - locomotion off unit was total dependence with support of one person physical assist; - bathing was total dependence with support of one person physical assist. 2. Interviews On 10/4/12 at 2:50 p.m., the Environmental Director (ED) stated he did not remove the shower chair, that had a wheel lock up resulting in the resident falling to the floor, from service. The ED stated he did not inspect any of the other shower chairs in the facility to determine if there were similar problems with wheels abruptly locking during the transportation of residents to and from the shower room. On 10/4/12 at 3:03 p.m., the Nursing Home Administrator (NHA) stated she did not possess any further documentation regarding the fall of resident #9 on 9/5/12. The NHA stated to her knowledge no other in-services were conducted to alert staff regarding shower chair wheels abruptly locking while transferring residents to and from the shower room On 10/4/12 at 3:05 p.m., the Staff Development Coordinator (SDC) stated nursing staffs were trained to document timely and accurately. The SDC stated no other in-services were conducted to alert staff regarding shower chair wheels abruptly locking while transferring residents to and from the shower room. Resident #9 sustained lower extremity fractures, with significant pain, after she fell out of a shower chair, while being transported by two facility staff members. The facility was unable to determine specifically what happened; the shower chair reportedly just stopped, unsure if a wheel hit something, or if the shower chair turned wrong, or or how the wheel of the chair locked up, even though two staff members present: one in front and one in back of the shower chair. Given the resident not only fell , however, she sustained significant injuries, the shower chair was not removed from service and other shower chairs were not inspected for similar problems. Moreover, no further staff in-services were conducted regarding potential shower chair wheel malfunctions. II. Unlocked Medication Cart On 9/27/12 at 9:00 a.m., observations documented an unlocked medication cart located on the hall by room #20. A male resident was sitting in a wheelchair beside the cart. The nurse assigned to the medication cart was not within sight of it. The licensed practical nurse (LPN) was interviewed after returning to the medication cart. The LPN observed the cart and agreed the cart was unlocked. The LPN stated the medication cart should not have been left unlocked. At 10:15 a.m., the NHA provided the facility policy, "Medication Cart Use SSP 0604.00 (revised 12/05)." The policy documented in pertinent part: "the medication cart and its storage bins are kept locked until the specified time of medication administration." III. Failure to Implement Interventions Following Skin Tears According to the admission record, resident #12 was an [AGE] year old female was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. 1. Observations On 10/1/12 at 3:33 p.m., the resident was observed in her room with a steri-stripped skin tear to her right lower leg. Her wheelchair was observed next to her recliner, and there was no padding on it. 2. Record Review On 7/3/12, the resident had a one inch skin tear (S/T) to her right lower extremity. The resident reported that she received it from the wheelchair during a transfer. On 7/5/12, the resident was transferring from the wheelchair to the toilet when she hit her right shin on the chair resulting in a S/T. On 9/18/12, the resident had a S/T to her right shin; the resident stated that she received the S/T when she hit her leg on her wheelchair. There were no documented interventions implemented to prevent further S/T from the wheelchair. 3. Interviews On 10/1/12 at 3:33 p.m., the resident was interviewed. She indicated she sustained the S/T on her leg from her wheelchair when she was moving from the wheelchair to the toilet. The resident stated that happened all the time because the wheelchair had sharp spots on it and said, "I need a new chair." On 10/3/12 at 4:10 p.m., the assistant director of nursing (ADON) was interviewed. She indicated the nurses were to complete the Change of Condition form and Incident reports. Then the interdisciplinary team (IDT) reviewed them to see if any additional interventions were needed. She indicated they padded wheelchairs if they noted a pattern showing the resident was getting injured from the wheelchair. The ADON confirmed that sustaining three S/T from the wheelchair would be a pattern and that should have been looked into. The ADON indicated that it may have been over looked and said she would look into it right away and pad the wheelchair.