Every finding on record at Capitol Lakes Health Center

Based on interview and record review, the facility failed to honor a resident's advanced directive of choosing to have basic life support measures provided including cardiopulmonary resuscitation (CPR) for 1 of 1 resident (R34) reviewed during a closed record review. R34, whose advanced directive indicated he chose to have basic life support performed in the event of an emergency situation, was found unresponsive by facility staff. R34's activated health care power of attorney (HCPOA) was contacted, stated he did not wish CPR to begin, and facility staff members were instructed not to begin CPR on R34. R34 passed away at the facility. The facility's failure to provide basic life support, including cardiopulmonary resuscitation, to a resident who wished to be a full code, created a finding of immediate jeopardy that began on [DATE]. Surveyors notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 3:01 PM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a severity/scope of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: Facility policy titled, Cardio Pulmonary Resuscitation (CPR) - SNF (Skilled Nursing Facility), created in 02/2015 and last revised in 10/2023, states in part: Policy: It is the policy of the Company to initiate cardiopulmonary resuscitation on any resident suffering from cardiac or respiratory arrest unless (1) otherwise specified by a physician's order made consistent with the resident's expressed wishes (directly or through legal decision-maker), (2) in the presence of obvious clinical signs of irreversible death, e.g., rigor mortis, decapitation, transection, decomposition, or dependent lividity, or (3) initiating CPR could cause injury or peril to the rescuer. Procedure: 1. The facility will not implement a facility-wide 'no CPR' policy to ensure that all residents have the ability to exercise their right to formulate an advanced directive. 2. Upon admission to the facility, admission orders will be completed including the patient's wishes as expressed in their Advanced Directives, resuscitation status and life sustaining treatment options. 4. The resident's Advance Directives and related physician's orders will be reviewed quarterly at the resident's Care Conference or upon significant change in condition. Resident and/or their legal decision-maker shall be asked whether the current orders are consistent with the resident's wishes. If changes or clarifications are requested, the attending physician shall be contacted to update orders to reflect such changes. Any changes shall be clearly documented by completion of a new life sustaining treatment form (national or state) or Advanced Directive. Edits or discontinuation to an existing life sustaining treatment options form or Advanced Directive is unacceptable. 6. If the resident, or legal decision-maker if applicable, desires full resuscitation efforts, the following procedure will be followed: a. The staff person finding the resident in need of CPR will verify if the resident is a full CPR. Resident without a 'DNR' (do not resuscitate) order is considered 'Full CPR'. b. The staff person will loudly call for help and activate bedside or bathroom call system, if available, start CPR and simultaneously, alert somebody to call 911 and get a Licensed Nurse (if first responder is not a nurse). c. The Licensed Nurse will respond 'stat' with the Emergency Cart and AED (automated external defibrillator) in states where AEDs are applicable, and help/direct resuscitation measures. d. The person calling 911 will request Advanced Life Support Assistance and say 'CPR in progress. e. Every available Licensed Nurse in the health center will respond to the Code 'stat', and assist in emergency measures including checking of vital signs, pulse ox, oxygen, finger stick blood sugar, etc. f. The Licensed Nurse will delegate responsibilities as needed. g. The CNAs assigned to the section of the involved resident will follow directions from the Licensed Nurse. h. CPR is to be continued until Advanced Life Support personnel arrive and take over or the resident revives.R34 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia (neurogenerative disorder resulting in motor issues, such as tremors, muscle stiffness, and postural instability with involuntary, uncontrollable body movements), neurocognitive disorder with Lewy Bodies (progressive dementia affecting attention, cognition, and visual perception), type 2 diabetes mellitus, depression, chronic kidney disease - stage 3 (moderate kidney damage), and dysphagia - oropharyngeal phase (difficulty initiating swallowing). R34's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] indicated R34 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating R34 was severely cognitively impaired. R34's HCPOA was activated on [DATE] and named his son as the POA. R34's physician orders indicated that R34 had chosen to be a full code. R34 had elected I do want CPR on the facility's Resident Advance Directive Regarding Cardiopulmonary Resuscitation form. R34 had signed the form on [DATE], upon admission to the facility. The form had a witness signature and was also signed by NP J (Nurse Practitioner). R34's Care Conference notes on [DATE] state the following, in part: A. General Data. 5. What are the Resident's Goals and Desired Outcomes? [R34] is here for long term care. Son, [HCPOA F], wanted to talk to [R34] in person about CPR status which is currently full code. [HCPOA F] will update us if this is to change. R34 was seen by his primary care provider (PCP), MD I (Medical Doctor), on [DATE]. Notes from the visit state the following, in part: .Goals of care, counseling/discussion: Discussed with [HCPOA F] that while [R34] is stable at this time, he is at risk for acute events that could change his health trajectory with infections (especially aspiration) being of concern. [HCPOA F] notes that at this time his father is a 'full code' and understands the implications of that. He would like to try to discuss with his father more at an upcoming visit. I did advise [HCPOA F] that as activated HCPOA he can certainly make a substituted judgment about medical interventions, based on his knowledge of his father's historical preferences as well as information about [R34's] prognosis. At this time he elects to keep [R34] a full code. I did advise him in the event of cardiac or pulmonary arrest, [R34's] prognosis would be grave even with interventions, and it would be unlikely he would return to baseline. [HCPOA F] will let us know if he decides to adjust code status. On [DATE], the facility completed a Significant Change in Status Assessment MDS for R34 due to a noted decline. The facility also held a Care Conference. R34's Care Conference notes on [DATE] state the following, in part: A. General Data. 5. What are the Resident's Goals and Desired Outcomes? [R34] is here for long term care. Son, [HCPOA F] spoke to [R34] in the meeting about CPR status which is currently full code. The possible complications of CPR were talked about and [R34] states he would still like to be full code at this time. No changes made. R34's Progress Note on [DATE] at 1:14 PM, written by LPN C (Licensed Practical Nurse) states the following, in part: Son [HCPOA F] was here this morning to see [R34] one more time before heading home out of state. [HCPOA F] states that since he has been able to spend a few days with his dad, he has noticed that [R34] wants to sleep/nap more, has less interest in eating and just generally more tired/weak. [HCPOA F] states that he and [R34] talked yesterday and in the past, [R34] was not receptive to Hospice but now states that he thinks it may be time to look into it. Writer let [HCPOA F] know that NP will be updated and will likely call him to touch base before putting a referral in. [HCPOA F] is okay with this and states he will be available by phone as they are driving home. R34 was seen by NP J on [DATE]. Notes from the visit state the following, in part: .Code Status: Full Code. Assessment & Plan: .I am concerned that [R34] continues to be more frail with declining health and mobility concerns. After discussions with [R34] as well as his son and aHCPOA, [HCPOA F], they are both interested for [Hospice Agency] referral for hospice. Will order this today and update PCP as well. R34's Progress Notes on [DATE] state the following: 11:30 AM - (Writer: Social Services): Writer called [Hospice Agency] re: referral for hospice services. [Hospice Agency] to follow up with HCPOA [HCPOA F] to coordinate visit date and time. Per [Hospice Agency] follow up, assessment arranged for 2/3 with arrival between 10-11 am. HCPOA [HCPOA F] to be via phone. 5:36 PM - (Writer: RN D (Registered Nurse)): At 15:45 hrs (hours) (3:45 PM), aide [initial] notified writer about resident's condition. Writer rushed to resident's room et (and) found him unresponsive with his mouth half-way opened while laying in bed. No breathing was noted et no pulse could be felt. No movement of his body part was noticed. Skin is semi-pale et very minimally warm. CPR declined per son following conversation with NP [NP J] at the time. [MD I's] office was notified at 16:25 hrs (4:25 PM) et she (M.D) returned call at 16:45 hrs (4:45 PM). She plans to come in to the facility soon afterwards. 5:53 PM - (Writer: LPN C): [MD I] came in at 1735 (5:35 PM) and pronounced [R34's] death at 1740 (5:40 PM). Call placed to medical examiners office and requested information was given with no further follow up needed and states the MD can put 'natural causes' on the certificate.[NP J] NP was here at time of change of condition and called son/AHCPOA, [HCPOA F] to update him and see if he wanted us to start CPR and [HCPOA F] stated no. On [DATE] at 2:04 PM, Surveyors interviewed NP J. NP J indicated R34 had a history of Parkinson's disease and dysphagia. NP J indicated he had discussed the possibility of R34 starting hospice with HCPOA F in [DATE] and R34's PCP had discussed starting hospice in [DATE] due to R34's ongoing disease progression, but HCPOA had not been ready for that yet. NP J indicated he had seen R34 on [DATE] for a routine compliance visit and R34 and HCPOA F had indicated they were ready to move forward with a hospice referral, so NP J wrote an order for this.NP J indicated on [DATE], a CNA had been doing rounds, saw that R34 was unresponsive, and went to the nurse on duty. The nurse went in and assessed R34. NP J had been walking down the hallway and ran in to assess R34. NP J indicated he listened to his chest for two minutes and noted no response to a sternal rub or physical stimulation. NP J noted R34 had fixed pupils. NP J indicated he called HCPOA F right away because they had talked about R34's hospice transition. NP J indicated at the time, R34 was still a full code, but his son was planning on switching him to a DNR with the hospice transition. Surveyor asked if HCPOA F said he wanted R34 changed to a DNR or if he only wanted him to get a hospice referral? NP J indicated HCPOA F had seen R34 declining and the general thought was that he was planning on changing him to a DNR. HCPOA F never verbally discussed changing R34's code status with NP J. HCPOA F had only indicated that he wanted R34 to start hospice. NP J indicated hospice had not seen R34 for an evaluation yet, but the initial visit was going to be within 24 hours. Surveyor asked NP J if someone can be a full code on hospice. NP J said no. NP J indicated if HCPOA F had said yes to doing CPR, NP J would definitely have started it. Surveyor asked if someone's code status says full code and has not been changed, should you perform CPR? NP J said yes. Of note: R34's hospice evaluation was scheduled for [DATE], not within 24 hours. Additionally, a resident on hospice can elect to be a full code. On [DATE] at 3:57 PM, Surveyor interviewed RN G. RN G indicated he notes residents' code statuses at the beginning of each shift. RN G indicated if he found a resident who was pulseless and not breathing, he would assess the resident, call for help, and begin CPR if the resident was a full code. If the resident was DNR, he would not initiate CPR. RN G indicated a CNA can initiate CPR