Every finding on record at Brighton Care Center

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents remained as free from accidents and hazards as possible.Resident #1, who had diagnoses of cerebral palsy (a movement disorder caused by brain damage during infancy), dorsalgia (back pain), adult failure to thrive, scoliosis (spine posture abnormality), dysphagia and osteoporosis, was admitted to the facility on [DATE]. Resident #1 was dependent on staff for transfers utilizing a Hoyer lift (mechanical lift).On 6/19/26 at 1:00 p.m. registered nurse (RN) #1 and certified nurse aide (CNA) #1 were transferring Resident #1 from her wheelchair to bed using the Hoyer power lift 700 using a large, full body sling. During the transfer, the staff heard a popping sound and the sling attached to the Hoyer lift's sling bar (a bar that did not have a safety latch but had a curled bar that was supposed to prevent the sling from slipping) came undone. Resident #1 fell onto the floor and hit her head on the floor. The resident experienced increased pain, sustained a forehead hematoma (a closed wound where blood collects after an injury causing pain and swelling), and a forearm bruise and was sent to the emergency room (ER) for further evaluation. The resident was diagnosed with a traumatic head injury. Resident #1 reported the incident caused her increased anxiety and she had increased pain to her head and forearm after the accident.Specifically, the facility failed to ensure Resident #1 was transferred safely using the Hoyer lift. Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #1's fall, including removing the two Hoyer 700 lift from use, prior to the onsite investigation on 7/20/26, which resulted in the deficiency being cited as past non-compliance with a correction date of 6/26/26.I. Incident on 6/19/26On 6/19/26 at 1:00 p.m. RN #1 and CNA #1 were transferring Resident #1 using the Hoyer lift. During the transfer, one of the sling loops came unhooked and the resident fell to the ground, striking her head. Resident #1 was transferred to the hospital and diagnosed with a head injury.II. Facility plan of correctionA. Immediate action to correct the deficient practiceResident #1 was transferred to the hospital for evaluation and treatment. An interview was completed with the resident when she returned and her care plan was updated.B. Identification of other residentsThe nursing home administrator (NHA), the director of nursing (DON) and the regional clinical resource reviewed and audited the care plans and assessments of all residents who required assistance with transferring via mechanical lifts. There were 14 residents who were dependent on staff for transfers and required the use of a mechanical lift out of a census of 83. C. Systemic changesOn 6/23/26 RN #1, who was hired on 4/30/26, received counseling and education regarding appropriate Hoyer lift transfers. The counseling included following policy on all transfers and lifts to ensure the correct sling size was used at all times. On 6/23/26 CNA #1, who was hired on 5/19/26, received counseling and education regarding appropriate Hoyer lift transfers. The counseling included following policy on all transfers and lifts to ensure the correct sling size was used at all times. The counseling also included to not be rushed, and to ensure the sling loops were securely latched.All nursing staff were re-educated on proper mechanical lift procedures, including appropriate sling sizes, and double checking the mechanical lift and the sling were secure before transfer. Also ensuring all sling loops were secured in place to the machine and did not slide off prior to transfer and provided a return demonstration of knowledge by 6/26/26.D. MonitoringThe DON/designee would conduct three random Hoyer lift transfer audits per week via observation to ensure proper transfers were conducted and that staff were competent to perform the transfers. Audits would be documented via excel spreadsheet and reviewed monthly in the quality assurance and program improvement (QAPI) meeting for a minimum of 12 weeks or until substantial compliance had been achieved. The last QAPI meeting was 7/15/26.III. Facility policy and procedureThe Activities of Daily Living (ADL), Lifting and Movement of Residents policy and procedure, revised 1/12/26, was provided by the NHA on 7/20/26 at 12:40 p.m. It read in pertinent part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transferbelts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Mechanical lifts are only to be operated with two staff members during transfers. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Enough slings, in the sizes required by residents in need, will be available at all times. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies.IV. Manufacturer recommendationsThe user instruction manual for the Hoyer power lift 700 mechanical lift, dated 2024, was provided by the NHA on 7/20/26 at 5:33 p.m. It read in pertinent part, Read and understand the user instruction manual before using the Hoyer power lift 700. Slings: the Hoyer HPL700 has a six-point bari loop spreader bar. The six-point system uses slings with webbing loops which allow positioning adjustment by selecting different colored straps. Loop strap slings: Hoyer bari quickfit and bari full back slings. The six-point system attaches to the spreader bar hooks via loop straps. Each sling is supplied with instructions. Please study the instruction guide before use. Warning: Hoyer recommends the use of genuine hoyer parts. Hoyer slings and lifts are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. Do not lift a patient unless you are trained and competent to do so. Always carry out the daily check list located towards the end of the manual before using the lift. Always fit the sling according to the instructions provided (user instructions). Always carry out lifting operations according to the instructions in the user manual.V. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included cerebral palsy, dorsalgia, adult failure to thrive, scoliosis, dysphagia and osteoporosis. The 5/8/26 minimum data set (MDS) assessment revealed the resident's short and long term memory were okay per staff assessment. The resident was normally able to recall the current season, location of own room, staff names and faces, and that she was in a nursing home. She was dependent on staff assistance for eating, oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, personal hygiene, rolling left and right, chair to bed-to-chair transfers and shower transfers. She was dependent on staff assistance for mobility with a manual wheelchair.The MDS assessment revealed the resident was not on a scheduled pain regimen and did not receive as needed (PRN) pain medication. The assessment revealed the resident experienced pain rarely or not at all and rarely or not at all interfered with sleep, therapy activities, or day to day activities. The assessment revealed the resident's worst verbal descriptor of pain was mild. B. Resident and resident representative interviewResident #1 was interviewed on 7/20/26 at 10:00 a.m. Resident #1 said she had a fall recently from the Hoyer lift and it made her feel anxious. Resident #1 said RN #1 was there and helped her after the fall. She said the other staff member, CNA #1, no longer worked at the facility. Resident #1 said the staff made a mistake in transferring her and CNA #1 did not hook up the strap correctly and went too fast. Resident #1 said CNA #1 was on her left side and that was the side that she fell from. Resident #1 said it was not a safe transfer. She said CNA #1 did not check the sling straps and the strap fell off on the left side. Resident #1 said after the fall, she was on the floor and she had pain in her arm, hit her head and had a headache for a few weeks.The resident's representative was interviewed on 7/20/26 at 2:30 p.m. The resident's representative said Resident #1 told her that during the Hoyer lift transfer on 6/19/26, CNA #1 was trying to rush. She said CNA #1 did not secure the top part of the Hoyer lift sling by hooking up the strap securely and the sling tipped and Resident #1 went down on her head. The resident's representative said Resident #1 had made complaints to her before about CNA #1, saying that he was always in such a hurry. The resident's representative said Resident #1 would try to tell CNA #1 something and he would just walk out. The resident's representative said she had talked to the DON. She said the DON assured the representative that she would have instructional classes and staff education after this incident. The resident's representative said Resident #1 had always been fearful of being dropped and she was always a little fearful of things, such as falling out of bed, so the fall from the Hoyer lift really increased her fear. The resident's representative said Resident #1 started taking a new antidepressant medication recently in July 2026 to help decrease her anxiety. The resident's representative said when Resident #1 first fell, she had a lump and knot on her head and her forehead was black and blue. The resident's representative said Resident #1 could have broken a bone when she fell. She said the incident worried her a lot. She said the resident also sustained a bruise on her arm during the fall. The resident's representative said she was uneasy about the caregiver, CNA #1, and when the facility first called her about the accident, the facility said the resident was very stiff. She said it made it seem like the facility was placing blame on Resident #1. The resident's representative said the main point was that Resident #1 needed gentle hands, especially because of her diagnoses and fears.C. Facility investigationThe facility investigation was provided by the NHA on 7/20/26 at 10:50 a.m. The investigation revealed Resident #1 had fallen from the Hoyer lift while RN #1 and CNA #1 were transferring her from her wheelchair to her bed. The investigation documented neurological checks were at baseline, no changes in mentation were noted at that time and a hematoma was noted by the nurse to the resident's left forehead and a bruise was noted to the resident's left forearm. The resident was sent to the ER for further evaluation. The resident returned to the facility on 6/19/26.The investigation documented that while Resident #1 was at the hospital, a computed tomography (CT-imaging) scan of the head and neck was completed for indication of trauma and pain. The findings of CT scan revealed mild to moderate left frontal scalp soft tissue swelling. There was no skull fracture or acute brain hemorrhage. The findings of the CT scan of the spine revealed no acute fractures. The hospital after visit summary, dated 6/19/26, documented a diagnosis of a fall with a traumatic injury of the head. The facility identified a concern regarding the Hoyer lift transfer incident with Resident #1.It was identified that the Hoyer lift did not have safety latches but had a curled bar that was supposed to prevent the sling from slipping. The Hoyer lift and sling were inspected and removed from use. There were no noted rips or tears to the sling utilized. The Hoyer lift was in working condition. Education was provided to staff on choosing the right sling for the right task. The DON audited all residents who utilized a Hoyer lift for transfers, to ensure their slings were in good condition and appropriate size for the resident. The NHA ordered all new Hoyer slings for each resident. The slings were labeled with the residents' last name and first initial, and each resident received two slings. The DON provided education to staff, from 6/19/26 to 6/26/26, who used a Hoyer lift to ensure they were competent with the use of the Hoyer lift. In addition, competencies were conducted with a return demonstration to ensure the staff members were competent with the transfers. They were also instructed on observing the Hoyer lift sling prior to application. The DON assessed all Hoyer lift slings for appropriate size and condition to ensure there were no slings that were frayed or in poor condition.The DON updated all physician's orders for residents who required Hoyer lift transfers with any changes to sling size that may need to be made to include which Hoyer lift to utilize for the resident. All care plans were reviewed, and changes were made as necessary. The appropriate size of sling and hoyer lift size was added to the residents' electronic medical records (EMR) and Kardex (staff directive tool) for easy access of reference for staff. The investigation documented Resident #1 was interviewed on 6/22/26 by the social services director (SSD). The SSD asked Resident #1 if she knew what happened or why she fell from the Hoyer lift on 6/19/26. Resident #1 responded that she did not know, but she thought it broke; it was so fast and then she was on the floor.The investigation documented RN #1 was interviewed on 6/19/26 by the SSD. RN #1 said she assisted CNA #1 with Resident #1's transfer using the Hoyer lift. RN #1 said that she was at the back of the resident's chair and CNA #1 was on the left side of the chair. The lift sling was in place and the resident was lifted up with the lift toward the bed. RN #1 heard a pop and one side of the sling gave way and Resident #1 fell toward the side that gave way. RN #1 said CNA #1 attempted to grab Resident #1 as she fell. RN #1 said CNA #1 was able to hold onto her and both the CNA #1 and Resident #1 went to the floor over the top of the legs of the lift. RN #1 said Resident #1 did bump her head on the ground. RN #1 said she completed a full body assessment, she had contractures and stiffness with minimal movement at baseline, and Resident #1 said her head was hurting, but no other pain. RN #1 said she initiated neurological checks and notified nurse management.The investigation documented CNA #1 was interviewed, undated, by the SSD. CNA #1 said he was getting ready to put Resident #1 in bed after lunch because she liked to go to bed after lunch. CNA #1 said he got Resident #1 in the sling in her chair. CNA #1 said he then asked RN #1 to come and help him with the Hoyer lift. CNA #1 said RN #1 was in the back and he was in the front and they turned Resident #1's body together. CNA #1 said he heard a pop and saw Resident #1 falling and he went straight under her with his knees and arms to try to prevent her from hitting her body on the ground. CNA #1 said he saw Resident #1 bump her head on the floor and to his knowledge, her head was the only thing that hit the ground. CNA #1 said after Resident #1 was checked out, they proceeded to put Resident #1 back into the bed using a different sling.The investigation documented the root cause of the fall was either due to not having a safety latch on the bar or a particular sling. The team removed all the Hoyer 700 lifts from use and were looking at purchasing additional Hoyer lifts with a safety latch on the bar where the slings attached. The maintenance resource was looking into manufacturer's logs to determine if the root cause was due to not having a safety latch on the bar or a particular brand of sling.The investigation documented the staff were educated on making sure that lift sling loops were properly secured on the Hoyer lift prior to transfers.D. Record reviewResident #1's fall care plan, revised 6/22/26, revealed the resident was at risk for falls. Pertinent interventions included ensuring the call light was within reach, following facility fall protocol, maintaining a clear pathway, reassessing appropriate lift sling size, and sending the resident to the hospital for evaluation and treatment status post-fall on 6/19/26. The 6/19/26 nursing progress note, documented by RN #1, revealed that at 1:00 p.m. RN #1 had assisted CNA #1 with a transfer using the Hoyer lift. The note documented RN #1 was at the back of the chair and CNA #1 was on the left side of the chair. RN #1 documented the sling was in place and Resident #1 was lifted up with mechanical lift. RN #1 moved the wheelchair and CNA #1 moved Resident #1 with the lift toward the bed. A pop was heard and one side of the sling gave way. Resident #1 fell toward the side that gave way and CNA #1 attempted to grab Resident #1 as she fell. CNA #1 was able to hold onto the resident and both CNA #1 and Resident #1 went to the floor over the top of the legs of the lift. Resident #1 struck her head on the ground and a 2.5 centimeter (cm) by 2.5 cm hematoma was starting to form on the left side of the resident's forehead. A 1 cm by 2 cm bruise was noted to the resident's left forearm. No other injuries were noted. Resident #1 stated her head was hurting, but had no other pain. RN #1 assessed the resident's hips, legs, back, elbow and arms. Resident #1 had contractures and was stiff with minimal movement at baseline; neurological checks were initiated. The nurse manager was notified.The 6/19/26, social services note revealed the SSD spoke with Resident #1 related to her fall and going to the hospital to get checked out. Resident #1 said she was okay with going to the hospital as a precaution since she bumped her head. The SSD stayed with Resident #1 while the paramedics got her onto the stretcher and reassured her. The 6/19/26 nursing note revealed that at 4:40 p.m. RN #1 spoke with the SSD and the DON. A decision was made to transfer Resident #1 to the hospital to evaluate her injuries. They spoke with Resident #1 and notified her of the request to be checked at the hospital and Resident #1 agreed to the transfer. The SSD assisted with calling the ambulance and the nurse manager assisted with the transfer form. The ambulance arrived at 4:50 p.m. and a report was given to emergency medical services (EMS). Resident #1 was transferred to a stretcher and paperwork was sent with the resident. The assistant director of nursing (ADON) called the hospital for a report and the SSD notified the family of the transfer.The 6/19/26 hospital ER encounter note revealed Resident #1's chief complaint was a head injury, neck pain and fall. The history report revealed that the resident was being transferred and fell, potentially hitting her head and causing neck pain. The physical examination revealed the resident had lateral (side) tenderness to her neck. The note documented the resident had a fall with traumatic injury to the head.The 6/19/26 hospital CT scans of the head and cervical spine revealed mild to moderate left frontal scalp soft tissue swelling with no underlying skull fracture. There was low-attenuation prominence of the extra-axial space along the right frontal convexity potentially reflecting a small subdural hygroma (a collection of cerebrospinal fluid that accumulates in the subdural space of the brain resulting from head trauma that damages the protective membranes around the brain) measuring up to 7 millimeters (mm) in maximum thickness. The note documented this could be followed to ensure stability and/or exclude the delayed development of hyperattenuating components (such as acute hemorrhage) that would suggest an admixture of blood products. The note documented the resident also had a right to left midline shift of approximately 7 mm. There was no fracture or subluxation of the cervical spine.The 6/19/26 hospital after visit summary documented the resident was seen for a fall with a diagnosis of a fall with a traumatic head injury. The 6/19/26 at 7:56 p.m. nursing noted revealed Resident #1 returned from the hospital ER visit via paramedics and an ambulance. No new orders were received. The resident's vital signs were stable and Resident #1 continued on neurological checks related to the fall during the day shift. Neurological checks were within normal limits and Resident #1 denied any pain or discomfort. The 6/19/26 alert charting nursing note for follow-up related to a fall revealed staff were to monitor for change in mentation, change in range of motion to extremities, or increased complaints of pain related to fall every shift for three days.Review of Resident #1's EMR revealed the following: On 6/19/26 the resident reported a pain level of 7 out of 10;On 6/20/26, the resident reported a pain level of 5 out of 10 pain and 3 out of 10 pain; On 6/21/26, the resident reported a pain level of 6 out of 10 pain and 2 out of 10 pain; and, On 6/22/26, the resident reported a pain level of 2 out of 10 pain levels. The 6/20/26 nursing note revealed Resident #1 had new skin issues due to an in-house fall on 6/19/26. The resident's left outer forearm presented with bruising. There was a skin issue to the resident's rear scalp, top of scalp and a head hematoma.The 6/20/26 at 4:47 a.m. medication administration note revealed Tylenol extra strength oral tablet was administered to the resident for generalized pain. The 6/20/26 at 8:20 p.m. medication administration note documented the resident had generalized pain and reported her pain as a 6 out of 10, with aching. The 6/20/26 at 8:24 p.m., nursing note revealed the resident continued on fall follow-up. The resident complained of pain and was relieved with as needed (PRN) pain medications and the resident denied any further pain or discomfort and made all needs known and would continue to monitor.Review of Resident #1's EMR revealed she received PRN Tylenol extra strength for headache and pain on 6/19/26, 6/20/26, 6/21/26, 6/22/26, 6/23/26, 6/26/26, 6/28/26, 7/9/26, 7/12/26 and 7/15/26. The 6/22/26 fall committee interdisciplinary team (IDT) note revealed Resident #1 had a fall in the restroom. The family, the physician and the DON were notified. The fall was witnessed, with injuries of a hematoma to the resident's forehead and a laceration to the forearm. The treatment was to send the resident to the ER for evaluation and treatment, and monitoring was in place. Predisposing factors were a cerebral palsy diagnosis, mobility deficit, and range of motion deficits. The root cause was not determined yet and an investigation was initiated. There were no medications affecting the transfer. Previous fall interventions included to avoid rearranging the furniture, be sure the call light was within reach and encouraging the resident to use it to call for assistance PRN, educate resident/family/caregivers about safety reminders and what to do if a fall occurred, and ensure resident was wearing appropriate footwear when ambulating or wheeling in wheelchair. New interventions were not implemented yet due to investigation pending and the resident was sent to ER for evaluation and treatment.The 6/22/26 social services note revealed the SSD checked in with Resident #1. The resident stated she was doing well and was happy she went to get checked out at the hospital on Friday. The resident revealed some anxiety related to the fall, however stated she felt better knowing the staff were doing extra training and they would walk her through each step when transferring her using the Hoyer lift. The resident was offered counseling/behavioral health services, but she declined at this time. The 6/22/26 occupational therapy (OT) note revealed a screening of Resident #1 was conducted related to status post-fall. OT continued recommendation of the Hoyer lift for transfers with two-person assist with further recommendations to use a U-shaped sling, size medium with the Hoyer lift. On 6/22/26 a new physician's order was implemented and indicated to use a medium sized U Body Hoyer lift sling for all transfers every shift.The 6/24/26 medication administration note revealed Resident #1 had a skin alteration related to a fall. The note documented the nurse was monitoring the hematoma to the resident's left forehead and a bruise to the resident's left forearm. The resident had increased pain related to the fall and was medicated at bedtime with PRN pain medication with positive effect.On 7/16/26 a new physician's order was initiated for Sertraline HCl (hydrochloride) oral tablet 50 mg. Give one tablet by mouth one time a day for anxiety. The 7/20/26 social services note revealed the SSD checked in with Resident #1 related to her psychosocial status. The SSD checked in on how Resident #1 was feeling about Hoyer lift transfers and the resident stated she had no concerns. Resident #1 had recently started on Sertraline due to anxiety and she reported she did have anxiety at times, but was doing okay despite that. The 7/20/26 fall committee IDT follow-up note revealed the team removed all the Hoyer 700 lifts from use and would look at purchasing additional Hoyer's with a safety latch on the bar where the slings attached. The maintenance resource was looking into manufacturer's logs to determine if the root cause of Resident #1's fall was due to not having a safety latch on the bar or a particular sling.VI. Staff interviewsRN #1 was interviewed on 7/20/26 at 1:05 p.m. RN #1 said Resident #1 fell to the left side during the Hoyer lift transfer on 6/19/26 that was completed with CNA #1. RN #1 said the Hoyer lift was lifting Resident #1 up. She said CNA #1 was moving the base of the lift and turned the lift towards the bed. RN #1 said there was a popping sound and Resident #1 went down to the ground. RN #1 said CNA #1 partially caught Resident #1, but they both went down to the ground together. RN #1 said Resident #1 hit her left forehead and left forearm on the ground. RN #1 said they were using a large sized full-body sling, but that sling did not seem to be the right one for Resident #1. She said the sling was labeled with a different person's name. RN #1 said she got a different medium sized sling to put Resident #1 back to bed but that one also seemed to want to slip off of the Hoyer lift and the type of sling was also not correct for her. RN #1 said the new plan was to keep the residents' slings in their rooms with their names on the slings. RN #1 said because of the way Resident #1 leaned, it seemed like the sling they used for the transfer was not right for her. She said it was a large size sling and the resident should have had a medium size and a different type of sling. RN #1 said the pop she heard was the lift sling loop coming out of the metal curled bar on the lift. RN #1 said the Hoyer 700 lift they used did not have safety latches. RN #1 said she had a concern because the Hoyer 700 lift was the only one with the capability of weighing the residents. RN #1 said the fall incident with Resident #1 occurred because the lift sling strap just slipped off on CNA #1's side. RN #1 said Resident #1 had a headache right after she fell. The NHA and the regional clinical resource were interviewed together on 7/20/26 at 4:05 p.m. The regional clinical resource said on 6/19/26, CNA #1 had Resident #1 in the sling and fastened on the Hoyer lift before RN #1 arrived to assist with the transfer. The regional clinical resource said RN #1 was the operator of the lift controls and CNA #1 was guiding Resident #1 when they heard a popping sound and Resident #1 started to fall. The regional clinical resource said CNA #1 tried to help hold Resident #1, but fell with the resident to the floor. The regional clinical resource said RN #1 did the assessment of the resident and started neurological checks and sent the resident out to the ER. The regional clinical resource said they checked the sling and the Hoyer 700 lift was pulled from the floor because the sling fell off the lift. The NHA said the Hoyer 600 lifts had safety latches, so they were still in use and there had been no other falls from Hoyer lifts and none prior to at least back to March 2026 when she first started as the NHA. The regional clinical resource said Resident #1 went from a full-body type of sling to a U-shaped sling which was better for her body type. The regional clinical resource said that all of the facility's slings were intact, but the Hoyer lift manufacturer wanted them to use a particular sling and only genuine Hoyer parts and slings (called Hoyer bari quickfit and bari full-back slings) and they said they were not designed to be interchangeable with other manufacturer's products. The regional clinical resource said the Hoyer 700 lift still did not come with the safety latches and that was a concern to her. The regional clinical resource said the root cause of Resident #1's fall was the loop/straps of the lift sling slipped off the bar due to the lift having no safety latches and the intervention was to remove the Hoyer 700 lifts from the floor. The regional clinical resource said the Hoyer 700 lifts did not use safety latches but a curled bar that was supposed to prevent the sling from slipping, but only if staff were using a particular sling. The regional clinical resource said the facility was still researching and looking into that but meanwhile, the Hoyer 700 lifts were not on the floor. The regional clinical resource said initially in the investigation, she noticed the trend of the sling loop slipping so that was addressed in the facility's plan of correction. The regional clinical resource said the DON/designee completed staff training for Hoyer lift transfers with return demonstrations and completed a plan of correction after Resident #1's fall on 6//19/26.The NHA said the facility completed maintenance checks of the Hoyer lifts monthly and recorded them in their computer system. She said in addition, a service company came and did inspections of the Hoyer lifts. The NHA said the type of Hoyer lift that Resident #1 used when she fell was a Hoyer HPL700 lift and the sling was a large full-body sling. The NHA said RN #1 and CNA #1 both received one-on-one education and training regarding a safe and appropriate Hoyer lift transfer. The NHA said the training included to watch the sling straps for slipping off and to ensure the Hoyer lift sling loops were properly secured before proceeding with the transfer. The NHA said the nurse and CNA training included a return demonstration of knowledge and also choosing the proper sling type and size. The NHA said there were new physician's orders in place for the proper sling size and type and every resident now had two slings. The NHA said the facility was now auditing three staff members a week via observation to ensure proper technique was used for the transfers. The NHA said that the facility's last QAPI meeting was on 7/15/26 where they discussed the mechanical lift malfunction and slings, and reviewed the plan of correction and monitoring. The NHA and the regional clinical resource said Resident #1 went through times where she had anxiety because she was very dependent on staff for assistance. The NHA and regional clinical resource said Resident #1 had been taking lorazepam for anxiety since March 2026 but psychopharmacology had added Sertaline in July 2026 for anxiety.

