Every finding on record at Boswell Transitional Care of Cascadia

-Regarding Resident #82: Resident #82 was admitted on [DATE], diagnosis included chronic systolic congestive heart failure, pleural effusion, Hypo-osmolality, Hyponatremia, hypertension, and hyperlipidemia. The Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that resident is cognitively intact. Resident #82 ' s care plan did not address that resident is able to self-administer medication. Review of the physician ' s orders revealed no orders to self-administer medications. Further review of the Physicians orders revealed no orders for Estradiol 0.01% vaginal cream 42.5gm or Betamethasone Dipropionate Ointment, USP 0.05%. A health status note dated May 6, 2025 at 12:26PM revealed that the resident's family was noted to bring ointments from home prescribed by her gynecologist. The nurse educated residents and residents' families about not bringing in home medications without notifying the facility staff. Education was provided for risks of medication at bedside without the nurse or physicians awareness. Residents and Residents' family verbalized understanding back to this Nurse and will not bring medication into this facility without permission. Provider notified. Resident stated she does not need the ointments at this time as it was for vaginal itching and she has no symptoms at this time An observation was conducted on May 6, 2025 at 12:12PM in Resident #82 room and revealed that there was unopened Estradiol Vaginal Cream (vaginal estrogen) on the table which had Walgreen sticker on it with resident #82 names on it. Also observed was Betamethasone Dipropionate (Corticosteroid) unopened laying on the table in a red box and immediately calling the nurse on the floor. An interview was conducted on May 6, 2025 at 12:20PM with Licensed Practical Nurse (LPN/staff #43), who identified the medications Estradiol 0.01% Vaginal Cream 42.5gm and Betamethasone Dipropionate Ointment, USP 0.05%. He stated that these ointments are not allowed to be on bedside and was not aware of these the resident #82 had them. Staff #43 also stated that no over the counter medication should be left on the bedside. He mentioned that there are risks of having these medications left on bedside such as drug interactions and over medication. -Regarding resident #47: Resident #47 was admitted on [DATE], diagnosis included metabolic encephalopathy, Pneumonia, epilepsy, anemia, major depressive disorder, and anxiety disorder. A significant change in admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 indicating cognitively impaired. Resident #47 ' s care plan did not address that resident is able to self-administer medication. Review of the physician ' s orders revealed no orders to self-administer medications. Further review of the Physicians orders revealed no orders for CryoDose Topical Anesthetic Spray or Zinc Oxide Ointment Skin Protectant 2 ounces. A health status note dated May 6, 2025 at 12:52 PM revealed that the resident wife at bedside brought over the counter zinc oxide cream and an aerosol topical antiseptic. The writer asked the resident's wife if the medication was specifically for her or the residents. The wife said, Give it to me, it ' s mine. The resident's wife snatched it out of the writer's hand. Zinc oxide cream was immediately discarded. The resident's wife was educated of the risks and benefits, and per facility protocol outside medication was not permitted. Patient with rash to buttocks and is currently being addressed by nursing. MD notified, no new orders. An observation was conducted on May 6, 2025 at 12:38 PM in Resident #47 room, revealed a resident eating his meal by himself in the room and observed a small bottle with the secured cap on named CryoDose (topical anesthetic spray) on the residents table as well as a tube laying on the table named Zinc oxide cream (skin protectant).A nurse on the hallway was immediately called. An interview was conducted on May 5, 2025 at 12:41 PM with Certified Nurse Assistance (CNA/staff #222), who identified the medications as CryoDose Anesthetic Topical Spray and Zinc Oxide Cream skin protectant. She stated they are not supposed to be on the table and there are risks posed to it such as the resident accidentally grabbing it thinking it is something else, getting sick, or hurt. Observed the wife entering the room. An interview was conducted on May 5, 2025 at 12:43 PM with the Licensed Practical Nurse (LPN/staff #61), who also identified the medication as CryoDose Anesthetic Topical Spray and Zinc Oxide Cream skin protectant. Staff #61 stated that these are not supposed to be on the table. He stated there are risks to having these medications left at bedside such as infection control and wrong medication taken by the resident. LPN was trying to take medication from the CNA, the resident ' s wife aggressively took the CryoDose Anesthetic Topical Spray from his hand and stated that it is her medication. An interview was conducted on May 09, 2025 at 12:43 PM with the Chief Nursing Officer (CNO/staff#220), who stated that the process for outside medication is to write them on inventory list upon admission and follow the policy. She stated that staff need to call the physician, send the medication home, and check with the pharmacy. CNO also stated that if they see medication left on the bedside where the family is educated, they call the physician if the physician will allow them to authorize the resident self administrator . She stated that if they see any topicals they follow their policy. She stated if medication is left at bedside she hopes not have a negative outcome. A further interview was conducted on May 09, 2025 at 01:35PM with the Chief Nursing Officer (CNO/staff#220), who stated that the facility process for self-administrating medication is to assess the resident if they are eligible to take medication on their own, to plan that, and the physician will have to write an order to self-administer medication. Reviewed the policy Self-Administration of Medications Release date 11/28/2017 revealed that the resident may self-administer drugs if the interdisciplinary team has determined that this practice is safe. Review of the policy Medication Management, revision date October 15, 2022 revealed that if medications are found at the bedside the staff will remove the medication immediately and the physician is notified immediately. Based on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for three residents (#193, #47, #82). The facility census was 78 and the sample was 3 residents. The deficient practice could result in harm to the residents, and/or visitors who have access to medications. Findings include: Resident #193 was admitted on [DATE], with the diagnoses of concussion with loss of consciousness, fall, pain in right hip, type 2 diabetes mellitus, transient ischemic attack, cerebral infarction, unspecified difficulty in walking, dysphagia, oropharyngeal phase. The minimum data set (MDS) was in progress for Resident #193, however the brief interview for mental status (BIMS) was conducted with a score of 15 which indicated the resident was cognitively intact. Resident #193's care plan did not address resident as able to self-administer medications. An observation took place on May 6, 2025 at 09:15 a.m. in Resident #193's room and revealed a small white round object on the resident's personal cell phone. An interview was conducted on May 6, 2025 at 09:16 a.m. with Resident #193 and revealed that the small white round object was a pill. Resident #193 believed it was Tylenol. The pills were left in a medicine cup and they leave them all the time. They do it all the time. An interview was conducted on May 6, 2025 at 09:19 a.m. with certified nursing assistant (CNA) Staff #99 and revealed that it is a pill and should not be there. Staff #99 then left the room to notify the nurse. An observation was conducted on May 6, 2025 at 09:20 a.m. in Resident #193's room with licensed and revealed Licensed Practical Nurse (LPN) Staff #212 asking why Resident #193 did not take her Tylenol. Resident #193 responded by stating she could not swallow the pill. An interview was conducted on May 6, 2025 at 09:21 a.m. with Staff #212 and revealed that the small round white object was a pill, Tylenol. If the pill was not taken, then it would not have been effective. Another patient could take the pill and it could contraindicate other medications and they should not take what is not prescribed to them. An interview was conducted on May 9, 2025 at 12:43 p.m. with Chief Nursing Officer (CNO) Staff #220 and revealed that the medication cup is handed to the resident and nurse stands there and watches the residents take their medications. When asked if there was any time that they leave the medications in the cup and leave the room, the response was, I would hope not. If medications are left at the bedside, hoping that a negative outcome would not happen if a resident used it. If a medication was found, a med cup would be brought in to collect the medication and the physician would be notified.

Based on observations, staff interviews, facility recipes, and policy review, the facility failed to ensure the nutritive value of puree food. The deficient practice could result in residents receiving food with altered nutritive value. Findings include: During an observation conducted on May 8 2025 at 10:57 AM in the kitchen, the cook (staff #75) was observed preparing puree food for one resident (#314). Staff (#75) placed one portion size of turkey into the blender, adding 20 ounces of apple juice with one ounce of thickener and proceeded to blend. Staff (#75) removed the pureed content from the blender, placing into a container. Stated it was ready to be heated and served. Staff #75 stated he is able to determine when a pureed mixture is at the right consistency, based on his years of experience and by visual observation. A taste test was conducted of the pureed turkey by the surveyor, staff #75, Culinary Manager (Staff #17) and Registered Dietitian (Staff #258, the flavor of the turkey puree tasted of apple juice, sweet and no longer tasted of turkey this was confirmed by all. Culinary Manager (Staff #17) stated the use of apple juice is used for all pureed meals to decrease the salt content in the resident's food. Resident #258 had an order for regular, puree consistency. Culinary Manager (Staff #17) further stated once the gravy is added to the pureed turkey, it would then taste like turkey. Culinary Manager (Staff #17) stated she was unaware that an observation should be made of the entire pureed meal; and stated, that's the first time that has ever been done. Staff (#75) proceeded to place the stuffing into the blender without washing the container from the turkey. Staff (#258) intervened the process and washed the container. Staff (#75) added one #12 scoop of stuffing to the container and an unmeasured amount of apple juice, blended and removed to be heated and served. The result was a gritty, sweet texture. Staff #75 asked, do you want me to blend it again? and was informed to follow his process. Staff removed the pureed stuffing placing on a plate to be heated and served. The third item for puree was green beans. Staff #75 placed a #12 scoop of green beans, two ounces of apple juice and 2 ounces of thickener. Staff #75 proceeded to blend the mixture, stopping twice to added unmeasured apple juice and unmeasured amounts of thickener to the blender. When adding the unmeasured amount of thickener, Staff #75 would dip the cup into the container of thickener, each time placing the cup back on the table surface. A request was made to taste the green bean mixture, again tasted by staff #75 and staff #258. The texture was a smooth, thick consistency, and the flavor of apple juice. An interview was conducted on May 9, 2025 11:10 AM with Registered Dietitian Staff (Staff # 258). Staff #258 stated the cook (staff #75) did not follow the recipe for the meal puree and did note that the turkey did have a sweet taste. Staff # 258 stated maybe once gravy was poured over the turkey, it would make it taste better. An interview was conducted on May 9, 2025 11:48 AM with the Culinary Manager (Staff #17), who stated. Staff # 75 stated he had become frustrated and nervous with being observed and with the surprise of having to puree all portions of the meal. Staff #258 reviewed the recipes for the meal, resident #258 and cross contamination of the thickener. Staff #258 stated, while the turkey was slightly sweet, the added gravy would have made it taste more like turkey. Stated would not add apple juice to a regular meal for a resident; and that, placing the cup into the thickener container with his hands did not cause any cross contamination because, the surface of the table had been cleaned before the meal prep. Review of the facility policy titled Therapeutic Diets and Meal Plans states the facility provided therapeutic diet/meal plans as nutrition intervention when resident's medication/nutrition diagnosis has identified the need for modification in the resident's meal plan. 5. Diet orders are written to match the terminology in the approved diet manual and therapeutic menu.