on a resident if they have training for it. RN G indicated he was working with R34 on [DATE]. RN G indicated R34 was a full code and had been declining - there had been discussions about transitioning him from a full code to hospice. RN G indicated he had been in another room providing cares and was informed that R34 was unresponsive. RN G entered R34's room and NP J came in behind him. RN G began assessing R34. RN G indicated NP J said he would call R34's son while RN G assessed R34 because he did not think HCPOA F would want CPR initiated.RN G noted R34 was laying down with his mouth halfway open and wasn't breathing. RN G said R34's name three times and he did not respond. RN G tried to feel R34's carotid pulse and did not see his chest rise. RN G indicated he told NP J that R34 is a full code and needs CPR initiated. RN G indicated NP J was on the phone with HCPOA F and told him he hadn't seen R34's chest rise or felt a pulse. NP J then told RN G HCPOA said not to start CPR, so he didn't.RN G indicated if he had been in R34's room by himself, he absolutely would have initiated CPR right away, but he had been told not to start it. RN G confirmed R34 had not transitioned to hospice yet and had not been a DNR at the time of this incident.On [DATE] at 4:07 PM, Surveyor interviewed CNA H (Certified Nursing Assistant) and asked what she would do if a resident was found pulseless and not breathing. CNA H indicated she would contact a nurse or supervisor on her walkie talkie. CNA H indicated she could then start CPR if the resident was a full code because she's CPR certified. If the resident was a DNR, she would wait for the nurse to arrive. CNA H indicated she tries to know the residents' code statuses when she starts her shift. The code statuses can also be looked up at the nurses' station.On [DATE] at 4:15 PM, Surveyor interviewed RN D and asked what she would do if a resident was found pulseless and not breathing. RN D indicated she would verify that there was no pulse and breathing and would have someone check on the resident's code status. If the resident was a full code, she would start CPR until more help arrived. If the resident was a DNR, she would stay with him or her, verify this, assess the resident, and then follow up with the physician or POA, as applicable. RN D indicated the most up-to-date code status information is in the electronic chart. The code status is on the resident's dashboard page as well as in the orders. RN D indicated CNAs with a red sticker on their name badge can start CPR, as they are CPR certified, but they would then have to get a nurse into the room to assess the resident.On [DATE] at 10:58 AM, Surveyor interviewed CNA E and asked what he would do if a resident was found pulseless and not breathing. CNA E indicated he would immediately notify a nurse. CNA E indicated most of the residents this happens to are on hospice, so it wouldn't be an issue. Surveyor asked if a resident on hospice can be a full code. CNA E indicated he wasn't 100% sure and would verify this with a nurse. CNA E indicated he usually knows the code status because he works with residents regularly, but could look it up in the chart if he didn't know. CNA E indicated he was CPR certified and could start compressions if the resident was a full code and then would call out for a nurse to come in.CNA E indicated he was working with R34 on [DATE]. CNA E indicated he looked at R34 during the last hour and he was fine and then went back into his room to get him up for dinner, noticed that he wasn't responding, and notified RN G. CNA E indicated he did sternal rubs, looked at the code status, and noted that R34 was a full code. CNA E indicated RN G wanted to check on the code status with the nursing supervisor. CNA E asked RN G if he should start chest compressions but came to the conclusion that R34 was not a full code because he was never told to start compressions. CNA E indicated he could not remember who told him not to start compressions.On [DATE] at 11:55 AM, Surveyor interviewed LPN C. NHA A had referred Surveyor to LPN C because the facility's Director of Nursing was on vacation during the survey. LPN C is a unit manager. Surveyor asked what the process is if a nurse finds a resident pulseless and not breathing. LPN C indicated the nurse should find out the code status. If the resident is a full code, CPR should be initiated. If the resident is a DNR, CPR would not be initiated. LPN C indicated code statuses can be found on the resident's face sheet in the physical chart or in the banner in the resident's electric chart. Surveyor asked what a staff member would do if they were in a room and didn't know the code status. LPN C indicated they could yell out for help to have someone look or they could run to find out. LPN C indicated DNR bracelets are available for residents on hospice in their chart, but they are not physically put on. LPN C indicated CNAs can initiate CPR if they are certified; otherwise, the expectation would be to get a nurse.LPN C was present during R34's care conference on [DATE]. LPN C indicated HCPOA F had briefly talked with R34 about his full code status. Code statuses are brought up at every care conference to see if any changes are to be made. LPN C indicated R34 said he'd be willing to talk about it, but no changes were made at that time. After the care conference, HCPOA F was visiting for a few days, had noticed some changes with R34, and decided to get hospice started. As of [DATE], R34 had not been seen by the hospice agency, and they hadn't signed on. R34 had not changed his code status at that point.LPN C was the unit manager on [DATE]. The Activities Director had notified her that R34 has passed away. LPN C indicated nobody had asked her what R34's code status was. LPN C indicated the nurse on the floor was in the room assessing R34 and NP J was in the room on the phone with HCPOA F. LPN C indicated from her understanding, RN G had asked CNA E to get NP J. RN G was still assessing R34 while NP J was on the phone with HCPOA F and RN G was told not to do CPR because HCPOA F did not want it started.Surveyor asked what LPN C's expectation would be for someone who is a full code. LPN C indicated as a unit manager, she would expect CPR to have been started.On [DATE] at 1:00 PM, Surveyor interviewed NHA A and asked what her expectation is for a nurse who finds a resident unresponsive and the resident is a full code. NHA A said, Start CPR.The facility's failure to follow R34's code status identified in his advance directives and not providing cardiopulmonary resuscitation created serious harm, thus leading to a finding of Immediate Jeopardy that began on [DATE]. The facility removed the immediate jeopardy on [DATE], however, the deficient practice continues at a severity/scope of D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: A nurse found a resident pulseless and not breathing and sought guidance from the resident's onsite APP (advance practice provider), who directed the nurse to hold off CPR until he could reach the activated POA. Residents who have documented wishes to have CPR have the potential to be affected.Licensed nurses to be reeducated on CPR policy and procedures and to perform CPR based on documented wishes regardless of direction of advanced care provider onsite or preference of activated POA. LN (licensed nurse) education started on [DATE] at 4:30 and will continue until all nurses reeducated prior to their next scheduled shift. On [DATE] CPR policy reviewed with Medical Director and Nurse Practitioner and determined it to meet current standards of practice. CPR will be initiated on a pulseless, non-breathing individual regardless of activated power of attorney's direction if CPR status change has not been documented. Also determined that code status will be reviewed with residents or activated POAs choosing CPR at each MD and APP compliance visits and with change of condition to ensure documented wishes are current. This discussion included reeducation/confirmation of provider understanding of residents' rights to choose to be a full code and to follow facility policy accordingly. This education to be provided to other facility providers by the Medical Director.Nurse managers will perform mock drills to ensure staff understand what actions to take when finding a resident pulseless and not breathing 5x/week for 4 weeks with immediate education provided as needed. Results of the audits will be analyzed to identify any trends and reviewed at quarterly QAPI meetings for further recommendations.

Based on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 30 residents. Residents (R) voiced concerns of food not being served at a desirable temperature (R132 and R133). 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy titled Food Production and Food Safety: Food Temperatures, dated 2023, includes in part: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. A. Cooking temperatures must be reached and maintained according to regulations, laws and standardized recipes while cooking. B. Hot food items may not fall below 135 degrees Fahrenheit (F) after cooking . 2. All cold food items must be stored at a temperature of 41 degrees F or below. 3. Temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the holding and plating process and until food leaves the service area . 5. Food preparation areas will follow these methods: A. Hold foods at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods (to keep food out of the temperature danger zone) . Example 1 R132 admitted to the facility on [DATE]. Her MDS (Minimum Data Set) has not been completed by the facility yet. On 11/4/24 at 9:50 AM, Surveyor interviewed R132 who indicated that she usually eats in her room and that her food is never hot. Example 2 R133 admitted to the facility on [DATE]. Her most recent MDS with an ARD (Assessment Reference Date) of 10/25/24 indicates her cognition is intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. On 11/4/24 at 10:14 AM, Surveyor interviewed R133 who indicated that she usually eats in her room, that it takes a while for the food to get to her, and that the food is not warm by the time it reaches her. Example 3 On 11/4/24 at 11:01 AM, Surveyor interviewed [NAME] D who stated that she takes the temperature of the food as it comes out of the oven, then it is placed on an electric cart that is plugged in and keeps the food warm. [NAME] D indicated that when the food is ready, the electric cart is taken up to the dining room, where the cook who is serving the food takes the temperatures again before plating the food. On 11/4/24 at 12:48 PM, Surveyor received a test tray after all of the dining room and hall trays had been served. (Of note, the plates for the room trays are set directly onto the tray and are covered by a thin metal cover that has a hole in the top center of it). Surveyor took the temperatures of the food that was served, including salmon, broccoli, mashed potatoes with gravy, cut up melon, milk, and coffee. Surveyor noted that several of the items were not palatable including the broccoli (temperature of 115 degrees F), which also tasted cold, melon (temperature of 52 degrees F), and milk (temperature of 44 degrees F). Example 4 On 11/5/24 at 8:50 AM, Surveyor received a test tray after all of the dining room and hall trays had been served. Surveyor took the temperatures of the food that was served, including scrambled eggs, sausage link, Belgian waffle, cottage cheese, and milk. All of the food items were found to be not palatable including the scrambled eggs (temperature of 124 degrees F), which also tasted cold, sausage link (temperature of 130 degrees F), waffle (temperature of 132 degrees F), cottage cheese (temperature of 49 degrees F). The milk's temperature was 41 degrees F. On 11/6/24 at 9:56 AM, Surveyor interviewed Executive Chef J (EC). Surveyor asked EC J if he would expect the food that is served, even the hall trays or at the end of meal service to be at the desired temperatures. EC J replied yes, that would be his expectation. EC J stated that periodically they get resident concerns about food not being served at the proper temperatures, but nothing recently.