Based on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure dietary staff wore intact gloves over artificial fingernails with nail polish when working with exposed food; and, -Maintain the kitchen in a sanitary condition. Findings include: I. Ensure staff wore intact gloves over artificial fingernails with fingernail polish A. Professional reference The Colorado Retail Food Establishment Regulations (3/16/24), were retrieved on 11/13/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. B. Observations During a continuous observation of the dinner meal on 11/5/24, beginning at 4:50 p.m. and ending at 5:45 p.m., the following was observed in the kitchen: At 5:03 p.m cook (CK) #1 began assembling meal plates to be served to residents. CK #1 assembled and served resident meal plates through the entire service until 5:45 p.m. while wearing artificial nails with nail polish. CK #1 did not wear gloves during the meal service. C. Staff interviews The dietary manager (DM) and the food and nutrition resource (FNR) were interviewed together on 11/7/24 at 10:00 a.m. The DM said she knew that staff that were wearing false nails should wear gloves covered when handling exposed food but she was unsure if CK #1 was aware. The DM said she noticed CK #1 had artificial nails and the nails were painted. The FNR said CK #1 was the only dietary staff member who wore artificial nails in the kitchen and she would be educated on proper glove use while handling exposed food with artificial nails. II. Ensure kitchen was maintained in a sanitary condition A. Professional reference The Colorado Retail Food Establishment Regulations (3/16/24), were retrieved on 11/13/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Physical facilities shall be cleaned as often as necessary to keep them clean, except for cleaning that is necessary due to a spill or other accident, and cleaning shall be done during periods when the least amount of food is exposed such as after closing. B. Facility policy and procedure The Kitchen Sanitation and Cleaning policy, revised August 2021, was provided by the nursing home administrator (NHA) on 11/7/24 at 12:05 p.m. The policy revealed in pertinent part, Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Tasks will be assigned to be the responsibility of specific positions. Frequency of cleaning for each task will be defined. On the cleaning schedule, employees will initial and date the tasks when completed. Deep cleaning tasks will be assigned periodically and as needed. C. Observations A tour of the kitchen was completed on 11/424 at 9:15 a.m. and revealed the following: -The floor under the coffee machine table and ice machine was soiled with spilled coffee that collected in the corner of the kitchen, under the table and behind the ice machine. Pieces of debris and a yellow towel were in the spilled coffee behind the ice machine. -The floor under the side preparation tables was soiled with crumbs, dust and food debris. -The floor under the dry storage shelves had dry pasta and two portion control cups filled with brown liquid stuck in a dried, brown liquid on the floor, hard taco shells inside a clear plastic bag, packages of crackers and a can of green chiles. -A drawer that stored clean utensils was lined with a shelf liner that was stuck to the bottom of the drawer and had a thin layer of dark crumbs underneath. -A plastic pump out of its bottle and a can of kitchen cleaner were on the floor under the three compartment sink. -The can opener blade had dried red substance on it. -The bottom shelf of the three door reach-in freezer had food crumbs throughout. -The vent in the dry storage room was covered with dirt and lint. -A dirty mop head was on the floor under the dirty side of the dish machine table. -The dry food bin lids and containers were covered in dust and the handles of two of the dry bins were filled with crumbs. -A baking rack stored in the walk-in cooler had crumbs on each shelf; two baking sheets of ready to eat pumpkin pie were stored uncovered on the shelves in the baking rack. -Two tubs of clean utensils stored on the top shelf of a preparation table had crumbs inside the bottom of the tubs. A second observation of the kitchen was conducted on 11/5/24 at 4:10 p.m. Observations identified the same concerns as identified on 11/13/23 during the initial tour. Additional items observed included: -A gray bus tub that contained cleaned built up utensils had a brown sticky substance in the bottom of the tub. -The floor under the back preparation table was brown and sticky and spots of a dried brown liquid were on the kitchen wall next to the prep table. -The shelf above the back prep table had brown splatter on the underside of the shelf. -Cleaned and sanitized mixer attachments were stored in food crumbs on a tray. C. Staff interviews The DM was interviewed on 11/7/24 at 10:00 a.m. The DM said she cleaned the utensil drawer and shelf liner during the survey. The DM said the utensil drawers were on the cleaning list and the dietary staff were supposed to empty the drawers and clean them out. The DM said the utensil drawers and dry bins were scheduled to be cleaned twice a month. She said she checked the cleaning list and completed a kitchen walk through almost daily to ensure staff completed tasks timely. The DM said she cleaned the utensil drawers during the survey. The DM said the side preparation tables do not move and they were connected to the wall. She said the floors underneath the shelves and the tables were swept and mopped twice a day. The DM said she had a cook that typically cleaned the floor under the tables, shelves and equipment. The DM said the coffee spill in the corner resulted from a spout that was left open while the coffee was brewing and then spilled onto the floor. The DM said the dry food bins were included on the cleaning list to be cleaned every two weeks and had been cleaned (during the survey). The DM said the baking rack in the walk in refrigerator usually got taken outside and power washed. She said twice a month one of the cooks would also do kitchen deep cleaning, but some of the deep cleaning could not happen during the day because too many things were moved. She said the staff have discussed moving some items from the monthly cleaning schedule to the bi-weekly cleaning schedule. Dietary aide (DA) #1 was interviewed on 11/7/24 at 2:15 p.m. DA #1 said she felt the staff could successfully get their cleaning tasks done. DA #1 said the staff tried to always clean if there was extra time and the staff noticed something really needed to be cleaned. DA #1 said kitchen cleanliness should be maintained over time. DA #1 said staff performed an extra cleaning task if they identified an item that needed to be cleaned.

Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure staff donned appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); -Ensure staff followed appropriate infection control practices during vaccination administration; and, -Ensure staff disinfected vital signs equipment before and after each use. Findings include: I. Failure to ensure staff donned appropriate PPE when providing care to a resident on enhanced barrier precautions (EBP) A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) About Enhanced Barrier Precautions (EBP) In Nursing Homes (6/28/24) retrieved on 11/12/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, EBP are an infection control strategy that involves wearing gowns and gloves during high-contact resident care activities. Enhanced Barrier Precautions are recommended for residents with any of the following: infection or colonization, or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO). B. Observations On 11/7/24 at 9:25 a.m. the wound care nurse (WCN) was observed performing wound care for Resident #79. The sign on the door to the resident's room indicated that the resident was on EBP and the required PPE included wearing gloves and a protective gown when providing high contact direct resident care. The WCN entered the resident's room and proceeded to perform the resident's wound care. -The WCN did not put on a protective gown prior to entering Resident #79's room and performing the wound care. C. Staff interviews The WCN was interviewed on 11/7/24 at 9:45 a.m., after she completed the wound care for Resident #79. The WCN said she forgot to don a gown prior to performing the wound care. She said the resident was on EBP and she should have donned a gown prior to performing the wound care. The infection preventionist (IP) was interviewed on 11/7/24 at 10:42 a.m. The IP said the WCN should have followed the appropriate PPE recommendations for EBP and donned a gown prior to performing the wound care for Resident #79. II. Failure to ensure staff followed appropriate infection control practices during vaccination administration A. Professional reference According to the CDC Vaccine Administration (6/20/23), retrieved on 11/12/24 from https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html, Persons administering vaccinations should follow appropriate precautions to minimize risk for disease exposure and spread. Hands should be cleansed with an alcohol-based waterless antiseptic hand rub or washed with soap and water before preparing vaccines for administration and between each patient contact. B. Observations On 11/4/24 at 1:48 p.m. a vaccination clinic was observed in the facility's lobby area. At 1:49 p.m. an unidentified technician (TECH) administered a vaccination to a resident. The unidentified TECH wore gloves to administer the vaccine injection to the resident. After administering the injection, and without removing her gloves, the unidentified TECH pushed the resident in her wheelchair back to the waiting area in the center of the lobby. -The unidentified TECH did not remove her gloves prior to touching the resident's wheelchair and she did not perform hand hygiene after she removed her gloves once she was finished pushing the resident's wheelchair. At 1:53 p.m. an unidentied TECH administered a vaccination to the next resident. After the vaccination was administered, she applied an alcohol swab to the resident's bleeding injection site. After the bleeding stopped, the unidentified TECH placed the alcohol swab, which was saturated with blood, on the receptionist's table and proceeded to administer a second vaccination to the resident. After she completed the resident's second vaccination, The unidentified TECH collected the alcohol swab from the receptionist's table and disposed of it by placing it in the sharps container. Without removing her gloves, the unidentified TECH pushed the resident in her wheelchair to the center of the lobby. When she returned to her station, she removed her gloves. The unidentified TECH did not remove her gloves prior to touching the resident's wheelchair and she did not perform hand hygiene after she removed her gloves once she was finished pushing the resident's wheelchair. At 2:13 p.m. another unidentified TECH was administering two vaccinations to a resident. After the unidentified TECH administered the first vaccination to the resident, he placed a used syringe in his chest pocket. After the second vaccine was administered, he disposed of both syringes into a sharps container. At 2:18 p.m. the unidentiifed TECH was observed collecting timers from residents while wearing the same gloves he used to administer other residents' vaccinations. He placed the timers in a basket without sanitizing them. The timers were then reused for other residents. C. Staff interview The IP was interviewed on 11/7/24 10:42 a.m. The IP said staff who conducted vaccination clinics were contracted from an outside company. She said the staff administering the vaccinations should have followed appropriate infection control practices when administering vaccinations to the residents. The IP said gloves should be immediately removed after the administration of a vaccination and hands should be sanitized. She said used syringes should not be stored in pockets, but disposed of into sharps containers immediately after use. She said the timers should have been disinfected before offering them to the next resident. 50315 III. Failure to ensure staff disinfected vital signs equipment before and after each use A. Professional reference According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), retrieved on 11/12/24 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin. B. Observations On 11/6/24 at 2:45 p.m. certified nurse aide (CNA) #1 took the vital signs cart into room [ROOM NUMBER] and asked the resident in bed A if he could measure her vital signs. The resident agreed and CNA #1 utilized the equipment on the vital signs cart to obtain the resident's blood pressure, temperature, heart rate and oxygen saturation (level of oxygen in a person's blood). After obtaining the vital signs for the resident in room [ROOM NUMBER], CNA #1 moved the vital signs cart into room [ROOM NUMBER] and woke up the sleeping resident to ask if he could measure her vital signs. The resident agreed and CNA #1 utilized the equipment on the vital signs cart to obtain the resident's blood pressure, heart rate, temperature and oxygen saturation. After obtaining the vital signs for the resident in room [ROOM NUMBER], CNA #1 moved the vital signs cart into the hallway and left it there for approximately five minutes. CNA #1 returned to the vital signs cart, wrapped the cords up and put the cart into a clean utility room. -CNA #1 did not disinfect the vital signs equipment between use for each resident or before putting the vital signs cart away in the clean utility room. C. Staff interview The director of nursing (DON), the IP and the clinical resource nurse (CRN) were interviewed on 11/7/24 at 12:00 p.m. The IP said staff were supposed to sanitize medical equipment, such as vital signs equipment, with sanitation wipes or bleach wipes after each use.

Based on record review and interviews, the facility failed to ensure one (#79) of four residents received treatment and care in accordance with professional standards of practice out of 42 sample residents. Specifically, the facility failed to correctly assess and care plan the progression of Resident #79's wound. Findings include: I. Facility policy and procedure The Skin and Wound Monitoring and Management policy was provided by the nursing home administrator (NHA) on 11/7/24 at 9:22 a.m. The policy read in pertinent part, It is the policy of this facility that a resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable, and a resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection and prevent new avoidable pressure injuries from developing. Current evidence documents that in certain circumstances the development of pressure injury is an avoidable occurrence. In accordance with the guidance issued by the National Pressure Ulcer Advisory Panel (March 2010), the facility recognizes that an unavoidable pressure injury is one that developed even though the provider evaluated the individual's clinical condition and pressure injury risk factors; defined and implemented interventions that are consistent with individual needs, goals and recognized standards or practice and monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Facility nursing staff will identify and document in the resident's clinical records, the condition and pressure injury risk factors related to the development of unavoidable pressure injury. This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout the assessment process for developing a comprehensive plan of care. Pressure injuries are staged to indicate the extent of tissue damage. The National Pressure Ulcer Advisory Panel (NPUAP) has the following staging definitions: Medical Device Related Pressure Injury: This describes an etiology and uses the staging system to stage. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the patterns or shape of the device. The injury should be staged using the staging system. II. Resident #79 A. Resident status Resident #79, over the age of 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), the diagnoses included fractured left tibia (shin bone), displaced bimalleolar (of the ankle joint) fracture of left lower leg, type 2 diabetes mellitus with diabetic neuropathy (nerve condition causing pain, tingling and numbness), acute kidney failure and depression. The 10/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for total assistance for dressing, putting on and taking off footwear, bathing, toileting hygiene, bed mobility and transfers. She needed set up assistance with personal and oral hygiene and was independent while dining. The MDS assessment documented she did not reject care and had a stage 3 pressure ulcer. -The assessment did not document the resident had a diabetic foot ulcer. B. Resident interview Resident #79 was interviewed on 11/4/24 at 2:43 p.m. Resident #79 said she had a wound on the back of her left heel as well as two surgical incisions on her left leg. She said she was told her heel wound was common with people who are put in a brace and likely resulted from her leg rubbing on the brace. Resident #79 said her goal was to walk again and discharge home but she was concerned the wounds delayed her healing. III. Record review A. Resident assessments The 4/15/24 initial admission assessment, completed by licensed practical nurse (LPN) #1, documented Resident #79 had a brace, but no splint or cast and was non weight bearing to her lower left extremity. There were no open areas noted, and no areas of concern noted and no skin condition was noted to her left heel. The 4/16/24 physician's assistant (PA)/nurse practitioner (NP) note documented the resident's lower left extremity (LLE) was in an immobilizing splint. Her surgical sites were covered by a splint, and clean, dry dressings and compression wraps (see the above admission assessment detail that documented the resident had a brace but no splint). B. Care plan Resident #79's pressure ulcer care plan, initiated on 4/16/24, documented she had the potential for pressure ulcer development related to impaired mobility, obesity, hypothyroidism (decreased thyroid function), and major depression. Pertinent interventions included administering treatments as ordered and monitoring for effectiveness, monitoring nutritional status, serving the diet as ordered, monitoring and recording meal intake, and monitoring, documenting and reporting to the physician as needed (PRN) changes in skin status that included appearance, color, wound healing, signs and symptoms of infection, wound size and stage. Resident #79's pressure ulcer care plan was revised on 8/11/24 to include that she had an unstageable pressure ulcer with the potential for an additional pressure ulcer related to impaired mobility, obesity, hypothyroidism, and major depression. -See progress notes below for wound progression. C. Progress notes On 4/22/24 Resident #79's orthopedic physician note documented the resident had a left heel ulcer with unspecified severity present. Foam padding was added to her posterior splint due to the heel ulcer with a recommendation to keep pressure off the heel. The 5/25/24 physician progress note documented Resident #79 had a left heel decubitus (pressure) ulcer related to use of a splint after surgery. -The facility failed to update Resident #79's pressure ulcer care plan with her new wound status until 8/11/24 more than three months after the new wound was initially documented, although her left heel ulcer was first documented on 4/22/24. Resident #79's pressure ulcer care plan interventions were not updated until 10/9/24. Resident #79's pressure ulcer care plan and interventions were revised again on 10/9/24 to document she had an unstageable pressure ulcer to her left heel with the potential for additional pressure ulcer development related to impaired mobility, obesity, hypothyroidism and major depression. -However, a review of Resident #79's wound tracking documentation completed by the wound physician (WP) revealed Resident #79's left heel wound was documented on 10/2/24 (prior to the 10/9/24 care plan update) as a stage 3 pressure ulcer to her left heel. -The facility failed to update Resident #79's pressure ulcer care plan to indicate she had a stage 3 pressure ulcer to her left heel until 11/4/24 (during the survey). The pressure ulcer care plan interventions were not updated on 11/4/24. D. Progress notes The 5/25/24 physician progress note (see above) documented Resident #79 had a left heel decubitus ulcer related to splint after surgery. -Resident #79's pressure ulcer care plan failed to include prior heel drainage or the use of the splint as a potential risk factor for developing a pressure injury. Resident #79's nutrition and dietary notes documented Resident #79 had a stable stage 4 pressure ulcer on the following dates in her electronic medical record: 5/26/24, 6/2/24, 6/9/24, and 6/16/24. On 6/21/24 the nutrition and dietary notes documented Resident #79 had a pressure ulcer SDTI (suspected deep tissue injury) to her left heel. -However, facility documentation failed to show Resident #79 was assessed to have a stage 4 pressure ulcer and during staff interviews, the staff were unsure where the documentation originated from that Resident #79 had a stage 4 pressure ulcer (see interviews below). E. Physician's orders A review of the April 2024 CPO revealed Resident #79 was prescribed the following orders: Avoid pressure on the left heel, a heel ulcer was present every shift for new padding placed by the orthopedic physician, ordered on 4/22/24. Elevate heels while in bed every shift, ordered on 4/24/24. Monitor the wound to the left heel and notify the physician of any changes every shift, ordered on 4/24/24. -The April 2024 CPO failed to include orders upon admission for the resident to elevate her heels or avoid pressure on her heels and the orders were started on or after 4/22/24 when the heel ulcer was documented in the orthopedic visit notes 4/22/24. The April 2024 CPO did not include an order to not remove the splint until 4/22/24. A review of Resident #79's CPO for May 2024, June 2024 and July of 2024 documented a physician's order of wound care to the left heel for a stage 4 pressure ulcer, and to apply skin prep daily every day shift, ordered on 5/24/24 and discontinued on 7/10/24. F. Chart review The NHA provided a chart review on 11/7/24 at 3:30 p.m. completed by Resident #79's primary care physician (PCP) on 11/6/24 (during the survey). The chart review referenced a podiatry note documented on 4/9/24 during the resident's hospital stay (prior to admission to the facility) that with assistance supporting Resident #79's limb, the distal dressing ace wraps were removed and there was some drainage into the heel. The chart review also referenced a podiatry note on 4/9/24 mentioned adding more padding which would have been for the posterior splint. The PCP documented he felt her left heel DTI started on 4/9/24 (in the hospital) as Resident #79 had severe pain starting then, but it took some time (a few weeks) for that injury to become visible at the surface. -However, the 4/16/24 daily skilled nursing note also documented Resident #79 had surgical wounds only upon her admission to the facility. There was no documentation Resident #79 had a skin injury/ulcer (examples: pressure, diabetic, arterial, vascular). IV. Staff interviews The director of nursing (DON) was interviewed on 11/6/24. The DON said Resident #79 was admitted with a hard cast which was a non removable brace to her lower left extremity upon admission. The DON said when the resident was admitted to the facility the cast was from her toes to bottom of her knee cap and covered her heel which was why the DTI was found during the visit to the orthopedic office on 4/22/24. The DON said the facility staff were unable to see the resident's left heel. The DON said the facility's wound provider's specialty was to handle pressure ulcers or DTI and was easier provide Resident #79 wound care at the facility. The DON said Resident #79's heel has always been a DTI. The DON said from 4/15/24 to 5/24/24 Resident #79 was seen by orthopedic physicians for her DTI to the left heel before her wound care transferred to their facility wound care provider. The food and nutrition resource (FNR) was interviewed on 11/7/24 at 10:00 a.m. The FNR said she was not aware Resident #79's heel wound was documented as a stage 4 pressure ulcer in the May and June 2024 nutrition and dietary notes. LPN #1 was interviewed on 11/7/24 at 1:00 p.m. LPN #1 said he completed Resident #79's initial admission assessment. LPN #1 said when he did Resident #79's initial skin assessment he did check her heels. LPN #1 said if Resident #79 was wearing an ankle brace he would have removed the brace to check her skin and do a total assessment. The director of rehabilitation (DR) was interviewed on 11/7/24 at 1:15 p.m. The DR said typically if a resident was admitted to the facility wearing a splint, the facility would not remove the splint without orders to do so. The DR said Resident #79 initially had a splint with a sterile dressing on for two weeks that was not to be removed. The DR said Resident #79's initial therapy documentation did not include her foot in their notes because she was admitted with a fracture, and they were trying to assess if the facility could provide therapy for Resident #79's knee. The DR said the type of splint Resident #79 wore upon admission was one that could be unwrapped (like an ace bandage) and the splint underneath could be removed. The DON was interviewed on 11/7/24 at 2:00 p.m. The DON said she was the facility's wound nurse from April 2024 to September 2024 prior to becoming the DON. The DON said if a resident was admitted with a non removable brace or splint the facility should look for break through bleeding and damage to the brace or splint and monitor the resident to ensure they have good circulation. The DON said Resident #79 had a visible surgical wound on her lower left leg, a second non visible surgical wound to the ankle under the splint and regular redness to the buttocks from being incontinent. The DON she was not aware that Resident #79 had anything on her heel upon admission to the facility. The DON said if a resident was admitted with a splint, the splint should be mentioned in the initial care plan. The DON said Resident #79's care plan only documented to monitor her surgical sites and failed to include her splints or immobilizing device. The DON said as a best practice it should be in a resident's care plan to mention the cast or splint so that the facility could make sure all precautions can be followed by all the staff. The DON said when staff asked a resident about pain they may be experiencing, the staff ask for the resident to describe the pain using a number from 1 to10, ask where the pain was located, how the resident described the pain and what made the pain worse or better. The DON said she was not sure why the facility documented Resident #79 had a stage 4 pressure ulcer. She said as the facility wound nurse she used to document a resident's wound status in her notes and provide the physician with her notes weekly. V. Facility follow up The NHA provided documentation from the WP on 11/8/24 (after the survey) at 3:45 p.m. The documentation included the WP became involved in the care of Resident #79 at the end of April 2024 at which time she already had a wound to her left heel which had been followed by her Orthopedic surgeon previously. Unfortunately, the patient's surgeon had an order in place not to remove her post surgical dressings and when the facility was finally able to visualize the left heel, a wound was present. It is likely this wound is diabetic in origin given the patient's limited mobility in the setting of diminished sensation. I feel this is an unavoidable wound as preventive offloading was being performed and the facility was not able to monitor the status of her skin or heel under the dressing which they were prevented from removing by a physician's order. -However, Resident #79's diagnosis of type 2 diabetes mellitus and her diminished sensation, splint or non removable dressings were not listed as a risk factor on the resident's pressure ulcer care plan. The wound physician also documented Resident #79's wound from 5/24/24 to 11/8/24 was an unstageable pressure ulcer and from 10/2/24 to 10/30/24 the wound was documented as a stage 3 pressure ulcer.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program to monitor for antibiotic use for two (#60 and #50) of seven residents reviewed for antibiotic use out of 42 sample residents. Specifically, the facility failed to effectively track and monitor the use of long-term antibiotics for Resident #60 and Resident #50. Findings include: I. Professional reference According to The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 11/11/24 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html, To track how and why antibiotics are prescribed, (providers) perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. II. Facility policy and procedure The Antibiotic Stewardship policy and procedure, revised August 2021, was received from the nursing home administrator (NHA) on 11/7/24 at 12:40 p.m. It documented in pertinent part, The program includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic use protocols include: -Nursing staff shall assess residents who are suspected to have an infection and complete a change in condition form prior to notifying the physician; -Laboratory testing shall be in accordance with current standards of practice; -The facility uses the McGeer's criteria to define infections; -The McGeer's criteria are used to determine whether or not to treat an infection with antibiotics; and, -All prescriptions for antibiotics shall specify the dose, duration, and indication for use. Monitoring antibiotic use includes: Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. Antibiotic use shall be measured by monthly prevalence, antibiotic starts, and/or antibiotic days of therapy. At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include: tracking C. difficile (clostridium difficile) infections, antibiotic resistance, and adverse drug events related to antibiotic use, or costs related to antibiotic use. III. Resident #60 A. Resident status Resident #60, age 81, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included cellulitis (infection) of the right lower limb, urinary tract infection (UTI), benign prostatic hyperplasia (enlarged prostate) and retention of urine. The 8/9/24 minimum data set (MDS) assessment revealed that Resident #60 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required complete assistance with bathing, hygiene, toileting, and transfers and substantial/maximum assistance with dressing. B. Record review Review of Resident #60's November 2024 CPO revealed the following physician's order: Macrodantin oral capsule 50 milligrams (mg). Give one capsule by mouth one time a day for UTI prophylaxis (prevention), ordered 7/2/24. -The physician's order for the Macrodantin failed to indicate the duration for the use of the antibiotic. A 7/2/24 infection surveillance progress note revealed Resident #60 was on Macrodantin daily for UTI prophylaxis prior to his hospitalization , but the physician's order was only continued for four days after admission. Resident #60 was prescribed Macrodantin oral capsule 50 mg, give one capsule by mouth one time a day for UTI prophylaxis. The note documented that the facility would continue to monitor at this time and the resident did not have an active UTI. A physician's progress note, dated 6/5/24, revealed Resident #60 took Macrodantin 50 mg daily and the facility was to monitor for signs and symptoms of a UTI and the resident was to follow-up with urology. It documented the resident was at a high-risk for a UTI and if he were to develop signs and symptoms of a UTI, staff was to obtain laboratory results and begin another antibiotic. -The resident did not have a risk versus benefit statement for the long-term use of an antibiotic. -The resident did not have a care plan to address the need for a long-term use of an antibiotic. -Review of Resident #60's electronic medical record (EMR) revealed no documentation to indicate the facility's infection preventionist (IP) completed an antibiotic use assessment or documented the McGeer's criteria met to justify the physician's order for Macrodantin. A review of the IP infection surveillance documents revealed the facility identified facility residents with active infections. -However, the IP failed to document and monitor Resident #60's long-term use of Macrodantin on the infection surveillance documents. IV. Resident #50 A. Resident status Resident #50, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included Alzheimer's disease, anxiety and history of UTIs. The 7/18/24 MDS assessment revealed that Resident #50 had severe cognitive impairment with a BIMS score of five out of 15. She required substantial/maximum assistance with hygiene, showering and bathing, dressing, and transferring. B. Record review Review of Resident #50's November 2024 CPO revealed the following physician's order: Macrodantin macrocrystal oral capsule 50 mg. Give one capsule by mouth one time a day for UTI prophylaxis, ordered 9/24/24. -The physician's order for the Macrodantin failed to indicate the duration for the use of the antibiotic. A 5/17/24 note from the pharmacist to the physician revealed the pharmacist recommended a risk versus benefit statement of Macrodantin for prophylaxis and to consider discontinuation of the antibiotic for Resident #50. -However, there was no documentation from the physician in response to the pharmacist's recommendation to determine risk versus benefit in order to justify the use of a long-term antibiotic. V. Staff interviews The director of nursing (DON), the IP and the clinical resource nurse (CRN) were interviewed on 11/7/24 at 12:00 p.m. The IP said the facility's process for monitoring and tracking infections and antibiotic use included making sure the McGeer's criteria was met when there was a new antibiotic started or a new resident came in on an antibiotic. She said she discussed antibiotic usage with the medical director once a month. She said Resident #60 came into the facility on Macrodantin to prevent UTIs because he got frequent UTIs. She said he was followed by a urologist and they put him on the Macrodantin. -However, there was no documentation from Resident #60's urologist which indicated the reason the resident needed to be on the antibiotic long term. The IP said Resident #50 went to the hospital for a UTI on 7/17/24 and the Macrodantin order was decreased from 100 mg to 50 mg once daily. She said the facility's protocol for residents on prophylactic antibiotics included a monthly review from the pharmacy, a call to the physician to confirm the order and to go through the antibiotic surveillance. -However, the physician did not provide a response to the 5/17/24 pharmacist's recommendation to consider discontinuing Resident #50's antibiotic (see record review above). The DON was interviewed a second time on 11/7/24 at 4:00 p.m. The DON said Resident #50 was trialed off Macrodantin on 9/30/24 and failed the trial. She said Resident #50 developed another UTI during the trial and that was how they determined she failed the trial and needed to be on the antibiotic long-term. She said monitoring antibiotics included monitoring every resident who started a new antibiotic for 72 hours to determine if there were any adverse reactions to the antibiotics. -However, there was no documentation in Resident #50's EMR to indicate the resident had failed a trial off of Macrodantin or a physician's note to justify the long-term use of the antibiotic due to the failure of the trial.