Based on clinical record review, staff interviews, review of facility documentation, policy and procedure, the State complaint database, the facility failed to ensure personal property for one resident (#198) was not misappropriated. Findings include: Resident #198 was admitted on [DATE] with diagnoses of type II diabetes mellitus with diabetic chronic kidney disease and spinal stenosis. The MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident had intact cognition. The care plan dated December 24, 2022 revealed that the resident had impaired mobility with risk for falls related to acute pain, instability and impaired mobility. The goal was that the resident will be free of falls. Interventions included to place personal items and assistive devices within reach and reinforce safety awareness. The patient valuables/assistive devices checklist form dated December 24, 2022 and signed by resident #198 and a staff revealed the following personal belongings documented: -One jacket; -One cell phone with charger; -One electric toothbrush; -Two pants; -Two shirts; and, -Eyeglasses with no case. A review of an evaluation summary note dated December 24, 2022 revealed that call light and personal items were within reach. The skilled charting note dated December 24, 2022 revealed the resident was alert and oriented x 4 and had her personal items within reach. A health status note dated January 1, 2023 revealed that the resident was alert and oriented x 4, was able to make needs known and had her personal belongings within normal reach. A health status note dated January 2, 2023 included that the resident was alert and oriented, pleasant, able to make needs known, and had all personal belongings close to her. A late entry progress note dated January 3, 2023 revealed the resident had a doctor's appointment earlier in the afternoon; and that, the resident was sent to ER from doctor's office. The clinical record revealed no evidence or documentation regarding whether the resident's personal belongings were stored at the facility for safekeeping while the resident was in the hospital. Review of the State Agency (SA) complaint database revealed that on January 10, 2023 revealed that the resident was admitted at the facility on December 24, 2025 and had lost her back brace the first night she was at the facility. It also included that she had personal belongings contained in 3 bags that was brought to the facility by her family. Further, it included that in these bags were multiple personal items such as Christmas ornaments, clothing, blanket, cosmetic bags toothbrush, hair brush and a phone charger. When the resident was taken to a doctor's appointment on January 3, 2023, the resident was immediately taken to the hospital ER. Per the information, the resident's family called the facility to have her personal belongings sent to the hospital; and that, a case manager from the facility informed the family that the items were found on January 9, 2023. However, when the family came to pick the personal items up, the family was told by the facility that the personal items of the resident had never been found. An interview with an LPN (Licensed Practical Nurse/staff #140) was conducted on March 21, 2023 at 1:11 p.m. The LPN stated that the CNAs (certified nursing assistant) logs the resident belongings on an inventory sheet and the nursing staff will assist as needed. The LPN stated if a resident wants the facility to keep money or high value items, it is logged and kept in the narcotic box of the nurse's medication cart and delivered to social services or DON (director of nursing) or ADON (assistant director of nursing). The LPN stated that if a resident complains of missing items the nurse/CNA will check the resident room, laundry (if clothing) and check with family. If the missing item is not found she will let the social worker and DON/ADON know. Further, the LPN said that it is the expectation that the CNA to notify the nurse if items are reported missing. In an interview conducted with a CNA (staff #102) conducted on March 21, 2023 at 1:16 p.m., the CNA stated that resident belongings are inventoried at admission by CNAs and the nurses will assist as needed. The CNA stated that items of high value or money is inventoried and given to the nurse or put in the storage room on hall one which has a room with resident belongings. The CNA stated that nurses and the CNAs have access to this room but was not sure whether any other staff have access to the room. Staff #102 stated that this room doubles as the lost belongings room. Staff #102 stated that if a resident says they were missing an item, the CNA should verify items lost by comparing them to the inventory sheet. If the item was listed on the inventory sheet and was not able to be located, the CNA will notify the nurse. An interview was conducted with an RN (Registered Nurse/staff #23) on March 21, 2021 at 1:26 p.m. Staff #23 stated that inventory of a resident's belongings was a CNA task and nursing staff can assist as needed. Staff #23 stated that high value items and money are encouraged to be sent home with family; but, if kept at the facility the resident can keep on his/her person or have staff keep belongings in storage/safe. Staff #23 stated that if a resident has missing items then the SA as well as other reporting agencies, police, APS (Adult Protective Services), ombudsman, etc. are notified. An interview was conducted with another LPN (staff #108) who stated the nursing staff complete the inventory sheets for new residents; and that, family/residents are advised that if any personal belongings are brought in after the initial admit they should let nursing staff know to update the resident inventory log. Staff #108 stated that residents are offered use of the safe that was on the 200-nursing station if they have valuables. Staff #108 stated that if an item was missing, staff will help look for the items and if not found a grievance sheet is completed and logged into the facility grievance binder. Staff #108 stated that if the facility was notified of missing property the expectation was that the staff would initiate a grievance form placed on the grievance binder which was kept in the office of CEO (Chief Executive Officer/staff #96). During an interview with the CEO (staff #96) conducted on March 22, 2023 at 9:50 a.m., staff #9603/22/23 @ 9:50AM to review the grievance binder. Staff #96 stated that the grievance binder revealed no grievance initiated for resident #198. The CEO further stated that the facility was not aware of the personal belongings missing. Staff #96 stated he was aware of the missing back brace and he placed an order online on January 2, 2023 to replace them. The CEO said the resident discharge from the facility on January 3, 2023 and the ordered braced arrived at the facility on January 2, 2023. However, the CEO was not aware if the facility notified the family of the replacement/new back brace. Staff #96 also said that he was not aware of the current location of the back brace. Staff #96 stated he spoke with the resident's family on March 21, 2023 to discuss the missing items. The facility's policy on abuse revealed that the facility respects the resident right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility policy on personal property included that residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Level 1 was completed for two (2) sampled residents (#22 and #13). The deficient practice could result in residents not receiving appropriate treatment or services. Findings include: -Resident #13 was admitted on [DATE] with diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), anemia, bipolar disorder, and anxiety disorder. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. However, review of the clinical record revealed no evidence that a Level 1 PASARR screening was completed for resident #13. -Resident (#22) was admitted on [DATE] with diagnoses of anemia, depression, and urinary tract infection. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately impaired. The clinical record revealed no evidence that a Level 1 PASARR screening was completed for resident #22. On March 22, 2023 at 12:38 p.m., an interview was conducted with social services (staff #114) who stated that the Level I PASARR should be completed in the hospital before the resident is admitted to the facility; and, the admission department will ensure that the Level I PASARR was uploaded into the resident chart. Staff #114 said that he does not screen the resident for Level I or Level II PASARR and the nursing department was responsible for completing a Level I or Level II PASARR if one is not completed for admission. During the interview, staff #114 reviewed the clinical record of residents #13 and #22. He stated that the Level I PASARR on file uploaded on March 08, 2023 looks completed to him. However, when asked if every question on the Level I PASARR was completed, he stated it is not completed and also stated that the Level I PASARR for resident #13 and #22 were incomplete. An interview was conducted on March 22, 2023 at 12:46 p.m., with the Director of Nursing (DON/staff #23), who stated that social service department will ensure the Level 1 PASARR was completed prior to admission; and that social service was primarily responsible for completing the Level I PASARR. She further stated that if a resident had a mental disorder or intellectual disability diagnosis, it would be identified on the Level I PASARR by the admission nurse or any nurse admitting residents into the facility for that day. The DON also stated social service would then complete a Level II PASARR for further evaluation if a mental disorder or intellectual disability is diagnosed . Review of the facility policy titled, Pre-Admission Screening and Resident Review (PASRR), revealed that the facility will strive to verify that a Level 1 PASRR Screening has been conducted, in order to identify Serious Mental Illness (MI) and/or an Intellectual Disability (ID) prior to initial admission of individuals to the facility. PASRR Level 1 Screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for MI or ID. If the resident is positive for a potential MI or ID, a Level 11 Screening referral must be submitted.

Based on observations, staff interviews, and review of the Food and Drug Administration's (FDA) 2017 Food Code, the facility failed to ensure foods were appropriately stored in the refrigerator and freezer, that expired food goods were disposed of, and that serving of meals was conducted in accordance with professional standards for food service safety. The deficient practice could result in foodborne illness. Findings include: Regarding food storage in refrigerator and freezer: An observation was conducted with the food service manager (staff #25) on [DATE] at 8:31 AM during the initial kitchen visit. Upon entering the first walk-in refrigerator, an unlabeled, undated, Ziplock bag of sliced white swiss cheese was noted to be in there. The food service manager stated that the senior cook (staff #104) was just working with it and had forgotten to label the cheese before replacing it into the refrigerator. Next to the swiss cheese was an unlabeled, undated, opened pack of natural yellow cheese. In the refrigerator was a large tub of whipped butter margarine that was not dated. Staff #25 stated that as it was a manufacturer's tub of margarine, a date is not required, but preferred for this item. Continuing through the refrigerator into the freezer, several bags of frozen food were found to be open and the food inside exposed and uncovered. This included a bag of breakfast sausage, bag of beef patty, bag of fish filets, bag of peas and corn, and bag of frozen pizza crusts. Regarding expired food goods: An observation was conducted on [DATE] at 8:40 AM during the initial kitchen visit. Upon entering the second walk-in refrigerator, fourteen (14) Kozyshack Orange Gels were found to have expired since [DATE]. Heading to the normal temperature storage goods, seven (7) Thick and Clear Ice teas were noted to be expired since [DATE], two (2) 1 Liter bottles of Glucerna Carb ready were noted to be expired since [DATE]. Regarding serving of meals: An observation was conducted on [DATE] at 11:25 AM during meal tray line serving. A nutrition technician (staff #66) was in charge of plating hot food onto plates of dinnerware. At 11:57 AM, staff #66 was running out of mechanical chicken to serve for mechanical soft diet patients, so she dug into the steam table pan with the scoop to remove the remaining chunks of chicken. However, this process led to excess chicken dripping to be on the plate. So, staff #66 grabbed the mechanical chicken with her gloved hand to bunch it together and pour off the excess dripping back into the steam table pan. Staff #66 continued to the serve tray line without changing her gloves, picking up multiple scoops, spoodles, tongs, and ladles to serve food. At 12:00 AM, staff #66 had to prepare a half portion serving of chicken, so she divided the chicken with her tongs, picked up the chicken with her gloved hand, and placed the chicken on the plate. At 12:00 PM, staff #66 used her gloved hands to open a burger bun and burger patty and combine them to make a burger. She then used the tongs to pick up a serving of potato wedges and rearranged the wedges on the plate with her gloved hand. While serving another plate of food, her gloved hand was used to rearrange the broccoli on the plate. At 12:03 PM, staff #66 picked up three (3) chicken fingers from the steam table pan using her gloved hands to place them onto a plate. Following this a question came up about a resident's meal from the Senior Cook (staff #67). Staff #66 ended up touching the meal ticket document with her gloved hand during the discussion of the resident's special ticket. At this point, staff #66 ran out of plates to serve, so she opened the plate warmer and removed a plate to use. At 12:06 PM, staff #66 rearranged chicken on a plate of food. Staff #66 needed more plates, so she removed four (4) more from the warmer with her gloved hands. She continued to serve and ended up grabbing more potato wedges with her gloved hands. At 12:08 PM, staff # 66 requested more mechanical chicken for a plate. She removed three slices of chicken from the steam table pan and placed it on a plate. A senior cook (staff #104) took the chicken to the preparation table and diced it into mechanical chicken. The mechanical chicken was plated to be served and the leftover chicken that was not used was grabbed by staff #104's gloved hand and replaced into the steam table pan. Staff #104 was then seen to change his glove after touching the chicken. At 12:10 PM, staff #66 touched another set of plates from the plate warmer with her gloved hands. She then also rearranged asparagus and chicken on a plate with her gloved hands, and then touched another plate from the plate warmer with her gloved hands. An interview was conducted on [DATE] at 2:55 PM with the Corporate Regulatory Quality Consultant (staff #109). Staff #109 stated she spoke to staff #25 about what food specific policies the skilled nursing facility (SNF) follows, and staff #25 responded that the SNF follows the 2017 US Public Health Service Food Code. Staff #109 stated she would continue to look for policies related to food and kitchen safety, but did not believe there were any others. Staff #109 then provided a link to the 2017 Food Code located on the FDA (Food and Drug Administration) website. An interview was conducted on [DATE] at 9:09 AM with the food service manager (staff #25). Staff #25 stated that open food should be dated and labeled and there should not be open boxes of frozen food in the freezer. He stated this should be a default process when preparing meals daily. He stated food in storage should be rotated and expired products should be discarded when discovered. Staff #25 stated the process for staff is to ensure that when they go into the storage area and they see something expired, they should pull it from the shelf. He stated storage areas for food including the refrigerator and freezer are routinely cleaned to ensure food does not spoil and mold. Staff #25 stated that he was confident that expired food would be caught prior to making it to the resident as the food products are checked in the process of being taken to the tray line, when they are being plated for tray line, and again checked during final check of food plate for tray line. For tray line serving, he stated he's expectation is that staff should use utensils to plate food and should wash hands prior to gloving up for tray line. Staff #25 stated that if staff have to touch food with their gloves, they are expected to replace their gloves before touching other foods. He said in these three instances, the kitchen service did not meet his expectations. The FDA 2017 US Public Health Service Food Code, revealed that -food shall be protected from cross contamination by storing the food in packages, covered containers, or wrappings. -processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner. -refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. -single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure an advanced directive was accurately documented for one sampled resident (#482). The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #482 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Advance Directive form in resident #482's clinical record revealed that the resident signed for full code. The form was signed by the resident and the facility representative on February 27, 2022. However, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record did not reveal the resident had changed the advance directive from Full Code to DNR (Do Not resuscitate)/DNI (Do Not Intubate). The admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15, which indicated the resident's cognition was intact. The transitional planning ongoing assessment dated [DATE] stated that the resident #482's code status is DNR. An interview was conducted with a Registered Nurse (RN/staff #111) on March 16, 2022 at 10:25 am. She stated an advance directive is signed on admission. She stated a bright green form is used for full code and a brownish colored form is used for DNR. She stated the unit secretary then will receive the filled-out form and will check for any conflicting code status. The RN stated she will look at the resident's clinical record for the resident's code status. The RN stated she can also look at the resident's Kardex to find out the resident's code status. The RN then looked at resident #482's Kardex and stated resident #482 code status is DNR. The resident's Kardex was observed with the staff and the code status was marked DNR. She stated that the Kardex is filled out after the resident's admission and is a snapshot of the resident. She stated the same Kardex then is passed on each shift and updated as necessary. The RN stated the code status reflected in the clinical record and the code status signed by the resident should match. She stated it is important for the records to match as the staff need to know what to do in the case of an emergency. She stated if the resident's wish is not followed then the staff will be liable. Staff #111 then looked at resident #482's clinical record and stated the resident is DNR/DNI. She then looked at the scanned document in the record that resident #482 signed for full code on 2/27/22. The RN stated the records were conflicting and she will check with the resident first. Staff #111 was observed asking resident #482 about what the resident wishes were on March 16, 2022 at 10:32 am. The resident was observed stating that the resident wanted a family member to decide. An interview was conducted with a RN (staff #105) on March 16, 2022 at 10:49 am. She stated advance directive is filled out on admission. She stated residents mostly are full code at the hospital as most of the residents get admitted to the hospital in an emergent situation. The RN stated the residents are not truly explained about code status at the hospital. Therefore, she stated that after the residents are admitted at the facility, the staff properly explain to the residents about code status and a new advance directive form is filled out. The RN stated residents are made aware that they can change their code status at any time. An interview was conducted with the Director of Nursing (DON/staff #58) on March 16, 2022 at 2:27 pm. She stated that an advance directive is filled out on admission and is offered to every resident on admission. She stated she conducts chart audits on new admissions. The DON stated the advance directive in the resident's clinical record and what the resident signed for should match. The DON stated it is important for code status to match as it is the resident's wish. During an interview with the Assistant Director of Nursing (ADON/staff #23) on March 16, 2022 at 3:32 pm, she stated that she was the one who entered the code status order for resident #482. She stated that the resident was a DNR/DNI at the hospital but then had signed for full code after admission to the facility. The ADON stated she failed to look at the filled-out form and entered DNR/DNI. The facility policy titled Arizona Advance Health Care Directives revised on October 21, 2020 stated that communication about the advance health care decisions is facilitated between patients and health care providers and the patient's wishes are followed as stated in their health care directives or by their legally authorized representative. The policy further stated that if there are conflicts among the provisions of apparently valid health care directives, the most recent directives are deemed to represent the patient's wishes.