Based on interview and record review, the facility failed to ensure that there was a system in place for standard transmission-based precautions to be followed to prevent the spread of infections. This had the potential to affect all 30 residents. The facility failed to do the following: The facility had 14 residents and 9 staff that tested positive for COVID 19. The facility did not complete contact tracing or broad-based testing timely of all residents to identify if others were COVID positive. CNA L (Certified Nursing Assistant) worked for three (3) shifts while experiencing symptoms of cough, body aches, headache, and a sore throat. CNA L did not notify staff of his symptoms until they worsened while he was working at the facility. The facility is not utilizing source control timely on the affected unit. The facility's policy, COVID-19 Testing, Outbreak Situation and Specimen Collection for Licensed Care Areas, reviewed 2/2024, documents in part, as follows: It is the policy of the facility to ensure the safety of its residents and staff in the event of an infectious disease outbreak by complying with any and all directives and other communication from federal, state or local authorities, including but not limited to, the World Health Organization, CDC (Centers for Disease Control) and state and local health officials. Interpreting Results: Positive Tests: Any positive COVID-19 test means the virus was detected and you have an infection. Isolate and take precautions including wearing a high-quality mask to protect others from getting infected. Tell people you had recent contact with that they may have been exposed. Monitor your symptoms. Negative Tests: A negative COVID-19 test means the test did not detect the virus, but this doesn't rule out that you could have an infection. If you have symptoms: You may have COVID-19, but tested before the virus was detectable, or you may have another illness. Maintain precautions and do not report to work while symptomatic. Testing Newly Infected Resident or Employee (Outbreak Situation): A single new case of SARS-CoV-2 infection in any HCP (healthcare provider) or resident should be evaluated to determine if others in the facility could have been exposed. When performing an outbreak response to a known case, facilities should always defer to the recommendations of their local public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g. unit, floor, other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Staff who do not test positive for COVID-19 but have symptoms should follow facility policies to determine when they can return to work. Residents who have signs or symptoms of COVID must be tested as soon as possible. While test results are pending, residents with signs or symptoms should be placed on transmission based (TBP). Asymptomatic residents with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests. Testing is recommended immediately but not earlier than 24 hours after exposure. If the test is negative, then test at 48 hours after the first test, and again 48 hours after the second negative test. This will typically be daily 1 (exposure day is 0)., then day 3, and day 5. The facility's policy, Infection Prevention and Control Program, last revised 7/2024, documents in part, as follows: Outbreak is the occurrence of more cases of a particular infection than is normally expected . The CDC (Centers of Disease Control), updated March 2024, includes the following guidance: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html states in part; Nursing Homes Assign one or more individuals with training in IPC (Infection Prevention/Control) to provide on-site management of the IPC program. Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Responding to a newly identified SARS-CoV-2-infected HCP (Health Care Provider) or resident. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested . In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. The facility's residents reside on one (1) floor (2nd floor) with the following four (4) halls and corresponding room numbers: East: 239-247 West: 213-223 North: 200-208 South: 224-233 The facility's outbreak affected 14 residents and 9 staff. On 8/19/24 DON B (Director of Nursing) began experiencing symptoms of cough and headache. DON B tested multiple times from 8/19 - 8/21/24. On 8/22/24 DON B tested Covid positive. On 8/19/24 and 8/20/24 RN M (Registered Nurse) completed treatments on all halls. On 8/21/24 RN M started experiencing symptoms of cough, sore throat, and congestion. On 8/22/24 RN M tested Covid positive. Of note after the facility discovered RN M was Covid positive there was no contact tracing or testing of the residents RN M had close contact with. On 8/22/24 CNA N (Certified Nursing Assistant) worked North and South halls. On 8/24/24 CNA N began experiencing symptoms of fever, cough, sore throat, headache, and fatigue. On 8/25/24 CNA N tested Covid positive. R3 (West Hall) began experiencing a cough on 8/23/24 and tested Covid negative. On 8/25/24 R3 tested Covid positive. R3's family member, who resides in Independent Living, was Covid positive and came to visit R3 at the facility. CNA L (Certified Nursing Assistant) worked the following shifts: On 8/21/24 CNA L worked on [NAME] Hall (except rooms [ROOM NUMBERS]). On 8/23/24 CNA L worked North Hall plus room [ROOM NUMBER] on South Hall. On 8/23 CNA L began experiencing symptoms of cough, body aches, headache, sore throat. CNA L worked his shift on 8/23. In addition, CNA L continued to work on 8/24 (below) and 8/26 (below) on the [NAME] Hall before testing Covid positive on 8/26 when his symptoms worsened. CNA L did not report his symptoms to the facility until 8/26, when he tested Covid positive. CNA L worked on 3 of 4 halls on the second floor. (Note, on 8/25 the facility began requiring all staff to wear masks.) On 8/25/24 the facility determined the outbreak began; the facility required all staff to wear masks. The facility did not initiate contact tracing or testing despite determining the facility was in an outbreak. Testing was not determined until 2 days later 8/27/24. On 8/26/24 two (2) other staff tested Covid positive. R15 (South Hall) began experiencing a cough on 8/26/24 and tested Covid positive the same day. On 8/26/24 R334 (South Hall) began experiencing symptoms (not documented) and tested Covid positive the same day. R334 was hospitalized for Covid and later discharged from the facility. On 8/26/24 the facility put admissions on hold, added additional air purifiers to the units, residents encouraged to mask during activities, put group therapy sessions on hold. RN C notified Public Health. On 8/27/24 the facility tested all residents. R2 (South Hall) began experiencing cough and hypoxia on 8/27/24 and tested Covid positive the same day. R2 was hospitalized for Covid and later returned to the facility. R20 (North Hall) began experiencing cough and congestion on 8/27/24 and tested Covid positive the same day. R10 (South) was not experiencing any symptoms. R10 tested Covid positive on 8/27/24. On 8/27/24 R335 (West Hall) began experiencing a cough and tested Covid positive the same day. R335 was receiving hospice care prior to being diagnosed with Covid and passed away a few hours after testing Covid positive. R336 (North) began experiencing a cough on 8/27/24 R336 tested Covid positive on 8/27/24. R7 (South) began experiencing symptoms (not documented) on 8/28/24. R7 tested Covid positive on 8/29/24. R8 (East Hall) was experiencing symptoms of cough on 8/30/24 and tested positive the same day. R11 (West Hall) began experiencing symptoms of fever, cough, and hypoxia on 8/30/24 and tested Covid positive the same day. R14 (West Hall) began experiencing symptoms of cough and body aches and sore throat on 9/2/24 and tested Covid positive the same day. R22 (West Hall) began experiencing symptoms of fatigue on 9/3/24 and tested Covid positive the same day. R13 (West Hall) began experiencing symptoms of loss of appetite on 9/4/24 and tested Covid positive on 9/5/24. RN C (Registered Nurse) completed, Covid outbreak August-September 2024 that documents the following: 8/22/24 two staff members test positive for Covid. 8/25/24 a 3rd staff member tests + for Covid and one resident tests + Masking required now for all staff on 2nd floor. 8/26/24 a 2nd resident tests + for Covid Admissions on hold. More air scrubbers (purifiers) placed on the unit (already had two out). Residents encouraged to mask during activities. Group sessions of therapy on hold. Public Health notified. 8/27/24 R2 with cough, Covid+. R20 (R2's roommate) then tested also + All 2nd floor residents Covid tested . 7 total residents with Covid on the unit. Public Health updated. All therapies now being held on the unit/staying in resident rooms if possible or masking if out of room. All group activities canceled for now. Admissions on hold. Limiting residents coming to dining room-primarily just residents needing assistance or oversight for swallowing come out to dining room. Only one resident at a table. Back dining room blocked off with wall divider and PPE (Personal Protective Equipment) placed for that to be the Covid+ resident dining area due to residents needing assistance with meals. Those residents masking to/from dining area and staff using appropriate PPE in that area. Covid negative residents encouraged to stay in rooms for meals. Encouraged visitors to mask, signs at elevators and on unit. 9/3/24 Three more residents tested positive for Covid over the weekend. Repeat testing done for surveillance of all 2nd floor residents who are not Covid positive. One more resident found to be positive during this testing. Continuing with all precautions listed above. 9/9/24 Back dining room opened back up for residents, (cleaned and disinfected). Covid+ residents to stay isolated in rooms (5 residents still in isolation). One staff member out with Covid, returning Friday 9/13. 9/10/24 Three residents still in Covid isolation, all on west hall. Resuming admissions, on north hall for now. Therapy resume taking residents down to therapy gym (continuing to mask or safely distance from others) 9/15/24 All resident now off Covid isolation. All staff have returned that were out with Covid. 9/16/24 Public Health Department notified by email of Covid + numbers for employees and residents. On 11/05/24 at 3:22 PM and 11/6/24 at 3:40 PM, Surveyor spoke with RN C, the facility's Infection Preventionist. Surveyor asked RN C, what Standard of Practice does the facility use for infection control. RN C stated, CDC (Centers for Disease Control) guidelines and CMS (Centers for Medicare and Medicaid Services). Surveyor asked RN C, how does the facility determine if an infection meets the criteria for the Standard of Practice. RN C stated, for Covid-19 it's based off the CDC, our Medical Director, and Infection Control through a local hospital. Surveyor asked RN C, is the Infection Control program conducted daily. RN C stated, yes. Surveyor asked RN C, when she works. RN C stated, Monday through Friday. Surveyor asked RN C, who monitor infections and potential outbreaks that occur on a weekend. RN C stated, on weekends staff has access to Covid tests, update providers, me, or the supervisor on call. Staff enter the information in progress note, communicate via PCC (Point Click Care), an electronic medical charting, do huddles so staff can identify outbreaks on the weekend and if they need to be monitoring other people for signs/symptoms. Surveyor asked RN C, when a staff member has signs/symptoms of illness how long are they out. RN C stated, the facility follows CDC guidelines. RN C added if there's a Covid-19 outbreak staff are out for at least 7 days. If they test negative that determines if they can return on day 8 otherwise, they are out for 10 days. Surveyor asked RN C, how do you determine if there is an active outbreak. RN C stated when we have 3 cases (residents and staff) together within 72 hours. Surveyor asked RN C, what date did you determine there was an outbreak. RN C stated, 8/25/24 was the third staff within 72 hours. Surveyor asked RN C, how many residents and staff had Covid. RN C stated, 14 residents and 9 staff. Surveyor asked RN C, did Covid positive staff work within 48 hours of symptom onset. RN C stated, yes. RN C reviewed the work assignments for staff that worked within 48 hours of symptom onset (below). RN C stated, on 8/25/24 they had 3 staff and 1 resident that tested Covid positive. Surveyor asked RN C, what did you do. RN C stated, we required all staff to wear a mask, added air purifiers to hallways, held admissions, encouraged all residents to mask, postponed group therapy, and notified Public Health on 8/26/24. Surveyor asked RN C, did the facility complete contact tracing or broad-based testing. RN C stated, on 8/27/24 the facility tested all residents. Surveyor asked RN C, did any residents test positive. RN C stated, yes, on 8/27/24 we ended up with a total of 4 more residents that tested Covid positive for a total of 7 Covid positive residents. Surveyor asked RN C, did you or anybody at the facility complete contact tracing. RN C stated, no. RN C stated, the nurses work at least two (2) wings during their shift. RN C added, contact tracing was hard to determine as nurses are all over. RN C added, she would not be able to contact trace residents over the last 48 hours prior to symptom onset. RN C stated, with future outbreaks the facility will keep residents to their rooms as much as possible if there's a respiratory outbreak or we know others have been exposed, eat in their rooms, wear a mask, distancing, and educate staff. RN C stated, we recently updated our Covid outbreak plan. Surveyor asked RN C, do you know why there was a delay with broad-based testing. RN C stated, no, we've gotten away from the asymptomatic testing. Once there was more affected and 2 halls affected, we decided to test the whole unit. RN C stated, that was part of our updated plan, educate staff and catching things earlier. RN C stated, staff were educated on PPE (Personal Protective Equipment), hand hygiene and masking. Surveyor asked RN C, for documentation of the training. RN C stated, there is no documentation just shift to shift education. RN C stated, the facility completed broad-based testing on 8/27/24 and did another round on 9/3/24. Surveyor asked RN C, who is responsible to do this. RN C stated, we usually discuss it as a team. Surveyor asked RN C, did the facility identify that it should happen sooner. RN C stated, Not in particular. Surveyor asked RN C, should broad-based testing have been completed on day 1, day 3 and day 5. RN C was not aware. Surveyor asked RN C, when CNA L (Certified Nursing Assistant) was working at the facility on 8/23, 8/24 and 8/26 was he experiencing symptoms of cough, body aches, headache, sore throat. RN C stated, yes. RN C added, CNA L started experiencing these symptoms on 8/23/24 and did not notify the facility until his symptoms worsened. Surveyor asked RN C, what would you expect staff to do when experiencing signs/symptoms of illness. RN C stated, staff should test for Covid and mask even if they think it's just allergies. RN C stated, if the Covid test is negative staff should retest two (2) days later or if they develop a fever or symptoms worsen. Surveyor asked RN C, did the facility educate CNA L. RN C stated, DON B (Director of Nursing) followed up with CNA L. Surveyor asked RN C, how soon would you expect CNA L and all staff to notify the facility when they are experiencing signs/symptoms of illness. RN C stated, Right away. Surveyor asked RN C, would you have expected CNA L to notify the facility right away when he started experiencing symptoms. RN C stated, Yes. Surveyor asked RN C, did the facility complete contact tracing for residents. RN C stated, no, we didn't know who comes out to the dining room or where staff worked or where residents are out and about more. RN C stated, the facility identified we need to isolate, test, initiate masking right away if 1 case. If a resident does have symptoms after hours or on a weekend we try to isolate them or mask. Like the first resident she did end up testing positive. Taking precautions such as masking if out and doing that retest. RN C stated, there is no documentation of this. On 11/06/24 at 4:05 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated, the facility just revamped their Covid policy. DON B stated if it's patient #1 (first case) we isolate them. DON B stated, we will report to public health. DON B added, if an employee tests positive we will have all employees mask, isolation resident, day 5 we test, day 7 we test again to be sure. If we have two (2) cases we mask the whole time and the facility locks down essentially, look for trends. DON B added, after 2 cases we will start swabbing everybody (broad-based testing, signs in elevator asking visitors to please be aware of the Covid case/outbreak)-we can't not let them visit, hand hygiene, ask them to mask. We looked at actual assignment to see if anybody is getting isolated. At that point in time, we did not swab everybody we consult with medical director. We started to address that at our daily huddle. We looked at our staffing. With 3rd positive we held off on admissions. A Covid positive resident from IL (Independent Living) was here visiting R3; R3 was our first positive. DON B stated, we got notification the same day the visitor was sent out via 911 later that same day for Covid. Surveyor asked DON B, you were able to determine who gave R3 Covid, but not R3's contacts and did not do this for the other Covid positive residents. DON B stated, Yes. DON B stated, on 8/25/24 we sent Covid tests home with staff and let them know if their test is positive to let us know. DON B stated, At that point in time I would have expected RN C to swab (Covid test) all residents. DON B stated, some staff opted to wear an N95 to not get sick. Surveyor asked DON B, was education provided to CNA L after he worked multiple shifts while symptomatic with Covid. DON B stated, yes, he was written up (verbal) because it was a safety issue. DON B stated, CNA L stated from here on out he understands if he has a sniffle he is testing; DON B added, she was highly upset with him. DON B shared her computerized calendar with Surveyor. On 9/4/24, the date CNA L returned to work, DON B has the following meeting documented. Verbal disciplinary action, next time will be written. Conversation with CNA L advised is NEVER to come to work sick again, explained they why's of issues and then advised it is a safety concern. Advised he will receive a final written warning if this ever occurs again. DON B stated, following this outbreak she has started doing weekly infection control meetings with RN C. DON B added, every Monday she has a one (1) hour meeting with RN C to go through infection control.