Based on record review and interviews, the facility failed to ensure three (#2, #8 and #9) of five residents reviewed for quality of care out of nine sample residents, received treatment and care in accordance with professional standards of practice. Specifically: The facility failed to ensure that registered nurse (RN) #2 promptly identified, intervened, monitored, and consulted with Resident #2's physician when the resident experienced a change of condition. The facility admitted Resident #2 on [DATE] for rehabilitation after abdominal surgery. On [DATE] at 4:13 a.m., the night nurse, registered nurse (RN) #2, documented the resident had labored breathing and a decreased oxygen saturation level. RN #2 documented she increased the resident's oxygen, but his breathing remained labored so she raised the head of his bed. There was no further assessment of Resident #2 at that time; RN #2 did not document vital signs (pulse, blood pressure, or respiratory rate) or assess his response to her interventions. Specifically, there was no documentation that the RN conducted a comprehensive assessment of the resident's respiratory status, or assessed the resident for pain, change in mental status, or skin color. Finally, RN #2 did not notify and consult with the resident's physician about the resident's labored respirations and increased oxygen needs. Although RN #2 documented, will continue to monitor (Resident #2), RN #2 failed to do so, either to evaluate Resident #2's response to her interventions or to assess the resident for continuing and/or additional signs of distress. Record review revealed RN #1, the oncoming day nurse, documented on [DATE] at 6:30 a.m., that the night nurse (RN #2) was giving report to her and licensed practical nurse (LPN) #1 when a certified nurse aide (CNA) came and told them Resident #2 did not look good, looked like he was transitioning (first stage, before actively dying). At that time, RN #1 entered the resident's room and found him unresponsive, gray in color, barely breathing, but with a pulse. Staff contacted emergency medical services (EMS) and, consistent with the resident's wishes (full code/full treatment), cardiopulmonary resuscitation (CPR) was initiated. EMS transported the resident to the hospital where he was transferred to the intensive care unit. Hospital staff instituted life support measures until they were terminated at the family's request and the resident expired at 11:44 a.m. Hospital records documented the resident had a cardiac arrest and acute respiratory failure, probably due to myocardial infarction (heart attack), possibly due to septic shock. RN #1 and LPN #1, in separate interviews, said RN #2 told them the resident had difficulty (labored) breathing for hours throughout the night. Additionally, the interviews revealed that RN #2 said she never went back to check Resident #2 because she was busy with medications to pass and paperwork. An interview with RN #2 revealed she was not sure what to do that night. Additionally, she said she was busy, and had medications to pass and paperwork to do. RN #2 confirmed she never went back to check Resident #2. RN #2 also confirmed she had not monitored the resident or evaluated his response to increased oxygen or to raising the head of the bed. RN #2's failure to timely assess, monitor, intervene, and consult with Resident #2's physician following the resident's change of condition contributed to an immediate jeopardy situation and to Resident #2 sustaining serious harm. Record review and interviews revealed the facility responded to the events on [DATE], in-servicing staff and developing a plan of correction that included training 100 % of staff; however, the facility's actions were not effective in addressing RN #2's response to residents' changes in condition. Record review and interview revealed that, contrary to facility expectations and training after [DATE], RN #2 failed to assess, monitor, document, and consult with the physician following Resident #8's change of condition in the early morning on [DATE], as well as Resident #9's change of condition in the early morning on [DATE]. Cross-reference F726: the facility failed to ensure licensed nurses were competent to respond to residents' changes of condition. Findings include: I. Immediate jeopardy Resident #2 experienced a change of condition in the early morning hours on [DATE] with labored breathing and decreased oxygen saturation levels. RN #2 documented she increased the resident's oxygen, but the resident's breathing remained labored so she raised the head of his bed. There was no further assessment of Resident #2 at that time; RN #2 did not document vital signs or document the resident's response to her interventions. Specifically, she did not document an assessment of the resident's respiratory status, or assess the resident for pain, a change in mental status, or skin color. Finally, RN #2 did not notify and consult with the resident's physician about the resident's labored respirations and increased oxygen needs. Although RN #2 documented, will continue to monitor (Resident #2), RN #2 failed to do so, either to evaluate Resident #2's response to her interventions or to assess the resident for continuing and/or additional signs of distress. Day shift staff (RN #1 and licensed practical nurse (LPN) #1) entered the resident's room at around 6:30 a.m. after receiving a report by a CNA that Resident #1 did not look good; she found the resident unresponsive, gray in color, barely breathing but with a pulse. She contacted emergency medical services (EMS) and, consistent with the resident's wishes (full code/full treatment), cardiopulmonary resuscitation (CPR) was initiated. EMS transported the resident to the hospital where he expired at 11:44 a.m. after the family requested that life support measures be terminated. Hospital records documented the resident had a cardiac arrest and acute respiratory failure, probably due to myocardial infarction (heart attack), possibly due to septic shock. The facility's failure to ensure RN #2 provided treatment and services consistent with professional standards of practice created a situation of immediate jeopardy for serious harm. II. Facility Response to immediate jeopardy A. The nursing home administrator (NHA) was notified of the immediate jeopardy situation on [DATE] at 5:11 p.m. and again on [DATE] at 9:45 a.m. On [DATE], the NHA provided the facility's plan to address the events on [DATE]. The plan was reviewed on [DATE] at 9:04 a.m. and again on [DATE] at 9:45 a.m. The plan read: -100% of education of nurses; -Morning meeting review with IDT (interdisciplinary team) of any change of condition for compliance of documentation; -Morning meeting review with IDT of any change of condition for compliance of MD (physician) notification; -Monthly review of all change of condition; -Review all change of conditions for trends and opportunity for improvement in QAPI (quality assurance program initiative); -If fall or skin do risk management; -Re-inservice nursing staff; -Medical director chart review of (Resident #2); and, -Ad hoc (as needed) QAPI for this PIP (process improvement plan). The facility's plan, dated [DATE], was accepted on [DATE] at 9:33 a.m. and reaffirmed on [DATE] at 9:45 a.m. and the immediate jeopardy was removed. However, the deficient practice remained at a G level, actual harm that was isolated. III. Expectations - Resident Change of Condition A. Facility policy and procedure The Significant Change Condition policy, revised ,d+[DATE], was received from the director of nursing (DON) on [DATE] at 5:45 p.m. It read, in pertinent part, If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation. The Nurse will perform and document an assessment of the resident and identify the need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR (Situation, Background, Assessment, Recommendation) or similar process to obtain new orders or interventions. B. Staff interviews on facility expectations 1. RN #1 was interviewed on [DATE] at 12:42 p.m. RN #1 said when a resident has a change of condition, the licensed nurse should assess the resident, fill out a change of condition form, check the resident's code status wishes, notify the family, notify nursing management and notify the physician. 2. The assistant director of nursing (ADON), who was responsible for reviewing nursing charting for physician notification and documentation with changes of condition, was interviewed on [DATE] at 1:00 p.m. The ADON said when a resident experienced a change of condition, the licensed nurse should conduct an assessment, complete necessary documentation, and notify the family and physician. She said if a resident was experiencing shortness of breath, the licensed nurse should complete an assessment, notify the physician and follow the physician's orders. 3. The director of nursing (DON) was interviewed on [DATE] at 1:21 p.m. and on [DATE] at 4:35 p.m. The DON said if a resident experienced a change of condition, she would expect the licensed nurse to do an assessment, document the assessment, notify the physician and family, and determine any interventions. The DON said current vitals should be taken when a resident was experiencing a change of condition. IV. Events on [DATE] involving RN #2 and Resident #2 RN #2 failed to provide Resident #2 with treatment and services consistent with professional standards of practice to avoid physical harm following his change of condition. A. RN #2 1. Interview a. The ADON was interviewed on [DATE] at 1:00 p.m. -The ADON said RN #2 had been at the facility for a few months (hire date [DATE]) and had resigned last Thursday or Friday. The ADON said she understood RN #2 was an experienced nurse and she knew the RN worked nights. -The ADON said the licensed nurse (LN) new hire orientation consisted of a day with human resources reviewing videos and paperwork. She said then the LN was scheduled by the DON for orientation with another LN on the floor. She said the LN receives three days of training on the west unit and three days of training on the east unit before they were allowed to work the unit by themselves. She said if the nurse was not comfortable after that, they would continue to put them with another nurse until they were comfortable. She said there was a checklist of items the nurse was oriented to that was completed during the floor orientation. -But see below; the schedule for RN #2 revealed she was only oriented to the rehabilitation unit on one night and the floor orientation checklist was not provided prior to the survey exit. b. The DON was interviewed with the NHA on [DATE] at 5:26 p.m. and on [DATE] at 1:45 p.m. The DON said RN #2 had experience working in skilled nursing facilities and had a nursing license. She said RN #2 had received on-the-floor training. She said the facility is not able to provide one-on-one supervision for extended times. 2. Record review A review of RN #2's personnel record revealed she was hired on [DATE]. The schedule for RN #2 was provided by the DON on [DATE] at 2:00 p.m. It revealed RN #2 received orientation to the floor on [DATE], [DATE], and [DATE]. RN #2 began working by herself on the overnight shift on [DATE]. However, the schedule for RN #2 revealed she was only oriented to the rehabilitation unit on one night ([DATE]). The floor orientation checklist was requested for RN #2 on [DATE] but was not received by the end of the survey. B. Resident #2 Resident #2, age 67, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included ischemic (lack of blood supply, tissue damage) bowel with right hemicolectomy (removal of part of the colon), history of respiratory failure with hypoxia, and diabetes mellitus. The [DATE] minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. He required extensive two-person assistance with transfers and toileting. He required extensive one-person assistance with bed mobility and dressing and limited two-person assistance with personal hygiene. Resident #2 was on oxygen. A review of the [DATE] physician orders revealed Resident #2 had an order dated [DATE] for oxygen via nasal cannula (NC) at two to three liters per minute (LPM) continuously to keep saturation at or above 90%. Nursing notes reviewed for the week prior to [DATE] revealed Resident #2's oxygen saturation level was consistently in the mid 90's range. On [DATE] it was 94%, on [DATE] it was 94%, on [DATE] it was 93%, and on [DATE] it was 95%. C. Events on [DATE] Record review revealed RN #2 failed to timely assess, monitor, intervene, document, and consult with Resident #2's physician following the resident's change of condition, contributing to Resident #2 sustaining serious harm. 1. Record review The progress notes were reviewed on [DATE]. -On [DATE] at 11:42 p.m., the primary care provider (PCP) documented in pertinent part, that the resident was alert and interactive. His chest sounded clear, his heart had a regular rate and rhythm with no murmur, and his abdominal incision was stable. He further documented he had some elevated blood pressures, and some medications would be discontinued. The PCP documented the resident had peripheral vascular disease, and some of his toes were gangrenous (dead tissue) and may need surgical intervention. The PCP documented, monitor for infection, and ordered some laboratory studies. He documented the resident was deconditioned, on physical and occupational therapy, and had a history of alcohol abuse. The PCP documented Resident #2 was a full cor (full code-CPR). -On [DATE] at 4:13 a.m., RN #2 documented that a certified nurse aide (CNA) was concerned about Resident #2, and asked RN #2 to check on him. RN #2 documented the resident's hands were cold to the touch, and he seemed to be having labored breathing. His oxygen was set at 3.5 liters and his oxygen saturation (O2 sat) reading was 88%. She documented the CNA tried to warm his hands, and his O2 saturation was 95%, but he was still having labored breathing. She raised the head of his bed, and documented will monitor. There was no documentation of physician notification, follow-up assessment, monitoring, or evaluation, and no documentation of further notes by RN #2. -On [DATE] at 6:30 a.m., LPN #1 documented that as she was receiving report when a CNA came to the nurses with a concern that Resident #2 was not doing well. She documented the nurses stopped report and went to assess Resident #2. The note further documented that RN #1 assessed the resident and instructed LPN #1 to call for emergency support, 911. LPN #1 documented that she called 911 at 6:35 a.m. and EMS arrived at the facility by 6:45 a.m. -On [DATE] at 7:02 a.m., RN #1 documented that she was receiving report when a CNA came and said Resident #2 was not doing well. RN #1 documented that she stopped report and went to assess Resident #2. She documented the resident was unresponsive, blood pressure was ,d+[DATE], temperature was 97.8, respirations were 6, and his blood sugar was 91. He was on 3.5 LPM of O2. His oxygen saturation was 91%, and his pupils were fixed and dilated. RN #1 documented she could not hear air moving on the right side of his lungs, and on the left side, the breath sounds were diminished. She documented his left and right index fingers were dark in color. RN #1 documented that she stayed with the resident until EMS arrived. -On [DATE] the hospital records documented the resident arrived unresponsive, hypotensive (low blood pressure) and he had to be intubated (breathing tube). His pulse stopped and resuscitation efforts (CPR) were done successfully. The physician documented the cardiac arrest was due to an unknown cause, but could have been due to septic shock with respiratory failure as a result. The physician's notes also documented some possible early pneumonia. The resident was sent to intensive care (ICU) in a critical, unstable condition. The physician documented he had multiple conversations with the family members. He documented the resident was critically ill with cardiac arrest. He told them his prognosis was poor. The family decided to withdraw care, and Resident #2 died on [DATE] at 11:44 a.m. 2. Interviews Staff interviews confirmed RN #2 failed to assess, monitor, intervene, and consult with Resident #2's physician regarding the resident's change of condition, contributing to Resident #2 sustaining serious harm. 1. LPN #1 was interviewed on [DATE] at 12:26 p.m. -LPN #1 said that on [DATE] at around 6:00 a.m., she and RN #1 were getting report from the night nurse, RN #2. CNA #1 came to the three nurses in report and said that Resident #2 was transitioning (first stage, before actively dying). LPN #1 said she was confused because she and RN #1 had worked with Resident #2 the previous day and he was fine. -LPN #1 said RN #1 checked the resident's advance directive and he was a full code. LPN #1 said she and RN #1 went down to the room to assess him. LPN #1 said the resident was barely breathing, his respirations were about 6 breaths per minute, but he was still alive and had a pulse. She said she remembered thinking they were going to have to start CPR. She said RN #1 told her to call 911, which she did, and RN #1 stayed with the resident. -LPN #1 said the night nurse, RN #2, had followed them to the resident's room. RN #2 said she thought this was his baseline, and that he had been like that all night. However, LPN #1 said Resident #2 was normally alert and he was able to make decisions. 2. RN #1 was interviewed on [DATE] at 12:42 p.m. -RN #1 said she came in at 6:00 a.m. for a day shift. She said she and LPN #1 were getting report from the night nurse, RN #2. She said CNA #1 came to the three nurses and said Resident #2 was transitioning. -RN #1 said she was surprised. She said she had just left the facility at 10:30 p.m. after doing an evening shift on [DATE]. She said Resident #2 was a sick man, but alert and oriented, and she had worked with him plenty. She said he had never complained of respiratory distress. -RN #1 said she and LPN #1 went to the resident's room immediately. She said he was gray in color, unresponsive, with respirations at 2 to 3 per minute. She told LPN #1 to call 911, and RN #1 said she stayed with the resident. She said EMS arrived quickly and she followed them out of the facility with him. She said EMS began CPR on him in the facility parking lot before getting him into the ambulance. -RN #1 said RN #2 came down to the resident's room that morning, after a few minutes. She said RN #2 told her the resident had difficulty breathing throughout the night. RN #1 said she told RN #2 that she should have sent the resident out to the hospital. RN #2 responded that she was too busy with paperwork. RN #2 said she had increased his oxygen and raised the head of his bed but then had gotten busy with paperwork and did not reassess the resident. RN #1 said she remembered that RN #2 kept saying the resident had been like that for hours. RN #1 said that she and RN #2 had conversations outside of work, and RN #2 said she was a newer nurse and did not know what to do. -RN #1 said she had expressed her concerns with RN #2 not sending Resident #2 to the hospital to the DON. She said she did not know what follow-up had been done. RN #1 said the ADON asked her to fill out a change of condition Interact (Interventions to Reduce Acute Care Transfers) form, and she told the ADON that she needed to ask RN #2 to do that. 3. RN #2 was interviewed on [DATE] at 2:22 p.m. over the telephone -RN #2 said she remembered Resident #2. She said he was at the facility for rehabilitation and he had a wound vac. RN #2 said one night, she did not recall what time, CNA #1 came and told her Resident #2's oxygen level was low. RN #2 said his oxygen saturation level was 83% and his hands were cold. She said when she grabbed his hand, he grabbed her hand back. She said she raised the head of his bed, and she turned up his oxygen from 3.5 LPM to 4 LPM. RN #2 said the CNA tried to warm his hands and rechecked his oxygen saturation level. It was 95%, but he still had labored breathing. -RN #2 said Resident #2's lungs were clear and his heart sounded good. RN #2 acknowledged she did not document that his heart and lungs sounded good. RN #2 said everything seemed to be within normal limits. RN #2 further acknowledged she did not document his vital signs or complete a change of condition assessment. -RN #2 said she was by herself, and she felt like she did not know what to do. She said it was her first night alone in the rehabilitation unit, and she did not know the residents. RN #2 said she did not think about the fact that it could be a change of condition for Resident #2. She said she should have called the physician, but she did not know the resident or his baseline. She said she did not review his history in the medical record. RN #2 then said his oxygen saturation was not that low at 83%. RN #2 said if it was in the 70s, she would have called the physician. RN #2 said she thought she had listened to his lungs and heart, and they were normal, however, she did not document this. -RN #2 said she asked CNA #1 to check on him throughout the night. She said CNA #1 said she would keep a close eye on the resident and she trusted CNA #1 to do so. She said CNA #1 had to switch halls at some point during the night, but she thought the CNA still came to check on the resident. -RN #2 said the DON called her the next day. She said the DON reassured her and said Resident #2's condition was fragile. RN #2 said she did not recall if the DON asked her about notifying the physician. RN #2 said she told the DON that the CNA was checking on him for her because she had medications she needed to administer. She said, I told the DON I did not check him or assess him again. -RN #2 said at shift change, the CNA came and said the resident did not look good. She said RN #1 sent him to the hospital. RN #2 said she had trusted the CNA to monitor the resident because she was busy by 4:00 a.m. passing medications. She said this was all over her head. She said the reason she did not work at the facility anymore was that she had to work alone, it was a lot of work, and she did not know what to do for Resident #2; this was her first time working with him. 4. CNA #1 was interviewed on [DATE] at 2:38 p.m. -CNA #1 said in the early morning hours on [DATE] she checked Resident #2's oxygen saturation and it was 83% or 88%. She could not remember. She said the nurse (RN #2) came in and turned up his oxygen and his oxygen level went up to 90%. She did not recall if Resident #2 said anything, or if the nurse listened to his lungs. She said that was the first time she worked in the rehabilitation unit and did not know Resident #2. -CNA #1 said she told RN #2 she would check on him again, but her assignment was changed and she did not check on him again until the end of her shift (approximately 6:00 a.m.). She said at that time, he did not look good to her, and she went and told the three nurses in report, the night nurse RN #2, and the two oncoming day nurses, RN #1, and LPN #1. D. Facility response to the events on [DATE] 1. Plan of correction The nursing home administrator (NHA) provided a plan of correction dated [DATE] which was reviewed on [DATE] at 9:30 a.m. The plan read as follows: -100% education of nurses; -Morning meeting review of any change of condition for compliance of notification and documentation; -Monthly review of all change of conditions; and, -Review all change of conditions for trends and opportunity for improvement. 2. In-service and All-staff meeting A review of facility documents revealed the facility completed an in-service on [DATE] and held an all-staff meeting on [DATE] that reviewed changes of condition. Some staff completed the in-service that was located in a binder at the nurses' station, while some nurses attended the all-staff meeting on [DATE]. Records from the meeting showed that all staff either attended or were informed of the contents of the meeting. (Three staff signatures were missing from the [DATE] education but it was confirmed on [DATE] that they were present for the in-service.) On [DATE] at 2:54 p.m., the DON provided the information that was put in the binder for the nurses to sign on [DATE]. There was a one-page typed document. There also was a six-page presentation from the American Association of Post Acute Care Nursing that went into detail on assessment of the body systems, things to look for, and chronic versus acute changes, and then gave scenarios to review and answer questions. On [DATE] at 12:42 p.m., RN #1 said she remembered the DON put an in-service to read and sign in a binder at the nurses' station. She said it was about documentation, and following up on change of condition. She said the in-service was a reminder to the nurses to complete an Interact form (Interventions to Reduce Acute Care Transfers) if there was a change of condition. RN #1 said the nurses were already supposed to be using this form. RN #1 said she remembered reviewing a one-page document in the binder; she did not recall a six-page document regarding changes of condition. She said there were no sample scenarios in the education provided in the binder. 2. Interviews revealed conflicting information on the events on [DATE], as well as potential gaps in the facility's response to events on [DATE] to prevent further failures in the provision of treatment and services. a. The DON was interviewed on [DATE] at 1:21 p.m. and again at 1:39 p.m. -The DON said she had conducted an investigation and it appeared Resident #2 had sepsis. She said she and the nurse managers had spoken to RN #2 about the events on [DATE] but she said she did not speak to CNA #1, RN #1, and LPN #1. She said they looked at the records. The DON said the outcome was not ideal. -The DON said she had looked at the nurse's charting and RN #2 had documented Resident #2 had labored breathing. The DON said she had called RN #2 but did not document her conversation with the nurse. The DON said RN #2 told her she kept an eye on the resident and his breathing was better. -But see above: RN #2 stated she did not check on the resident again until the change of shift. -The DON said she did not think the nurse necessarily needed to document a follow-up assessment or vital signs. She said RN #2 felt the resident was fine; RN #2 had used her clinical judgment and felt Resident #2 was all right and at his baseline, so she was not concerned with her charting. The DON said it was reasonable that the resident was not checked again for two hours until the day shift arrived. -But see above: facility expectations on change of condition and RN #2 interview that she was not aware of Resident #2's baseline status. -The DON said there was an all-staff and nurses meeting on [DATE]. She said she had discussed changes of condition and physician notification in general at the meeting. -But see above: RN #1 said the education was about documentation; a reminder to the nurses to complete an Interact form if there was a change of condition which nurses were already supposed to be using. She did not remember a six-page presentation from the American Association of Post Acute Care Nursing that included scenarios to review and answer questions. -The DON said there was no plan for making sure a situation of a resident with labored breathing and no follow-up, did not happen again. The DON said Resident #2 was sick, he could have (changed condition rapidly) in ten minutes. She agreed, however, that RN #2 should have done a follow-up note and said, without documentation, you can not prove what happened. The DON further said she had not done any follow-up one-to-one education with RN #2, and RN #2 had not attended the [DATE] meeting (but had signed the [DATE] in-service education in the binder.) She further said she should have reached out to the night CNA to find out what she knew about that night. b. The nursing home administrator (NHA) was interviewed on [DATE] at 5:05 p.m. -The NHA said he remembered Resident #2. He said the resident had low oxygen saturations, was monitored throughout the night and went to the hospital in the morning, and later passed away. -But see above: CNA #1 reported she did not go back into Resident #2's room until around 6:00 a.m. and RN #2 reported she did not go back to assess Resident #2 after 4:13 a.m. -He said he had reviewed the situation, and RN #2 could have made better decisions in the moment, as it resulted in a tragic event. In response to a question about follow-up, he said the day nurse did the right thing to send the resident to the hospital. -The NHA said the DON would be the one to investigate a clinical issue. He said she had long conversations with the nurses who were on that day. He said RN #2 could have made better decisions, but he said he was not a clinician and had to trust the clinician. He said RN #2 should have called someone if she did not know what to do. He said he did not know anything else about the situation. -But see above: The DON said she did not interview RN #1, LPN #1, and CNA #1. 4. The DON and NHA were interviewed again on [DATE] at 5:26 p.m. -The DON said this was not a perfect situation but her perspective on the severity of the situation was different and she did not feel the residents were at risk. She said she felt the nurses knew what to do when a change of condition occurred. She said she had done education with them after this situation occurred and she did not feel the nurses needed to be educated again about documenting a change of condition. She said the nurses did not need to do a post-test or any return demonstration to indicate competency or to measure if the information was understood. -The DON said she did not do a competency check with RN #2 or any 1:1 training with her after the situation with Resident #2. The DON said she had concerns with the nurse's charting, and her strength as a nurse. The DON said RN #2 did not feel comfortable working in the rehabilitation unit. She also said the nurse was not comfortable with documentation and said the documentation and the situation could have been better. She said they train staff and put them on the floor and, people make mistakes. The DON said RN #2 thought the resident was okay, and RN #2 felt comfortable with the interventions she had put in place. -The DON said, again, that she educated RN #2 on the phone on [DATE], but she did not have any documentation of what was reviewed, and agreed it was hard to prove the education she had provided since she lacked documentation of it. She said she would write something up regarding their conversation. The DON said this was a documentation issue. She said the facility did investigate the situation, and just did not document it. -But see record review and interviews above: The events on [DATE] involved more than a documentation issue. Record review revealed there was no further assessment, monitoring, intervention, or evaluation of the resident after 4:13 a.m., as well as no physician notification of the resident's change of condition. V. Events on [DATE] invo[TRUNCATED]