Based on clinical record review and staff interviews, the facility failed to ensure a copy of the written notice of discharge for one resident (#32) was sent to the Office of the State Long Term Care Ombudsman. The sample size was 2. The deficient practice could result in the ombudsman not being notified of transfers and discharges. Findings include: Resident #32 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated January 26, 2022 revealed that the resident's goal was to discharge to home. Review of the NOMNC (notice of Medicare non-coverage) revealed the coverage for skilled nursing services would end on February 3, 2022 and that the resident signed the NOMNC on February 1, 2022. A case manager note dated February 1, 2022 revealed that the case manager reviewed the NOMNC with the discharge date of [DATE]. It further revealed that the resident's tentative discharge plan was to return home with family. The discharge summary dated February 4, 2022 revealed that the resident was discharged to home with home health. However, further review of the clinical record revealed no evidence the ombudsman was notified of the discharge. On March 16, 2022 at 11:30 AM, an interview was conducted with a Licensed Practical Nurse (LPN/staff #44). She stated that contacting the ombudsman is not part of the nursing process for transfers and discharges. The LPN stated notification is made to the family and documented in a nursing note in the resident's clinical record. An interview with the ADON (assistant Director of Nursing/staff #23) was conducted on March 16, 2022 at 11:46 AM. The ADON stated that the Ombudsman is not notified unless the transfer is something that would be notified to the State such as a fall with a major injury or an unexpected death. An interview was conducted on March 16, 2022 at 12:35 PM with a transitional care associate (staff #38), who stated a NOMNC was issued and reviewed with the resident. Staff #38 stated nursing notifies the resident, family and provider. She further stated that the ombudsman is not notified of the transfer/discharge. She said that to the best of her knowledge, the ombudsman is not notified unless a referral to APS (adult protective services) is required. Transitional care associate (staff #53) entered the office at approximately 12:45 on March 16, 2022 and he stated that the facility does not notify the ombudsman unless there is a concern with APS or safe discharge for a resident. Another interview with the ADON (staff #23) was conducted on March 16, 2022 at 1:58 PM. She stated that the facility does not have a specific policy for notifications required when residents are discharged or transferred. She stated that they use the hospital policy as their own. Staff #23 stated that there was no further policy or procedures regarding notifications for residents leaving the facility. An interview was conducted on March 16, 2022 at 2:39 PM with the Director of Nursing (DON/staff #58), who stated that a transfer requires nursing to notify the resident, the family and the provider. She stated that the ombudsman is not told at any time about a transfer/discharge. The DON stated that is not the practice of the facility to notify the ombudsman of transfers and discharges. She stated that the facility does go by the policy of the hospital. The DON stated that she does not recall ever advising the ombudsman of any transfers or discharges. She stated that this is a short term stay facility so they expect them to transfer out very soon. The DON stated that she was not aware that notification to the ombudsman was required regarding facility-initiated transfer and discharges. The facility did not have a policy regarding transfer and discharge per the ADON and DON.

Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment for one sampled resident (#1) was transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completion. The deficient practice could result in resident specific MDS data for payment and quality measure purposes not being submitted as required. Findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission MDS assessment dated [DATE] included the resident was admitted on [DATE] from an acute hospital. Review of the case management narrative note dated October 29, 2021 revealed the resident was presented with the notice for last covered day of October 31, 2021; and, discharge was set for November 1, 2021. The transition planning ongoing assessment dated [DATE] revealed the resident was discharged home with family on November 1, 2021. The discharge MDS assessment dated [DATE] revealed the resident was coded for discharge to community with return not anticipated on November 01, 2021. Review of facility documentation revealed that the admission and discharge assessments were accepted in the CMS Quality Improvement and Evaluation System (QIES). However, the Certification and Survey Provider Enhanced Reports (CASPER) revealed that resident #1 had a missing OBRA (Omnibus Budget Reconciliation Act) assessment; and that the assessment on record was dated October 18, 2021. An interview was conducted on March 15, 2022 at 2:20 p.m., the MDS Coordinator (staff #15) stated that she has 13 days to complete an assessment and another 13 days to transmit to CMS the completed assessment. Staff #15 said she submits completed assessments on a weekly basis and she receives validation report(s) from CMS whether or not the assessment was accepted or rejected. She stated that if the assessment was rejected, she will re-open the assessment, correct the mistake and re-submit the corrected assessment. In another interview with the MDS coordinator (staff #15) conducted on March 16, 2022 at 8:20 a.m., she stated the discharge MDS assessment for resident #1 was completed and was supposedly transmitted. However, when she ran the CMS CASPER Report, the report showed resident #1 had a missing OBRA assessment. Staff #15 stated she reached out to their IT (information technology) department who told her there was a glitch in their electronic record system. She also said their IT could not explain why the discharge assessment showed in EHR (electronic health record) as in accepted status; but, there was no Final Validation Report found. The MDS coordinator said that the discharge MDS assessment dated [DATE] was only submitted and accepted on March 15, 2022. Review of the CMS Submission Report Final Validation Report revealed that the discharge MDS with a target date of November 1, 2021 was submitted and accepted only on March 15, 2022. The RAI manual stated that the MDS discharge assessment must be transmitted (submitted and accepted into the QIES ASAP (Assessment Submission and Processing) system electronically no later than 14 calendar days after the MDS completion date.

Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was accurate for one resident (#32). The sample size was 16. The deficient practice could result in incorrect discharge tracking information and data that is not accurate for quality monitoring. Findings include: Resident #32 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated January 26, 2022 revealed that the resident's goal was to discharge to home. A case manager note dated February 1, 2022 revealed that the resident's tentative discharge plan was to return home with family. The discharge summary dated February 4, 2022 revealed that the resident was discharged to home with home health. However, review of the discharge MDS assessment dated [DATE], revealed that the resident was discharged to an acute care hospital. An interview was conducted with the Director of Nursing (DON/staff #58) and the assistant Director of Nursing (ADON/staff #23) on March 17, 2022 at 8:24 AM. The DON stated that the resident was not discharged to the acute hospital as indicated on the discharge MDS assessment, that the coding was an error. The DON stated the resident went home and not to a hospital. An interview was conducted on March 17, 2022 at 8:30 AM with the MDS coordinator (staff #15). She stated that the discharge MDS assessment was coded incorrectly for this resident, that the resident was discharged to the community and not the acute care hospital. She stated that the error will be corrected. Staff #15 stated that there was no policy for MDS inaccuracies. She stated the RAI manual is the reference that they use for MDS coding. Review of the RAI manual stated to review the medical record including the discharge plan and discharge orders for documentation of the discharge location. Code 01 community, if the discharge location is to a private home or apartment.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #337 was admitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was conducted of the resident on 03/14/22 at 2:21 PM. The resident was observed in the resident's room receiving oxygen from an oxygen concentrator via nasal cannula at 1.5 liters per minute. On 03/15/22 at 12:21 PM, the resident was observed receiving oxygen via nasal cannula at 1.5 liters per minute in the resident's room. During an observation conducted of the resident in the resident's room on 03/16/22 at 9:37 AM, the resident was observed receiving oxygen via nasal cannula at 1.5 liters per minute. Review of the Flowsheet sheet for oxygen therapy revealed the resident was on room air 3/5/2022 to 3/11/2022. Continued review of the Flowsheet revealed the resident was receiving oxygen via nasal cannula on 3/12/22, 3/13/22, 3/14/22 and 3/15/22. Review of a progress note dated 3/14/2022 stated the oxygen flow rate was 1.5 liters per minute. However, review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with a Licensed Practical Nurse (LPN/staff #44) on 3/16/2022 at 11:38 AM. The LPN stated that regarding a resident receiving oxygen, she would confirm that there is an oxygen order in the system and that the resident needed to be on oxygen. The LPN stated oxygen use requires an order. When reviewing the orders for this resident it was confirmed by the LPN that this resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted with the Director of Nursing (DON/ staff #58) on 03/16/22 at 11:50 AM. She stated that any resident on oxygen would need an order. When reviewing the clinical record for this resident, the DON confirmed there was no order for oxygen. Review of the facility's oxygen policy, revised on 7/31/2019, revealed that oxygen is a medication and requires that all medication safety measures are observed, including verification of order, administration by a licensed healthcare professional and reconciliation with home use of oxygen. All adult patients receiving oxygen therapy will have a provider order in place for oxygen therapy.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (#2) received physician ordered cold therapy (ice packs), and one resident (#6) received physician ordered treatments for a non-pressure wound. The deficient practice could result in additional residents not receiving care in accordance with professional standards. Findings include: -Resident #2 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for acute pain initiated on December 17, 2020 included to identify non-pharmacological methods of pain relief, and to attempt non-pharmacological pain interventions and repositioning for comfort. A care plan for impaired mobility initiated on December 18, 2020 included to encourage and promote the highest level of mobility, increase the resident's activity level when pain is reported as minimal or relieved, and initiate progressive early ambulation, and passive or active range of motion as tolerated. A Physical Therapy Flow Sheet record included an entry dated December 18, 2020, entered at 8:02 a.m. included under Treatment Comment that resident #2 was given an ice pack for the left hip at the end of the session. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physical Therapy progress note entered on December 21, 2020 at 2:11 p.m. included that resident #2 had an order to apply cold therapy (ice pack) to the left thigh three times a day, and that resident #2 had recent left hip open reduction internal fixation (ORIF) surgery. An admission Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 which indicated that resident #2 had intact cognition. The assessment included that resident #2 received non-medication interventions for pain, and that the resident had frequent pain that did not make it hard to sleep at night, but did limit day-to-day activities. A Physical Therapy progress note entered on December 22, 2020 at 12:15 p.m. included resident #2 had an order to apply cold therapy (ice pack) to the left thigh three times a day, and that nursing staff was informed that the resident requested pain medication at the end of his therapy treatment A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for resident #2 from December 21 through December 28, 2020 did not reveal any documented evidence that the resident had been provided cold therapy three times a day as ordered by the physician, or that the resident had refused cold therapy. A Discharge Summary dated December 28, 2020 included that resident #2 was discharge to a hospital. During an interview conducted on May 5, 2021 at 12:25 p.m. with the DON (Director of Nursing/staff #123), she stated that resident #2 did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the DON stated that she was unable to show where the staff had documented that cold therapy had been provided at any time during the resident's stay. The DON stated that if it was not charted, it was not done. -Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for impaired skin integrity initiated on April 30, 2021 had goals that included outcomes to prevent skin breakdown and facilitate healing, and included to inspect the skin every shift, and utilize protective measures and devices to prevent further compromise. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care note dated April 30, 2021, at 6:07 p.m. included that the resident had a wound on the anterior left leg, which was circumferential, and also described as [CONDITION(S)] and pale pink/red. The note included that a dressing change had been provided to resident #6 which included xeroform (a petroleum impregnated type of gauze dressing) gauze, and wound cleanser. The wound care note dated April 30, 2021 did not include that the resident's anterior left leg wound had been treated with a dressing of gauze impregnated with [MEDICATION(S)]. A wound care note dated May 1, 2021, at 2:33 p.m. for the left anterior calf included that the wound had [CONDITION(S)], and that the wound was cleansed, xeroform was applied, and the wound was wrapped with gauze. Review of clinical records for May 2, 3, and 4, 2021, did not reveal any additional documented evidence that wound care had been provided to the wound on the resident's left anterior calf for May 2, 3, or 4, 2021. During an observation of wound care to the left anterior calf conducted May 5, 2021 at 9:31 a.m. the following observations were made: -A gauze bandage was wrapped around the left lower leg from just below the knee to the toes. -An RN (Registered Nurse/staff #118) removed the gauze wrap from the left leg, and underneath the gauze wrap was a xeroform dressing. -After completing the cleaning of the wound, the nurse did not apply a dressing the to the left anterior calf wound. During an interview conducted on May 5, 2021 at 9:50 am with the RN (staff #118), she stated that the reason she did not apply a dressing to the left anterior calf wound was because she did not have physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #118 stated she would have to reach out to the provider to get orders for the wound on the back of the leg, and that although wound care had been provided to the back of the left leg (the left calf), she is not sure where the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care note dated May 5, 2021, at 11:11 a.m. regarding the left calf anterior wound included that the wound was cleaned with a wound cleanser, a [MEDICATION(S)] gauze was applied, and the wound wrapped with a gauze bandage roll. During an interview conducted on May 5, 2021 at 12:25 p.m. with the DON (staff #123), she stated resident #6 had orders for wound care to be provided to the back side of her left lower leg, and that wound care was documented for wounds on the left foot but not specifically for the left calf. The DON stated that the wound care documented on April 30, 2021 was provided to the front of the leg (anterior), and she did not know why there was no documentation of daily wound care to the left anterior calf for May 2, 3, or 4. The DON stated that if it was not documented, it was not done. A policy and procedure titled Processing Provider Orders: Inpatient and Outpatient included that the purpose for the policy, was to provide guidelines to meet regulatory agency requirements and the medical staff rules and regulations with regard to Provider orders, and that the policy was for all employees. The policy included that a provider order is required to admit a patient, and for all tests, services, therapies and procedures. A policy titled Adult Standards of Care included a statement that adult patients at Banner Health can expect that patient care will be provided according to established guidelines. The policy included that interventions are implemented based on patient assessment, the prescribed medical regime, cultural needs and any special needs of the patient.