Based on observation and interview, the facility did not distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 30 residents. Facility staff were observed touching multiple items in the kitchenette while serving and handling food without changing gloves or performing proper hand hygiene. Multiple cooks and dietary aide were observed dishing up lunch from the steam table with gloves on, stepping away from the steam table, touching other surfaces in the kitchenette, and returning to the steam table for meal plating with the same gloves on. Facility staff were also observed touching common surfaces in the kitchenette, then touching ready to eat foods while wearing the same pair of gloves. Cook E and [NAME] F were observed taking the food temperatures of several food items. [NAME] E and [NAME] F were observed wiping the thermometer probe with an alcohol wipe and inserting it into the next food item without allowing the alcohol to fully air dry, causing a risk of food cross contamination. Evidenced by: Facility policy, entitled Infection Control Policies, Hand Washing, dated 2023, includes in part, Policy: Employees will wash their hands as frequently as needed throughout the day using proper hand washing procedures . Procedure: Hands and exposed portions of arms should be washed immediately before engaging in food preparation . 1. When to wash hands: . F. After handling soiled equipment or utensils. G. During food preparation, as often as necessary, to remove soil or contamination and prevent cross contamination when changing tasks . I. Before donning disposable gloves for working with food and after gloves are removed. J. After engaging in other activities that contaminate the hands (i.e., answering a phone call, using a computer, table, or smartphone, handling trash, etc.) . On 11/4/24 at 11:28 AM, Surveyor observed [NAME] E temping the food in the steam table before serving. [NAME] E was noted to insert the thermometer probe into one food item, wait approximately 2-3 seconds, and then insert the thermometer probe into the next food item without waiting for the alcohol on the thermometer probe to fully dry. On 11/4/24 at 11:36 AM, [NAME] F took over for [NAME] E and began temping the food. Surveyor observed [NAME] F temping the food in the steam table by inserting the thermometer probe into one food item, wait approximately 2-3 seconds, and then insert the thermometer probe into the next food item without waiting for the alcohol on the thermometer probe to fully dry. Surveyor observed [NAME] F placing the bare thermometer probe on the kitchenette counter in between temping of the food without properly sanitizing the thermometer probe. On 11/4/24 at 11:46 AM, [NAME] F donned two pairs of disposable gloves and began meal service. Surveyor noted that the first pair of gloves was torn by the left thumb. Surveyor observed [NAME] F dishing up food from the steam table, stepping away from the steam table and touching drawers, a pen, the refrigerator door, meal cart doors, cupboard doors, and then returning to the steam table and dishing up food without changing gloves or performing hand hygiene. Surveyor also observed [NAME] F touching cookies, bread, and pats of lemon butter with the same pair of gloves. On 11/4/24 at 12:13 PM, Surveyor observed Dietary Aid G (DA) enter the kitchenette, wash hands, and donn a pair of disposable gloves. Surveyor observed DA G touching the silverware, refrigerator door, meal tickets, stepping to the steam table to dish up food, stepping away from the steam table and touching a dinner roll with the same pair of gloves. On 11/4/24 at 12:31 PM, Surveyor observed [NAME] H enter the kitchenette and donn a pair of disposable gloves. Surveyor observed [NAME] H dishing up food at the steam table, stepping away from the steam table, touching the freezer door and scooping ice cream, then touching a cookie and touching bread to make a sandwich while wearing the same pair of gloves. On 11/4/24 at 12:56, Surveyor interviewed [NAME] F, who indicated that all kitchen staff had received education on topics such as sanitation, hand hygiene, and food safety. Surveyor asked [NAME] F if there was a risk for cross contamination if wearing the same gloves to touch food after touching common surfaces. [NAME] F stated yes there would be a risk for cross contamination. Surveyor asked [NAME] F how long he had waited for the alcohol to dry after using it on the thermometer probe. [NAME] F replied he had only let it dry for three seconds before inserting the thermometer probe into the next food item. On 11/5/24 at 8:12 AM, Surveyor observed [NAME] H wearing disposable gloves during meal service. Surveyor observed [NAME] H touching the oven handle, waffle maker, a pen, the sink faucet, the refrigerator door, and then handling cooked waffles and a hardboiled egg with the same pair of gloves. On 11/5/24 at 8:41 AM, Surveyor observed [NAME] I wearing disposable gloves and touching the drawer, refrigerator door, bread for toast, the toast lever, and the toast coming out of the toaster while wearing the same pair of gloves. On 11/5/24 at 9:06 AM, Surveyor interviewed [NAME] H who indicated they had received education at their weekly meetings about hand hygiene and food safety. Surveyor asked [NAME] H when hand hygiene should be performed. [NAME] H stated anytime you switch between activities, you should wash hands or change gloves. Surveyor asked [NAME] H if he had followed that during meal service. [NAME] H replied no, as he was constantly grabbing the cooked waffles off the waffle maker. Surveyor asked how often the common surfaces in the kitchenette were sanitized. [NAME] H stated they are cleaned weekly. Surveyor asked if cross contamination could occur if the kitchen staff were touching common surfaces and then touching food without changing gloves or performing hand hygiene. [NAME] H replied, yes, definitely. On 11/6/24 at 9:56 AM, Surveyor interviewed Executive Chef J (EC). Surveyor asked EC J when he would expect staff to perform hand hygiene or change gloves. EC J indicated that he would expect staff to perform hand hygiene or change gloves during meal service anytime their gloves get contaminated by touching common surfaces and when switching between tasks.

Based on record review and interview, the facility did not ensure that 4 of 4 sampled residents (R333, R5, R7, and R131) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to ensure daily diabetic foot checks were completed for R333, R5, R7, and R131. As evidenced by: The facility does not have a policy for diabetic foot care. The current standard of practice per the American Diabetes Association copyright 1995-2024, https://diabetes.org, includes, in part: .1. Check your feet daily for sores, cuts, cracks, blisters, or redness . The facility follows PALTmed (Post- Acute and Long- Term Care Medical Association) standard of practice (SOP) dated 8/22/24, .Table 24. Suggested Elements of Comprehensive Monitoring for Patients with Diabetes Who Have Minimal Physical and Cognitive Impairments (emphasis intended) . Foot care: *Daily inspection by patient if able. *Weekly inspection by caregivers * Annual comprehensive foot examination by practitioner (Inspection, evaluation of foot pulses and loss of protective sensation) . Diabetes_Text-August22-2024.pdf It should be noted the SOP is in regard to persons with minimal physical and cognitive status as it relates to allow patient to check feet daily. Example 1 R333 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2 with neuropathy, fracture of upper and lower end of left fibula, chronic kidney disease stage 3, muscle wasting and atrophy, idiopathic chronic gout, Parkinson's Disease, Dementia. R333's MDS (Minimum Data Set) with a ARD (Assessment Reference Date) of 10/31/24 indicates R333's BIMS (Brief Interview of Mental Status) was an 11 indicating R333 has moderate cognitive impairment. Surveyor reviewed R333's medical record and current physician orders. There is no evidence that CNA's (Certified Nursing Assistants) are checking diabetic residents' feet daily and reporting to the nurse. The facility failed to ensure daily diabetic foot checks were completed for R333. On 11/6/24 at 2:48 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, does the facility complete daily diabetic foot checks. DON B indicated all CNAs (Certified Nursing Assistants) are instructed to check the feet when they do head to toe check with cares twice daily and to let the nurses know if there are any issues. DON B stated, we do not treat diabetics any differently because all residents get washed up daily. DON B also stated, the nurse does a weekly head to toe and skin assessment on the resident's bath day. DON B stated they don't have a specific diabetic foot check policy and nurses are not doing daily diabetic foot checks. It should be noted due to R333's cognition staff should be assisting R333 with daily foot inspections. 42038 Example 2 R5 was admitted to the facility on [DATE] with diagnoses that include displaced comminuted fracture of shaft of right femur, malignant neoplasm of esophagus, wedge compression fracture of fourth lumbar vertebra, and type 2 diabetes mellitus with moderate NPDR (nonproliferative diabetic retinopathy (early stage of diabetic eye disease)). R5's most recent MDS (Minimum Data Set) dated 10/15/24 states that R5 has a BIMS of 12 out of 15, indicating that R5 has moderate cognitive impairment. R5's CNA (Certified Nursing Assistant) Kardex states in part .Transfer: 2A SPT (2 Assist Stand Pivot Transfer) to commode or w/c (wheelchair) with FWW (Front wheeled walker) GB (Gait Belt). AMB (Ambulation): 2A Short walk to bathroom with FWW . R5's care plan created on 10/8/24 and updated on 10/15/24 and 10/24/24 states in part .Impaired Functional Status r/t (related to) s/p (status post) fall with comminuted and displaced right intertrochanteric femur fracture with s/p IMN (Intramedullary Nailing (a nail inserted inside if the canal of the bone)) (9/17), dx (diagnosis) of esophageal cancer, constipation, neuropathic pain, hyperphosphatemia, DM2 (diabetes mellitus type 2), NPDR, ESRD (End Stage Renal Disease) with hemodialysis .Interventions: .Dressing Assistance Level: Assist of 1 mod (moderate) to max (maximum) assist, Bathing Assistance Level: Assist of 1 mod assist . Surveyor reviewed R5's nurse's notes, MAR/ TAR (Medication Administration Record/ Treatment Administration Record) and there was no evidence that facility staff were completing daily diabetic foot checks. On 11/6/24 at 1:02 PM, Surveyor interviewed RCM K (Resident Care Manager), who is also the wound nurse. Surveyor asked RCM K if the nurses completed daily diabetic skin checks, RCM K stated that they have weekly skin checks that the nurses complete and that there are certain things that the CNAs do and report back to the nurses. On 11/6/24 at 2:45 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the Standard of Practice was that they follow for diabetic foot checks, DON B reported that they do not treat diabetic residents any differently than residents without diabetes and that the CNAs are told to report any changes immediately. Surveyor requested a copy of the facility's Diabetic Foot Check Policy, DON B stated that they do not have one. It is important to note that R5 has impaired mobility and impaired vision and should not be expected to complete his own daily diabetic foot checks. 