Based on interviews and record review, the facility failed to ensure that seven out of seven licensed nurses (registered nurses (RNs) #2, #3, and #4, and licensed practical nurses (LPNs) #1, #2, #3, #4) had the specific competencies and skill sets necessary to identify, intervene, and notify the physician of residents' acute changes of condition. This affected three residents (#2, #8, and #9) and contributed to Resident #2 sustaining serious harm. Cross-reference F684J. Specifically: I. The facility failed to ensure that registered nurse (RN) #2 had the competency and skills to identify, intervene, and notify the physician of Resident #2's change of condition on [DATE]. -Resident #2, was admitted to the facility's rehabilitation unit on [DATE] after abdominal surgery. According to interviews and his medical record, he was alert and oriented on [DATE]. The resident's advance directive documented he wished for life-sustaining intervention (cardiopulmonary resuscitation). -On [DATE] at 4:13 a.m. the night nurse, RN #2, documented the resident had labored breathing. She documented his oxygen was turned up, but his breathing was still labored and she put the head of his bed up. RN #2 did not document an assessment of the resident's condition at that time; there were no vital signs, no assessment of the resident's respiratory status, his mental status, or the color of his skin. Although RN #2 documented she would monitor the resident, there was no further documentation of the resident's condition or documentation the physician was notified of the resident's change in condition. -Interviews confirmed RN #2 had not gone back to assess Resident #2 or to evaluate his response to her interventions (the increased oxygen and elevation of the head of the bed). And, she had not notified the physician. Additional interviews and record review revealed the dayshift nurses, RN #1, and licensed practical nurse (LPN) #1, observed the resident in his room at 6:30 a.m. RN #1 documented the resident was unresponsive, gray in color, barely breathing, but with a pulse. The resident was sent to the hospital but died that day. Hospital records documented the resident had a cardiac arrest and acute respiratory failure, probably due to myocardial infarction (heart attack), possibly due to septic shock. -RN #2 told the dayshift staff that Resident #2 had been in that condition (labored breathing) for hours throughout the night. Additionally, the interviews revealed that RN #2 said she never went back to check Resident #2 because she was busy with medications to pass and paperwork. Furthermore, RN #2 had told RN #1 she was a newer nurse did not know what to do. II. The facility further failed to ensure that registered nurse (RN) #2 had the competency and skills to identify and intervene timely after the events on [DATE], when Resident #8 and #9, experienced a change of condition. -Despite RN #2 participating in a change of condition in-service on [DATE], the RN failed to assess and notify the physician on [DATE] when Resident #8 was in distress with fever, rapid respirations, and low oxygen saturation. Further, the RN failed to conduct and document a thorough assessment and monitor Resident #9's acute change in condition (low oxygen levels post placement of a port) on [DATE]. Cross-reference F684J for further details. Findings include: I. Facility policy and procedure The Nursing Staff Competency policy, revised in [DATE], was received from the nursing home administrator (NHA) on [DATE] at 5:35 p.m. The policy read in pertinent part: Within 30 days of hire the nursing staff shall complete the orientation competency assessment. The competency in skills and techniques necessary to care for residents' needs include but [are] not limited to .identification of changes of condition. Director of staff development, nurse manager or designee must validate all skills listed on the form for competent performance. Each nursing staff member shall complete an annual competency assessment and additional competency assessments as needed based on [the] resident population. II. RN #2 and Residents #2, #8, and #9 A. Events on [DATE] - RN #2 and Resident #2 Record review and interviews revealed: Resident #2, was admitted to the facility's rehabilitation unit on [DATE] after abdominal surgery. According to interviews and his medical record, he was alert and oriented on [DATE]. The resident's advance directive documented he wished for life-sustaining intervention (cardiopulmonary resuscitation). -On [DATE] at 4:13 a.m. the night nurse, RN #2, documented the resident had labored breathing. She documented his oxygen was turned up, but his breathing was still labored and she put the head of his bed up. RN #2 did not document an assessment of the resident's condition at that time; there were no vital signs, no assessment of the resident's respiratory status, his mental status, or the color of his skin. Although RN #2 documented she would monitor the resident, there was no further documentation of the resident's condition or documentation the physician was notified of the resident's change in condition. -Interviews confirmed RN #2 had not gone back to assess Resident #2 or evaluated his response to the increased oxygen, and she had not notified the physician. Additional interviews and record review revealed the dayshift nurses, RN #1 and LPN #1, observed the resident in his room at 6:30 a.m. RN #1 documented the resident was unresponsive, gray in color, barely breathing, but with a pulse. The resident was sent to the hospital but died later that day. Hospital records documented the resident had a cardiac arrest and acute respiratory failure, probably due to myocardial infarction (heart attack), possibly due to septic shock. -RN #2 told the dayshift staff that Resident #2 had been in that condition (labored breathing) for hours, throughout the night. Additionally, the interviews revealed that RN #2 said she never went back to check Resident #2 because she was busy with medications to pass and paperwork. Furthermore, RN #2 had told RN #1 she did not know what to do. A review of RN #2's personnel record revealed she was hired on [DATE]. The schedule for RN #2 was provided by the DON on [DATE] at 2:00 p.m. It revealed RN #2 was only oriented to the rehabilitation unit on one night ([DATE]). The floor orientation checklist was requested for RN #2 on [DATE] but was not received by the end of the survey. Cross-reference F684J for further details. B. Events on ,d+[DATE] and [DATE] - Residents #8 and #9 The facility further failed to ensure that registered nurse (RN) #2 had the competency and skills to identify and intervene timely for Resident #8 and #9, both of whom experienced a change of condition. -Despite RN #2 participating in a change of condition education after [DATE], the RN failed to assess and notify the physician when Resident #8 was in distress with fever, rapid respirations, and low oxygen saturation. Further, the RN failed to timely and accurately document a thorough assessment and monitor Resident #9's acute change in condition (low oxygen levels post placement of a port) on [DATE]. Cross-reference F684J for further details. C. Interviews on staff training and competency 1. The NHA was interviewed on [DATE] at 5:05 p.m. He said he had reviewed the situation with RN #2 and Resident #2, and said RN #2 could have made better decisions in the moment as it resulted in a tragic event. He said the DON would be the one to investigate a clinical issue. 2. The director of nursing (DON) and NHA were interviewed later on [DATE] at 5:26 p.m. regarding the events and care of Resident #2 on [DATE]. The DON was interviewed again on [DATE] at 10:38 a.m. -The DON said she felt the nurses knew what to do when a change of condition occurred. She said she had educated them after this situation occurred. She said the nurses did not need to do a post-test or any return demonstration to indicate competency or to measure if the information was understood. She said she did not do a competency check with RN #2 or any one-to-one training with her after the situation with Resident #2 on [DATE]. -The DON said she had concerns with RN #2's charting and her strength as a nurse but said, How were we going to know how competent someone was? She said they orient new staff and put them on the floor; stating, We can not hold their hand forever. She said people make mistakes. The DON said she did not feel the nurses needed to be educated again and that the situation on [DATE] was a documentation issue. -The April schedule for RN #2 was received from the DON on [DATE] at 2:00 p.m. It revealed RN #2 received orientation to the floor on [DATE], [DATE], and [DATE]. RN #2 began working by herself on [DATE]. The schedule indicated she was only oriented to the rehab unit on [DATE]. -The DON was interviewed again on [DATE] at 10:38 a.m. regarding competencies for licensed nurses. She said the licensed nurses were clinicians. She said their nursing license should indicate they are competent. She said her standard was to do a verbal competency check with licensed nurses over the phone because it was hard to nail them down once they started on the floor. She said, I can not check or test every skill before they hit the floor. She said none of the nurse managers had come in to precept or monitor RN #2, after the events on [DATE], ,d+[DATE], or [DATE]. 3. The assistant director of nursing (ADON) was interviewed on [DATE] at 5:08 p.m. She said Resident #9 had a surgical procedure with a port placed in the left side of her neck on [DATE]. -The ADON said she had completed a change of condition form for Resident #9 on [DATE], but RN #2 should have done it. She said the nursing note by RN #2 on [DATE] was a late entry that RN #2 put in after the ADON asked her to. The ADON said she did not meet with RN #2 to review the process, but she sent her a text on her phone and reminded her to notify the physician, especially since the resident just had a procedure and could have been having complications. The ADON said she also reminded RN #2 in the text to complete an Interact change of condition form. III. Review of seven licensed nurse competencies A. Record review On [DATE] at 1:00 p.m., seven licensed nurse competencies, titled, Nurse Comprehensive Clinical Competency Review Skills Checklist, were received from the DON. The competency checklists did not include identifying a change of condition, or how to determine what was normal for a resident's current health and what was abnormal. The licensed nurse competencies included a section on head-to-toe assessments but in relationship to skin assessments and wounds. The competency did not evaluate the nurses' ability to identify, intervene, and notify the physician of a resident's change of condition. The competencies reviewed revealed the following: RN #2 had a competency checklist that documented her date of hire (DOH) was [DATE], and the competency checklist was reviewed via phone on [DATE]. It was signed by the DON under observer, but not by RN #2. The competency checklist documented all skills were met. RN #3 had a competency checklist, undated, with no DOH listed. The competency documented it was an annual review, and was signed by RN #3, and the DON under observer. The checklist documented all skills were met. RN #4 had a competency checklist with DOH documented as [DATE], with no date of when the competency was done. The competency indicated it was an annual review but without a date. The form was signed by the employee, and the DON under observer. The checklist documented all skills were met. However, RN #4 was not observed for skills (see interviews below). LPN #1 had a competency review, undated. No DOH was listed and it was signed only by the employee. It indicated it was an annual review. The checklist documented all skills were met. LPN #2 had a competency checklist which documented it was reviewed with the nurse via phone on [DATE]. The competency review indicated it was the initial competency. There was no DOH listed. It was signed by the DON under observer. The checklist documented all skills were met. LPN #3 had a competency checklist undated, signed by the employee only. There was no signature under observer. The checklist documented all skills were met. LPN #4 had a competency checklist, with DOH [DATE], signed by the employee only. The checklist documented all skills were met. B. Interviews 1. RN #4 was interviewed on [DATE] at 6:21 p.m. She said the DON had asked the licensed nurses to complete competency checklist forms last night ([DATE]). She said the DON called and said to check off the competency as met for the things they were comfortable with, sign the forms, and return them to her. RN #4 said she had not had anyone do a competency check with her for any skills either on hire or since then. She said she was hired in September of 2022. RN #1 was interviewed on [DATE] at 6:25 p.m. She said the DON had asked the nurses last night ([DATE]), including her, to complete the competency checklist with the things she felt she was competent in, mark it as skills were met, and sign it. She said she had not had a competency review since she was hired two years ago. RN #1 said she may have had training in transfer techniques for residents at one point, but that was all she could recall.

Based on observation, interview, record review, and policy review, the facility failed to conduct a self-administration of medication assessment for 3 (Residents #6, #137, and #44) of 7 residents observed during medication administration. Specifically, Residents #6, #137, and #44 had medications left in their rooms without a self-administration of medication assessment being completed. Findings included: The facility policy titled, Administering Medications, undated, indicated, 20. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely, and the resident has a self administration order from their attending physician. 1. A review of Resident #6's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The resident had diagnoses that included Alzheimer's disease, end-stage renal disease, heart failure, and diabetes. Review of the electronic health record (EHR), which included the Order Summary Report, for Resident #6 revealed no physician orders or assessments for self-administration of medications. An observation and interview on 04/24/2023 at 1:21 PM revealed Resident #6 was in their room with six pills in their right hand. At that time, the resident's door had been closed, the resident was alone in their room and there was not a nurse or a certified nurse aide with medication authority (med tech) in the room. Resident #6 stated staff brought a cup of pills, set them down, and left the room. During an interview on 04/24/2023 at 1:38 PM, Licensed Practical Nurse (LPN) #9 stated Resident #6 had an order to have medications administered with food when the resident returned from dialysis. LPN #9 stated the resident was supposed to take the medications with food, and the resident should have taken their medication with their lunch. During a follow-up interview on 04/25/2023 at 8:52 AM, LPN #9 stated he left the medication at Resident #6's bedside because the resident should take the medications with food. LPN #9 stated the resident took the medications slowly. LPN #9 stated he was trained to wait for a resident to take their medication, but he stated he had no answer why he left the medications with the resident, and that it was a mistake. LPN #9 stated a potential outcome was the resident could drop a medication, and they would have missed the dose. 2. Review of the electronic health record (EHR), which included the Order Summary Report, for Resident #137 revealed no physician orders or assessments for self-administration of medications. An observation of medication administration on 04/25/2023 at 8:27 AM revealed Med Tech #1 mixed 30 milliliters (ml) of lactulose (a laxative) into 120 ml of a house supplement shake for Resident #137. Med Tech #1 stated the resident preferred the medication in the shake. At 8:35 AM, Med Tech #1 administered medications to Resident #137, set the house supplement shake containing the lactulose on the resident's bedside table, and left the room. During an interview on 04/25/2023 at 8:36 AM, Med Tech #1 stated she was trained to watch the residents take their medications; otherwise, the resident could spill the medication, and the med tech or nurse would not know if the resident took the medication. During an interview on 04/27/2023 at 12:56 PM, Resident #137 stated at times the nurses left the lactulose on the table and the resident finished it after the staff person left the room, and other times the staff person stayed in the room while the resident finished the shake with the lactulose. During an interview on 04/25/2023 at 1:46 PM, LPN #11 stated she did not believe Resident #137 had an assessment for self-administration of medication. LPN #11 stated staff should not leave medication in the resident's room. She stated possible outcomes might be the resident not getting their prescribed medication or someone else might take the medication. She stated if a resident took a heart medication or blood sugar medication, they might develop symptoms of illness. LPN #11 stated if someone else would take the medication, they might be allergic to it, or it may be contraindicated with their other medications. 3. A review of Resident #44's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The resident had diagnoses that included dementia and diabetes. Review of the electronic health record (EHR), which included physician's orders, for Resident #44 revealed no physician orders or assessments for self-administration of medications. An observation of an insulin injection on 04/25/2023 at 8:56 AM revealed Licensed Practical Nurse (LPN) #8 gave Resident #44 the injection. A small paper medication cup with medication tablets sat on the resident's bedside table. LPN #8 asked the resident to take their medications which had been there, and Resident #44 took them. During an interview on 04/25/2023 at 9:01 AM, LPN #8 stated she did not leave the medications in the resident's room; she only administered the insulin. She stated she was trained to watch a resident take their medications because they might drop the medication or wait too long to take it. LPN #8 stated an outcome might be the resident would become ill, or if it were a blood pressure medication, it might cause problems. She stated the resident might miss an antibiotic dose, or another resident might wander in and take the medication who may be allergic to it. During an interview on 04/25/2023 at 9:09 AM, LPN #9 stated he gave the oral medications to Resident #44, and stated he observed the resident taking the medication. He stated the medication may have already been in the resident's room, but he did not observe it when he went into the resident's room to take the medication in. LPN #9 stated again that he remembered watching the resident take the oral medications. During an interview on 04/27/2023 at 12:12 PM, Resident #44 stated only LPN #9 left their medication on the table and left their room, but all of the other staff remained in the room when Resident #44 took their medication. During an interview on 04/25/2023 at 1:21 PM, Registered Nurse (RN) #10 stated it was wrong to leave medications in a resident's room, and whoever administered it should make sure the resident took the medication. She stated risks might be a roommate might take the resident's medications and have adverse reactions, if the medication were for high blood pressure or high blood sugar the roommate might fall, or they would be medicated unnecessarily. During an interview on 04/25/2023 at 2:00 PM, the DON stated staff were not allowed to leave the medications at a resident's bedside unattended, and she would not want someone else to take the medications. During an interview on 04/26/2023 at 8:50 AM, the Executive Director (ED) stated the facility did not have a self-administration of medication assessment for Residents #6, #137, or #44, so the medications should not have been left with the residents.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure 1 (Resident #145) of 3 residents reviewed for beneficiary notification was provided a Notice of Medicare Non-Coverage (NOMNC) a minimum of two calendar days prior to the last covered day of Medicare Part A services. Findings included: Review of a facility policy and procedure titled, Medicare Notice of Non-Coverage (NOMNC), revised in July 2013, indicated, A SNF [skilled nursing facility] or Medicare Advantage Plan must give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to patients receiving skilled nursing services not later than two days before the termination of services. Review of an Admission Record revealed the facility admitted Resident #145 from an acute care hospital with diagnoses that included type 2 diabetes mellitus, dementia, need for assistance with personal care, and difficulty walking. According to the Admission Record, Resident #145's primary payor was Medicare Part A. Review of Resident #145's Order Summary Report, dated 03/09/2023, indicated occupational therapy (OT), physical therapy (PT), and speech therapy (ST) were to evaluate and treat as indicated. Review of the SNF Beneficiary Notification Review form, completed by the facility, revealed Resident #145's Medicare Part A skilled services episode start date was 03/09/2023 and the last covered day of Medicare Part A service was 03/16/2023. The form indicated no NOMNC had been provided to the resident or resident representative. During an interview on 04/24/2023 at 4:04 PM, the Administrator stated Resident #145 had not been provided a NOMNC. He stated it was an oversight on behalf of the facility that the NOMNC was not provided.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure 1 (Resident #30) of 2 residents reviewed for care plan participation had been invited to their care plan conference. Findings included: Review of a facility policy titled, Comprehensive Resident Centered Care Plan, revised in January 2022, revealed, The facility will provide the resident and resident representative, if applicable, advance notice of care planning conference to encourage resident and/or resident representative participation. Care conference may be in the form of face to face meeting, conference calls or video conferencing. If not practicable, the reason will be documented in the medical record. Review of an Admission Record indicated the facility admitted Resident #30 with diagnoses that included diabetes mellitus with hyperglycemia, cognitive communication deficit, and need for assistance with personal care. Review of a care plan, with an initiation date of 03/09/2023, indicated the resident had diabetes mellitus, risk for impaired cognitive function, and a self-care performance deficit related to activities of daily living. Appropriate goals and interventions were addressed in the care plan. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #30 had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. During an interview on 04/24/2023 at 10:12 AM, Resident #30 stated they had not been invited to participate in their care plan conference. During an interview on 04/25/2023 at 1:17 PM, the Social Services Director (SSD) reviewed Resident #30's electronic health record (EHR) and stated she could not find documentation the resident had been invited to their care plan conference. She stated the date of the initial care plan conference was not documented in the EHR. The SSD stated the previous case manager was responsible to invite the resident during that time frame. During an interview on 04/26/2023 at 3:26 PM, the Director of Nursing stated residents should be invited to their care plan conferences. During an interview on 04/26/2023 at 3:27 PM, the Administrator stated residents should be invited to their care plan conferences.