Based on clinical record reviews, staff interviews, observations of care, and review of policies and procedures, the facility failed to ensure that a provider was notified after that a pressure ulcer for one resident (#8) had developed an odor, and failed to ensure that two residents (#8, and #9) with pressure injuries received accurate wound assessments and monitoring of their wounds. The deficient practice could result in additional residents with pressure injuries not being provided necessary care and services to prevent worsening of their wounds. Findings include: -Resident #8 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A treatment order for a wound on the medial sacrum, included to clean with wound cleanser, pat dry, protect surrounding tissue with no-sting prep, apply Leptospermum honey, and cover the wound with a foam-bordered dressing. -A treatment order for a wound on the left medial buttock included to clean with wound cleanser, protect tissue with no-sting skin prep, and cover the wound with a foam-bordered dressing. A wound assessment dated [DATE] included that resident #8 had a pressure ulcer on the medial coccyx, the skin was red and yellow in color, and the wound was located over a bony prominence and had an attached wound edge. The assessment included that the wound measured 3 cm (centimeters) in length, 2 cm in width, and 0.3 cm in depth. The wound had 60% necrotic tissue and was partial thickness open. The wound bed was described as having necrotic, slough, pink dermis, and subcutaneous tissue. The surrounding tissue had butterfly pattern of [CONDITION(S)] (redness). The assessment included that the wound was present on admission. Review of the clinical record for resident #8 revealed the following care plans initiated on April 14, 2021: -A care plan with a focus of risk of infection and included interventions to assess and document skin conditions, maintain asepsis for dressing changes, and wound care, catheter care. -A care plan with a focus of impaired skin integrity included interventions to inspect the skin every shift, provide treatments per order, and skin prevention measures per protocol. Review of wound assessments for the medial coccyx pressure ulcer dated April 14, and 15, 2021 did not include any measurements of the pressure ulcer, or a description of the wound. An admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 10 which indicated that resident #8 had moderate cognitive impairment. The assessment included that resident #8 had a stage 1 or greater, a scar over bony prominence, and one or more unhealed pressure ulcers at stage 1 or higher. The assessment also included resident #8 had one unstageable pressure ulcer on admission with slough and/or eschar and two deep tissue injures on admission. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for April 16, through April 24, 2021 revealed the following wound assessments for the medial coccyx pressure ulcer: -An assessment dated [DATE] did not include any measurements of the pressure ulcer, or a description of the wound. -An assessment dated [DATE] included a description of the wound and exudate. However, the assessment did not include any measurements of the wound. -An assessment dated [DATE] did not include any measurements of the pressure ulcer, or a description of the wound. -An assessment dated [DATE] included the wound was unchanged, reassessed, and the dressing was changed. The wound was described as pink, yellow with a pink wound bed. However, the assessment did not include any measurements of the wound. -An assessment dated [DATE] included the wound was improved and re-assessed. The wound was described as red, yellow. However, the assessment did not include any measurements of the wound. -An assessment dated [DATE] for the medial coccyx reclassified the pressure ulcer to moisture associated skin damage and included the wound was pink, open to air, and that a reassessment was completed. Further review of the wound assessment for the medial coccyx pressure ulcer did not reveal any additional documentation that pressure ulcer had healed. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's note did not include that the medial coccyx pressure ulcer had ben reclassified to be moisture associated skin damage. Review of the clinical record for April 25 and 26, 2021 revealed the following wound assessments for the stage 2 medial coccyx pressure ulcer: -An assessment dated [DATE] included that the wound was reclassified again from moisture associated skin damage to a pressure ulcer and included that the wound was pink, red, and white in color, and had a scant amount of exudate, and did not include any measurements of the wound. -An assessment dated [DATE] included the wound was pink, and red in color. The assessment included that wound was cleaned with a wound cleanser and debridement was completed with a biological agent. The assessment also included the wound had a small amount of serous exudate without any odor. The surrounding tissue had [CONDITION(S)] (redness) and the wound was documented as improving. Continued review of the clinical record for April 26, 2021 did not reveal any evidence that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound assessment dated [DATE] that the medial coccyx pressure ulcer was red in color, had a scant amount of serous exudate, and also included that the wound was cleaned with soap and water, dressed, and reassessed. Continued review of the clinical record for April 26, 2021 did not reveal any evidence that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for April 28 and 29, 2021 revealed the following wound assessments for the stage 2 medial coccyx pressure ulcer: -An assessment dated [DATE] included foam and CDI (Clean Dry Intact). The assessment did not include measurements of the wound. -An assessment dated [DATE] included the wound dressing had drainage present, the wound was reassessed. However, the assessment did not include any additional description of the wound or the type of drainage that was present on the wound. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound assessment for the medial coccyx pressure ulcer dated April 30, 2021 included that the wound was red in color, with a small amount of serous drainage which had a faint odor. Review of the clinical record for April 30, 2021 did not include any additional information that the resident's physician had been notified that the medial coccyx pressure ulcer had drainage which had an odor. A wound assessment for the medial coccyx pressure ulcer dated May 2, 2021 included that the wound was black, gray, pink, red, and yellow in color. The wound had a moderate amount of serosanguineous drainage with a moderate odor. The surrounding tissue was boggy, friable, macerated, moist with increased pain. The assessment included that the resident continued to complain of burning and painful stinging before and after the wound dressing was changed. Review of the clinical record for May 2, 2021 did not include any additional information that the resident's physician had been notified that the condition of the medial coccyx had changed to include moderate amount of serosanguineous drainage with a moderate odor, surrounding tissue that was boggy, friable, macerated, and moist with increased pain, and that the resident continued to complain of burning and painful stinging before and after the wound dressing was changed During an observation conducted of wound care for resident #8 on May 5, 2021 at 8:55 a.m. with an RN (Registered Nurse/staff #118) the following was observed: -The old dressing was removed from the wound, and there was a small amount of drainage on the old dressing. -The wound was assessed as 1.5 cm. (centimeters) long, 2.0 cm. wide, and .5 cm. deep. The wound was assessed to be a full thickness stage II pressure ulcer that was red/pink in color. During an interview conducted on May 5, 2021 at 12:25 p.m. with the DON (Director of Nursing/staff #123), she stated that there are documented changes in the pressure ulcer for resident #8 that should have been reported to the physician. The DON stated that when the wound started to have a change in drainage had an odor, those findings should have been reported to the physician and documented in the clinical record. The DON stated there is no documentation of any notification to the physician on the days of the assessments when there were changes in the wound. The DON stated that the facility is not equipped to perform biological debridement. -Resident #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for impaired skin integrity initiated on April 11, 2021 included to inspect the resident's skin every shift, reposition frequently when mobility-impaired, utilize protective measures and devices to prevent further compromise, and provide treatments per order to the resident. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound care and dressing changes to the medial coccyx pressure ulcer every 72 hours and as needed, cleanse the wound with wound cleanser, pat dry, and cover with a foam-bordered dressing. -Wound care and dressing change to the left hip every 72 hours and as needed, cleanse the wound with wound cleanser, pat dry, apply Leptospermum honey, and cover with a foam-bordered dressing. A wound assessment of the medial coccyx pressure ulcer dated April 11, 2021 included that the wound was a pressure ulcer, purple/red in color, 2 cm. long, 3.5 cm. wide, had no depth and was present on admission. An admission MDS assessment dated [DATE] included that the a BIMS score of 3 which indicated severe cognitive impairment. The assessment included that resident #9 had a stage 1 or greater unhealed pressure injury, and 1 unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar and that this injury was present on admission. The assessment also included that resident #9 had three unstageable pressure ulcers with suspected deep tissue injury in evolution that were present on admission. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for April 11 through May 3, 2021, revealed only two dates that wound care to the pressure injury on the medial coccyx wound were documented in the clinical record: -April 11, 2021 at 8:54 p.m. -April 16, 2021 at 12:27 a.m. Review of the clinical record for April 12 through May 3, 2021 did not reveal any additional documented wound assessments for the medial coccyx wound. During interview conducted on May 5, 2021 at 12:25 p.m. with the DON (staff #123), she stated that resident #9 was admitted on [DATE] with a pressure injury, and that there is only one other documented dressing change for the wound on the medial coccyx from April 11 to May 5, 2021. The DON stated that there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on May 6, 2021 at 10:35 a.m. with an LPN (Licensed Practical Nurse/LPN/staff #104), she stated that wound assessments are the responsibility of the assigned nurse, and that if there is a change in the wound she would notify the physician. The LPN stated that even without measurements you can tell if a wound is getting better. She stated that wounds used to be assessed weekly but she is not sure how often it is done now. During an interview conducted on May 6, 2021 at 11:35 a.m. with an RN (staff #113), she stated that skin assessments are completed every day and that based on the wound and wound care orders, wounds are assessed weekly by the nurse manager. The RN stated that when a dressing change is completed a wound assessment should be completed as well, and that wounds are measured every Monday. During an interview conducted on May 7, 2021 at 9:40 a.m. with an RN (staff #103), she stated that wound assessments are supposed to be done by an LPN on every shift, and that staging and measurements of pressure injuries are completed by the admitting nurse which is often an LPN. The RN stated they need to have a check with an RN or another LPN to verify the wound assessment, and she was not sure how often pressure ulcers were measured in the facility. The RN stated that if there is change in the wound the provider should be notified right away. During an interview conducted on May 7, 2021 at 8:55 a.m. with the DON (staff #123), she stated that the admitting nurse should complete a two-nurse assessment on of the resident admission, which includes wound measurements. The DON stated that a resident with a pressure injury should have wound care orders, and it is the expectation that the staff follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the physician should be notified if there is a change in the wound, and that wounds should be assessed per the physician's care orders. The DON also stated that the nurses should measure the resident's wound at least once a week and follow facility policy, and that she is the one responsible for making sure weekly assessments and measurements are completed, and is responsible for monitoring wound care in the facility. A policy and procedure titled [NAME] Rehabilitation Center: Skin, Wound, and Pressure Ulcer Risk Assessment, Prevention, and Management, included that the purpose of the policy is to prevent skin injury and promote healing of wounds, through the use of evidence-based guidelines, ongoing assessment, and coordinated treatment. The policy also included that the purpose of the policy is to achieve these objectives in concordance with current regulatory standards and clinically accepted guidelines. The policy included that assessments are performed by the RN and by the LPN under supervision, and that patient's skin condition including any wounds is assessed and documented on admission and at time of treatment. The policy included that wound measurements are done on admission or wound discovery, weekly and at regular intervals and patient's skin integrity is assessed daily and as condition warrants.