50285 Example 4 R131 was admitted to the facility on [DATE] with diagnoses that include fracture of Unspecified part of neck of left femur, Unspecified fracture of the lower end of left radius, Fibromyalgia, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Major Depressive Disorder, Pain in left hip, Muscle wasting and atrophy, Muscle weakness generalized, Other lack of coordination, Other reduced mobility, Need for assistance with personal care. R131 is unable to check her own feet daily due to two recent fractures and impaired mobility. R131 is reliant upon the facility staff to check her feet daily, per standard of practice. Surveyor reviewed R131's medical record and current physician orders. There is no evidence that CNA's (Certified Nursing Assistants) are checking diabetic residents' feet daily and reporting to the nurse. The facility failed to ensure daily diabetic foot checks were completed for R131. On 11/4/24 at 2:10 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the facility completes daily diabetic foot checks. DON B indicated the CNAs are instructed to do head to toe skin checks on the residents when they do their cares on a daily basis, and to let the nurses know if there are any concerns. DON B stated that the nurse's do a weekly skin assessment on the resident's bath day. DON B indicated that the facility did not have a specific policy regarding diabetic foot checks, as all residents are treated the same. Surveyor asked DON B if the nurses were doing daily diabetic foot checks. DON B replied that they were not. 30992 Example 3 R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2. R7 was later diagnosed with malignant neoplasm of prostate, secondary malignant neoplasm of bone, dementia with neuropathy, and chronic gout. R7's (Minimum Data Set) with a ARD (Assessment Reference Date) of 7/31/24 indicates R7's BIMS (Brief Interview of Mental Status) was a 0 indicating severe cognitive impairment. R7 cognitive impairment documents: R7 has impaired cognitive function/dementia and impaired though processes r/t dx(s) of dementia and malignant neoplasm of prostate. Goal: R7 will be able to communicate basic needs on a daily basis through the review date. Interventions: .ask yes/no questions in order to determine R7's needs. Re-approach if needed. Identify yourself at each interaction. Face R7 when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door, etc. Cue reorient and supervise as needed; R7's family member is his APOAHC. Include her in all health care related decisions Surveyor reviewed R7's medical record and current physician orders. There is no evidence that CNA's (Certified Nursing Assistants) are checking diabetic residents' feet daily and reporting to the nurse. The facility failed to ensure daily diabetic foot checks were completed for R7. It should be noted that R7 has Dementia and would not be able to complete his own diabetic foot checks.

Based on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 4 residents (R19) reviewed for PIs. R19 was admitted with a PI, the facility failed to obtain wound measurements for a 3-week period in June 2024 and 1 missed measurement in October 2024. Evidenced by: The facility policy titled Pressure Injury and Prevention approved on 6/2024 states in part .II. Determining the presence of a PI .E. Throughout stay in facility actions taken to continue ongoing evaluation of skin includes: 1. Weekly total body examination and documentation on the PCC (Point Click Care (electronic health record)) Nurse Advantage Skin Assessment or PCC Skin and Wound App (Application) . R19 was admitted to the facility on [DATE] with diagnoses that include fibromyalgia, generalized anxiety disorder, protein- calorie malnutrition, edema, and reduced mobility. R19's most recent MDS (Minimum Data Set) dated 9/4/24 states that R19 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R19 is cognitively intact. The MDS also indicated that R19 is dependent on staff for positioning, toileting, and bathing. Surveyor reviewed weekly wound notes. Surveyor noted that there were no wound measurements completed on 6/12/24, 6/19/24, 6/27/24, and 10/16/24. R19's wound remained stable with the following before and after measurements: 6/5/24: length: 4.16 cm (centimeters), width: 2.63 cm 7/3/24: length: 5.0 cm, width: 2.7cm 10/9/24: length: 4.01 cm, width: 2.76 cm 10/23/24: length: 4.16 cm, width: 2.78 cm On 11/6/24 at 1:02 PM, Surveyor interviewed RCM K (Resident Care Manager), who is also the wound nurse. Surveyor asked RCM K if R19 should have weekly wound measurements completed, RCM K stated yes. Surveyor asked RCM K to review R19's wound documentation from June 12, 19, 27, and October 16. RCM K noted that there were no wound measurements documented on those days, but there was documentation regarding the characteristics of the wound, areas of tunneling, and areas of undermining. Surveyor asked RCM K if there should be a measurement of the length and width of the wound, RCM K stated yes. RCM K stated that the facility uses a camera for wound measurements and if the sticker falls off, the measurement is not captured. RCM K also reported that there is a delay in getting the information from the camera to PCC (Point Click Care), so they may not notice that they camera did not capture the measurement.

Based interview and record review the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 of 4 residents (R11 & R3) reviewed for limited range of motion (ROM) of 14 sampled residents. R3 is not receiving her restorative care per care plan. There are three different splint instructions for R11's splint for staff to follow making it difficult for staff to know which is the correct order. This is evidenced by: The facility policy entitled, Contracture Prevention and Treatment, dated 10/23, states, in part: . POLICY: It is the policy of this Company that each resident will be assessed for potential for developing contractures. Residents at risk will have a care plan for preventative intervention. For residents who do develop contractures due to their diagnosis and general condition, a treatment plan will be followed to minimize the contractures as much as possible. PROCEDURE: . 2. Prevention and/or treatment of contractures will be addressed on the resident care plan . 3. Routine nursing intervention towards prevention of contractures will be an integral part of the basic nursing care for each resident. This includes the following: . C. Range of Motion will be performed during ADL's (activities of daily living) as assigned on the resident care plan. D. Supportive devices such as pillows, foot drop stops, splints, trochanter rolls, and hand rolls shall be used as appropriate . Notice of Resident Rights under Federal Law, states, in part: . Planning and Implementing Care . The right to receive services and/or items included in the plan of care . Respect and Dignity . The right to reside and receive services in the facility with reasonable accommodation of your needs . Example 1 R3 was admitted to the facility on [DATE] and has diagnoses that include Unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Contracture, Right Knee (shortening of muscles, tendons, skin, or other soft tissues that limits movement in a joint), and Contracture, Left Knee. R3's Annual Minimum Data Set (MDS) Assessment, dated 10/9/24, shows R3 has a Brief Interview of Mental Status (BIMS) score of 8 indicating R3 has moderate cognitive impairment. R3's Care plan, dated 2/22/20, states, in part: . Problem: Restorative Nursing Program: Active Range of Motion. Date Initiated: 2/22/20. Created on: 2/22/20. Goal: R3 will maintain flexion of BLE (bilateral lower extremities). Date Initiated: 2/22/20. Created on: 2/22/20. Revision on: 11/5/24. Target Date: 1/11/25. Interventions/Tasks: -Perform PROM (Passive Range of Motion- the movement of a joint when an outside force, like a therapist or device, moves the body part while the person receiving the exercise is relaxed) to BLE (Bilateral Lower Extremities) 10 repetitions per scheduled time and tolerance using therapy exercises provided . Date Initiated: 2/22/20. Created on: 2/22/20. Revision on: 6/24/20 Position: CNA (certified nursing assistant) . R3's CNA Kardex, dated 11/6/24, states, in part: . Resident Care . -Perform PROM to BLE 10 repetitions per scheduled time and tolerance using therapy exercises provided . CNA's Care Sheet, dated 11/5/24, does not show R3 is to receive PROM to BLEs. R3's CNA Task Charting in PCC (Point Click Care) does not list: Perform PROM to BLE 10 repetitions per scheduled time and tolerance using therapy exercises provided. On 11/5/24, at 2:55PM, Surveyor interviewed OT R (Occupational Therapist/Rehab Director). OT R indicated the facility does not have a restorative program. If a resident coming off therapy requires restorative it would be completed by the CNA's (Certified Nursing Assistants) or the wellness center downstairs. The therapist would make the determination who would do the restorative care. OT R indicated if the restorative care recommended is straight forward like, the walking program or the arm bike, CNAs would complete the restorative care. If the care requires more training the wellness center would be recommended. OT R indicated CNAs would not do any type of range of motion exercises with the residents. On 11/6/24, at 9:33AM, Surveyor interviewed DON B (Director of Nursing) and asked if the facility has a restorative program. DON B indicated no but if a resident is care planned to receive ROM the CNAs would provide it. DON B indicated the facility does offer walk to dine program that the CNAs would complete with residents. Surveyor asked if R3 is receiving PROM as care plan indicates. DON B looked in PCC under tasks and indicated it is not there. DON B checked the CNA Kardex and PROM instructions for BLE was on the Kardex. DON B indicated the PROM R3 is to be receiving should be listed under the tasks for CNAs to complete and document completion. Surveyor asked if R3 is receiving PROM and DON B indicated we would not know if it were being completed but if it is not documented can't prove it was completed. Surveyor asked if R3 should be receiving PROM according to care plan and Kardex and DON B indicated yes. Surveyor asked if staff should be documenting completion of the PROM and DON B indicated yes. On 11/6/24, at 12:57PM, Surveyor interviewed CNA O and asked if R3 receives PROM. CNA O went to computer, looked, and indicated R3 does not receive PROM. Surveyor asked CNA O if a resident were to receive PROM how would staff know and CNA O indicated it would be in PCC for CNAs to see and chart on. CNA O indicated the computer shows R3 does not receive PROM. On 11/6/24, at 1:00PM, Surveyor interviewed CNA P and asked how CNAs would know if a resident were to receive PROM. CNA P indicated by the resident's plan of care in the computer or by actual