Based on interview, record review, and facility policy review, the facility failed to implement a discharge plan for 1 (Resident #278) of 2 residents reviewed for admission, transfer, and discharge. Resident #278 was discharged to an assisted living facility and the facility failed to provide evidence it arranged for home health services for the resident to ensure wound care was provided. Findings included: A review of a facility policy titled Admission, Transfer and Discharge Rights, revised November 2016, revealed a policy subject titled Discharge Planning Process. The policy indicated The Facility's discharge planning process shall: provide and document sufficient preparation and orientation to residents, in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the facility. The policy further indicated, If the resident indicates an interest in returning to the community, the Facility shall document any referrals to local contact agencies or other appropriate entities made for this purpose. Review of an Admission Record for Resident #278 revealed the facility admitted the resident on 11/20/2022 with diagnoses including essential hypertension, personal history of transient ischemic attack, infarction without residual deficits, and depression. The admission record further indicated the facility discharged the resident on 12/09/2022 to a private home. Review of Resident #278's discharge Minimum Data Set (MDS), dated [DATE], revealed the facility did not anticipate the resident would return to the facility and that the discharge was planned. The MDS further indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The discharge MDS indicated no evidence of skin problems and further indicated active discharge planning was already occurring for the resident to return to the community and no referrals were made because a referral was not needed. Review of physician orders revealed an order with a start date of 12/05/2022 that indicated the resident had a wound to the right buttocks. The order directed staff to cleanse the wound with wound cleanser, pat it dry, apply Xeroform (a sterile, non-adherent wound dressing), and cover the wound with a dry dressing daily. A review of a Discharge Summary and Post-Discharge Plan of Care dated 12/09/2022 revealed Resident #278 required ongoing treatment for the wound to the right buttocks. Further review revealed community resources for home health services were arranged by the facility to include nursing services and therapy. The form did not identify the name, contact number, or contact person of the agency responsible for providing the services. An interview on 04/25/2023 at 12:36 PM with Community Provider (CP) #12 revealed the facility was supposed to set up in-home health care services to ensure ongoing treatment for Resident #278's wound care. CP #12 stated the resident was discharged early and the facility sent the resident to an assisted living facility, where the resident was admitted . CP #12 stated after Resident #278 was admitted , they discovered that home health services for the resident's wound care was never set up. CP#12 said staff at the assisted living facility tried contacting the facility that discharged Resident #278, but they were not returning calls or getting back in touch with the assisted living staff. CP #12 said they reached out to the resident's family and notified them that home health care was never arranged for wound treatment and that the assisted living facility would not be able to meet the residents needs at their facility because of the resident not having services for wound care. CP #12 stated the family was able to find alternative placement at another location in another city and the resident was discharged to that facility. An interview on 04/26/2023 at 10:35 AM with the Social Services Director (SSD) revealed she had been in the position since 01/04/2023. The SSD said the type of insurance a resident had affected which agencies could provide home health services. The SSD stated prior to a resident's discharge, the facility had three days to identify which home health care provider would provide services after a resident was discharged . The SSD stated the facility sent referrals to all agencies that accepted a resident's insurance and the agency, name of the company, the contact number, and which services would be provided should be documented in the resident's medical record. The SSD stated an agency would then let the facility know by phone if they accepted the referral, which should also be documented. The SSD stated the facility waited for the first agency to confirm acceptance and, if none of the agencies accepted prior to discharge, she notified the resident or their responsible party to inform them to notify the resident's primary care physician upon discharge that services were not in place. The SSD stated it would then be the responsibility of the resident to work with their primary care physician to get services in place in the community. The SSD stated the pervious person in her current position would have sent the email referrals in December 2022 for home health services, but the facility no longer had access to those emails, and she was not sure if a referral was sent for Resident #278 prior to discharge or if there was any follow-up after discharge. An interview on 04/27/2023 at 8:33 AM with the Director of Nursing (DON) revealed when a resident needed home health services the facility would try to get those services in place prior to discharge. The DON stated if services could not be arranged, she expected staff to communicate with the resident at discharge to ensure the resident and/or their responsible party knew they would need to notify their primary physician to get services in place after discharge. The DON stated she expected staff to communicate and respond to an accepting facility after a resident was discharged related to services, but she stated it was difficult after a resident was discharged . An interview on 04/27/2023 at 8:37 AM with the Administrator revealed he expected staff to ensure a resident was discharged safely and appropriately to the community.

Based on observation, interview, record review, and facility policy review, the facility failed to provide sanitary administration of medications to prevent to the development and transmission of disease and infection for 1 (Resident #15) of 7 residents observed during medication administration. Findings included: The facility's undated policy titled, Administering Medications indicated, 18. Staff should follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. The facility policy titled, Infection Prevention and Control Program, revised October 2022, indicated, Goals. Promote individual resident's rights and well-being while trying to prevent and control the spread of infection. A review of Resident #15's Order Summary Report, dated 04/25/2023, revealed an order dated 07/22/2021 directing staff to administer dorzolamide timolol eye drops in the right eye twice daily for glaucoma and an order dated 01/23/2022 directing staff to administer Flonase spray, providing one spray in each nostril once daily for nasal drip. An observation on 04/25/2023 at 7:26 AM revealed Licensed Practical Nurse (LPN) #9 took the bottles of dorzolamide timolol and Flonase to Resident #15, who was sitting in a wheelchair in the hallway. At that time, LPN #9 squatted down near the resident and placed the dorzolamide timolol bottle and the Flonase bottle on the floor in front of the resident's wheelchair. LPN #9 then administered the medications and returned the medication bottles to the medication cart drawer. During an interview on 04/25/2023 at 7:30 AM, LPN #9 stated the floor was contaminated but stated he did not have anywhere else to place the medications except on the floor. LPN #9 stated he should have taken the resident to their room to administer the nasal spray and the eye drops. He also stated he should have cleaned the medication bottles before putting them away in the medication cart. During an interview on 04/25/2023 at 1:17 PM, LPN #8 stated medication bottles should not be on the floor based on infection control concerns. The LPN stated the floor was contaminated, and germs would be on the medication bottles. She stated the bottles of medicine should have been wiped down before putting them back into the medication cart, or they should have been thrown away and reordered. During an interview on 04/25/2023 at 1:21 PM, Registered Nurse (RN) #10 stated medications should not be placed on the floor because of infection control concerns. She stated floors were dirty and may have contaminated the medication or the medication bottle. She stated she would have disposed of the medications and reordered new medications. During an interview on 04/25/2023 at 2:00 PM, the Director of Nursing (DON) stated that, ideally, she did not want the medications on the floor for infection control reasons. She noted she expected staff to use an appropriate surface like a table. During an interview on 04/25/2023 at 4:12 PM, the Executive Director (ED) stated LPN #9 may have placed the medications on the floor to ensure resident rights and preferences. The ED stated he was unsure whether the floor was contaminated.

Based on observations, record review, and interviews, the facility failed to ensure two (#5 and #211) of four out of 27 sample residents received care consistent with professional standards of practice to promote prevention and healing of pressure injuries. Resident #5 was dependent on staff for mobility, toileting, transfers and repositioning and was identified to be at risk for developing pressure injuries and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to continue utilizing identified interventions to prevent the development of a new pressure injury for Resident #5 who previously had pressure injuries that were healed. This indicated the resident had the ability to heal. On 2/7/22 a pressure wound was discovered on Resident #5's coccyx measuring approximately 2 centimeters (cm) by 4 cm. The nurse documented the wound was reddened around the border and blackened in the center. The resident reported pain at the site and notified the nurse of her concerns of having a new wound which prompted the nurse to assess the resident and document at 11:01 p.m. Additionally, the facility failed to ensure accurate documentation as evidenced by the same day of 2/7/22, the daytime nurse documented no new skin concerns on the resident's February 2022 treatment administration record (TAR). Resident #211 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was dependent on staff for mobility assistance, toileting and transfers and was identified as at moderate risk for developing pressure injuries. The facility failed to identify and implement preventative interventions to prevent the development or repeat of a pressure injury for Resident #211. On 1/31/22 the initial nurse skin assessment revealed Resident #211 had redness to his bilateral buttocks area. The medical administration record (MAR) revealed perineal care (cleaning the private areas of a resident) was provided to the resident daily from time of admission with no new skin concerns noted. The facility's failure to ensure a resident who depended on staff for off loading had interventions in place to prevent the development of a pressure ulcer. This failure contributed to Resident #211 sustaining a facility acquired an unstageable necrosis pressure injury on 2/4/22 to the coccyx measuring 3.2 cm by 5.6 cm. Not until 2/7/22 was an air mattress ordered and implemented for a resident who was at high risk for developing skin concerns. Findings include: I. Professional reference The National Pressure Injury Advisory Panel (2016) NPIAP Pressure Injury Stages, retrieved on 2/16/22 from: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed the following pertinent information: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. II. Facility policy and procedure The Wound Management Policy, revised on 8/25/2020, was provided by the medical records coordinator (MRC) on 2/9/22 at 12:55 p.m. It documented in pertinent part: The purpose of these guidelines is to facilitate necessary treatment and cae, consistent with professional standards to promote healing, prevent infection and promote prevention of new ulcers. Upon admission the admitting nurse and or designee will complete a skin evaluation and document the patient's skin condition in the residents' clinical record. A Braden Risk Assessment is completed upon admission, weekly x(for) three weeks and then quarterly, annually and with a significant change of condition. Skin checks are completed by the licensed nurse weekly. The certified nursing aides (CNA) will report any alterations in skin identified during routine care. If a resident is identified to have a new skin alteration the licensed nurse will do the following: -Notify the nurse manager or designee and they will initiate risk management and investigate the potential cause, develop and implement interventions; -Documentation of the new skin alteration will be completed in the resident's clinical records; -Documentation will include location, size, description, drainage type and surrounding tissue; -Notify the physician and obtain new orders as indicated. Orders will include area to be treated, frequency of treatment, and treatment type; -Update the mediation and treatment record as indicated; -Notify the resident and or representative; -Initiate a referral to the registered dietitian if indicated, and; -The comprehensive person-centered care plan will be revised to include the new skin alteration. Actual pressure injuries, venous stasis ulcers, arterial ulcers, diabetic neuropathic ulcers and open surgical wounds will have weekly documentation that includes measurements and how the wound is progressing. Monthly tracking through the Quality assurance performance improvement (QAPI) process will be completed for identification of trends by the director of nursing (DON) to assess progress towards healing new wounds, how many were avoidable versus not avoidable and why based on the registered nurse (RN) assessment/investigation. Weekly the facility interdisciplinary team (IDT) will meet to review and discuss current wounds and pressure injuries for improvements, worsening or unchanged areas. The IDT will discuss additional recommendations, referrals and revise care plans to reflect the current status of each wound/pressure injury. III. Resident #5 A. Resident status Resident #5, age 82, was admitted on [DATE] and readmitted after a hospitalization on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/9/21 annual minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status score of 12 out of 15. Rejection of care was not coded to be exhibited. She was totally dependent on staff for mobility, transfers, toileting, and activities of daily living (ADLs). She was always incontinent of bowel and bladder. She was at risk for developing pressure ulcers and did not have any pressure ulcers identified during the review period. She had a pressure reducing device for her bed and her chair coded. She was not on a turning program or a restorative program. B. Record review Nursing care note on 12/6/2020 noted two new pressure ulcers to the right buttocks area and on 12/7/2020 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/5/21 the wound care note revealed the two pressure ulcers on the right buttocks had resolved. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The interdisciplinary team (IDT) progress note on 10/23/21 revealed the resident had two new open areas to her right buttocks and a new gel cushion for her wheelchair and air mattress were ordered on 10/26/21. Resident to resume restorative program. Nursing care note on 11/19/21 revealed the two open areas on her buttocks resolved and the air mattress was discontinued and removed from her bed for the second time. Braden scale assessment for predicting pressure sore risk were completed weekly upon re-admission on 10/7/21, 10/14/21, 10/28/21, 11/5/21, 11/12/21 and 2/8/22 revealed Resident #5 was at mild risk for developing pressure ulcers with a score of 16 out of 23 and 17 out of 23. There was a gap in assessments from November 2021 until February 2022. There was a failure to continuously monitor and document weekly and as needed assessments. The February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing care note on 2/7/22 at 11:01 p.m. revealed the resident notified the nurse that she had a painful bottom and stated, my butt is hurting, I think I have a wound. The nurse assessed and documented a wound to her right buttocks which was reddened around the border and blackened in the center, measuring approximately 2 cm x 4 cm. The resident reported pain at the site. The February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing care note on 2/8/22 revealed a new gel cushion for wheelchair and pressure relieving air mattress were ordered and in place. -The air mattress and gel cushion had been removed on 11/19/21. -The gel cushion for wheelchair and pressure relieving air mattress was observed to be in place on 2/10/22. A skin care plan dated 2/8/22 revealed the resident was at risk for skin impairment with limited mobility, [CONDITION(S)], obesity and venous insufficiency. New skin impairment on 2/7/22 to bilateral buttocks initiated on 10/24/18 and revised on 2/8/22. The goal for skin impairment to bilateral buttocks will resolve without complication through the next review. The new interventions initiated on 2/8/22, included an air mattress for her bed, new gel cushion for her wheelchair, check often and offer assistance for incontinence care and toileting needs as well as referral to wound clinic for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] C. Observations and interviews Licensed practical nurse (LPN) #3 was interviewed on 2/9/22 at 10:20 a.m. She stated weekly skin assessments performed by nurses included all skin, head to toe, in skin folds, heels, buttocks, and peri-area. If a skin issue was found on the skin assessment or by certified nurse aides (CNAs) the resident's physician was notified and a progress note was completed. She said the weekly skin audits were documented in the resident's treatment administration record (TAR) with a plus or minus to indicate if the resident had a new skin concern. If the resident had a new skin concern then a progress note was entered and the director of nursing and physician were notified. She said she did not complete the weekly skin assessment for Resident #5 on 2/7/22, but if the peri-area was assessed then the coccyx wound should have been identified. Registered wound nurse (RN) #1 was interviewed on 2/10/22 at 9:30 a.m. during a wound treatment observation. RN #1 was observed providing treatment on Resident #5 for a coccyx wound. Resident #5 was lying in bed on her back. There was an air mattress on her bed. RN #1 said Resident #5 had pressure injuries previously to the coccyx area that had been resolved (indicating the resident had the ability to heal, and the facility had an obligation to prevent future or recurrent wounds). There was a small amount of pink tinged drainage on the old dressing. The wound on the right upper outer buttock was black in the center and the surrounding skin was reddened. The wound was cleansed with a wound cleanser and patted dry. [MEDICATION(S)] (medical grade honey-based product for wounds) was applied to Maxsorb (absorptive alginate dressing-derived from algae) and was applied to the center of the wound. A foam dressing was then applied to cover the wound. Restorative aide (RA) was interviewed on 2/10/22 at 10:57 a.m. He said the restorative department tracked all the ordering for air mattresses, cushions and special equipment orders. He said the restorative nurse manager (RNM) was the one who placed the orders as well as discontinued the orders for the equipment. He said he was not sure why Resident #5's air mattress and gel cushion were discontinued in November 2021 after her coccyx wounds had resolved previously. He said the air mattress and gel cushion could be considered preventative maintenance. Restorative nurse (LPN) #4 was interviewed on 2/10/22 at 12:15 p.m. She said Resident #5 did have a history of multiple facility acquired wounds on her coccyx. She said the air mattress and gel cushion for her wheelchair were ordered as part of her treatment plan once the wounds had been identified. She said the resident expressed she did not like the air mattress and the decision was made to remove the air mattress after the wounds were resolved. LPN #4 said a geo mattress which was an upgraded regular mattress was placed on her bed after they removed the air mattress and thought that mattress would help distribute pressure. She said unfortunately the geo mattress did not help in the prevention of acquiring new pressure ulcers on her coccyx. She said the air mattress and gel cushion could be considered preventative maintenance and may have prevented her new acquired pressure ulcers on her coccyx. -The facility failed to ensure the appropriate interventions remained in place for a resident who was totally dependent on staff for offloading, bed mobility and transfers. The physical therapist (PT) and the occupation therapist (OT) were interviewed on 2/10/22 at 12:30 p.m. They said they were not sure why the air mattress and gel cushion for the wheelchair were discontinued. They said the restorative program generally ordered the special medical equipment however, it is the entire team that would help identify the need. The OT said she completed the wheelchair evaluation after the new gel cushion was installed so she was not sure how the regular cushion affected how she sat in her chair. She said the new gel cushion was thicker and placed the resident higher in her chair which seemed to be a good fit and more comfortable for the resident. PT and OT both stated the resident was not consistent with her reporting and her participation in therapy. They said the resident would be agreeable at times and report she liked her air mattress and at times would state she did not like the air mattress. They both agreed the air mattress and gel cushion would benefit the resident and could be considered a preventative measure for pressure ulcers. The OT said that the staff should provide guidance and direction when deciding what is best for the resident and should help her understand the benefit of keeping the air mattress and gel cushion even after her wounds had resolved. The director of nursing (DON) was interviewed on 2/10/22 at 1:56 p.m. She said Resident #5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the last time she had wounds on her coccyx was in October 2021. She said once those wounds were resolved the air mattress was removed based on resident request. She said a geo mattress was provided when the air mattress was removed. She said the geo mattress was not an air mattress but an upgraded mattress that could help with pressure distribution. She said the air mattress and gel cushion could be considered preventative maintenance if tolerated by the resident. She said there was a concern of the resident self transferring at that time and it was a safety concern. -However, there was no documentation to support that concern. She said the resident was no longer self transferring and was dependent on staff for all activities of daily living including transferring, mobility and toileting. She said the resident was not always reliable in her reporting and did have inconsistencies. She said she understood the staff could have revisited the removal of her air mattress and explain the risk and benefits before removing it based on the resident's request. She said the skin audits were done once a week on Monday. She said the skin audit on 2/7/22 completed by the nurse did not indicate any new skin concerns or wounds on her buttocks. She said the evening nurse did identify the two bilateral wounds to her buttocks on the same day of 2/7/22 and understood the concern the wounds were not identified by the day nurse. IV. Resident #211 A. Resident status Resident #211, age 71, was admitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/4/22 admission minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score of seven out of 15. He was dependent on staff for mobility, transfers, toileting and activities of daily living (ADLs). He was always incontinent of bowel and bladder. He was at risk for developing pressure ulcers and did have two stage four pressure ulcers coded to be present. He had a pressure reducing device for his bed and his chair coded. He was not on a turning program or a restorative program. B. Record review Braden scale assessments completed weekly from time of admission on 1/31/22 and 2/7/21 revealed the resident was at moderate risk for pressure injuries with a score of 13 out of 23. The initial nurse skin assessment completed on 1/31/22 documented abrasions to the right knee, right foot and right toe, and redness to the bilateral buttock area. An order was placed for barrier cream to the coccyx area on 2/1/22 to be applied three times a day at every shift. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The daily nurse skilled evaluation notes on 2/1/22, 2/2/22, and 2/3/22 revealed perineal care was provided by the nurse. No skin concerns were noted on the coccyx during the evaluations. The physician note on 2/3/22 revealed wound care treatment was provided to the right foot ulcer, however there was no documentation related to skin care concerns to the coccyx area. The nursing care note on 2/4/22 revealed new wound orders were obtained and entered for a new unstageable necrosis wound on the coccyx area measuring 3.2 centimeters (cm) x 5.6 cm. An order was placed for weekly skin audits to be completed one time a day every Monday on 2/7/22. A new order was obtained for an air mattress to be placed on his bed on 2/7/22. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin care plan initiated on 2/2/22 and revised on 2/9/22 read: The resident was at risk for skin impairment, with decreased mobility. He had a coccyx and right foot wounds. Resident will maintain skin integrity through the next review date. The interventions to have the wound team to follow the resident's care and implement an air mattress were initiated on 2/7/22. C. Observations and Interviews Licensed practical nurse (LPN) #3 was interviewed on 2/9/22 at 10:20 a.m. She stated resident skin assessments were completed on the same day of admission. She said skin assessments performed by nurses included all skin, head to toe, in skin folds, heels, buttocks, and peri-area. If a skin issue was found on the skin assessment or by certified nurse aides (CNAs) the resident's physician was notified and a progress note was completed. She said there was redness noted on the buttocks area in the initial skin assessment for Resident #211, however an air mattress was not ordered upon admission. Registered wound nurse (RN) #1 was interviewed on 2/10/22 at 9:00 a.m. during a wound treatment observation. RN #1 was observed providing treatment on Resident #211 for his coccyx wound. The resident was lying in bed on his back. He had an air mattress on his bed. The dressing on his coccyx was removed, there was no drainage or odor. The wound was open with the center covered in whitish tissue and the surrounding skin was pink. The perimeter of the wound had scar tissue from previous pressure injury to the area (indicating the resident had the ability to heal, and the facility had an obligation to prevent future or recurrent wounds). RN #1 said it appeared smaller than it did last week. The wound was cleaned with a wound cleanser and patted dry. An antimicrobial gel was applied as well with a gauze dressing applied to the center of the wound. Restorative nurse (LPN) #4 was interviewed on 2/10/22 at 12:15 p.m. She said Resident #211 was not currently on a restorative program, however she was aware of a new order for an air mattress related to his new wound on his coccyx. She said she thought the order was obtained on 2/4/22 however the air mattress was delivered and implemented on 2/7/22. She said an air mattress could be used for preventative measures especially if a new admission is underweight and was at risk for skin breakdown. She confirmed that Resident #211 was considered to be underweight and at risk for skin breakdown, however the air mattress was ordered and implemented seven days after his admitted . -The air mattress was not ordered until the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] The physical therapist (PT) and the occupational therapist (OT) were interviewed on 2/10/22 at 12:30 p.m. They said Resident #211 was a new admission and currently was on a therapy program. The PT said the restorative nurse (LPN) #4 ordered an air mattress for the resident on 2/7/22. The director of nursing (DON) was interviewed on 2/10/22 at 1:56 p.m. She said the floor nurse completed a full head to toe assessment on the day of admission. She said the assessment identified skin abrasions to his knee, foot and toe as well as redness to the coccyx area. She said the redness was monitored and as soon as the open area was identified, orders were obtained for an air mattress. She said an air mattress may be ordered at time of admission if the resident was frail and at risk for skin breakdown. She confirmed Resident #211 was underweight and could be considered frail. He did have a history of skin integrity concerns. She said the air mattress could be considered as preventative as tolerated.