Based on observations, review of facility records, staff interviews, review of policies and procedures, and review of guidance from the CDC (Centers for Disease Control), the facility failed to ensure infection control guidelines and standards were followed regarding the screening of visitors entering the facility, and during a wound care observation for one resident (#8). The deficient practice could result in the spread of infections including COVID-19. Findings include: On May 3, 2021 at 8:55 a.m. the following observations were made in the facility lobby: -Two visitors were at a reception desk being screened by a receptionist (staff #23). Staff #23 asked the visitors if they had any symptoms? The visitors replied No and entered the facility. Staff #23 did not ask the two visitors any additional specific screening questions regarding COVID-19. -A visitor entered the facility and approached the reception desk, and was asked by staff #23 if the if the visitor had any symptoms? The visitor replied No and entered the facility. Staff #23 did not ask the two visitors any additional specific screening questions regarding COVID-19. -The State Surveyor approached the reception desk, and staff #23 asked the Surveyor if he had any symptoms, When the Surveyor asked staff #23 for clarification of her question regarding symptoms, she then asked have you had a fever? Headache? After the surveyor identified himself and the purpose of his visit, the receptionist read a series screening questions from a form. The questions included do you have a fever of 100 degrees Fahrenheit or higher? Are you experiencing a cough or shortness of breath not related to other health conditions? Are you experiencing any two of the following symptoms: chills, repeated shaking and chills, muscle pain, headache, sore throat, new loss of taste or smell? Have you been advised to self-quarantine because of exposure to someone with [CONDITION(S)]-Cov2 (COVID-19 infection? During an interview conducted on May 7, 2021 at 8:25 a.m. staff #23, she stated that it is her role to greet everyone who enters the facility, and that she screens all visitors and staff that enter the building by obtaining their temperature and asking them COVID-19 screening questions. Staff #23 stated that on the morning of May 3, 2021 she asked three visitors and (the State Surveyor) if they had symptoms and she did not ask the three visitors and the State Surveyor the individual screening questions for COVID-19. Staff #23 stated she did fill out all the screening questions for the visitors, even though she did not ask the screening questions. During an interview conducted on May 7, 2021 at 8:55 a.m. with the DON (Director of Nursing/staff #123), she stated it is the expectation that everyone entering the facility should be screened per the facility policy, and that the screening process includes asking all of the questions on the screening form. She stated that just asking if you have symptoms is not acceptable practice. -Resident #8 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of wound care for resident #8 conducted on May 5, 2021 at 8:55 a.m. an RN (Registered Nurse/staff #118) who was wearing gloves, removed a soiled brief from the resident and completed peri-care, then removed the old dressing from the resident's sacrococcygeal pressure ulcer. The dressing on the pressure ulcer was observed to have drainage on old dressing. Staff #118 then proceeded to complete the dressing change and wound care to the sacrococcygeal pressure ulcer. Staff #118 did not remove soiled gloves after providing per-care to the resident, wash hands, and [NAME] fresh clean gloves prior to providing wound care which included measuring the wound and covering the wound with a fresh new dressing. During an interview conducted on May 5, 2021 at 9:05 a.m. with staff #118, she stated that she did not change her gloves or wash hands in between providing peri-care to the resident and providing wound care. Staff #118 stated I did not, I should have, and stated that before providing wound care and measuring the depth of the wound she should have changed her gloves. During an interview conducted on May 7, 2021 at 8:55 a.m. with the DON, she stated that the expectation for wound care is that it is done timely and as ordered by the physician and that staff should follow professional standards when providing wound care. The DON stated that wound care is a clean process unless ordered by a physician to be provided to the resident as a sterile process, and that after cleaning stool from a resident, the soiled gloves are to be removed prior to providing wound care. During an interview conducted on May 7, 2021 at 9:40 a.m. with the Administrator (staff #130), she stated that the expectation for the staff is that they follow facility policies at all times. A policy and procedure titled Banner [NAME] Rehabilitation Center Covid-19 Visitation Policy included that it is the policy of the facility to provide a healthy and safe environment to patients, staff, and visitors during the COVID-19 pandemic. The policy included that the visitation policy has been implemented in accordance with guidelines from ADHS (Arizona Department of Health Services) and CMS (Centers for Medicare and Medicaid Services) and the CDC (Centers for Disease Control and Prevention). The policy included that all visitors are required to: be screened for signs and symptoms of COVID-19 and have a temperature taken upon entering the facility, and are to be screened for recent exposure to a person with COVID-19 infection. The policy included that persons with signs/symptoms or with close contacts to a person with COVID-19 infection in the last 14 days should not be allowed to visit, regardless of their vaccination status, and visitors are to perform hand hygiene at the beginning of their visit. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated February 23, 2021 included guidance that screening for symptoms of COVID-19 remains an important strategy to identify those who could have COVID-19 so that appropriate precautions can be implemented. The guidance included to establish a process to ensure everyone entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed [CONDITION(S)]-CoV-2 infection.

Based on concerns identified during the survey, facility documentation, staff interviews, and policies and procedures, the Quality Assessment and Assurance (QAA) committee failed to implement appropriate plans of action to correct identified quality deficiencies regarding pressure ulcer assessment, monitoring, and treatment. Findings include: During the complaint survey, there were identified quality concerns for two residents (#8 and #9) whose pressure ulcers were not being adequately assessed, measured, or provided wound treatments as ordered by the physician. A review of the Quality Assessment and Performance Improvement (QAPI) Plan documentation revealed the following data: -QAPI data for January 2021, included a recommendation to audit 100% or fifteen charts, whichever number is less than the number of residents who have wounds and routine daily wound care documentation. The QAPI data included a plan to use quantifiable objective data as a means to track and trend specific areas identified for improvement, and included that of the 15 residents identified with wounds, 12 of those residents required wound measurements, and 7 of the identified residents did not have wound measurements. -QAPI data for February 1 through February 28, 2021 included that of the 15 residents identified with wounds, 13 residents required wound measurements, and 3 of the identified residents did not have wound measurements. The data also included that only 3 of the 15 residents had interventions in place for their wounds. -QAPI data for March 2021 included that of the 15 residents identified with wounds, 13 of the identified residents required wound measurements and only 8 of the identified residents had wound measurements documented. QAPI meeting notes dated May 4, 2021 included a description of QAPI data collected for January, February, and March, 2021. The QAPI notes included that the following: Head to toe Assessment completion including appropriate wound care/skin assessments-wound measurement documentation still lagging at 61 % compliance. During an interview conducted on May 7, 2021 at 8:55 a.m. with the DON (Director of Nursing/staff #123), she stated that wound care is managed by the individual nurses caring for the residents, and that wounds are documented on admission, and dressing changes are done per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that when the wound has a change of condition, that the physician should be notified and the notification should be recorded in the medical record. The DON stated that two of the residents identified in the survey did not have measurements of their wounds weekly. During an interview conducted on May 7, 2021 at 9:40 a.m. with the Administrator (staff#130), she stated that during a mock survey that the facility conducted in January 2021 it was identified that there was a concern in the documentation of wound care in the facility. The Administrator stated that the QAPI committee met in January 2021, discussed the concerns identified regarding wound care documentation, and started collecting data. The Administrator stated that data that was collected from January, February, and March 2021 that indicated that there was a concern. During an conducted on May 7, 2021 at 9:40 a.m. with the Administrator, she stated that it was identified in March that there was a 61% success in the documentation of wounds in the facility. However, the Administrator stated that in-service education to the staff was not provided until April 27, 2021. The Administrator stated that the staff education provided on April 27, was the first (performance improvement) intervention that was initiated after collecting QAPI data from January through April 2021 regarding the identified concerns with wound care documentation. A policy and procedure titled, Quality Assessment and Performance Improvement (QAPI) Plan included Quality/QAPI Program is an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The QAPI plan included that the facility promotes the delivery of person-centered, high quality and safe care. The QAPI plan identified quality measures which include (but are not limited to) changes in skin integrity. The QAPI plan identified plans of action that included best practices, intervention actions and monitoring approaches/activities. A policy and procedure titled Banner Health System Quality and Safety Plan included a statement that the facility's quality goal is to continuously improve and increase reliability of (our) processes and outcomes for the safety and betterment of (our) patients. The policy included that appropriate improvement action is determined by analyzing and interpreting data over time. The policy included that when data indicates a need to identify and correct the root cause of a problem, improvement projects are established.