care plan. Surveyor asked if CNAs perform PROM exercises on a resident would it be charted, and CNA P indicated yes in PCC. On 11/6/24, at 1:13PM, Surveyor interviewed CNA Q and asked how a CNAs would know if a resident was to receive PROM. CNA Q indicated it would come up in Q Shift (every shift) in PCC for CNAs to see and chart completion. Surveyor asked if R3 was to receive PROM and CNA Q looked up in PCC and indicated no. Surveyor asked CNA Q if a resident was to receive PROM do CNAs chart on completion and CNA Q indicated yes under the Q shift tabs and R3 does not have PROM in her tabs. Example 2 R11 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body) and Hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), Vascular Dementia (chronic condition that occurs when the brain's blood supply is interrupted, damaging brain tissue and causing a decline in thinking, memory, and behavior), and contracture, left hand. R11's Quarterly MDS Assessment, dated 10/3/24, shows R11 has a BIMS score of 6 indicating R11 has severe cognitive impairment. R11's Care Plan, dated 2/17/20, states, in part: . Problem: Impaired mobility/falls related to: HX (history) s/p (status post) fall with left hip fracture with hemiarthroplasty, hx of ischemic frontal lobe CVA with left sided weakness, worsening Left hand contracture, Hyperlipidemia . Date Initiated: 2/17/20. Created on: 2/17/20. Revision on: 1/10/24 . Interventions: . R11 may wear his resting hand splint to left hand, his wife may apply as desired. Date Initiated: 1/3/24. Created on: 1/3/24.Revision on: 3/25/24 . R11's Care Sheet, dated 11/5/24, states, in part: . Resting hand splint to left hand over night . CNA tasks in PCC for R11 indicates CNAs are to wash and dry left hand thoroughly then apply wrist support every day. On in morning and off at bedtime. On 11/4/24, at 10:31AM, Surveyor observed R11 with left arm/hand splint on but not strapped into place, hanging loosely. On 11/4/24, at 10:31AM, Surveyor interviewed FM W (family member) who indicated CNAs apply the splint to R11's left hand/arm. It does not have to be on 24 hours, but it is usually kept on most of the day, every day and during night. FM W indicated the CNAs do not know how to put the splint on correctly and showed Surveyor it was not strapped on at this time. On 11/5/24, at 2:01PM, Surveyor interviewed CNA X who indicated R11's hand splint to left hand goes on at bedtime and comes off in the morning for cares then a rolled-up wash cloth is placed in left hand. R11's left hand gets washed when splint is removed. On 11/5/24, at 2:25PM, Surveyor interviewed LPN S (Licensed Practical Nurse). LPN S indicated the facility does not have a restorative program, but therapies will give nursing direction for example a resident is to walk so many steps a day. The nursing staff will provide that. LPN S indicated whatever staff is assigned to a resident would be responsible to carry out therapy directions. Surveyor asked LPN S how CNAs would know therapy directions and LPN S indicated it would be on the CNAs care sheet. Surveyor asked when R11 is to wear his arm splint and LPN S indicated R11 should be wearing it now. LPN S then looked at the CNA care sheet and indicated the sheet states the splint is to be on at night and off during the day. Surveyor asked LPN S if we could go make an observation of R11. LPN S and Surveyor noted R11 had the left splint on R11's left hand. LPN S removed the splint and indicated according to the care sheet he is not to have it on. LPN S then looked at R11's care plan and indicated the care plan states R11 may wear splint as desired, and the care sheet states at night. LPN S indicated they should be in sync with each other and are not updated. Surveyor asked how CNAs would know what to follow and LPN S indicated they wouldn't as they should be the same. As Surveyor was talking with LPN S, LPN Y who was sitting at desk next to LPN S indicated looking at R11's CNA tasks in PCC, it states left arm splint is to be on in am and off at bedtime. LPN S indicated now we have three different directions. The directions should be the same on care sheet, care plan and tasks. On 11/5/24, at 2:55PM, Surveyor interviewed OT R and asked when R11 should have his left arm splint on, and OT R indicated the splint is to be on when R11 is up out of bed. If R11 is napping or at night, there is no need to have the splint on. On 11/6/24, at 9:33AM, Surveyor interviewed DON B. Surveyor informed DON B of LPN S and Surveyor's findings regarding conflicting instructions for R11's left arm/hand splint. Surveyor shared there are conflicting orders in the care plan, care sheet and CNA tasks. DON B indicated the instructions should be the same on all three and DON B indicated they are fixing that. Surveyor asked how staff would know which instruction to follow and DON B indicated they would not.

Based on interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R5) reviewed for dialysis. Facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis fistula site. This is evidenced by: The facility's policy titled Dialysis Services last revised on 8/2013 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: Hemorrhage from an AV access is an uncommon but potentially fatal complication if it is not recognized promptly and acted on with an appropriate intervention. Most fatal vascular access hemorrhages occur outside of the dialysis facility, but occasionally, they rupture at the dialysis unit (120). Patients and their families should be educated about the recognition and emergent management of a bleeding AV access . In the event of bleeding from vascular access site, direct continuous pressure with a finger for 15-20 minutes is the most effective method of controlling the bleeding. In the event of rupture of a PSA or aneurysm away from dialysis unit or hospital, direct pressure with a finger at the site of bleeding is the best method of controlling bleeding. Patients should be advised to continue holding direct pressure until emergency medical help arrives and avoid applying a tourniquet, towel, or BP cuff to the extremity . Diagnosis, Treatment, and Prevention of Hemodialysis Emergent .: Clinical Journal of the American Society of Nephrology R5 was admitted to the facility on [DATE] with diagnoses that include displaced comminuted fracture of shaft of right femur, malignant neoplasm of esophagus, wedge compression fracture of fourth lumbar vertebra, and type 2 diabetes mellitus with moderate NPDR (nonproliferative diabetic retinopathy (early stage of diabetic eye disease)). R5's most recent MDS (Minimum Data Set) dated 10/15/24 states that R5 has a BIMS of 12 out of 15, indicating that R5 has moderate cognitive impairment. R5's care plan initiated on 10/8/24 does not include steps for staff to take if R5 is bleeding from his dialysis fistula. R5's CNA (Certified Nursing Assistant) Kardex does not include steps for staff to take if R5 is bleeding from his dialysis fistula. On 11/5/24 at 2:25 PM, Surveyor interviewed CNA U. Surveyor asked CNA U what steps she would take if she walked in and saw a resident bleeding from their dialysis fistula, CNA U reported that she would go get the nurse. On 11/5/24 at 2:27 PM, Surveyor interviewed CNA V. Surveyor asked CNA V what steps she would take if she walked in and saw a resident bleeding from their dialysis fistula, CNA V reported that is a nurse's area. CNA V also indicated that she would make sure the resident is ok and then step out to let the nurse know. On 11/5/24 at 2:30 PM, Surveyor interviewed CNA T. Surveyor asked CNA T what steps she would take if she walked in and saw a resident bleeding from their dialysis fistula, CNA T stated that she would call the nurse via walkie talkie, make sure the resident is comfortable, and wait for the nurse. Surveyor asked CNA T how staff knows which residents are receiving dialysis, CNA T reported that there is a sheet of paper in the charting room with information on it. Surveyor asked CNA T if she knew what residents are currently on dialysis, CNA T stated no. It is important to note that CNA T was working on R5's hallway. On 11/5/24 at 3:30 PM, Surveyor interviewed LPN S (licensed Practical Nurse). Surveyor asked LPN S what steps he would take if he walked in and found a resident bleeding from their dialysis fistula, LPN S stated that he would apply pressure, notify the MD (Medical Doctor), and obtain further orders. Surveyor asked LPN S what he would expect the CNAs to do in that situation, LPN S stated that they should get one of the nurses ASAP (as soon as possible). On 11/5/24 at 3:38 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation is for CNAs if they walk into a dialysis resident's room and the resident was bleeding from their fistula, DON B reported that she would expect them to make sure the resident is safe, apply direct pressure, and call the nurse immediately. Surveyor asked DON B if she expects the CNAs to know what residents are on dialysis, DON B reported that the night shift CNAs know who they are so they can get them up and ready in the morning. Surveyor asked DON B if she expects that the CNAs know how to respond to a resident that is bleeding from their dialysis fistula, DON B stated that if it is not something that is taught in their CNA class, she can't expect them to know how to respond. They are told and advised to call the nurse right away because it is a change in condition and that's how they should respond. Surveyor asked DON B if staff is trained upon hire, DON B deferred Surveyor to RN C (Registered Nurse). Surveyor reviewed the staff training checklist that was provided; the checklist does not include education about dialysis safety. On 11/6/24 at 8:46 AM, Surveyor interviewed RN C. Surveyor asked RN C what the expectation is for CNAs that come across a dialysis patient that is bleeding from their fistula, RN C reported that the CNAs should get the nurse right away, and that she is training staff on that now. Surveyor asked RN C if she would expect the CNAs to know which residents are on dialysis, RN C stated yes. Surveyor asked RN C if the CNAs have previously been trained on what to do if a dialysis patient is bleeding out of their fistula, RN C stated no. On 11/6/24 at 10:06, DON B reported to Surveyor that she met with R5 who reported that he doesn't have a fistula, but instead has an Ellipsys device and R5 reported that he doesn't bleed. On 11/6/24 at 1:48 PM, Surveyor interviewed RN Z (dialysis center nurse). Surveyor asked RN Z to explain R5's dialysis access, RN Z stated that he has a fistula in his upper left arm and that it is called an Ellipsys. Surveyor asked RN Z if this is a new type of device, RN Z stated that it is an endo- vascular access, so instead of having a large scar and access, this is a tiny incision where they insert a catheter type of tool. RN Z stated that it is a minimally invasive process. Surveyor asked RN Z if R5 has a decreased risk for bleeding, RN Z stated that they treat it the same as a normal fistula- they hold pressure for 10-15 minutes after dialysis and tell the patient to report any bleeding; there is the same risk as any other access.