Based on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#39) of three residents reviewed for falls out of 27 sample residents. The facility failed to timely and appropriately revise Resident #39's care plan and implement interventions including required extensive assistance with all activities of daily living and ambulation to and from the bathroom as documented in her 12/27/21 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light. The facility failed to monitor the effectiveness of Resident #39's care planned interventions and modify the interventions to prevent her from falling. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple falls for Resident #39, with falls that resulted in injuries that required transfer to a hospital. Due to the facility's failures, lack of supervision and effective interventions resulted in eight falls within 38 days, in which she sustained injury that caused right hip dislocation on 12/23/21 and required two trips to the emergency department for assessment and treatment of closed right hip reduction (a procedure for treating a hip dislocation without surgery, using manipulation of thigh bone to put the hip back in place) on 12/23/21 and 1/22/22. Findings include: I. Facility policy The Assessing Falls and Their Causes policy, revised March 2018, was provided by the nursing home administrator on 2/10/22 at 1:30 p.m., it read in part: Falls are leading cause of morbidity and mortality among the elderly in nursing homes .Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known functional impairment, etc .Evaluate chains of events or circumstances preceding a recent fall .Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. II. Resident #39 A. Resident status Resident #39, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the December 2021 computerized physician orders, diagnoses included [CONDITION(S)], nontraumatic [CONDITION(S)] (acute brain bleed), [CONDITION(S)], diabetes mellitus with diabetic polyneuropathy and dislocation of right hip. The 1/8/22 minimum data set (MDS) assessment (significant change in status) revealed the resident cognition was intact with a brief interview for mental status (BIMS) score 15 out of 15. No rejection of care behaviors were documented. She required extensive assistance of two staff with bed mobility, transfers, dressing and toilet use, extensive assistance of one with personal hygiene, and supervision with eating. The assessment revealed the resident was not observed walking in her room or corridor during the seven days look back period (activity did not occur). The resident was under hospice care. B. Resident's son, her power of attorney (POA) interview and resident observation. The resident was observed in her room on 2/7/22 at 2:30 p.m. She was sleeping in her bed. The non-skid strips were observed on the floor next to the bed. The resident's son was interviewed on 2/7/22 at approximately 3:00 p.m. He said his mother experienced a significant decline in functional and mental status within the last month and was currently under hospice care. He said the resident suffered several falls within a few weeks period. He said his mother was always very independent person and did not like to ask for help. C. Record review The 9/26/21 MDS assessment revealed intact cognition with BIMS score 15 of 15. She was independent with bed mobility, transfers, walking in room, toilet use and personal hygiene, required supervision with walking on unit, dressing and eating. No falls were documented. The 12/27/21 MDS assessment (quarterly) revealed intact cognition with BIMS score 15 of 15. She required extensive assistance of two staff with bed mobility, transfers, dressing and toilet use, extensive assistance of one with walking and personal hygiene, and supervision with eating. One fall with major injury was documented. 1. Care plan -(Resident) is s/p (status post) reduction of R (right) hip dislocation (Dated 1/11/22). Interventions included: Right knee brace at all times. Ok to remove for hygiene. Check CMS Q (every) shift (Dated 1/17/22). Strict posterior hip precautions at all times, weight bearing as tolerated as long as posterior hip precautions can be followed (Dated 1/11/22). -(Resident) is at risk for falls related to limited mobility, impulsivity, use of 4ww (four wheeled walker) device, although often walks without it. 3/28/21 fall in dining room, hematoma back of head. 3/31/21 fall in room, no injury. 4/2/21 fall in activity room, no injury. 4/24/21 fall in room, bruise lt (left) knee. (Dated 4/26/21) -(Resident) is at risk for falls related to limited mobility, impulsivity, use of 4ww (four wheeled walker) device, although often walks without it. 10/15/21 fall, abrasion/bruise lt (left) upper back. 12/21/21 skin tear RLE (right lower extremity). (Dated 12/23/21). -(Resident) is at risk for falls related to confusion, poor safety awareness, poor cognition, limited mobility, impulsivity. 12/22/21 fall in dining room. 12/22/21 assisted fall in restroom doorway. 1/3/22 slid from bed, no injury. 1/9/22 assisted to floor, no injury. 1/15/22 fall, no injury. 1/24/22 fall, no injury. 1/27/22 fall no injury. 1/28/22 fall, small lump lt (left) temporal area which resolved. (Dated 1/28/22). Interventions included: Review and update fall risk assessment quarterly, post any fall and PRN (as needed). Notify physician of any fall. Notify family/responsible party of any fall. (Dated 8/11/19). Monitor for decline or improvement in mobility. (Dated 8/11/19). Provided with reacher to grab items that are out of reach. (Dated 9/15/2020). Non-skid strips to floor in restroom and beside bed. (Dated 10/5/2020). Non-skid strips in front of recliner chair to decrease risk of sliding. (Dated 1/17/22). Hospice bolster cover to define edges of bed. (Dated 1/24/22) 2. Falls Record review revealed the resident sustained four falls between 3/28/21 and 4/24/21 including one fall with injury, hematoma to the back of resident's head. Additionally the resident had a fall with injuries on 10/15/21, as documented in nursing progress note: resident was sitting on the floor. This writer observed resident siting on floor next to bed with legs extended in front of her sitting on her bottom next to bed in front of her fan that is close to the wall by head of bed. Bed was in low position, call light was within reach, lights were on. Resident was in the process of changing her clothes to get ready for bed. Resident stated she stepped back lost her balance and fell . Resident obtained an abrasion to her upper left side of her back with bruising already appearing, bruising purple/red in color. Resident had full ROM (range of motion) to all extremities, with no difficulty noted. Resident able to get up with assistance of staff, with no difficulties. Resident able to ambulate with no issues. Resident sat back onto bed to finish getting ready for bed. No s/sx (signs and symptoms) of pain/discomfort. Needs anticipated and met by staff. (Physician) notified via message, ADON (assistant director of nursing) on call notified. Will notify next on coming shift nurse to notify POA (power of attorney)/Son (name). Currently resident is in bed resting comfortably with no acute distress noted. Neuro checks in place and WNL (within normal limits). Resident encouraged to utilize call light when needing assistance for ADL's (activities of daily living). Will continue to observe and follow plan of care noting any changes as needed. The resident was identified as a high risk for falling as noted by the resident falling as indicated on her fall care plan due to her limited mobility, impulsivity, use of 4ww (four wheeled walker) device, although often walks without it. Nursing notes review and provided by the nursing home administrator (NHA) records from 12/1/21 to 2/10/22 revealed the following: 12/22/21 (noted at 5:53 a.m.), This writer was notified by NOC CNA (night shift certified nurse aide) that she heard a voice in the dining room, CNA (certified nurse aide) noted resident laying on the floor around 0525 (5:25 a.m.). This writer observed resident laying on floor in dining area laying flat on her back with her legs extending out her walker in front of her feet. Resident wearing slippers, slippers noted to not be fully on her feet. Full head to toe assessment completed by RN (registered nurse) in building, full ROM (range of motion) noted to all extremities with no difficulty noted. Resident obtained a reddish bump to the back of her head on the occipital area. Resident PERRLA (pupil, equal, round, reactive to light and accommodation), equal hand grasps bilaterally. No c/o (complaints of) pain/discomfort at this time. Resident assisted up by staff and assisted back to room. Resident was educated on the importance of wearing proper foot wear as well as calling for assistance. CNA applied Ice to area. Resident currently in room with no acute distress noted, sitting up in bed. (physician) notified via message. On call notified. Responsible party notified spoke with (name). Neuro (neurological) checks started and WNL (within normal limits). Will continue to observe and follow plan of care noting any changes as needed. 12/22/21 (noted at 9:43 p.m.), CNA was ambulating with resident with 4WW (four wheeled walker) to BR (bathroom) and due to weakness and unsteadiness on ft (feet) CNA assisted to floor in BR (bathroom) doorway with resident stating her legs wouldn't move. Head to toe survey done, complains of bil (bilateral) leg pain. ROM WNL (range of motion within normal limits). CDI dsg (clean, dry and intact dressing) to rt (right) medial distal lower leg. A 2 (assistance of two) to stand and sat on toilet. Taken back to bed via w/c (wheelchair). Scheduled pain medication given and soon asleep. MD (physician) notified of assisted fall and son (name) returned TC (telephone call) and circumstances explained, he states he will stop by tomorrow morning. Bedside commode placed at bedside. -However, according to the 12/27/21 MDS assessment she required extensive assistance of two staff with bed mobility, transfers, dressing and toilet use during the seven day look back period. There was only one CNA documented to be with her at the time of the fall in the bathroom. 12/23/21 (noted at 10:00 a.m.), read in part: res (resident) c/o (complained) rt (right) hip pain. Did not attempt to stand as we are waiting for stat (immediately) rt (right) hip x-ray to be completed. 12/23/21, IDT (interdisciplinary) review: Res (resident) had a fall in the dining room and an assisted fall in her restroom on 12/22/21. Res noted with increased confusion and has c/o (complained) rt (right) hip pain this am (morning). Stat CBC, BMP, and UA with C&S (complete blood count, basic metabolic panel, urinalysis with culture and sensitivity) if indicated ordered and drawn by lab tech. Stat rt (right) hip x-ray ordered from (company name). Msg (message) left for son (name). 12/23/21 (noted at 12:06 p.m.), Reported to nurse from x-ray tech (technician) that right hip has dislocation. Orders recvd (received) to send to ER (emergency room ) for eval (evaluation) and treat (treatment). Spoke with resident and son (name) about discharge. 24 hour bed hold policy sent with resident. Report called to (name) at (hospital). Resident was awake and alert and oriented x 3 (times three) upon transport. 12/23/21 (noted at 11:18 p.m.), Returned from (hospital) at 1912 (7:12 p.m.) via ambulance and transferred into bed with new orders for strict hip precautions at all times, weight bearing as tolerated as long as precautions can be followed. PT (physical therapy) to Eval (evaluate) and treat, follow-up with (name) in 1-2 (one to two) weeks. Closed rt (right) hip reduction done in OR (operating room) per hospital report, not to bend at up to 90 degress so hip doesn't pop out, do not cross legs, wedge between legs. Placed on bed pan to void. Fed self 50% supper with set-up and HOB (head of bed) elevated 45 degress, drank 360cc fluid with some assist to drink from straw. Scheduled pain medication given for rt (right) knee pain. Asleep since 2015 (8:15 p.m.). 1/2/22 (noted at 1:06 p.m.), Received a call from (name) RN (registered nurse) with (name) Hospice. Resident's son (name) reached out to her with concerns about resident's right hip and her pain r/t (related to) right hip. This nurse assessed resident and noted her right hip to appear with dislocation with leg rotated inward. Resident reported pain 6/10 (with 10 being the worst on a pain scale) pain. PRN (as needed) [MEDICATION(S)] given with some relief. Son (name) at bedside and would like resident to be sent to ER (emergency room ) for Eval (evaluation) and TX (treatment). (Physician) aware of resident clinical status. Resident sent out to (hospital) for eval (evaluation). Bed hold policy sent with pt (patient). Called (hospital) to give nurse to nurse report spoke with (name) RN (registered nurse). -However, the facility did not determine if the resident had fallen again after she returned from the hospital on 12/23/21 and was alerted to the resident's right hip pain after the son called the nurse, which was 10 days after the resident returned from the hospital. 1/2/22 (noted at 6:59 p.m.), Returned from (hospital) via ambulance, closed rt (right) hip reduction done. 1/3/22 (noted at 1:27 a.m.), resident returned from (hospital) s/p (status post) closed hip reduction. New orders obtained and noted for right knee brace at all times and may remove for hygiene. resident is compliant with brace at this time. In bed denies pain/discomfort. Alert and able to make needs known. Call light within reach. No s/s (signs or symptoms) of distress noted at this time. 1/3/22 (noted at 9:35 p.m.), Res (resident) was sitting on the edge of her bed for dinner (sic) where she stated she slid off the bed and right on to the floor. Her leg brace was in place and non-skid socks. She denies any pain, son and the MD (physician) were notified. 1/4/22, IDT (interdisciplinary team) review: Res (resident) sitting at edge of bed and slid to floor, no injury per RN assess. RLE (right lower extremity) brace was on and nonskid socks/strips were in place. Res (resident) has poor core strength and has difficulty maintaining upright sitting position. Recent overall decline, hospice services in place. Staff to assist res (resident) up in wc (wheelchair) with 1/2 lap tray for meals as res (resident) allows. Son (name) updated and in agreement. 1/8/22 (noted at 6:46 p.m.), Res (resident ' s) roommate was hollering out for help as a CNA was walking by. Res (resident) was lowered gently to the floor. She states she was throwing something away. Brace to R (right) leg was put in place and res (resident) was assisted back to her recliner. Res (resident) denies pain at this time. (Physician) and son notified of incident. 1/10/22, IDT (interdisciplinary team) review: Res (resident) was attempting self-transfer and cna (certified nurse aide) was able to assist with lowering res (resident) to floor. No injury per RN assess. Silent call light pad to recliner chair initiated to alert staff to offer assist as res (resident) is not using call light for assistance. Recent increase in confusion. (name) RN with (hospice) notified and will f/u (follow-up) with possible UA (urinalysis) or prophylactic abx (antibiotic). Msg (message) left for son (name). 1/15/22 (noted at 11:03 p.m.), Had been sitting in recliner in room. Nurse found resident sitting in front of recliner on floor with resident stating she was going to her closet to get her clothes. Body assessment done by (name) RN without apparent injury. A 2 (assisted of two) into w/c (wheelchair). Neuro's initiated . 1/17/22, IDT review: Res (resident) on floor in front of recliner, no injury per RN assess. Res states ' I was going to get clothes out of my closet. ' Res (resident) is forgetful and confused at times, believes she can walk by herself but is unable to stand indep (independent) or ambulate d/t (due to) overall weakness, continue WBAT RLE (weight bearing as tolerated on right lower extremity) and brace is in place. Nonskid strips placed in front of recliner to decrease risk of sliding. Continue current interventions. -This was the resident second time falling trying to get something without initiating her call light and asking staff for assistance. 1/24/22 (noted at 5:04 a.m.), This writer was notified by NOC (night shift) CNA that resident was observed sitting on floor on buttocks around 0240 (2:40 a.m.), this writer observed resident, next to bed, bed was in low position, call light within reach, resident had no non-skid socks on, resident was wearing brace and alarm connected to bed, alarm is what notified CNA's. Lights off in room, sitting on buttocks legs extended out in front of her. Full head to toe assessment completed, full ROM (range of motion) to all extremities brace to R (right) leg resident is limited to what she is able to do, still able to move extremity with no difficulty noted to her best ability. Probable cause; resident was trying to stand up from bed when feet slipped resident slid down to floor. Resident educated on the importance of utilizing the call light for assistance. Staff educated to make sure resident has proper footwear. Resident has no s/sx (signs/symptoms) of pain/discomfort noted. Staff assisted resident up from floor resident was able to ambulate short distance to commode and pivot to sit on commode with no difficulty. Needs anticipated and met by staff. (Physician) notified via message as well as DON (director of nursing) made aware. This writer will relay to next on coming shift nurse to notify responsible party (name). Will continue to observe and follow plan of care noting any changes as needed. 1/24/22, IDT review: Res (resident) sitting upright on floor next to bed, no injury per RN assess. Bolster cover ordered from (name) Hospice to help define edges of bed as resident has a rt (right) leg brace and will often hang it over the side of the bed. Son (name) updated and in agreement. 1/27/22 (noted at 7:06 p.m.), Resident's cna (certified nurse aide) informed me that the resident was on the floor. Upon entering residents room, resident was sitting on the floor, with her legs straight in front of her. Assessed the resident, no injuries observed, and resident does not complain of any pain. With the help of a staff member and gait belt, we assisted the resident back to bed. Residents son notified, physician notified. 1/28/22 (noted at 7:00 a.m.), This writer was walking back from East station delivering refreshments for next oncoming shift nurse around 0600 (6:00 a.m.), noted resident in hallway outside of her entrance of room, laying on floor with head propped up with pillow case filled with clothing, resident laying on left side, resident stated she bumped her head. Resident did not have non skid socks on, no shoes. RN completed a full head to toe assessment, resident has full ROM (range of motion) to all extremities with no difficulty noted. Staff assisted resident into w/c (wheelchair) utilizing gait belt. No s/sx (signs and symptoms) of pain/discomfort noted. Resident noted to have a slight bump on left side of temporal area, ice applied as resident will allow. Neuros started. (Physician) notified via message. Reported off to next on coming shift nurse. Next oncoming shift nurse will call son. Will continue to observe and follow plan of care noting any changes as needed. -The resident did not have appropriate footwear, which she had fallen previously due to not having non-skid footwear on to prevent her from falling when out of bed. 1/28/22, IDT review fall 1/27/22: Resident was sitting on the floor in her room, no injury. Per restorative aide, resident had been in bed prior to fall and told him she was reaching for the phone but the phone was right there. The call light was also within reach. Resident has poor memory and safety awareness. Increased confusion at times. Continue hospice services dx (diagnosis) [CONDITION(S)]. -There were no immediate intervention added after the 1/27/22 fall and no added interventions from the IDT until after she had an additional fall on 1/28/22. 1/28/22, IDT review fall 1/28/22: Resident on floor in the doorway of her room with her clothes in a pillow case under her head. Had been sitting in wc (wheelchair) prior. Resident was attempting to walk to the laundry to take her dirty clothes for cleaning. Small bump to left temporal area is resolved. No other injury noted per RN assess. Resident was barefoot. Educated resident that she is unable to walk safely and needs to call for staff assistance and use her w/c. Res verbalized understanding however has STM (short term memory) loss and believes she can do more physically than she actually can. Frequent rounding. Continue to monitor. -However, the facility added frequent rounding after they were aware she could not recall to use the call light for staff assistance (also indicated on previous falls, see above). -The facility failed to timely and appropriately revise Resident #39's care plan and implement interventions including required extensive assistance with all activities of daily living and ambulation to and from the bathroom as documented in the MDS assessment. -The facility failed to provide staff education and increase resident's supervision to prevent falls. -The facility failed to monitor the effectiveness of Resident #39's care planned interventions and modify the interventions. 3. Physical therapy screen 12/26/21, physical therapist documented: Patient (resident) experienced a witness fall on 12/22/21. X-ray performed and pt (patient) dx (diagnosed ) with right hip dislocation. Strict hip precautions at all times, WBAT (weight bearing as tolerated) following closed hip reduction. Discussed and educated patient and son on 12/24/21 on current restrictions .Pt (patient) currently opting for hospice services and as result further skilled intervention is not indicated at this time. -The physical therapist did not recommend a restorative nursing program or nursing staff training related to restrictions after the fall. D. Interviews The physical therapist (PT) was interviewed on 2/10/22 at 10:00 a.m. She said Resident #39 was currently under hospice care. She said the resident was at a high risk for falls due to poor safety awareness as she was leaving her four wheeled walker parked and frequently walked without an assistive device. She said the resident was independent with all activities of daily living (ADLs) until the end of December (2021). She said the resident was evaluated by a physical therapist in July 2021 after hospitalization and skilled therapy was not recommended at that time. She said the resident was screened by PT after the fall on 12/22/21, however skilled therapy was not recommended (see note above). Restorative CNA (RA) was interviewed on 2/10/22 at 11:00 a.m. He said the resident was on and off the restorative nursing program. He said Resident #39 was independent with all ADLs and frequently refused to participate in structural exercise programs (Omni Cycle, NewStep). He said after the falls in December (2021) and January (2022) a silent call pad was placed on the resident's bed to alert staff when the resident was trying to get out of bed. Licensed practical nurse (LPN #4), who was the restorative nurse, was interviewed on 2/10/22 at 11:30 a.m. She said residents ' falls were reviewed every morning (five times per week) during stand-up morning meetings with the nursing home administrator (NHA), director of nursing (DON), assistant director of nursing (ADON), unit managers, restorative nurse and therapy manager. She said Resident #39 was always independent and not aware of her physical limitations. She said the resident was not on the restorative nursing program in December (2021) or January (2022). She said Resident #39 was cognitively intact however she was not compliant with safety precautions after her fall with hip dislocation. She said the interventions after the resident's falls included non-skid strips in front of her recliner chair and silent call pad to alert staff when the resident was trying to get up. She said frequent checks on Resident #39's and staff training were not implemented. The director of nursing (DON) was interviewed 2/10/22 at 2:10 p.m. She said the resident was very impulsive and was uncooperative with safety. She said falls were reviewed during the mornings interdisciplinary team meeting and additional interventions were implemented to prevent further falls. She said staff training and frequent checks, close supervision were not implemented to prevent Resident #39 falls.

Based on observations, record review, and interviews the facility failed to ensure all drugs and biologicals were removed from use timely in one of two medication storage rooms. Specifically, the facility failed to: -Ensure expired intravenous (IV) antibiotic medications and expired tablets, cough syrup and topical cream were removed timely from a medication storage room refrigerator and storage cabinet. Findings include: I. Facility policy The Storage of Medications policy, revised November 2020, provided by the director of nursing (DON) on 2/9/22 at 1:20 p.m. read in part: The facility stores all drugs and biologicals in a safe, secure and orderly manner. -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. -Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Observations and interviews On 2/9/22 at 11:45 a.m. review of the East hall medication storage room refrigerator and storage cabinet with licensed practical nurse (LPN) #1 revealed the following expired medications: [MEDICAL RECORD OR PHYSICIAN ORDER] The refrigerator contained the following: -One 105 milliliter (ml) bag of IV [MEDICATION(S)] (antibiotic) 500 milligram (mg) that expired 1/31/22. -One 200 ml bag of IV [MEDICATION(S)] 1000 mg that expired 2/6/22. The storage cabinet contained the following: -One four ounce bottle of Ultra Tuss cough syrup that expired 10/31/21. -Five bottles that contained 14 tablets each of Omeprazole (acid reducer) 20 mg that expired 1/31/22. -Two bottles that contained 50 tablets each of Non-Aspirin sleep-aid (PM) extra strength (ES) Pain Reliever that expired 12/31/21. -Two bottles that contained 10 tablets each of [MEDICATION(S)] (lipid lowering agent) 250 mg that expired 1/31/22. -One opened foil blister pack that contained 10 tablets of [MEDICATION(S)] (decongestant)10 mg that expired 1/31/22. -Two bottles that contained 60 tablets each of Calcium 600 mg plus Vitamin D that expired 6/30/21. -Two bottles that contained 100 tablets each of Folic Acid (vitamin) 400 microgram (mcg) that expired 11/31/21. -Five bottles that contained 100 tablets each of [MEDICATION(S)] [MEDICATION(S)] (iron) 324 mg that expired 10/31/21. -One opened bottle of COQ10 (a [MEDICATION(S)] used to treat conditions affecting the heart) 50 mg that contained 30 soft gel tablets that expired 11/31/21. -A one ounce tube of Hydrocortisone (steroid) Cream 1% that expired 12/31/21. LPN #1 was interviewed on 2/9/22 at 11:50 a.m. She said it was all the nurse ' s responsibility to review the medication storage room refrigerator and cabinet to ensure no medications were expired. She said, It appears no one has gone through this medication room in quite a while. She said some of the expired medications were hardly ever used, so I don't know why they are even in there. She acknowledged the IV medications, however, were still an active order for that resident. III. DON and central supply staff interview The DON and the central supply staff member (CS) were interviewed on 2/9/22 at 12:10 p.m. The CS said she recently took over the role of CS but she and the nursing staff were responsible for reviewing the medication storage rooms and medication refrigerators routinely to ensure all expired medications were removed from use. The DON said the East hall had been used as their Covid unit quite a while back and she said that was when over the counter medications were added to the cabinet in that medication storage room. She said that the cabinet did not normally store any medications. She said the pharmacist would come to the facility monthly and she reviewed the medication carts. The pharmacy consultant was to review the medication storage rooms quarterly, but the last time she was there was 10/19/21. She said the consultant missed coming in January 2022 because the facility was in Covid-19 outbreak status and she would be due to return in April 2022. -Although the facility was in outbreak status the pharmacy consultant was not required to stay out of the building and should have made the visit in January 2022.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure food and beverages stored in the unit refrigerators were covered, labeled and dated (two of two refrigerators); -Ensure that food stored was stored in the dry pantry appropriately; and, -Remove dented cans from service. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf. It read in pertinent part, Food specified in 3-501.17(A) or (B) shall be discarded if it is in a container or package that does not bear a date or day II. Facility policy and procedure The Food Safety and Sanitation policy, revised May 2017, was provided by the medical records coordinator (MRC) on 2/9/22 at 2:20 p.m. It documented, The food service department will follow all local, state and federal standards and regulations in order to assure a safe and sanitary food service department. Any bulging or leaking cans, cans with severe dents on the seams, or broken containers are not to be used. All time and temperature control for safety (TCS) leftovers are labeled, covered, and dated when stored and should be used within 72 hours or discarded. In addition, foods with expiration dates are used prior to the use by date on the package. III. Food storage A. Observations On 2/7/22 at 9:55 a.m. the initial kitchen walk through revealed multiple food storage concerns in the refrigerator and freezers to include: -The walk in refrigerator had three trays of staff packaged condiment cups sitting on the middle shelf with no labels or dates on the cups or on the trays; -The walk in refrigerator had a silver tub of cooked bacon sitting on the middle shelf with no label or dates to identify when it was cooked or a use by date; -The walk in refrigerator had a separate silver serving cart inside, the door was ajar and a large silver serving bowl with seran wrap over contained what appeared to be a vanilla pudding, there was no label or date provided, and; -The silver serving cart inside the walk in refrigerator had a large silver sheet cake with what appeared to be a berry cake. The sheet cake did not have a covering over it and it was exposed to the elements and did not have a label or date provided. The cake appeared to be used with one quarter of the cake used. The cake was hard to the touch and was stored underneath the large silver bowl of pudding. On 2/7/22 at 9:55 a.m. the initial kitchen walk through revealed multiple food storage concerns in the walk in dry storage to include: -The walk in dry storage had three boxes stored on the floor; -The walk in dry storage middle shelf held a tray of what appeared to be serving cups of syrup packaged by the staff that was not labeled or dated. 2/8/22 observations with the dietary manager -At 11:45 a.m., the dietary manager (DM) was observed to carry a large silver bowl of pudding out of the walk-in refrigerator. The bowl continued to not have a date on the plastic wrap. -Single wrapped there were staff packaged single serving condiments in the walk-in refrigerator that were not labeled or dated and said she had her staff discard those condiments. B. Interview The DM was interviewed on 2/8/22 at 11:45 a.m. The DM said the food stored in the walk in refrigerator needed to be covered, labeled and dated when stored in the refrigerator. She said the uncovered berry cake found in the walk in refrigerator was from a previous meal, and it was discarded. The DM identified the staff-packed single serving maple syrup cups stored on the middle shelf and stated the syrup should have been dated before it was placed in the walk in dry storage pantry. IV. Dented cans A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf. It read in pertinent part, Food shall be protected from contamination, to include hermetically sealed containers, containers that are designed and intended to be secure against entry of microorganisms and, in the case of low acid canned foods, to maintain the commercial sterility of its contents after processing. The U.S. Department of Agriculture (2019) article Is is safe to use dented cans, https://ask.usda.gov/s/article/Is-it-safe-to-use-food-from-dented-cans. It read in pertinent part, If a can containing food has a small dent, but is otherwise in good shape, the food should be safe to eat. Discard deeply dented cans. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam. B. Observations On 2/7/22 at 9:55 a.m. the initial kitchen walk through revealed multiple food storage concerns in the walk in dry storage to include: -The walk in dry storage had a storage rack for large (number 10) canned goods revealed two black bean cans with large dents compromising the seams, and; -The walk in dry storage revealed a box of approximately 12 clam chowder soup cans stored on the top shelf with multiple cans damaged and dented with compromised seams, as well as the box appearing to be damaged. C. Interviews On 2/8/22 at 11:45 a.m. a second walk through and interview was conducted with the dietary manager (DM). She said the display of large canned goods held cans that were ready to use and serve. She said she inspected all the deliveries of canned goods before setting them on the serving shelf. She said if a canned item had a dent or a compromised seam she would place those cans on a designated area on the second shelf towards the back of the pantry. She said she did not return those damaged cans and would throw them away. She reviewed the cans placed on the ready to serve shelf and identified two cans of black beans and one can of corn that were damaged at the seam and should not be used. The DM said she was not sure how those three cans were overlooked and placed on the ready-to serve shelf. The DM also identified the box of damaged clam chowder soup and stated the box looked like it was dropped and the majority if not all of the 12 cans appeared to be damaged and dented with compromised seams. The DM did not move the damaged box of clam chowder to the designated discard shelf and left the box on the ready-to serve shelf. D. Facility follow-up The DM was interviewed a second time on 2/9/22 at 2:32 p.m. She said she removed the dented cans and placed them on the designated shelf for damaged cans to be discarded.