Based on observations, clinical record review, interviews and policy review, the facility failed to ensure that one resident (#222) with a pressure ulcer received the necessary treatment and services to promote healing. The deficient practice resulted in a delay in wound treatment being initiated, a lack of thorough assessments being completed and consistent monitoring of the pressure ulcer at least weekly, and the wound was discovered to have deteriorated. Findings include: Resident #222 was admitted to the facility on (MONTH) 21, 2019, with [DIAGNOSES REDACTED]. A Braden Scale dated (MONTH) 21, 2019 revealed a score of 14, which indicated the resident was at moderate risk for the development of a pressure ulcer. A care plan dated (MONTH) 21, 2019 for impaired skin integrity included the following goals: demonstrate behaviors or techniques to prevent skin breakdown or facilitate healing, maintain optimal nutrition and physical well being, and verbalize understanding of condition and causative factors. Interventions were to consider nutrition services, consider use of specialty bed, inspect skin every shift, maintain clean, dry skin at all times, reposition frequently while mobility impaired, teach behaviors or techniques to prevent skin breakdown or promote healing and teach proper nutrition and hydration for prevention maintenance and repair. Review of an incision/wound/skin assessment dated (MONTH) 21, 2019 performed by a floor nurse revealed the resident had a flat, localized maroon [DIAGNOSES REDACTED] (redness) area on the medial sacrum, with surrounding tissue intact and normal in color. This assessment showed that this was over a bony prominence. The assessment did not include any measurements of the area or the type of wound. A physician's orders [REDACTED]. However, these orders did not include any wound treatment to the [DIAGNOSES REDACTED] area on the medial sacrum. A functional abilities assessment dated (MONTH) 22, 2019 revealed the resident was at substantial/maximal assistance for rolling left and right and was dependent with toileting, hygiene, wheelchair mobility and chair to bed transfers. A cognitive-linguistic evaluation dated (MONTH) 22, 2019 revealed a brief interview for mental status score a 4 out of 15, indicating severe cognitive impairment. Review of an incision/wound/skin assessment dated (MONTH) 22, 2019 performed by a floor nurse revealed the resident had a flat, non-blanchable pink-red localized [DIAGNOSES REDACTED] area on the medial sacrum, with surrounding tissue intact and normal in color. There were no measurements of the area and the type of wound was not defined. Review of an incision/wound/skin assessment dated (MONTH) 23, 2019 performed by a floor nurse revealed the resident had a localized purple pressure ulcer on the medial sacrum, with attached edges and surrounding tissue showing [DIAGNOSES REDACTED] on intact skin. The pressure ulcer measured 2.5 cm in length by 3 cm width. The documentation included the wound had deteriorated, and described it as denuded and darker red, with no signs or symptoms of infection. Per the assessment, the wound was cleaned with a commercial cleansing solution and a foam dressing was applied. However, further review of the clinical record revealed there was no documentation that the physician/nurse practitioner was notified of the pressure ulcer to the medial sacrum, and there was no treatment order for the sacrum on (MONTH) 21, 22 or 23, 2019. In addition, there was no clinical record documentation of the use of a specialty bed or mattress, which was in place from (MONTH) 21 through (MONTH) 23, 2019, as mentioned in the care plan. An incision/wound/skin assessment dated (MONTH) 24, 2019 performed by a floor nurse included the resident had a localized purple pressure ulcer on the medial sacrum, with wound edges unattached to wound bed, with surrounding tissue showing [DIAGNOSES REDACTED] on intact skin. Documentation included the wound had deteriorated and was described as denuded and darker red, with no signs or symptoms of infection. The wound was cleaned with a commercial cleansing solution and a foam dressing was applied. There were no measurements of the pressure ulcer in this assessment. A physician's orders [REDACTED]. Review of an OMBRA admission Minimum Data Set (MDS) assessment dated (MONTH) 27, 2019, revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Per the MDS, the resident required the assistance of two staff with bed mobility, transfers and hygiene. The MDS further included that the resident had a suspected deep tissue injury. A Braden score dated (MONTH) 1, 2019 revealed a score of 13, which indicated the resident was at moderate risk for development of a pressure ulcer. A physician's orders [REDACTED]. The order also included for a consult with the wound/ostomy nurse. An observation was conducted on (MONTH) 2, 2019 at 12:26 p.m., of the resident in bed with a pressure reducing mattress in place. At this time, an interview with a family member was conducted, who stated that the resident has a bedsore near his anus and thinks that it happened here. The next pressure ulcer assessment was completed 10 days after the last assessment (November 24). According to the incision/wound/skin assessment dated (MONTH) 3, (YEAR) performed by a floor nurse, the medial sacrum pressure ulcer was now described as maroon, red and yellow in color, had 90% granulated tissue and 10% slough, with a small amount of serous exudate, and the surrounding tissue had maceration and moisture. The wound measured 3.2 cm x 3.0 cm x 0.1 cm. The first assessment performed by the wound consultant was dated (MONTH) 4, 2019. Per the wound ostomy inpatient consult form dated (MONTH) 4, 2019, the sacrum had an open wound which measured 3.1 cm x 3.3 cm x 0.1 cm, with purple discoloration to the periwound. Per this document, nursing reports that slough has been present initially and is not resolving (however, there is no documentation of any slough to the wound until the (MONTH) 3 assessment), and that the wound appears consistent with a stage 3 pressure ulcer. The documentation also stated that charting indicates this wound may have initially presented as a deep tissue injury, which progressed into an open wound. Per the note, this wound nurse consultant spoke with a family member who stated that the resident did not have open wounds to the sacrum in the past. A wound observation was conducted on (MONTH) 5, 2019 at 10:00 a.m., with a RN (staff #12) and a LPN (staff #157 ). Staff #12 provided wound care as ordered. The wound was observed to have a pink wound bed with a flaky, macerated appearance and the wound measured 3.1 cm x 3.3 cm x 0.1 cm. During the observation, staff #12 stated that wounds are measured once a week by the charge nurse. An interview was conducted on (MONTH) 6, 2019 at 9:11 a.m., with a licensed practical nurse (LPN/staff #157), who stated that if we find a wound, then we do a wound consult. She said that she obtained a wound consult because the wound was deteriorating. She said that she doesn't see any wound consult before the one that she asked for on (MONTH) 2. She also pulled up the physician orders [REDACTED]. An interview was conducted on (MONTH) 6, 2019 at 9:30 a.m. with the Director of Nursing (DON/staff #115), who stated that her expectations for wounds was for the nurses to assess the wound, notify the physician, and obtain new orders. While reviewing the clinical record for this resident, she stated that she did not see where the nurses notified the doctor before (MONTH) 24, and that the wound consult was not requested until (MONTH) 2. She said the pressure ulcer was getting worse, but they were following it and putting interventions in place, however, she did not have any documentation of this. A follow up interview was conducted on (MONTH) 6, 2019 at 11:55 a.m., with staff #157. She stated if there is no order for wound treatment, she would immediately notify the provider and would also obtain an order for [REDACTED].>An interview was conducted on (MONTH) 6, 2019 at 12:36 p.m., with a RN (staff #37). She stated that all wounds should have a treatment order and an order for [REDACTED].#37 stated that on admission the nurse should have called the physician for a wound consultant, as it could develop into a deeper wound and get worse. She said that you don't know how deep it is when it's a deep tissue injury. She stated that they did not do a good wound assessment with measurements, until (MONTH) 23. She said the size of the wound should be included on the assessments. She stated that it might take until the next day for a wound consultant, but the nurse can put interventions in place, such as she would talk with the manager and order a special mattress, turn the resident every two hours and refer the resident to the dietician for wound healing. A copy of a text conversation dated (MONTH) 6, 2019 at 2:04 p.m. was provided by the DON. The text was between the DON and and a RN (staff #150). Per the text, staff #150 reported that she was there when the resident was admitted and that a waffle mattress was put on that night. The DON also provided a handwritten note dated (MONTH) 6, 2019 from a RN (staff #204). Per the note, staff #204 stated that she removed the waffle mattress from the bed and replaced it with an APP overlay mattress on (MONTH) 24. However, there was no documentation in the clinical record that a waffle mattress had been utilized. Review of a policy regarding Skin, Wound, and Pressure Ulcer Risk Assessment, Prevention, and Management revealed the purpose was to prevent skin injury and promote healing of wounds associated with pressure friction, shear, immobility and moisture through the use of evidence based guidelines, ongoing assessment, and coordinated treatment, so that residents may enjoy optimal health and comfort and participate to their fullest potential in daily living. The policy included that an unavoidable skin injury occurs even when a facility evaluates a resident's clinical condition and risk factors, defines and implements interventions consistent with the resident's needs/goals/recognized standards of practice, monitors and evaluates the impact of interventions, and revises the interventions as appropriate. The policy included that an avoidable skin injury occurs when the facility does not perform one or more of the above functions. The policy stated that a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Under the section for wound assessment, it included the following should be documented: location; wound bed; drainage; odor; color and periwound skin for [DIAGNOSES REDACTED], warmth, induration or damage. Resident's skin condition including any wounds is assessed and documented on admission and at time of treatment. Wound measurements are done on admission or wound discovery, weekly and at regular intervals. Residents identified at risk for skin breakdown will have preventative measures implemented and appropriately documented. Per the policy, pressure ulcers are staged by Wound Ostomy Continence Nurses, wound care specialists or designee, nurse practitioners and physicians.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy regarding reporting and protection for an allegation of abuse involving one of two sampled residents (#72). The deficient practice could result in the potential for abuse to be unreported and ongoing. Findings include: Resident #72 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. Review of a facility report dated (MONTH) 27, (YEAR) revealed that on (MONTH) 23, (YEAR) at approximately 7:30 a.m., the resident's Certified Nursing Assistant (CNA/staff #42) reported to the nurse the resident had a skin tear on the hand that was bleeding. The nurse assessed the injury and noted the resident was bleeding from a foam dressing that was already in place. As the nurse was leaving the room to get supplies, a family member was entering the room. When the nurse returned to the resident's room, she observed the family member screaming at the CNA and taking pictures. The unit manager Registered Nurse (RN/staff #114) was notified and took over the care of the resident. The report included the resident had multiple skin tears and that the family member accused the CNA of abusing the resident. An investigation was initiated. The report did not include measures were implemented to prevent further potential abuse while the investigation was in progress. Further review of the report revealed no evidence the allegation of abuse was reported immediately, but not later than 2 hours after the allegation was made to the administrator, State Survey Agency and adult protective services (APS). The report included the State agency was notified via the after-hours number on (MONTH) 23, (YEAR) at 9:09 p.m. and APS was notified on (MONTH) 27, (YEAR). An interview was conducted with staff #114 on (MONTH) 4, 2019 at 1:57 p.m. Staff #114 stated that regarding the incident that occurred on (MONTH) 23, (YEAR), she thought the family member had retracted the abuse allegation so she did not immediately inform the Director of Nursing (DON/staff #115) and did not notify the administrator (staff #70) and did not suspend staff #42. Staff #114 stated staff #42 continued to provide care to residents and that the residents were not protected from the potential for further abuse. An interview was conducted with the DON (staff #115) on (MONTH) 6, 2019 at 11:15 a.m. Staff #105 stated the administrator, who is the designated facility abuse officer, is to be immediately notified when there is an allegation of abuse. Staff #115 stated the administrator was eventually notified of this incident; however it was much later that day (December 23, (YEAR)). Staff #115 also stated the State Survey Agency and APS were not notified within the required two hour time frame. Staff #115 stated that when there is an allegation of abuse and the perpetrator is staff, the staff is suspended until the investigation is completed for the protection of the residents. Staff #115 further stated staff #42 was not suspended, per policy, and continued to provide resident care. An interview was conducted with the administrator (staff #70) on (MONTH) 6, 2019 at 12:15 p.m. Staff #70 stated staff are to immediately notify her when there is an allegation of abuse. Staff #70 stated that she has to report the abuse allegation to the State Survey Agency and APS within two hours. Regarding the incident that occurred on (MONTH) 23, (YEAR), staff #70 stated staff #114 did not immediately report the abuse allegation and therefore the allegation was not reported to the State Survey Agency and APS within the required time frame. Staff #70 also stated staff #42 was not suspended and was allowed to continue to provide care to residents which was not in compliance with their policy. The facility's policy regarding abuse revised (MONTH) 16, (YEAR), revealed abuse allegations are reported per Federal and State Law. Staff must always report any abuse or suspicion of abuse immediately to the administrator. The policy also revealed the facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency and APS. The policy also included it is their policy that the resident(s) will be protected from the alleged offender(s). Staff accused of alleged abuse will be placed on administrative leave pending the results of a thorough investigation.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse involving one of two sampled residents (#72) was reported to the administrator, State Survey Agency, and adult protective services (APS) within the required timeframe. The deficient practice could result in abuse allegations not being report as required. Findings include: Resident #72 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. Review of a facility report dated (MONTH) 27, (YEAR) revealed that on (MONTH) 23, (YEAR) at approximately 7:30 a.m., the resident's Certified Nursing Assistant (CNA/staff #42) reported to the nurse the resident had a skin tear on the hand that was bleeding. The nurse assessed the injury and noted the resident was bleeding from a foam dressing that was already in place. As the nurse was leaving the room to get supplies, a family member was entering the room. When the nurse returned to the resident's room, she observed the family member screaming at the CNA and taking pictures. The unit manager Registered Nurse (RN/staff #114) was notified and took over the care of the resident. The report included the resident had multiple skin tears and that the family member accused the CNA of abusing the resident. Further review of the report revealed no evidence the allegation of abuse was reported immediately, but not later than 2 hours after the allegation was made to the administrator, State Survey Agency and APS. The report included the State agency was notified via the after-hours number on (MONTH) 23, (YEAR) at 9:09 p.m. and APS was notified on (MONTH) 27, (YEAR). An interview was conducted with staff #114 on (MONTH) 4, 2019 at 1:57 p.m. Staff #114 stated that regarding the incident that occurred on (MONTH) 23, (YEAR), she thought the family member had retracted the abuse allegation so she did not immediately inform the Director of Nursing (DON/staff #115) and did not notify the administrator (staff #70). An interview was conducted with DON (staff #115) on (MONTH) 6, 2019 at 11:15 a.m. Staff #115 stated the administrator, who is the designated facility abuse officer, is to be immediately notified when there is an allegation of abuse. Staff #115 stated the administrator was eventually notified of this incident; however it was much later that day (December 23, (YEAR)). Staff #115 also stated the State Survey Agency and APS were not notified within the required two hour time frame. An interview was conducted with the administrator (staff #70) on (MONTH) 6, 2019 at 12:15 p.m. Staff #70 stated staff are to immediately notify her when there is an allegation of abuse. Staff #70 stated that she has to report the abuse allegation to the State Survey Agency and APS within two hours. Regarding the incident that occurred on (MONTH) 23, (YEAR), staff #70 stated staff #114 did not immediately report the abuse allegation and therefore the allegation was not reported to the State Survey Agency and APS within the required time frame. The facility's policy regarding abuse revised (MONTH) 16, (YEAR), revealed abuse allegations are reported per Federal and State Law. Staff must always report any abuse or suspicion of abuse immediately to the administrator. The policy also revealed the facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency and APS.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure action was taken to prevent further abuse from occurring while the investigation was in progress for an allegation of abuse involving one of two sampled residents (#72). The deficient practice could result in residents not being protected from the potential for further abuse. Findings include: Resident #72 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. Review of a facility report dated (MONTH) 27, (YEAR) revealed that on (MONTH) 23, (YEAR) at approximately 7:30 a.m., the resident's Certified Nursing Assistant (CNA/staff #42) reported to the nurse the resident had a skin tear on the hand that was bleeding. The nurse assessed the injury and noted the resident was bleeding from a foam dressing that was already in place. As the nurse was leaving the room to get supplies, a family member was entering the room. When the nurse returned to the resident's room, she observed the family member screaming at the CNA and taking pictures. The unit manager Registered Nurse (RN/staff #114) was notified and took over the care of the resident. The report included the resident had multiple skin tears and that the family member accused the CNA of abusing the resident. An investigation was initiated. However, the report did not include measures were implemented to prevent further potential abuse while the investigation was in progress. An interview was conducted with staff #114 on (MONTH) 4, 2019 at 1:57 p.m. Staff #114 stated that she did not suspend staff #42 and that staff #42 continued to provide care to residents. She stated staff #42 was not suspended until the Director of Nursing (DON) was aware staff #42 was still providing care to resident. Staff #114 stated the residents were not protected from the potential for further abuse. An interview was conducted with the DON (staff #115) on (MONTH) 6, 2019 at 11:15 a.m. Staff #115 stated that when there is an allegation of abuse and the perpetrator is staff, the staff is suspended until the investigation is completed for the protection of the residents. Staff #115 further stated staff #42 was not suspended, per policy, and continued to provide resident care. An interview was conducted with the administrator (staff #70) on (MONTH) 6, 2019 at 12:15 p.m. Staff #70 stated staff #42 was not suspended and was allowed to continue to provide care to residents which was not in compliance with their policy. The facility's policy regarding abuse revised (MONTH) 16, (YEAR), revealed it is their policy that the resident(s) will be protected from the alleged offender(s). Staff accused of alleged abuse will be placed on administrative leave pending the results of a thorough investigation.

Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#73) was provided adequate supervision to prevent an elopement. The deficient practice has the potential for residents to be at risk for elopement. Findings include: Resident #73 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of an elopement risk assessment dated (MONTH) 25, (YEAR) revealed a score of 7, which indicated the resident was at risk for elopement. A score of 5 or greater meant the resident was at risk for elopement. The assessment revealed the resident had a [DIAGNOSES REDACTED]. The assessment included addressing elopement precaution on the care plan and did not include an elopement device was in place. The admission baseline care plan dated (MONTH) 25, (YEAR) revealed the resident had no safety care problems regarding elopement wandering and to monitor the resident for adjustment to being placed in the facility. The care plan included the resident could be up with assistance and that the resident used a manual/electric wheelchair for mobility. The care plan did not include the resident was assessed to be at risk for elopement or interventions for elopement precaution. Review of the facility's mobility assessment tool dated (MONTH) 26, (YEAR) revealed the resident did not display safety awareness/alert. The admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed a score of 12 on the Brief Interview for Mental Status, which indicated the resident had moderate cognition impairment. The assessment included the resident had not exhibited wandering behavior and was self-sufficient once in the wheelchair for locomotion on and off the unit. The assessment also included cane/crutch was checked for mobility devices that were normally used; wheelchair was not checked. The facility's mobility assessment tool dated (MONTH) 8, (YEAR) at 10:45 a.m. revealed the resident did not display safety awareness/alert. Review of a psychologist progress note dated (MONTH) 8, (YEAR) revealed the resident presented with cognitive dysfunction with a severity rating of at least a moderate level. A physician progress notes [REDACTED]. The resident thought she was going out to dinner with her husband and that her husband was going to put her away. The resident denied fever, chills, or urinary symptoms. The note included the resident's intermittent confusion was worse today and that the urine would be checked as this was a recent change. Review of the clinical record revealed no evidence the nursing staff had observed and assessed a change in the resident's cognition/confusion on (MONTH) 8, (YEAR). Review of a nursing note dated (MONTH) 8, (YEAR) at 8:18 p.m. revealed visitors reported that upon entering the facility, they saw a woman in a wheelchair just outside the front door. The visitors stated the woman was talking and not making any sense. The note included the writer went to the front entrance and saw resident #73 in a wheelchair approximately 30 feet from the entrance with a staff member beside her. The resident appeared confused and believed there was danger inside of the facility. Another nursing note dated (MONTH) 8, (YEAR) at 8:28 p.m. revealed this writer heard staff talking about a resident being outside. The writer went outside and found the resident in front at the parking area with one of the staff. The resident was confused, thinking that someone was trying to blow up the place. The writer was able to convince the resident to go inside. Notifications were made to the physician and family. The note included staff were given instructions to keep a close eye on the resident and that a wander guard would be put on. Review of a physician progress notes [REDACTED]. The noted included the resident was started on an antibiotic and would follow cultures. An interview was conducted with the front lobby receptionist (staff #90) on (MONTH) 4, 2019 at 10:46 a.m. She stated her work hours are from 8:00 a.m. until 5:00 p.m. with a 30 minute lunch break. Staff #90 stated that when she is having lunch and when she leaves for the day at 5:00 p.m., there is no staff at the front lobby desk. She stated a sign is placed on the counter when she not there. Staff #90 stated the sign instructs to proceed down the hall to the nurse's station for assistance. She stated that if a resident is confused and does not have a wander guard, the resident would be able to leave the facility through the front doors when no staff is present. Staff #90 stated that if a resident has a wander guard and tries to leave through the front doors; an alarm would sound to alert the staff. During an interview conducted with a Certified Nursing Assistant (staff #97) on (MONTH) 4, 2019 at 1:25 p.m., staff #97 stated that if a resident has a change in their usual condition and becomes confused she must immediately report this change to a nurse. An interview was conducted with a Registered Nurse (staff #114) on (MONTH) 6, 2019 at 9:35 a.m. She stated that for an elopement risk assessment with a score of 7, a wander guard should be placed on the resident. Staff #114 stated she was unsure why resident #73 did not have a wander guard. Staff #114 stated the admission elopement risk assessment for resident #73 was incorrect because the resident had the ability to be independently mobile (which would have increased the score to 10). Staff #114 further stated the provider is usually very good about alerting the nursing staff when a resident has a change. The Registered Nurse stated that on (MONTH) 8, (YEAR), the provider should have told the staff about the change in the resident's cognition/confusion. Staff #114 stated that if the provider had notified them, maybe they would have kept a closer eye on the resident. An interview was conducted with the Director of Nursing (staff #115) on (MONTH) 6, 2019 at 10:44 a.m. Staff #115 stated an elopement risk assessment is completed for a resident on admission and that if the resident is assessed to be a high risk, a wander guard would be placed on for safety. She stated the expectation is that the elopement risk assessment be accurate. She stated the front lobby area is unsecured after 5:00 p.m. and a resident who is confused and without a wander guard, could exit the facility without staff knowing. The Director of Nursing stated that the provider did not notify the staff of the change in resident #73 on (MONTH) 8, (YEAR) so the staff were not aware of the resident's change in cognition/confusion. The facility's policy regarding elopement revised (MONTH) 16, (YEAR) revealed elopement is the ability of a resident who is not capable of protecting themselves from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. The purpose included implementing prevention strategies for those residents identified as an elopement risk. A facility provided risk assessment tool or scoring system is utilized. The risk score includes a defined parameter which, when reached, indicates an increase risk and prompts prevention strategies. Interventions that may be used for residents identified as high risk for elopement included frequent monitoring of the resident's whereabouts to assure the resident remains in the facility (e.g., every one-half hour check) and implementation of alert device or other electronic alert systems. The policy also included if a resident is identified as moderate to high risk for elopement, establish an interim plan of care.

Based on clinical record reviews and staff interviews, the facility failed to develop baseline care plans for five residents (#'s 5, 11, 77, 78 and 267). Findings include: -Resident #11 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. and diabetes mellitus type II. Review of a 5-day Minimum Data Set (MDS) assessment dated (MONTH) 15, (YEAR) revealed the resident was cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15. Review of the (MONTH) (YEAR) physician orders [REDACTED]. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the resident's baseline care plans including the Interdisciplinary Plan of Care revealed that no care plans had been developed to address the following areas: depression and the use of psychoactive medications, the use of insulin/diabetes and diuretic therapy. During an interview conducted on (MONTH) 26, (YEAR) at 10:46 a.m. with a registered nurse (RN/staff #93), she stated that care plans are started on admission for issues which include areas such as oxygen, glucose monitoring for diabetes and the use of [MEDICAL CONDITION] medications. During an interview conducted on (MONTH) 26, (YEAR) at 12:25 p.m. with a licensed practical nurse (LPN/staff #28), she stated that care plans are initially done by the RN's, then she adds or subtracts information from the care plan as needed. During an interview conducted on (MONTH) 26, (YEAR) at 12:48 p.m. with the Director of Nursing (DON/staff #56), she stated that initial care plans are completed by the RN's and should include diabetes. Staff #56 said that the care plans should include functional goals and customized care. She further stated that psychiatric issues are not always on the 48 hour care plan, but should be generated on the Interdisciplinary Plan of Care. -Resident #5 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Physician admission orders [REDACTED]. A review of the baseline care plans revealed there were no care plans that had been developed to address the resident's [MEDICAL CONDITION] disorder, anxiety, depression or the use of psychoactive medications. An interview was conducted on (MONTH) 20, (YEAR) at 1:30 p.m., with a LPN (MDS nurse/staff #16). He stated that he could not locate the baseline care plans for this resident regarding mental/behavioral disorders. He stated that if a resident was admitted with these problems and was receiving psychoactive medications, a baseline care plan should have been developed. An interview was conducted with a RN (staff #102) on (MONTH) 20, (YEAR) at 1: 32 p.m. She stated the admission nurse is responsible for the completion of the baseline care plans, however the mental/emotional problems are not care planned upon admission, because staff need time to assess the mental/emotional needs of the resident even though all other major medical issues or conditions are included on the care plan. She further stated that it made sense that all major areas both medical and mental, would be included on the baseline care plans, so staff would have the information which was needed. -Resident #77 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission physician orders [REDACTED]. A review of the MAR for (MONTH) (YEAR) revealed the resident was administered the [MEDICATION NAME]/[MEDICATION NAME] on multiple occasions. Review of the resident's baseline care plans revealed there was no care plan developed to address the resident's pain. A policy was requested on (MONTH) 21, (YEAR) at 11:30 a.m. related to the development of baseline care plans, and the Administrator stated that the facility did not have a policy. An interview was conducted with a LPN (staff #16) on (MONTH) 27, (YEAR) at 1:25 p.m. He stated the resident was being treated with as needed pain medication and that there was no baseline care plan developed. Staff #16 also said that the resident's admitting [DIAGNOSES REDACTED]. An interview was conducted with a RN (staff #102) on (MONTH) 27, (YEAR) at 1:48 p.m. She stated this resident had pain issues, which needed to be included in the baseline care plans. -Resident #78 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving [MEDICAL TREATMENT] three times a week and had an arteriovenous (AV) fistula on the left arm. Review of the resident's baseline care plans revealed there was no care plan developed that addressed [MEDICAL TREATMENT] and the AV fistula site. An interview was conducted on (MONTH) 27, (YEAR) at 9:41 a.m., with a RN (staff #94). She stated that resident #78 goes to [MEDICAL TREATMENT] treatments every Tuesday, Thursday and Saturday. She stated the resident has an AV fistula on her left arm and that [MEDICAL TREATMENT] should be care planned with interventions. An interview was conducted on (MONTH) 28, (YEAR) at 9:16 a.m. with a LPN (staff #16). He stated that care plans are initiated by the RN's. He stated on admission the baseline care plan should include [MEDICAL TREATMENT] treatments. At this time, he reviewed the resident's clinical record and stated there was not a [MEDICAL TREATMENT] care plan, however, there should be one. An interview was conducted on (MONTH) 28, (YEAR) at 12:34 p.m., with the DON (staff #56). She stated that care plans are developed based on the resident's diagnoses, central lines, pain, and psychiatric needs. -Resident #267 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. A review of the baseline care plans revealed they did not address the resident's needs related to a delusional disorder and the use of an antipsychotic medication. An interview with staff #56 was conducted on (MONTH) 28, (YEAR) at 10:18 a.m. Staff #56 stated that the Health Unit Coordinator coordinates the baseline care plans and that all team members contribute to the baseline care plan. Staff #56 said that she expects the baseline care plan to include any medical conditions, therapy goals, and discharge plans of the resident. She stated that they were not addressing psychosocial concerns or mental health concerns on the baseline care plans.

Based on clinical record review, hospital and facility documentation, staff interviews, and review of policies and procedures, the facility failed to ensure that a gait belt was used when ambulating one resident (#386), who sustained a fall with injury. Findings include: Resident #386 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Physical Therapy (PT) evaluation dated July 3, 2016 indicated the resident had decreased balance, endurance, mobility and had a safety awareness deficit. Review of the PT plan of care dated July 3, 2016 revealed a goal to provide supervision with ambulation, and to use a Front Wheeled Walker (FWW). The treatment plan included for balance training, gait training and safety training. An Occupational Therapy (OT) evaluation dated July 3, 2016 included the resident had balance impairment, decreased coordination, decreased muscle strength, mobility impairment, and had a safety awareness deficit. The treatment plan was for balance training, coordination activities, safety training and functional transfer training. A nursing note dated July 10, 2016 indicated the resident was being wheeled out of the bathroom in a wheelchair and started to slide down and was lowered to the floor. The resident sustained [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, the resident was assessed to be unsteady and was only able to stabilize, with human assistance when walking and required a one person assist with this task. A fall care plan identified that the resident was at risk for falls. Interventions included to implement environmental safety measures, provide ambulation assistance, and utilize walking aids when ambulating. The care plan did not include the extent of assistance that the resident required with ambulation. PT notes dated July 23, 2016 indicated the resident required contact guard to limited assistance when ambulating. The notes included the resident ambulated 40 feet and that a gait belt was used. Review of a fall risk assessment dated [DATE] revealed the resident was at high risk for falls. The assessment noted the resident had a weak gait and was to call for assistance. The documentation also included the need for assistance and supervised transfers. Review of the nursing notes dated July 25, 2016, revealed the resident turned on her call light to be assisted to the bathroom. A Certified Nursing Assistant (CNA/staff #2) answered the call light and while assisting the resident to the bathroom, the resident lost her balance, falling to the floor. Per the note, the resident hit the left side of her head on the corner of the bed, and landed on her left hip. The resident was bleeding from the left side of her head and complained of pain to her left hip, so the resident was transferred to the emergency room . According to the emergency room records, an x-ray of the left hip showed a fracture of the left femur. The resident required surgery for [REDACTED]. Review of the facility's investigation revealed a CNA (staff #2) was with the resident at the time of the fall. Staff #2 had taken the resident to the bathroom three times during the shift, twice before the fall. On the third time, staff #2 assisted the resident to the bathroom using her FWW. Staff #2 was opening the bathroom door and had one arm under the resident's arm, when the resident indicated that she was falling. Staff #2 was unable to stop the resident from falling. The report included that staff #2 had not used a gait belt. The investigation further included a written statement from staff #2. Staff #2 reported that with one arm he guided the resident's walker, and the other arm was under the resident's right armpit, as they walked to the bathroom. When they were at the bathroom door they stopped, so he could open the door, but as he was reaching for the door, the resident indicated that she was falling. He tried to grab under her arm to stabilize her, but the door and the walker were in his path and she slipped out of his grasp. The resident fell hitting the left side of her body, including her head and hip. The investigation further included that after the incident, staff #2 was counseled regarding not using a gait belt during a transfer. Review of facility employee documentation revealed that staff #2 had gotten the resident up two times earlier that night and had used a gait belt, however, the third time he did not use a gait belt, as the resident had done well so he felt that he did not need the gait belt. An interview was conducted with an OT (staff #139) at 8:25 a.m. on July 6, 2017. She said the expectation regarding gait belts is that they should be used at all times, during ambulation and transfers. She stated that on occasion, there are residents who are at a very high level of functioning and are independent, so in those cases therapy may tell nursing that the resident does not need to wear a gait belt during transfers and ambulation. Staff #139 stated that this is very rare, and requires discussion between nursing and therapy. She stated the therapy department does provide education to staff regarding gait belts and that they had a skills fair about 6 months ago on how to correctly apply a gait belt. She also said that nurses are trained to know that a gait belt should be used each time a resident is ambulated. She stated that this resident needed staff assistance with ambulation and transfers, as she was unsteady and that the resident had fallen on more than one occasion, so a gait belt should have been used. She further stated that the resident may have fallen regardless of using a gait belt, but if staff would have used a gait belt, it would have been easier for the CNA to steady her, and this may have prevented the fall or lessened the impact. In an interview with a Licensed Practical Nurse (LPN/staff #73) at 8:30 a.m. on July 6, 2017, staff #73 stated that CNAs and nurses are to use gait belts when ambulating or transferring a resident. He said this is always the case, especially if a resident has an unsteady gait. Staff #73 stated that therapy does provide gait belt training and that staff are told to use gait belts at all times. He said that all nursing staff receive a gait belt, which is part of their uniform. During an interview with a CNA (staff #118) at 8:45 a.m. on July 6, 2017, she stated that in this facility, all residents are considered to be at risk for falls and that gait belts should be worn during all transfers and when ambulating a resident. She said that ambulating a resident with a gait belt is safer. The clinical rehabilitation services manager (staff #140) for the therapy department was interviewed at 10:40 a.m. on July 6, 2017. She stated that all staff who assist a resident with ambulation or transfers should have a gait belt on at all times. She said the only exception is when a resident is very steady and therapy assesses them to be able to walk on their own, without a gait belt or assistance. She said this is rare, but when this does occur, the resident gets a walk badge that they wear so staff know this is okay. She stated that if a gait belt had been worn, the CNA would have been able to provide more stability for the safety of the resident. At this time, staff #140 reviewed the resident's therapy evaluations and notes and indicated that when the resident came in, she would have needed contact guard to minimum assistance with ambulation. She stated that the resident's status with ambulation did not change between the PT evaluation and the time of her discharge to the hospital, so a gait belt should have been used. After reviewing the residents who had walk badges, she stated this resident did not qualify and so a gait belt should have been used. An interview was conducted with staff #2 on July 7, 2017 at 8:25 a.m. He stated that he had assisted the resident to the bathroom that night. He said her walker got caught on the door when they were going into the bathroom. He said he tried to grab her, but he was unable to steady her. He said that gait belts should be used at all times, but could not remember if he used a gait belt that night. He said that having a gait belt on stabilizes the resident. The Director of Nursing (DON/staff #72) was interviewed at 9:00 a.m. on July 7, 2017. She stated that the CNA was not using a gait belt at the time of the incident but should have, because the resident had a weak gait. Staff #72 stated that if he had used a gait belt, the fall may still have occurred, but there is a good chance that the injury may not have been as bad. She said that after this incident they put an action plan in place regarding gait belt use to ensure staff use gait belts at all times. She said the facility does not have a specific gait belt policy, as gait belt use is standard CNA practice. Review of the facility's fall prevention policy and procedure revealed the purpose was to improve patient safety, by implementing interventions to decrease the risk of falling for high risk patients. Review of the Adult Standard of Care policy revealed that safety measures begin on admission and are addressed each shift. The policy included that staff incorporates the appropriate safety measures into the patient's plan of care, based on patient need.