Based on observation, interview, and record review the facility failed to ensure that residents (R) receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 (R131) of 14 sampled residents. R131 voiced concern with not being able to put on her own compression stockings/TED (thrombo-embolic deterrent) hose, and that she was supposed to be wearing them daily, but that staff were not assisting her. Findings: The facility policy and procedure entitled Care Planning, created on 11/2016, with last revise date of 10/2023, states in part: Policy: . A person-centered care plan will include resident's strengths, needs/problems, personal history, and cultural preferences . Purpose: The care planning process serves as a means to identify the resident's individual needs, goals for care, and provide staff direction on resident's care . Procedure: . 2. Based on the resident's admission assessment, a baseline care plan will be developed withing 48 hours of admission. A. The baseline care plan will provide staff the necessary information to care for the resident including: . ii. Admission orders including physician orders . R131 was admitted to the facility on [DATE] with diagnoses that include fracture of Unspecified part of neck of left femur, Unspecified fracture of the lower end of left radius, Fibromyalgia, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Major Depressive Disorder, Pain in left hip, Muscle wasting and atrophy, Muscle weakness generalized, other lack of coordination, Other reduced mobility, Need for assistance with personal care. R131's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/29/24 indicates her cognition is intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. Section GG of R131's MDS indicates the following: GG G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear - Substantial Maximum Assist. GG H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Dependent on staff assistance. R131's admission physician orders, dated 10/22/24, include may remove TED hose from non-operative extremity one hour twice daily for hygiene. R131's Baseline Care Plan, created on 10/22/24, states in part: Focus: Impaired functional status related to fall with left hip fracture and left distal radial fracture with need for surgical intervention to both sites, diagnoses of fibromyalgia, insomnia, hyperlipidemia, gastro-esophageal reflux disease, diabetes type 2 with need for insulin, depression with antidepressant use, narcotic use, anticoagulant use, anticonvulsant use . Intervention: Personal Hygiene Assistance Level: Assist of 1, Grooming Assistance Level: Assist of 1, Bathing Assistance Level: Assist of 1, Toileting Assistance Level: Assist of 1 may use bedside commode . (Of note, R131's Baseline Care Plan does not include anything about the need for assistance with lower body dressing or the application of TED hose). R131's Nursing Notes state in part: -Skilled Daily Charting 10/24/24 - Edema: Yes. Wears BLE (Bilateral Lower Extremity) TEDS. -Skilled Daily Charting 10/25/24 - Edema: Yes. Wears BLE TEDS. -Skilled Daily Charting 10/26/24 - Edema: Yes. Wears BLE TEDS. -Skilled Daily Charting 10/27/24 - Edema: Yes. Wears TED stockings. -Skilled Daily Charting 10/28/24 - Edema: Yes. Non-pitting BLE. TEDs on at all times except for skin care. -Skilled Daily Charting 10/29/24 - Edema: Yes. -Skilled Daily Charting 10/31/24 - Edema: No. -Skilled Daily Charting 11/1/24 - Edema: No. -Skilled Daily Charting 11/3/24 - Edema: Yes. +1 to bilateral ankles. -Skilled Daily Charting 11/4/24 - Edema: Yes. Bilateral lower extremities 1+ edema. R131's Treatment Administration Record (TAR) states in part, may remove TED hose from non-operative extremity one hour twice daily for hygiene. Start date: 10/22/24. On 11/4/24 at 9:40 AM, Surveyor interviewed R131 who indicated that she has TED hose and that she is supposed to wear them every day. R131 stated that the staff will assist her with putting them on, but she has to ask them, and sometimes they are too busy to assist her. Surveyor observed that R131's TED hose were not on at this time. (Of note, facility staff were marking removal of TED hose as being completed, twice daily at 6:00 AM and 4:00 PM every day, even when R131 was not wearing her TED hose). On 11/5/24 at 1:29 PM, Surveyor interviewed CNA X (Certified Nursing Assistant). Surveyor asked CNA X how she was made aware of resident care needs. CNA X stated that she uses the Kardex and care cards, which are located in a binder at the Unit Clerk desk. Surveyor asked CNA X what personal cares she had provided for R131 today. CNA X stated that R131 got herself dressed today and that R131 probably put on her TED hose herself. CNA X said the care cards are updated daily. Surveyor reviewed the care card with CNA X, which did not indicate the need for R131 to have assistance with dressing, or assistance with applying TED hose. On 11/5/24 at 1:40 PM, Surveyor interviewed R131, and observed R131 sitting up in her chair, dressed, with socks and shoes on but not wearing her TED hose. Surveyor asked R131 if she got herself dressed today. R131 replied that staff had assisted her, and this was the first day since she was admitted that they helped her put on her socks and shoes. Surveyor asked R131 if she was able to put on her own TED hose, as staff had suggested. R131 held up her left arm that was in a cast and stated that she is unable to put on TED hose herself with two good hands, let alone one. R131 then pointed to her dresser, where Surveyor observed her TED hose sitting on top of the dresser. On 11/5/24 at 3:41 PM, Surveyor interviewed CNA V. Surveyor asked CNA V how she was made aware of the level of assistance that residents needed. CNA V replied she would look at the care card in the binder at the Unit Clerk desk. Surveyor asked CNA V what help R131 would need from staff. CNA V stated that R131 needs one assist from staff for dressing. Surveyor asked CNA V if R131 required assistance putting on TED hose. CNA V replied she wasn't sure, but that it should say on the care card if she had TED hose. On 11/5/24 at 3:48 PM, Surveyor interviewed LPN S (Licensed Practical Nurse) about R131's care. LPN S stated that R131 wears some kind of compression stocking, but he would have to check the order. LPN S left to check R131's physician orders and returned to say that R131's order stated she is to always wear TED stockings and can remove twice a day for cares. Surveyor asked LPN S who was responsible for assisting residents with putting on and removing their TED hose. LPN S replied the CNAs put them on but ultimately the nurse is responsible for checking to ensure that they are on per physician order. On 11/6/24 at 8:47 AM, Surveyor interviewed CNA Q. Surveyor asked her if R131 wore TED hose. CNA Q replied she did not think R131 wore TED hose, and that when she has assisted R131, she did not put them on or take them off. Surveyor asked CNA Q how a resident's need for TED hose assistance should be conveyed to staff. CNA Q said it would be listed on the CNA care cards, which are updated daily. On 11/6/24, Surveyor interviewed DON B. Surveyor asked DON B (Director of Nursing) how staff are to know what type of care and assistance the residents require. DON B replied that the binder at the Unit Clerk's desk is where they keep that information, and they would also get it in shift-to-shift report. DON B indicated these care cards are updated each night and printed out and put in the binder for the CNAs. DON B stated it was her expectation that staff would refer to the Kardex and care cards in the white binder to know how to provide the proper cares for the residents. Surveyor asked DON B if aides were trained on how to apply TED hose. DON B stated yes, they were trained on TED hose by their preceptors. Surveyor asked DON B how she monitored staff to ensure that they were implementing the care plan. DON B replied that the aides follow the task list in Point Click Care (PCC). Surveyor asked DON B what kind of staff assistance was required to care for R131. DON B referred to PCC and replied that R131 was an assist of one staff for cares. Surveyor asked DON B if R131's MDS indicated that she was a maximum assist for lower body dressing, would that include help with TED hose. DON B stated she would have to check on that, but she did expect staff to follow the Kardex. (Of note, R131's Kardex and CNA care card did not include anything about the need for assistance with lower body dressing or the application of TED hose). Per R131's plan of care the facility had an order for continual wearing of TED hose with removal twice daily for personal hygiene, yet this was not being followed. Facility staff were marking on the TAR the removal of the TED hose, but there was no consistent evidence, per observations and interviews, that the TED hose was even being put on by staff or that they were aware of her need for assistance with TED hose. R131 voiced concerns over not wearing her TED hose and the inability to put them on herself. R131 was not receiving the services dictated in her plan of care.

Based on observation, interview, and record review, the facility did not ensure residents were being offered nourishing snacks at bedtime daily when there is more than 14 hours between a substantial evening meal and breakfast the following day. This has the potential to affect 31 of 31 residents and 4 of 4 units. R14, R19, R2, R15, and R135 voiced concerns that residents were not consistently being offered a snack at bedtime. There was more than 14 hours between the evening meal and breakfast that facility staff were not offering snacks to all residents. This is evidenced by: The facility policy, entitled Meal Service, dated 8/23, states in part, .Resident (meal) service begins at the following times: breakfast 7:45 AM, dinner 11:45 AM, supper 4:45 (PM) . (It is important to note there is 15 hours between the substantial evening meal and breakfast.) The facility policy, entitled Nourishment/Supplement dated 1/20, states in part, It is the policy of the company that snacks will be offered per resident choice and per their careplan. The type of snack offered will depend on the individual resident's diet and/or texture restrictions and nutritional needs. Resident's may request, and will be provided, a snack at any time unless contraindicated . Purpose: To offer additional food and fluids with between-meal servings. To provide special nourishments to residents with decreased appetite, weight loss or special medical conditions. To offer nutritional snacks at times other than regular mealtimes that accommodate resident choices . Example 1 R14 was admitted to the facility on [DATE], and has diagnoses that include: type 2 diabetes, vitamin D deficiency, and chronic kidney disease. R14's Minimum Data Set (MDS) quarterly assessment, dated 9/1/23, indicates that R14 has a Brief Interview for Mental Status (BIMS) score of 11 indicating that R14's cognition is intact. R14's MDS annual assessment, dated 6/5/23, Section F0400 indicates that it is somewhat important to R14 to have snacks available between meals. On 10/5/23 at 8:25 AM, Surveyor interviewed R14 regarding nourishing snacks offered at bedtime. R14 indicated that she is not offered a snack from facility staff before bedtime. R14 indicated that she would like to be offered snacks at bedtime daily. Example 2 R19 was admitted to the facility on [DATE], and has diagnoses that include: protein-calorie malnutrition, anemia (iron deficiency,) and chronic kidney disease. R19's MDS admission assessment, dated 9/6/23, indicates that R19 has a BIMS score of 13 indicating that R19's cognition is intact. Section F0400 indicates that that it is very important to R19 to have snacks available between meals. On 10/5/23 at 9:13 AM, Surveyor interviewed R19 regarding nourishing snacks offered at bedtime. R19 indicated that she is not offered a snack from facility staff before bedtime. R19 indicated that she does not recall facility staff offering her a snack at bedtime since her admission. R19 indicated that she would like to be offered snacks at bedtime daily. Example 3 R2 was admitted to the facility on [DATE], and has diagnoses that include anemia and chronic kidney disease. R2's MDS quarterly assessment, dated 9/8/23, indicates that R2 has a BIMS score of 14 indicating that R2's cognition is intact. On 10/5/23 at 9:26 AM, Surveyor interviewed R2 regarding nourishing snacks offered at bedtime. R2 indicates that she is offered a snack from facility staff before bedtime twice a week. R2 indicated that she would like to be offered snacks at bedtime daily. Example 4 R15 was admitted to the facility on [DATE] and has diagnoses that include: congestive heart failure, end stage renal disease, celiac disease, anemia, type 2 diabetes, vitamin D deficiency, and chronic kidney disease. R15's MDS admission assessment, dated 8/4/23, indicates that R15 has a BIMS score of 15 indicating that R15's cognition is intact. On 10/5/23 at 9:38 AM, Surveyor interviewed R15 regarding nourishing snacks offered at bedtime. R15 indicated that she was offered a snack once since her admission to the facility. R15 indicated that facility staff never comes around in the evenings and offers snacks to her. R15 indicates that her family is providing her with snacks. Surveyor asked R15 how often she would prefer to be offered a snack at bedtime by facility staff, R15 indicated every day. Example 5 R135 was admitted to the facility on [DATE], and has diagnoses that include: malignant neoplasm (cancer) of prostate, malignant neoplasm of bone, moderate protein-calorie malnutrition, muscle wasting and atrophy (progressive and degeneration or shrinkage of muscles or nerve tissues), anemia, and abnormal weight loss. R135's MDS quarterly assessment, dated 9/21/23, indicates that R135 has a BIMS score of 14 indicating that R135's cognition is intact. Section F0400 indicates that it is somewhat important to R135 to have snacks available between meals. On 10/5/23 at 9:18 AM, Surveyor interviewed R135 regarding nourishing snacks offered at bedtime. Surveyor asked R135 if facility staff is offering him a snack at bedtime. R135 