Based on observation, record review and interviews the facility failed to ensure that one (#9) of five residents reviewed, out of 27 sample residents were free from unnecessary [CONDITION(S)] medications. Specifically, the facility failed to: -Provide the resident and/or the resident's family/representative sufficient information for their understanding of the intended/actual benefit and potential risk(s) or adverse consequences associated with the prescribed multiple antidepressant medications; -Ensure target behaviors were monitored and tracked for the use of multiple antidepressant medications and to justify the need for those [CONDITION(S)] medications; -Reassess the need and provide a clinically pertinent explanation for duplicate pharmacological therapy for simultaneous use of two or more antidepressant medications; -Implement and document the use of non-pharmaceutical interventions; and, -Develop and implement a care plan specific to the resident's preferences and goals for the use of antidepressant medications. I. Facility policy The Antipsychotic Medication Use policy, revised December 2016, was provided by the nursing home administrator on 2/10/22 at 2:17 p.m., read in parts: Resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. Residents who are admitted .and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will re-evaluate the use of the antipsychotic medications at the time of admission and/or within two weeks to consider whether or not the medication can be reduced, tapered, or discontinued .The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. II. Resident #9 A. Resident status Resident #9, age 72, was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO) diagnoses included cerebral aneurysm, cerebral infarction, [CONDITION(S)] affecting left non-dominant side, acute infarction of spinal cord, [CONDITION(S)], anxiety, other specified depressive episodes, mood disorder and diabetes mellitus. The 11/8/21 minimum data set (MDS) assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score 15 out of 15. Mood interview PHQ-9 (the nine questions of patient health questionnaire objectifies degree of depression severity) score was 0/27 which indicated no depression. No rejection of care or other adverse behaviors were present. She required extensive assistance of two staff with bed mobility, transfers and dressing, extensive assistance of one person with toilet use and personal hygiene, and supervision with eating. She received daily insulin injections, scheduled pain medications (opioid), antianxiety and antidepressant medications. The 8/8/21 MDS assessment revealed BIMS score 14 out of 15. Mood interview PHQ-9 score of 1/27 indicated borderline mild depression. No rejection of care was documented. She received daily insulin injections, scheduled pain medications (opioid), antianxiety and antidepressant medications. B. Observation and interview The resident was observed in her room, in bed on 2/7/22 to 2/10/22. She was on isolation/quarantine due to a positive test for COVID-19. She was watching a program on television. She was pleasant and cooperative during the interview. The resident said she did not know anything about her prescribed medications for depression and anxiety. She said she did not remember if anyone talked to her about the side effects and risks and benefits of antidepressants she was administered daily. She said she did not understand the reason she needed to take multiple antidepressants. She said she was not a social person and did not like group activities. She said she always liked to read books however because of her stroke she had a difficult time holding a book and focusing on reading. Two new books were observed on the nightstand. She said she would enjoy it if someone could read it to her. C. Record review Care plan -Interests: (Resident) enjoys time with family, being outside, puzzle books, reading the daily chronicle, watching TV, reading and entertainment/music. (Resident) has a hx (history) of riding bikes and long walks with her dad. (Dated 11/17/21) Interventions included: Encourage family to visit by phone, window or in-person as needed/requested. Provide with a copy of visitation policy as needed. Nephew is active in visiting resident. Keeps in touch by phone. (Dated 11/17/21) Encourage (Resident ' s) nephew to bring in (Resident ' s) pet dog during in-person visits as needed/requested. (Dated 8/17/21) (Resident) has a TV in her room that she is able to manage on her own. (Dated 8/17/21) (Resident) is Catholic by faith. Provide reading material as needed/requested. Offer/assist with link to virtual Sunday Mass as requested. (Dated 11/17/21) Invite to entertainment groups as scheduled. Provide reading material as needed/requested. Provide (Resident) with independent activity material as needed/requested. Interview (Resident) on her hobbies and interests as she is adjusting to LTC (long term care) placement. (Dated 5/5/21) -Mood/Behavior/Psychosocial Issues Psychiatric diagnosis of depression and anxiety (Dated 8/24/21) Interventions included: Behavior monitoring as needed. Monitor for side effects of [CONDITION(S)] drug use if applicable. Notify SSD (social service director) of any decline in mood or behavior (Dated 8/24/21) Physician Orders The December 2021 medication administration record (MAR) revealed the following orders: -[MEDICATION(S)] SR Tablet Extended Release 12 Hour ([MEDICATION(S)] (SR)), (antidepressant, with black box alert of increased risk for [CONDITION(S)]), give 50 mg by mouth two times a day for depression, start date 9/20/21 -[MEDICATION(S)] HCl (antidepressant, antianxiety medication with black box alert of increased risk for [CONDITION(S)]), capsule 100 mg, give 1 capsule by mouth at bedtime for situational depression, start date 4/30/21, was tapered to 75 mg on 9/16/21 and to 50 mg start date10/20/21 -[MEDICATION(S)] HCl (antidepressant, with black box alert of increased risk for [CONDITION(S)]), capsule delayed release sprinkle 30 mg, give 1 capsule by mouth at bedtime for depression, start date 4/30/21 -[MEDICATION(S)] HCl capsule delayed release sprinkle 60 mg, give 1 capsule by mouth one time a day for depression, start date 5/1/21 -[MEDICATION(S)] tablet (benzodiazepine, anticonvulsant, antianxiety medication with black box alert when used with opioids may result in profound sedation, coma and death), 0.5 mg, give 1 tablet orally three times a day for anxiety, start date 5/27/21 -[MEDICATION(S)] Tablet 7.5-325 ([MEDICATION(S)]-Acetaminophen, Opioid), give 1 tablet by mouth two times a day for chronic pain, nte (not to exceed) 3 gm (grams) apap (acetaminophen) from all sources, start date 4?30/21 -The resident record failed to show documentation that the resident and/or resident's representative/guardian was provided education of the risks and benefits of the prescribed antidepressant and antianxiety medication for the specific identified symptoms the medication was prescribed to treat, prior to the resident starting on the medications ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]). -The 12/15/21 [CONDITION(S)] medication review did not contain documentation of the resident having any behaviors related to identified target behaviors or any new concerning behavioral expression. There was no assessment of behavior monitoring or a status of the behaviors for which the medication was prescribed to treat. There was no documentation of whether or not the resident was experiencing any side effects of the prescribed [CONDITION(S)] medication and there was no documentation of non-pharmaceutical interventions being needed or provided. Interdisciplinary notes -5/11/21 social worker documented: (Resident) is a [AGE] year old female at (facility) for long term care. She is a new admit from AL (assisted living facility) with the support of her family. (Resident) is a DNR (do not resuscitate) with no changes to the MOST (medical orders for scope of treatment) form after review. BIMS (brief interview for mental status) 14/15 indicating intact cognition. (Resident) is her own decision maker but will defer to her nephew (name) in cases. PHQ9 (patient health questionnaire) 3/27 indicated minimal s/sx (signs/symptoms) of depression. (Resident) does take [MEDICATION(S)] dx (diagnosis) anxiety; [MEDICATION(S)] and [MEDICATION(S)] dx (diagnosis) depression. She does have a history of trauma 6/30 on the post-traumatic checklist showing no stressors or triggers. (Resident) plans to stay LTC (long term care) at (facility) and will visit ancillary services as needed or requested. Initial CC (care conference) requested with nephew for 5/13/21. CP (care plan) reviewed. -5/26/21 a nurse noted: Res(ident) c/o (complained of) increased anxiety, nothing specific states 'It's just a feeling I have.' Breathing even/unlabored, stayed in bed this shift. [MEDICATION(S)] dose was recently decreased . -8/7/21 a nurse noted: States she doesn't want any medication changes unless it's discussed first with her stating it took 1 (one) year for the neurosurgeon and cardiac doctors to regulate it. States 'I'm usually way more cheerful than this, I feel sick to my stomach, I can't hold a thought, my head and stomach ache, I feel terrible, he (doctor) doesn't want to make me mad because I'm a (expletive).' Statements reported to inhouse (physician). -8/10/21 activities director noted: Quarterly note: Resident is here for LTC placement and has adjusted well to her new living environment. She is alert and able to make her activity needs known. Resident enjoys time with her nephew by phone or in-person. At times, he will bring her dog to visit during in-person visits. This [NAME] her up as she enjoys showing the dog off to the staff. Resident spends most of her day in her room per her choice. Activity team continues to offer attending scheduled activities, resident usually declines. Resident usually participates in social events with food and drinks being offered room to room. Spoke with resident and she has voiced no concerns with the activities being offered, she just prefers to stay in her room. Care plan reviewed. -9/19/21 Physician's Risk/Benefit Note revealed: She has a diagnosis of depression and anxiety that has been chronic and requiring many meds to manage her symptoms. She is on [MEDICATION(S)] to help manage her depression symptoms. She has benefitted from the current dosing and is high risk to decline if her dose were decreased. The benefits of the [MEDICATION(S)] outweigh the potential risks or side effects. In addition, we have initiated [MEDICATION(S)] for depression and have started a slow taper of her [MEDICATION(S)]. D. Interviews The social worker was interviewed on 2/9/22 at 10:45 a.m. She said she was not very familiar with Resident #9. She said the resident was admitted from out of state with lots of [CONDITION(S)] medications. She said the resident's medications were reviewed monthly during [CONDITION(S)] medications review meetings with the medical director, pharmacist and director of nursing present among other team members. She said she did not recall any discussions about non-pharmacological interventions implemented for Resident #9. The medical director (MD) was interviewed on 2/9/22 at 3:15 p.m. He said he was not aware the resident's behaviors during the course of her antidepressants treatment. He said the resident's behavior sheets were not reviewed during the medications review meeting. He said he was notified by nursing staff a couple times of Resident #9's increased anxiety however he did not know that was related to a room and roommate change. He said no discussions were initiated about non-pharmacological interventions during [CONDITION(S)] medication review meetings. He said the resident would definitely benefit from one on one activities. He said he will consider requesting psychologist's counseling services for Resident #9. The activities director (AD) was interviewed on 2/9/22 at 4:00 p.m. She said Resident #9 did not like to participate in group activities and did not like to leave her room. She said the activities staff provided the resident with an activities calendar every month and invited her to group activities. She said there was no documentation in the resident's record of her participation in activities. She said she was not aware the resident likes reading books. She said one-on-one visits should be offered to the resident at least three times per week. The restorative aide (RA) was interviewed on 2/10/22 at 11:10 a.m. He said Resident #9 was removed from the restorative nursing program (RNP) about two weeks ago. He said the resident was resistant to participate and did not want to get out of bed. He said the resident did not participate in RNP for at least two months. The director of nursing (DON) was interviewed on 2/10/22 at 2:16 p.m. She said she was not aware there were no behavior monitoring documentation in Resident #9's medical record for several months until August (2021). She said the behavior monitoring records should be reviewed during the [CONDITION(S)] medication review. She said the non-pharmacological interventions must be attempted and documented instead of using [CONDITION(S)] medications and with use of [CONDITION(S)] medications. E. Facility follow-up Care plan update (Resident) has been placed on a 1:1 (one-on-one) program 3x (three times) a week to provide extra social support from the activity team as interest allows. (Dated 2/9/22)

Based on observations, record review and interviews the facility failed to ensure safe medication storage in two out of two medication storage refrigerators. Specifically, the facility failed to: -Store medications in a non-dormitory style refrigerator; -Store insulin and [MEDICATION NAME] purified protein derivative (PPD) at proper temperatures to preserve integrity; and, -Ensure food and medications were not stored together. Findings include: I. Facility policy and procedure The Storage of Medication policy, revised April 2007, was provided by the medical records director (MRD) on 2/15/01 at 1:18 p.m. It read in pertinent part:medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. II. Professional reference According to the Centers for Disease and Control and Prevention (CDC) Vaccine Storage and handling (February 2021) retrieved 2/16/21 from: https.//www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. Do not store any vaccine in a dormitory style or bar-style combined refrigerator/ freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an ice maker/freezer compartment. These units have been shown to pose a significant risk of freezing vaccines, even when used for temporary storage. All staff members who receive deliveries and/or handle or administer vaccines should be familiar with storage and handling policies and procedures at your facility. Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease. According to the FDA ( Food and Drug Administration) (2017), retrieved 2/16/21 from: https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency. Insulin loses some effectiveness when exposed to extreme temperatures. The longer the exposure to extreme temperatures, the less effective the insulin becomes. You should try to keep insulin as cool as possible. If using ice, avoid freezing the insulin. Do not use insulin that has been frozen. According to the FDA [MEDICATION NAME] package insert, retrieved 2/16/21 from: https://www.fda.gov/media/ /download#:~:text=Store%20at%202%C2%B0%20to,product%20if%20exposed%20to%20freezing.&text=A%20vial%20of%[MEDICATION NAME]%20which,30%20days%20should%20be%20discarded. Turbesol should be stored at 35 to 46 degrees. Do not freeze. Discard product if exposed to freezing. III. Observations and interviews East station medication refrigerator On 2/15/21 at 11:28 a.m. the East medication refrigerator was inspected with the director of nursing (DON). The refrigerator was located on a counter behind the nurses station. The refrigerator was a small dormitory size refrigerator with a freezer located at the top inside the refrigerated section. One vial of Insulin and two vials of Turbesol were located in the top shelf of the door. The top shelf of the door was against the freezer when the door was closed. The DON said the [MEDICATION NAME] package read: do not freeze so it should not have been stored on the top shelf of the door next to the freezer. She said if the medication became frozen it would not be as effective. West station medication refrigerator On 2/15/21 at 11:40 a.m. the West medication refrigerator was inspected with the DON. The refrigerator was located on a counter behind the nurses station. The refrigerator was a small dormitory size refrigerator with a freezer located at the top inside the refrigerated section. Five vials of Insulin were located in the top shelf of the door. The top shelf of the door was against the freezer when the door was closed. In the bottom of the refrigerator, there were two chocolate supplement shakes, seven Ensure supplement and four cartons of fortified shakes. The DON immediately removed the food items from the refrigerator. The small freezer was over filled with ice packs which the DON threw away as well. The DON said nourishments should not be stored with medications. She said she was not aware that dormitory style refrigerators should not be used to store medications and she would order new refrigerators immediately. The nursing home administrator (NHA) was interviewed on 2/15/21 at 12:12 p.m. She said if a medication was not supposed to be frozen but was, the medication would not be as effective and should not be used. She said the medication should be destroyed and new vials ordered. She said no food items should be stored with medications in the medication refrigerators. She said they would order new medication refrigerators immediately. IV. Facility follow-up New medication refrigerators were ordered for both nurses stations and the medication that was in the refrigerators were destroyed and new medication was ordered.

Based on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility kitchens. Specifically, the facility failed to follow accepted food service industry standards to minimize the risk of foodborne illness and ensure: -Staff followed accepted hand hygiene practices during the meal service; -Appropriate use of gloves when handling ready-to-eat foods; -Cleanliness of bread storage rack; -Potential cross-contamination of food and food contact surfaces was prevented; -potential contamination was prevented of pans and pots stored on the dry rack from the dietary staff clothing and personal items. Findings include: I. Professional reference The Colorado Retail Food Establishment Rules and Regulations (CRFERR), revised January 2019, read in pertinent part, .Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and before handling or putting on single-use gloves for working with food, and between removing soiled gloves and putting on clean gloves . According to the CRFERR (effective January 1, 2019) page 72, Food shall only contact surfaces that are clean .and sanitized . The Food and Drug Administration (FDA) Food Code (2019) pp. 47-48, detailed the following instances when foodservice staff should wash their hands: -Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service articles and single-use articles; -After touching bare human body parts other than clean hands and clean, exposed portions of arms; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -When switching between working with raw food and working with ready-to-eat food; -Before donning gloves to initiate a task that involves working with food; and -After engaging in other activities that contaminate the hands. - According to the Food Code 2017, Recommendations of the United States Public Health Service Food and Drug Administration, page 24, A utensil was defined as a food contact implement or container used in the storage, preparation, transportation, dispensing, sale, or service of food, such as kitchenware or single-use gloves used in contact with food. -According to the Food Code 2017, Recommendations of the United States Public Health Service Food and Drug Administration, page 149, Non-food contact surfaces of equipment should be kept free of dirt, food residue and other debris. Food contact surfaces should be clean to sight and touch. -The FDA Food Code (2017) p.11, defines a highly susceptible population (HSP) as: Persons who are more likely than other people in the general population to experience foodborne disease because they are .immunocompromised or older adults .or persons who obtain food at a facility that provides services such as custodial care, health care, or assisted living .such as a nursing home. II. Observations On 2/8/2021 at 10:30 a.m. a bread storing rack was observed in the dry food storage room. All shelves were discolored and covered with dark black sticky substance. On 2/8/2021 the lunch meal was observed continuously from 11:00 a.m. to 12:10 p.m. Cook #1 was observed on the trayline serving the meal. She was observed touching multiple surfaces with her gloved hands including the eating surface of plates, serving utensils, and the resident's diet cards. Cook #2 touched the garlic bread, a ready-to-eat food, when serving it with the main entree. She made alternative entrees based on resident requests like cold sandwiches, grilled cheese sandwiches, burritos and hamburgers and did not change gloves or wash hands when touching bread slices, bun, cheese and tortilla. The hairnet did not cover all her hair and her bangs were above the food she served at all times. On 2/10/2021 the lunch meal was observed continuously from 11:10 a.m. to 11:50 a.m. Cook #2 was observed on the trayline serving the meal. She was observed touching multiple surfaces with her gloved hands including the eating surface of plates, serving utensils, and the resident's diet cards. She pulled two slices of bread from a plastic bag, placed on the grill, went to a metal cabinet, opened the drawer and pulled a spatula. With the same gloved hand she pulled a slice of cheese from a bag and placed on one bread slice. Then she used the spatula to place the other slice of bread on the top of the cheese and placed the grilled cheese sandwich on the plate. She did not change gloves or wash hands. The kitchen food prep area was observed on 2/15/2021 between 11:25 a.m. and 12:00 p.m. Cook #3 was observed cutting/chopping green bell peppers and onions preparing white bean chicken chili for residents ' supper. She was wearing a pair of single-use gloves. She scooped the chopped peppers and onions into a pan. She read the recipe and touched the paper and pen. She touched her shirt and pants. She opened two large cans of white beans and corn with a can opener and poured them into the pan. Without changing her gloves and washing her hands she poured all of the ingredients into a larger pan, added water, covered with aluminum foil and put it into the oven. On 2/15/2021 at 12:00 p.m. a winter coat was hung on a metal rack next to the food prep area. There were several clean pots and pans stored on the shelves of the rack for air drying. The coat was touching some of the clean pans. Below the coat was a backpack sitting on the lid of a trash can. Cook #2 said the coat and the backpack belonged to her. The dietary manager (DM) was interviewed on 2/15/2021 at 12:07 p.m. She said the dietary staff cannot touch ready-to-eat foods and utensils wearing the same pair of gloves. She said the cooks should change gloves and wash their hands between glove changes every time they have contact with non-food surfaces before they touch read-to-eat food items. The DM said the hairnet must cover all of the staff hair in the kitchen area. She said the cooks should use separate utensils for all the food items to prevent cross-contamination. DM said the dietary staff should not touch the eating surface of plates with their fingers. She said there was an area outside the kitchen for the dietary staff to leave their coats, jackets, backpacks and other personal belongings and they can not use the pans and pots storage rack as a coat hanger. She said she will provide additional training to all of the dietary staff to address cross-contamination and hand hygiene. The nursing home administrator (NHA) was interviewed on 2/15/2021 at 2:00 p.m. She said she was made aware by the DM of the above findings in the kitchen area. She said the dietary staff will be re-educated on infection control and prevention. She said she ordered several aprons for the dietary staff to wear it while working to cover their street clothes.