Based on clinical record review, staff interviews, facility and hospital documentation and policy review, the facility failed to ensure ongoing nursing assessments were completed as indicated, and failed to initiate CPR (cardio [MEDICAL CONDITION] resuscitation) to one resident (#179), who was a full code. Findings include: Resident #179 was admitted to the facility on [DATE] at approximately 5:30 p.m., with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Prior to admission, the resident was in the hospital. According to the hospital discharge summary dated February 1, 2013, the resident was to resume the use of a [MEDICAL CONDITION] (bilevel positive airway pressure) machine to wear at night for sleep apnea. Admission physician orders included for the following: oxygen at two liters via nasal cannula/titrate to keep oxygen saturation (O2 sat) levels greater than or equal to 92 percent, [MEDICAL CONDITION] to wear while sleeping at night-family to bring from home, [MEDICATION NAME] 0.5 mg/2 ml unit dose inhalation solution twice a day, and [MEDICATION NAME] 0.83 mg/ml (milligram per milliliter) 3 ml unit dose inhalation solution via SVN (small volume nebulizer) every four hours as needed for shortness of breath or wheezing. admission orders [REDACTED]. Care plans for pneumonia and ineffective breathing patterns dated February 1, 2013, included the following interventions: administer medications as needed; monitor effects of nebulizer treatments; monitor O2 sats, observe for deterioration in condition; administer oxygen therapy, notify physician of changes in respiratory status as appropriate and patient to be on a [MEDICAL CONDITION] at bedtime. Vital sign documentation dated February 1 at 5:24 p.m., included the resident's temperature was 98.2 degrees F (Fahrenheit) and O2 sats were 93 percent. Review of the admission health profile dated February 1, 2013 at 7:58 p.m., revealed documentation that the resident's family accompanied the resident upon admission. However, there was no documentation that the resident's family had been contacted regarding bringing in the [MEDICAL CONDITION] machine, nor documentation that the facility attempted to provide or obtain one. A physician's order dated February 1, 2013, included for [MEDICATION NAME] ,[DATE], two tablets every four hours as need for severe pain ,[DATE] (using a pain scale of ,[DATE]) According to the February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, in an interview the nurse stated the resident had complained of chest pain at that time and the physician was called. Despite the resident's complaints of chest pain, there was no clinical record documentation of a thorough nursing assessment that was completed, nor was there documentation of any respiratory assessment, including O2 sat monitoring that was done. Review of the activities of daily living form dated February 1, 2013 at 8:32 p.m., revealed the resident was resting with his eyes closed and that he falls asleep quickly, even during conversation. Per the MAR, the resident's pain level was reassessed at 9:16 p.m., and was documented at a 3. Documentation on the activities of daily living form on February 2 at 2:40 a.m., included the resident was sleeping. Further review of the clinical record revealed that at 3:06 a.m., the resident's temperature was 97.7 degrees F; blood pressure was ,[DATE]; heart rate was 90; respiratory rate was 20; and O2 sats were 91 percent on two liters of oxygen. There was no documentation that the oxygen was titrated to maintain O2 sats at or greater than 92 percent as ordered. There was also no documentation that any additional O2 sat monitoring was done, in order to determine the need for respiratory medications or the need for any other interventions. A nursing note entry dated February 2, 2013 at 5:54 a.m., documented the following: At 9:00 p.m., "Patient new to us, had a very restless evening and I did call physician with whom we looked at X-ray and determined that his upper right chest pain was due to the pneumonia for which he was admitted from the hospital on antibiotics...Was febrile and was given ice packs for comfort. Resting well now with mouth opened." A nursing note entry dated February 2 at 5:56 a.m., documented that at 2:00 a.m., the resident was "resting well, snoring." A nursing note entry at 6:01 a.m. documented that at 5:25 a.m. the following occurred: "I am called in emergency in the room where I find patient without respiration and heart rate. Nursing assistant was in the room changing roommate 10 minutes ago, when patient was still sleeping. Found him without any signs of suffering and I do not want to call 911 as he is obviously left his body; in peace, Procedure started as needed, physician and family called, family coming in." There was no clinical record documentation that CPR was initiated, despite the resident being a full code. The resident was pronounced dead at 5:25 a.m. on February 2, 2013, with a preliminary cause of death, as pneumonia right upper lobe. Review of the facility's investigative report revealed the CNA was given report that the family was bringing in the [MEDICAL CONDITION] machine. Per the investigation, the CNA went to check on the resident when making rounds and he was sleeping and coughing. She did not like the way he looked or the way he was acting and told the nurse around 11:15 -11:30 p.m., that he was snoring and coughing lots of phlegm. Per the CNA, the nurse observed him, but she does not know if she called the physician. The CNA reported that the resident would sleep for awhile and cough off and on. At 4:30 a.m., the CNA put a towel on his side, as there was lots of phlegm and she asked the resident's nurse if he needed to be suctioned and the nurse replied that orders were needed. The investigation also included that the RN charge nurse caring for the resident did not contact the family to bring in the [MEDICAL CONDITION] machine, because she thought he would "not die with one night without machine." Per the report, the resident was having chest pain in the evening and she called the physician, who had her look at his X-ray, which showed pneumonia. Pain medication was given. The nurse later went to check on the resident and he was restless, sleeping, and snoring loudly. The nurse reported his saliva was very thick, but she did not want to wake him. She did not think he needed suctioning, and if she thought it was needed, she would do it even before calling the physician. The report included that the nurse stated the CNA was outside of his doorway all shift and said he was sleeping well and could hear him snoring. Despite the reports that the resident's saliva was very thick, and the concerns from the CNA regarding coughing and lots of phlegm, there was no clinical record documentation that a thorough assessment of the resident's respiratory status was completed throughout the night. The investigative report further included an interview with the first RN on the scene to arrive. This RN immediately assessed the resident and determined that there were no respirations, no pulse, and pupils were fixed and dilated. Per the report, the decision was made not to start CPR because he was cold and stiff. When the RN was asked if there had been any indications of a change in condition he stated that a CNA had said she informed the nurse caring for the resident that the resident did not look good. When asked if he thought that everything was done that could have been done for the resident the RN stated that when the CNA informed the RN of a change in condition, it falls on the RN for decision making. The report included that another nurse (LPN) responded as she heard the CNA call out for help. She went into the room and then went to get the chart to find out the code status. He was a full code, so she said a code needed to be started. She then left because someone said we were not going to start the code. In addition, the report included the following interview with the RN charge nurse: Question: "Why did you not start CPR?" Answer: "It's my own belief. I see too many people, too much CPR on dead people. I know heart will be started and be in ICU (intensive care unit). I see too much...I don't believe this is right.." Question: "What did the other RN do?" Answer: "He immediately deferred to me. All staff ready to start CPR." Question: "Who was that?" Answer: "CNA and others." Question: "Did you stop it?" Answer: "Yes, I know...policy and procedure...but..." Question: "Who else was in room?" Answer: (names two other staff members) Question: "Did they want to start CPR?" Answer: "Yes, but they respected my decision not to start CPR An interview was conducted on [DATE], with the RN (registered nurse) caring for the resident the night he expired. This RN was also the charge nurse at the time of the incident. The nurse stated that a CNA called out to her around 5:30 a.m., that the patient was not responding. She said when she assessed the resident he looked peaceful, so she followed her feelings instead of policy and did not do resuscitation (CPR). The nurse stated that it may have to do with her French culture. She also stated that she knew that after 10 minutes without oxygen the brain is damaged, but she did not know how much time had lapsed. She further stated that when the resident complained of chest pain, she called the the physician for pain medication and talked about the chest x-ray results. The nurse stated that after the pain medication and after talking to the resident he began to calm down and feel better. An interview was conducted on [DATE], with the RN first on the scene. He stated that he had been at the nursing station and had not known this resident. He stated he was called into the room by the CNA. He observed the resident to be unresponsive and there appeared to be secretions or vomit around his mouth. He stated he went out of the room to check on his code status and when he returned, the nurse assigned to the resident was present and he was told not to start resuscitation, because the resident was dead. When asked if any one else was present at the time he stated that another nurse (LPN) had responded, but she left when the charge nurse (RN caring for the resident) stated that the resuscitation was not to be done. When asked if the CNA had told him anything about the condition of the resident he recalled that the CNA had told him that she told the nurse caring for the resident that the resident had not looked good earlier, but he could not recall if the CNA mentioned the time this was reported to the nurse. An interview was conducted on [DATE], with the CNA who found the resident unresponsive. She was unable to recall the incident or the resident stating it had been too long ago. An interview was conducted on [DATE], with the DON (Director of Nursing). She stated that due to the incident it was identified that the staff involved had not followed facility policy regarding code status. She said the charge nurse had been dismissed from the facility. She said the staff were inserviced regarding the need to bring information forward using the chain of command if care issues/policy issues are observed, and discussed the initiation of basic life support (BLS) per training, if situation presents. The DON acknowledged that there was no documentation of any follow-up regarding corrective actions that were implemented related to ongoing monitoring of code status/CPR implementation. The DON further stated that they identified a concern regarding not providing the [MEDICAL CONDITION] machine and that now the facility provides the machines, until the family brings them in. The DON stated that there was no follow-up/audits to ensure that this plan of correction was monitored. A review of the facility policy on code blue/code 99 management revealed the following: Purpose; Patients, staff and visitors may expect emergency medical care which includes care necessary to deal with life-threatening events and improve chances of survival. The Code Team may be summoned at any time a patient without a do not resuscitate armband...becomes unresponsive. This may include but not limited to respiratory distress/threaten airway/acute decrease in oxygen saturation and absence of respirations and or pulse.