Based on observations, record review and interviews, the facility failed to ensure two (#25 and #39) residents out of three who required respiratory care received the care consistent with professional standards of practice, out of 25 sample residents. Specifically, the facility failed to: -Ensure physician orders [REDACTED]. -Follow manufacturer recommendations to maintain, clean and sanitize the residents ' Continuous Positive Airway Pressure ([MEDICAL CONDITION]) non-invasive ventilation equipment; -Accurately complete section O in residents comprehensive minimum data set (MDS) assessments under respiratory treatments; and, -Review and revise the residents' care plan and to include cleaning, disinfection and storage of [MEDICAL CONDITION] machines. Findings include: I. Facility policies and procedures The [MEDICAL CONDITION]/[MEDICAL CONDITION] (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) Support, undated, was provided by the medical records director on 2/15/2021 at 1:18 p.m. The policy revealed, in parts: Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a [MEDICAL CONDITION] mask .Document the following in the resident's medical record: time [MEDICAL CONDITION] was started and duration of the therapy; mode and settings; oxygen concentration and flow; oxygen saturation during therapy, and notify the physician if the resident refuses the procedure. The policy specified the cleaning process for the filter and tubing. The policy did not address the cleaning and disinfection process of the [MEDICAL CONDITION] mask. II. Manufacturer recommendations According to https://www.[MEDICAL CONDITION].com/, January 7, 2021, retrieved on 2/15/2021, in part: From illnesses such as colds, infections, the flu, and COVID-19, proper [MEDICAL CONDITION] cleaning techniques can help reduce the likelihood of you getting sick while ensuring you breathe cleaner air. Keeping your [MEDICAL CONDITION] machine, mask, and supplies clean is an essential part of your health, wellness, and the longevity of your [MEDICAL CONDITION] equipment . For nasal pillow mask wearers, the problem is especially difficult. Nasal pillows seal around your nostrils, which harbor bacteria from your sinuses during a cold. Due to the nasal pillows ' proximity to your nose, the germs from your mask have a direct path to making you feel sick again. Without proper [MEDICAL CONDITION] cleaning, you breathe in germs while wearing your mask, which makes good hygiene especially important during cold and flu season. According to https://www.resmed.com/en-us/sleep-apnea/[MEDICAL CONDITION]-parts-support/cleaning-[MEDICAL CONDITION]-equipment/, retrieved on 2/15/2021, in parts: Daily cleaning: in a sink or tub, clean your mask cushion and headgear to remove any oils. Gently rub with soap and warm, drinking-quality water. Avoid using stronger cleaning products, including dish detergents, as they may damage the mask or leave harmful residue. Rinse again thoroughly with warm, drinking-quality water. Place the cushion and frame on a flat surface, on top of a towel, to dry. Avoid placing them in direct sunlight. III. Facility Assessment Tool The Facility Assessment Tool was provided by the nursing home administrator (NHA) on 2/10/2021 at 2:00 p.m. Under Special Treatments and Conditions was documented three residents received [MEDICAL CONDITION]/[MEDICAL CONDITION] respiratory treatments. IV. Residents #25 A. Resident status Resident #25, age 59, was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The 12/10/2020 minimum data set (MDS) assessment revealed the resident's cognition was intact with the brief interview for mental status (BIMS) score 15 out of 15. He had no impairment in range of motion (ROM) in upper and lower extremities. He required oxygen therapy. The use of [MEDICAL CONDITION]/[MEDICAL CONDITION] was not marked/coded in MDS section O. Further review of the comprehensive MDS assessment revealed the use of [MEDICAL CONDITION]/[MEDICAL CONDITION] was not coded in following assessments: 3/19/2020; 6/19/2020; 9/19/2020; 11/20/2020; and, 12/7/2020. B. Observations and resident interview Resident #25 was observed on 2/8/2021 at 1:30 p.m. He was in his room sleeping in his bed. The [MEDICAL CONDITION] machine was on the nightstand next to the bed. The [MEDICAL CONDITION] mask and tubing was laying over the [MEDICAL CONDITION] machine. Resident #25 was interviewed on 2/9/2021 at 11:00 a.m. He said he was using the [MEDICAL CONDITION] most of the nights. He said usually a certified nurse aide (CNA) was helping to put the mask on his face and turned the machine on. He said he takes the mask off early in the morning when he wakes up. He said a few months ago the staff was cleaning the mask, tubing and machine but no one does it now. He said the mask and the tubing were always placed on top of the machine, not covered or stored in a plastic bag. The mask and tubing were observed on top of the machine. The mask had oily grayish discoloration with skin residuals around the cushion. On 2/10/2021 at 10:00 a.m. the resident said I told the nurses that you were concerned about my [MEDICAL CONDITION] not being cleaned and they did it this morning. The tubing and the mask were stored in a plastic bag attached to the [MEDICAL CONDITION] machine after the facility had been notified during survey. C. Record review 1.Computerized physician orders [REDACTED].>The January 2021 CPO documented: Oxygen via n/c (nasal cannula) continuously for [MEDICAL CONDITION] at 4 L/min (four liters per minute). Ensure the humidifier is in place and filled with water. The CPO did not include a [MEDICAL CONDITION] treatment. The February 2021 CPO was reviewed on 2/8/2021 and documented: Oxygen via n/c (nasal cannula) continuously for [MEDICAL CONDITION] at 4 L/min (four liters per minute). Ensure the humidifier is in place and filled with water. The CPO did not include a [MEDICAL CONDITION] treatment. 2. Physician notes -2/13/21: O2 remains stable at 8L/min; using [MEDICAL CONDITION] most night . -1/17/21: Visit completed via video with his personal phone; doing well; no complaints; no changes; O2 remains stable at 7L/min; reports using [MEDICAL CONDITION] most nights . -12/21/2020: Doing well; no complaints; no changes; O2 remains stable at 7L/min; reports using [MEDICAL CONDITION] each night except not last night . O2 @ 7L/min (baseline is 5L/min) .[MEDICAL CONDITION] qHS and when sleeping . -11/17/2020: Returned from the hospital yesterday due to COVID-19 infection and acute on chronic hypoxic resp (respiratory) failure; he reports he was on 13L/min O2 (13 liters per minute oxygen) for one night but has now returned to his baseline of 4L/min . using [MEDICAL CONDITION] with supplemental O2 . 3. Nursing notes -2/11/21: [MEDICAL CONDITION]: auto settings with 4L O2, apply at night when sleeping or when napping. -12/23/20: Res (resident) also continue to refuse to wear his [MEDICAL CONDITION] . -12/22/2020: Resident awake till 0400 (4:00 a.m.) Refused to use his c-pap ([MEDICAL CONDITION]). Encouraged x 2 still refused. -11/23/2020: Resting quietly at this time. [MEDICAL CONDITIONS] in place. Denies SOB (shortness of breath) or cough. 4. Medication administration record/treatment administration record (MAR/TAR) The January 2021and February 2021 MAR/TAR were reviewed on 2/8/2021 and revealed: Oxygen via n/c continuously for [MEDICAL CONDITION] at 4L/min. Ensure the humidifier is in place and filled with water, every shift. Order date 1/13/2021 The above MAR/TAR did not include a [MEDICAL CONDITION] treatment. 5. Care plan -(Resident's name) has Oxygen Therapy r/t [MEDICAL CONDITION] (related to [MEDICAL CONDITION]), [MEDICAL CONDITIONS], OSA (obstructive sleep apnea), chronic resp (respiratory) failure, and chronic cor pulmonale. Has auto [MEDICAL CONDITION] at night which resident refuses at times but is independent with using. Date initiated was 3/15/2017 with the last revision on 9/19/2018. Interventions included: Oxygen at 2 LPM (two liters per minute) via NC (nasal cannula) or, encourage him to use [MEDICAL CONDITION] at HS (hours of sleep), he is independent with using (3/15/17). Remind/assist as needed with auto [MEDICAL CONDITION] at night. Date initiated: 9/19/2018 with last revision on 5/15/2020. -The resident's care plan was not updated/revised in a timely manner. -The approaches were not revised after resident's readmission from a hospital on [DATE] (see physician orders [REDACTED]. -The care plan did not include cleaning, disinfection and storage of the [MEDICAL CONDITION] machine, tubing and mask. V. Facility follow-up during survey after being informed Resident #25 CPO and MAR/TAR were reviewed on 2/15/2021 at 9:30 a.m. The February 2021 CPO included: -[MEDICAL CONDITION]: auto settings with 4L O2, apply at night when sleeping or when napping. Order date 2/9/2021 -Oxygen [MEDICAL CONDITION] Tubing: Replace every 3 months. Order date 2/15/2021 -Wash [MEDICAL CONDITION] mask with soapy water and rinse every day shift. Order date 2/10/2021 The February 2021MAR/TAR included: -[MEDICAL CONDITION]: auto settings with 4L O2, apply at night when sleeping or when napping, every shift. Order date 2/09/2021. The first check mark was on 2/9/2021 -Oxygen [MEDICAL CONDITION] Tubing: Replace every 3 months, every day shift every 30 day(s). Order Date: 2/9/2021 -Wash [MEDICAL CONDITION] mask with soapy water and rinse every day shift. Order date 2/09/2021. The first check mark was on 2/10/2021. VI. Resident #39 A. Resident status Resident #39, age 74 was admitted on [DATE]. According to the CPO, [DIAGNOSES REDACTED]. The 12/26/2020 MDS assessment revealed the resident's cognition was intact with the brief interview for mental status (BIMS) score 15 out of 15 She had no impairment in range of motion (ROM) in upper and lower extremities. She required oxygen therapy. The use of [MEDICAL CONDITION]/[MEDICAL CONDITION] was not marked/coded in MDS section O. Further review of the comprehensive MDS assessment revealed the use of [MEDICAL CONDITION]/[MEDICAL CONDITION] was not coded in the 9/25/2020 assessment, however was coded in the 6/25/2020 admission assessment. B. Observations and resident interview Resident #39 was observed on 2/8/2021 at 2:10 p.m. She was in her room sleeping. The [MEDICAL CONDITION] machine was on the nightstand next to the bed. The [MEDICAL CONDITION] mask and tubing was laying over the [MEDICAL CONDITION] machine. Resident #39 was interviewed on 2/9/2021 at approximately 10:50 a.m. She said she was not using the [MEDICAL CONDITION] too often recently because it was very uncomfortable for her. She said she did not remember the last time staff cleaned the mask and tubing. She said the mask and the tubing were always placed on top of the machine, not covered or stored in a plastic bag. The mask and tubing were observed on top of the machine. C. Record review 1 Computerized Physician order [REDACTED].>The February 2021 CPO documented: -Oxygen via humidifier at 2 LPM (two liters per minute) via nasal cannula continuously for [MEDICAL CONDITION]. Order date was 12/3/2020. -Resume [MEDICAL CONDITION] with previous settings via supplemental O2 (oxygen) at 2L/min. Use at bedtime for OSA (obstructive sleep apnea). Order date was 8/5/2020. 2. MAR/TAR The December 2020 and January 2020 TAR documented: -Assist Pt (patient) with applying [MEDICAL CONDITION] at NOC (night). Order date was 6/17/2020. -Resume [MEDICAL CONDITION] with previous settings with supplemental O2 @ 2L/min; use at bedtime. Order date was 8/5/2020. Resident refused the treatment 11 times. Oxygen saturations were documented on the nights the resident used [MEDICAL CONDITION]. -Oxygen with humidifier @2LPM via nasal cannula continuously for [MEDICAL CONDITION] every shift. Order date was 12/3/2020. -The MAR/TAR did not include cleaning and disinfection of the mask and tubing. 3. Care Plan -(Resident's name) has shortness of breath/history of decreased oxygen saturation and uses supplemental oxygen as needed via nasal cannula and a [MEDICAL CONDITION] at night, due to Obesity Date initiated: 6/17/2020 and revised 7/10/2020. Interventions included: Administer oxygen as ordered by physician. Check pulse oximetry as ordered. -Inadequate or compromised respiratory function AEB Sleep Apnea. Date initiated: 6/17/2020 and revised 7/10/2020. Interventions included: Monitor for signs/symptoms of respiratory problems such as: Anxiety, dyspnea, discolored nail beds, discoloring around eyes and/or mouth, cyanosis, change in mental status, fatigue, SOB (shortness of breath), rapid/shallow respirations, cough, restless/anxious behaviors, abnormal breath sounds. Assist with [MEDICAL CONDITION] at night. -The care plan did not include cleaning, disinfection and storage of the [MEDICAL CONDITION] machine, tubing and mask. D. Facility follow-up during survey after being informed Resident #39 CPO and MAR/TAR were reviewed on 2/15/2021 at 9:30 a.m. The February 2021 CPO included: Cleanse [MEDICAL CONDITION] mask with soapy water and rinse, every day shift. Order date was 2/10/2021. VII. Staff interviews Licensed practical nurse (LPN#1) was interviewed on 2/9/2021 at 1:30 p.m. She said she was not aware the residents ' [MEDICAL CONDITION] machine, mask and tubing should be cleaned daily after the treatment and stored properly. The NHA and the director of nursing (DON) were interviewed on 2/15/2020. They agree the residents ' [MEDICAL CONDITION] mask and tubing should be cleaned daily and stored appropriately. The NHA said the facility corrected the deficient practice immediately when it was brought to the nursing staff attention during survey. She said the [MEDICAL CONDITION] masks and tubing will be cleaned on a daily basis and stored in plastic bags attached to the machine.

Based on observation, record review and staff interviews, the facility failed to ensure that two of 40 sample residents (#114 and #77) received appropriate care and monitoring of their pressure ulcers. Specifically: Resident #114 entered the facility with two pressure ulcers. The facility failed to accurately monitor and manage the resident #114's pressure ulcers and there was evidence that one of the ulcers had worsened. Resident #77, who entered the facility at risk due to recent [MEDICAL CONDITION] and dependence, developed pressure ulcers on both heels after admission. The ulcers were not adequately monitored. Findings include: A. Resident #114 1. Resident #114, age 66, who had numerous facility admissions, was most recently readmitted on [DATE] from the hospital. According to her computerized physician orders, she was admitted with [DIAGNOSES REDACTED]. Review of her most recent Minimum Data Set (MDS) documented that the resident required the extensive assistance of two staff for transfers, dressing, bathing, personal hygiene and toileting. She was able to participate in limited personal care (washing her face and combing her hair). 2. Presence of Pressure Ulcers - Facility Response On 10/3/12 a wound care consult was obtained while the resident was hospitalized . It read, in pertinent part, "66 y.o. female with a Stage IV coccygeal PS (pressure ulcer) and unstageable right lateral ankle wound and a left heel wound (Stage III)...Has had an ORIF (open reduction, internal fixation) of right hip and ankle March 2012...She has had + cultures for rare bacteroides fragilis as well [MEDICAL CONDITION]. She has also had + culture for a rare [MEDICAL CONDITION], pseudomonas and e. coli in right ankle..." Review of the resident's admission nursing assessment 10/23/12 revealed the resident was admitted with a stage IV ulcer to her coccyx, a stage III ulcer to her left heel and a healing surgical wound on her left ankle. On 1/7/13 at 4:00 p.m., the Director of Nurses (DON) was interviewed about the resident's wounds. -She stated that when readmitted on [DATE], the resident's "left heel was healed and was just a scab." -However, review of the resident's orders revealed the facility had an order dated 10/23/12 to "use skin prep to bilateral heels "mushy" and Left heel ulcer." This order was not discontinued until 11/25/12. Moreover, review of the resident's Treatment Administration Records (TARs) documented the nurses continued to provide the care for the left heel ulcer throughout October, November, December and January. Record review during survey (1/2/13 to 1/9/13) revealed no care plan addressing the resident's pressure ulcer care. However, following survey, the DON faxed an undated "Impaired Skin Integrity" care plan. Review of the care plan revealed it read, in pertinent part: -Problem: Pressure Ulcer, Stage IV to coccyx -Goal: Encourage healing -Interventions: encourage resident to reposition and offload as possible; follow current physician orders for wound care; monitor and document all changes weekly; keep physician and family informed of her progress or lack thereof. -The care plan also showed a stage III ulcer to left heel that was noted as healed 11/25/12. 3. Observations and Documentation of Coccyx Ulcer 1/8/13 and 1/9/13 - Evidence of Worsening Observations 1/8/13: On 1/8/13 at approximately 1:30 p.m., resident #114 was observed during a dressing change by a nurse surveyor. A staff licensed practice nurse (LPN) did the dressing change, although she did not measure the wound. (Per the LPN, the DON, who was wound care certified, did measurements.) The [MEDICATION NAME] dressing, dated 1/3/13, was removed and the wound bed was observed. The wound was approximately 1 cm x 1 cm. Odorous serosanguinous drainage poured from the wound when the old dressing was removed. The wound appeared to have tunneling. A new dressing was applied and dated. During the dressing change the facility staff nurse stated that the wound looked like it was tunneling. The nurse also stated that the dressing that was ordered was not appropriate for such a large wound. Observations 1/9/13: On 1/9/13, the DON conducted a coccyx dressing change at the surveyor's request for wound measurements while in the presence of the resident's physician and nurse surveyor (and another surveyor to document measurement/description). The dressing was removed and the ulcer measured by DON. The DON and nurse surveyor confirmed the presence of the following: Foul odor, serous purulent, thick drainage and tissue granulation. Measurements were: -Depth -.4 cm -Length - 1.4 cm -Width - 1.3 cm Record Review: Review of weekly pressure ulcer report revealed the previous measurements, taken on 1/3/13 were as follows. At that time, measurements were: -Depth - .2 cm -Length -.9 cm -Width - .7 cm Using the National Pressure Ulcer Advisory Panel (NPUAP) www.npuap.org, formula multiplying the length of the wound by the depth to arrive at a surface measurement (sq cm - square centimeter), there was an increase of 1.19 square centimeters between the previous measurement on 1/3/13 (.62 sq cm) and measurement on 1/9/13 (1.82 sq cm) documented and confirmed by the DON. The wound had worsened since 1/3/13. The DON acknowledged, based on measurement, the wound had increased in size from the previous observation on 1/3/13. 4. Failures in Facility Response in Monitoring and Managing the Resident's Pressure Ulcers a. Failure to follow physician orders for coccyx ulcer On 1/3/13 a new Telephone Order (T.O.) was received. It read, "Cleanse wound to coccyx with wound cleanser, cover with [MEDICATION NAME] dressing. Change (every) third day and PRN (as necessary)." On 1/8/13 at approximately 1:30 p.m., resident #114 was observed during a dressing change by a nurse surveyor. The dressing was dated 1/3/13, 5 days earlier. According to the TO above, the dressing should have been changed on 1/6/13. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The DON, interviewed on 1/8/13 at approximately 3:30 p.m., stated she had interviewed the nurse on duty who had signed off the treatment as being completed 1/6/13. The DON stated the nurse was new and had signed it off in advance and then did not get to it. The resident stated during the dressing change 1/8/13 (see above) that when she was in the facility in another room, the nurses changed the dressing whenever they got around to it. When asked for clarification the resident stated that the facility nurses sometimes waited four or five days to change the coccyx wound dressing. b. Failure to follow proper infection control practices During the coccyx pressure ulcer observation on 1/9/13, a break in infection control was observed. Specifically: The DON was observed to measure the coccyx wound using a "MediRule Wound Care Measuring Device," a sheer plastic measuring tool with concentric increments printed on the tool that is laid on top of the wound to measure length and width. After measuring the coccyx ulcer once, the DON laid the tool on top of the dirty dressing she had removed and that had wound drainage on it. She then reused the dirty tool to measure the ulcer again. The measuring tool is disposable and not meant to be placed on a wound more than once. c. Inconsistent Documentation Monitoring the Resident's Pressure Ulcer Status Review of the resident's Weekly Pressure Ulcer Reports showed that the resident's pressure ulcers were not being documented every seven days on the form. Specifically: Review of the "Weekly Pressure Ulcer BWAT Report" showed documentation of the presence of the resident's pressure ulcers (coccyx and left heel) on the following dates: 11/8/12, 11/23/12 (14 days later), 11/30/12, 12/14/12 (14 days later), 12/20/12, 12/24/12, 1/3/13 (10 days later) and 1/9/13. On 1/7/13 at approximately 1:30 p.m., the DON provided copies of Resident Progress Notes that provided additional documentation. She confirmed that a person would have to go from the Weekly Pressure Ulcer Report form (when there were missing weekly measurements) to the Resident Progress Notes to find wound measurements. -The DON also provided a redacted copy of her monthly "Pressure Ulcer Log." Review of the DON's "Pressure Ulcer Log" showed documentation of the presence of the resident's pressure ulcers (coccyx and left heel) on the following dates: 10/26/12, 11/2/12, 11/8/12, 11/23/12, 11/30/12, 12/7/12, 12/14/12, 12/20/12, 12/28/12 and 1/3/13. -The DON said her "Pressure Ulcer Log" was not available to physicians or nursing staff and which was stored on her computer. She said this was a personal tool to document and to oversee all pressure ulcers in the building. This information was not part of the resident record. On 1/9/13 at approximately 11:15 a.m., the DON provided another form they used titled "Daily Monitoring/Pressure Ulcers" for the month of January 2013. It was provided to demonstrate that staff monitored the wound daily. However, on 1/9/13, the form for the coccyx ulcer showed only two entries for January - 1/3/13 and 1/5/13. Seven other opportunities in the month of January were not documented. d. Failure to monitor continued need for antibiotic treatment Review of the resident's record revealed that on 12/29/12, the facility called the physician on call for the resident's care to report white drainage from the resident's coccyx wound. The physician ordered [MEDICATION NAME] (an antibiotic) 300 mg P.O. bid x 10 days. On 1/3/13 the lab faxed initial report stating no culture and sensitivity was indicated as the results were negative for infection. However, as of 1/9/13 (during survey), the resident continued to receive [MEDICATION NAME] for the coccyx wound. While the resident's physician on 1/7/13 at approximately 2:30 p.m. stated the [MEDICATION NAME] should 'not necessarily' have been discontinued 1/3/13, there was no evidence in the resident's record that the facility notified the physician of the report or discussed the report and continued need for the antibiotic with the physician. 5. Facility Follow-up After survey exit on 1/9/13, the DON faxed information not previously provided which was from prior admissions, not the most recent admission on 10/23/12 that was reviewed during survey. The DON also provided her documentation of the wound observation made on 1/9/13 in the presence of the DON, the physician/Medical Director, and a nurse surveyor. While she documented the same measurements she did not document the foul odor observed during the 1/9/13 observation. Specifically, under the data collection portion if their "Weekly Pressure Ulcer BWAT (wound assessment tool) Report", question #7 (Exudate type) revealed the DON documented the drainage as a 5 (purulent; thin or thick; opaque, tan or yellow). However, the drainage was confirmed by all parties to the observation to be thick, purulent, opaque and with a foul odor which would have scored it as a 6 (Foul purulent; thick/opaque; yellow/green with odor). B. Resident #77 1. Resident #77 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment, dated 12/6/12, indicated the resident required extensive to total assistance for all activities of daily living (ADLs). No pressure ulcers or other skin issues were identified. 2. Pressure Ulcer Risk See above [DIAGNOSES REDACTED]. The resident's Impaired Skin Integrity Potential care plan, dated 12/6/12, identified the resident was "at risk for impaired skin integrity." One of the Approaches listed on the care plan included: "Visualize skin during cares and bathing. Report abnormal skin conditions to nurse if noted." 3. Development of Pressure Ulcers A nurse's note written on 12/23/12 read, "Quarter-size black areas to bilateral heels - skin prep applied and floating heels in bed." Review of the resident's record revealed an order on 12/23/12 to "float heels while in bed and skin prep q (every) shift for pressure areas." 4. Facility Failure to Timely Assess and Monitor Pressure Ulcers Record review revealed there were no other nurses' notes in the record referencing the ulcers until 1/1/12, 10 days later, when there was a new order for soft boots to be worn in bed. Body Check Worksheets, to be completed at the time of bathing, instructed CNAs to "mark the location of each skin condition/wound/skin tear on the illustration below." Body check worksheets from 12/20/12 through 12/27/12, completed by certified nurse aides (CNAs) during the resident's bathing days (Mondays and Thursdays) between 12/20/12 and 12/27/12, did not include any reference to the resident's two heel wounds. On the worksheet, dated 12/27/12, a CNA wrote, "Skin ok." The first assessment of the "pressure areas" was done on 1/3/13, 12 days after the heel wounds were first identified. This assessment, entitled "Weekly Pressure Ulcer BWAT Report," was completed by the director of nursing (DON), who also served as the facility's wound care nurse. The DON documented that the pressure areas on both heels were staged as deep tissue injuries. The size of the left heel wound was 3.0 cm x 4.0 cm, and the size of the right heel wound was 1.5 cm x 1.3 cm. The resident's Skin care plan was updated, on 1/3/12, to include "unstageable wound to R and L heels." 5. Interview On 1/3/13 at 5:30 p.m., the DON was interviewed. -When asked about the facility's protocol for assessing wounds, the DON reported that wounds were to be evaluated on a weekly basis. The DON stated she was first notified about the resident's heel wounds on 1/1/13, when she returned from vacation. The DON explained that the 12-day delay in assessing the resident's new heel wounds was due to not having other nurses in the facility who were trained to do comprehensive assessments of wounds. -The DON further verbalized that CNAs played an important role in looking at residents' skin during the scheduled bathing times and communicating any concerns to the nurses. The DON said the progress of the wounds was supposed to be monitored daily by the nursing staff when they were identified, but that was not started until 1/3/13. 6. Facility Policy According to the facility's Pressure Ulcer/Non-Pressure Ulcer Assessment policy, dated 8/31/12, "Pressure ulcer/non-pressure ulcer assessment is completed at least weekly to determine the progress of healing, the presence of possible complications, the presence of pain, and the status of the area surrounding the ulcer...Monitor daily progress of the pressure ulcer/non pressure ulcer toward healing and for potential complications..."