stated, Sometimes. R135 indicated that he asks facility staff for an evening snack when he wants a snack. R135 stated, I like OJ (orange juice) routinely in the evenings. R135 indicated that staff is not offering OJ to him in the evenings/bedtime. R135 indicated that he would like to be offered snacks including his preferred glass of OJ at bedtime daily. On 10/5/23 at 11:10 AM, Surveyor observed facility's kitchenette to be stocked with nourishing snacks including, but not limited to, pudding, applesauce, yogurt, hard boiled eggs, tuna sandwiches, fruit cups, ice cream, sherbert, chex mix, milk, and juices. On 10/5/23 at 2:48 PM, Surveyor interviewed CNA P (Certified Nursing Assistant) regarding nourishing snacks offered at bedtime. CNA P has worked at the facility going on 2 years. CNA P was unable to recall a training process for an evening snack pass offering residents a nourishing snack at bedtime during this time. CNA P indicated that he offers snacks to resident that are not eating well. Surveyor asked CNA P if he is offering snacks to all residents? CNA P stated, Depending on the day, I get so busy, it gets to be hard. We try our best, at the end of the day some things fall short. On 10/5/23 at 1:12 PM, Surveyor interviewed CNA Q regarding nourishing snacks offered at bedtime. Surveyor asked CNA Q what the facility process is for offering snacks at bedtime? CNA Q indicated that snacks are offered to residents that didn't eat well, if a resident requests a snack, or if there is a snack order, the facility will offer resident snacks at the time the order specifies. CNA Q stated, There is no set time that we pass snacks. On 10/5/23 at 1:25 PM, Surveyor interviewed CNA S regarding nourishing snacks offered at bedtime. CNA S has worked at the facility for one and a half weeks. CNA S stated, I haven't had official training for a snack pass. On 10/5/23 at 2:34 PM, Surveyor interviewed CNA E regarding nourishing snacks offered at bedtime. CNA E indicated that he has worked at the facility for two years on the PM shift 2 PM-10 PM. CNA E indicated that if a resident asks for a snack, he provides residents with snack. CNA E stated, I don't offer residents a snack. Surveyor asked CNA E if he has received education or training on a snack pass process at bedtime? CNA E indicated that no training or education was provided. CNA E stated, I have never offered a snack. Surveyor asked CNA E if he offers diabetic resident a snack at bedtime? CNA E stated, We don't. On 10/5/23 at 3:06 PM, Surveyor interviewed LPN T (Licensed Practical Nurse) regarding nourishing snacks offered at bedtime. LPN T stated, I don't think that we have a scheduled snack routine. Surveyor asked LPN T if residents should be going 15 hours without a nourishing snack? LPN T indicated that a nourishing snack with proteins and carbs (carbohydrates) should be provided to diabetic residents to keep sugar levels up and prevent crashes. On 10/5/23 at 3:14 PM, Surveyor interviewed LPN F regarding nourishing snacks offered at bedtime. LPN F indicate that she has worked the PM shift at the facility for [AGE] years. LPN F indicated that facility staff does not pass snacks after supper. LPN F indicated that there is 15 hours in between supper and breakfast, and residents should be offered snacks at bedtime, especially diabetics. Surveyor asked LPN F why it is important to offer diabetic residents a snack, LPN F stated, Diabetic resident could crash without snack. On 10/5/23 at 3:37 PM, Surveyor interviewed DON B (Director of Nursing) regarding nourishing snacks offered at bedtime. Surveyor asked DON B what the process is for snack pass at the facility? DON B indicated that nursing staff request snacks as needed from the dietary department. The dietary staff stocks the kitchenette with snacks. DON B indicated that there is not designated staff responsible to pass snacks at bedtime. DON B stated, We don't have a lot of people who request snacks or have (eat) snacks. Surveyor asked DON B when PM snack should be passed? DON B indicated when a resident is a brittle diabetic. Surveyor asked DON B if she expects residents to go 15 hours without being offered a snack? DON B stated, If they are not hungry, I don't expect snacks to be offered. On 10/5/23 at 4:04 PM, Surveyor interviewed RD U (Registered Dietician) regarding the facility bedtime snack program. RD U indicated that when there is more than 14 hours in between mealtimes, a snack needs to be offered to residents. RD U indicated that the dietary department stocks the kitchenette with nourishing snacks and provides residents with the Always Available menu upon admission. The facility did not ensure residents were being offered nourishing snacks at bedtime daily when there is more than 14 hours between a substantial evening meal and breakfast the following day.

Based on interview and record review, the facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for 1 of 13 residents (R181) reviewed for code status. R181's most current code status preference form documents I do want CPR . (Cardiopulmonary Resuscitation, Full Code status) and his code status physician order and banner in the Electronic Health Record (EHR) indicate Do Not Resuscitate (DNR); these do not match. This is evidenced by: The Facility's Policy and Procedure titled Cardiopulmonary Resuscitation (CPR) - SNF (Skilled Nursing Facility), approved ,d+[DATE], documents, in part: .Procedure .2. Upon admission to the facility, admission orders will be completed including the patient's wishes as expressed in their Advanced Directives or POLST (Physician Orders for Life Sustaining Treatment) and resuscitation status .4. The resident's Advance Directives and related physician's orders will be reviewed quarterly at the resident's Care Conference or upon significant change in condition. Resident and/or their legal decision-maker shall be asked whether the current orders are consistent with the resident's wishes. If changes or clarifications are requested, the attending physician shall be contacted to update orders to reflect such changes. Any changes shall be clearly documented by completion of a new POLST or Advanced Directive . R181 admitted to the facility on [DATE] and has an activated Power of Attorney for Health Care (POAHC). During the initial screening process of the survey, Surveyor reviewed the paper chart and electronic health record for R181. The [Facility Name] Resident Advance Directive Regarding Cardiopulmonary Resuscitation form in the resident's paper chart notes a typed x slightly outside of the box next to I do want CPR. The form is electronically signed by R181's activated power of attorney FM I (Family Member) on [DATE]. Of note, no time is listed. The form is also signed by a witness and the provider on [DATE] with no times listed. The Physician Orders and the banner in the facility's EHR indicate R181's code status as DNR. On [DATE] at 9:25 AM, Surveyor interviewed RN N (Registered Nurse) and asked where she would you look for a resident's code status. RN N indicated she would look on the face sheet in the EHR, the banner in the EHR or in the chart in the nurse charting room that has the code status form. Surveyor asked RN N where the first place she would look for code status is. RN N indicated the easiest place would be the chart in the charting room because that would have the signed sheet for code status. Surveyor requested RN N to look at R181's code status. RN N opened R181's EHR chart on her computer at her cart and indicated that R181's Advanced directive on his face sheet says DNR, the banner indicates DNR and RN N stated that DNR means do not resuscitate and so that means not to start CPR. On [DATE] at 9:45 AM, Surveyor interviewed RN D and asked where he would look for a resident's code status. RN D indicated, he looks in the computer underneath their banner or on the face sheet in the chart. Surveyor asked where he would look first. RN D indicated, probably the computer but really it depends on where I am in the building; for example, if I'm closer to the chart I would go there, if closer to the computer I would look there. Surveyor reviewed R181's DNR status in the banner of the electronic health record with RN D and asked what he would do if he saw this status. RN D indicated, it says DNR, so I would not start CPR. On [DATE] at 9:32 AM, Surveyor interviewed SDN O (Staff Development Nurse) and asked where she would look for a resident's code status. SDN O indicated, mainly in Electronic Health Record on the banner. Surveyor asked SDN O if this is the first-place staff should look. SDN O indicated it is the easiest because it's right there in the computer, otherwise in the chart on the face sheet. Surveyor asked SDN O who goes through the code status with residents/representatives on admission. SDN O indicated any of the admission nurses. Surveyor asked SDN O if she completes this. SDN O indicated, yes. Surveyor asked SDN O to review the process of code status with new admissions. SDN O indicated, they explain the form and what it means to be a full code versus a DNR. The form is filled out right there and then the form is signed by the provider if they are on site. Otherwise, when the doctor is called with the admission, we get the order with the other orders or other clarifications that are needed. We would write as a phone order or fax to get signature. Surveyor asked SDN O who is responsible for putting the code status in the different places. SDN O indicated when orders are put in the system, it flags into the banner. Whoever is checking off the orders makes sure there is a code status, and the unit clerk scans in all the paperwork. Surveyor asked SDN O who makes sure that the signed CPR/DNR form matches the order in the electronic health record. SDN O indicated, usually the HUC (Health Unit Coordinator) puts in the initial orders and then a nurse checks them off to ensure they are correct. Surveyor clarified with SDN O, the person checking the orders after the HUC should verify the code status form is the same and the orders that were put in the electronic health record. SDN O indicated, right, one nurse checks the orders after the HUC. On [DATE] at 9:40 AM, Surveyor interviewed MI/Coder M (Medical Information/Coder) and asked what the process is for new admissions and orders. MI/Coder indicated, when we get the signed orders from the hospital, basically we enter them in the electronic health record and then we let the nurse managers, or whoever is going to be doing the second look to sign them off, know and they will come and get the chart and get the second look and sign them off. Surveyor asked MI/C if she double checks the code status form that is filled out on admission with the orders, she puts in. MI/Coder M indicated this is done by the nurse. On [DATE] at 10:59 AM, Surveyor interviewed DON B (Director of Nursing) and asked who is responsible for obtaining the code status and having the form signed. DON B indicated when the facility gets the admission, the HUC or a nurse will put in the first orders and then it's double checked by one of the nurse supervisors or myself. The RCM (Resident Care Manager) also helps with check offs. If we notice we don't have orders for a DNR then we reach out to the provider, get the order, and put it in the computer. Surveyor asked DON B who checks the code status from the paper form matches the electronic health record. DON B indicated, either the nursing supervisors or myself, whoever puts them in, then a second person checks them. Surveyor asked DON B, once you have the code status, what is the process for getting the order into the electronic health record. DON B indicated, the nursing supervisors. The HUC is usually the first line person and then it is checked by a RN. Surveyor asked DON B if the HUC is putting in the orders from the hospital. DON B indicated, yes. Surveyor asked DON B if the HUC is checking the signed code form against the order. DON B indicated this would be done by the nurse. Surveyor showed DON B R181's facility code form that has the x marked just outside the box that indicates, I do want CPR, and his banner and physician orders currently in the electronic health record that show DNR. DON B indicated agreement that they did not match. DON B indicated that AA/QA J, (Admissions Assistant/Quality Assurance) in admissions, sent the form to R181's daughter, who is the POA, through the computer so she is the one who marked the form and sent it back. Surveyor asked DON B who would have been responsible for checking the form against the physician orders when it was received back. DON B indicated, the nurse but that she didn't see any initials on the form and usually there would be initials once it is checked by the nurse. DON B continued, when the daughter sent it back it would have gone to AA/QA J, and she would have printed it off. Surveyor asked DON B what AA/QA J should have done with the form when she received it. DON B indicated she should have given it to the HUC since it is an actual order. On [DATE] at 12:59 PM, Surveyor interviewed AA/QA J and asked if she sent the facility Resident Advanced Directive Regarding CPR form to R181's daughter AA/QA J indicated, yes and that an electronic document/signature program was used to send it. Surveyor asked AA/QA J if when the document is sent this way, it makes the document fillable. AA/QA J indicated, yes. Surveyor asked AA/QA J if the document was returned to her. AA/QA J checked the document program and indicated that the form was sent back to her and that she sent it to HUC L (Health Unit Coordinator), the upstairs HUC and that it was forwarded on [DATE] at 2:40 PM. Surveyor asked AA/QA J if she is only responsible for forwarding the document on. AA/QA J indicated, yes. On [DATE] at 1:11 PM, Surveyor interviewed HUC L and asked what she does with the facility labeled Resident Advance Directive Regarding CPR form when it is sent to her filled out. HUC L indicated, she makes sure it is complete, prints them, scans them into the system, and she usually looks to see that there is an order because it's usually already been put in. Surveyor asked HUC L, if she is responsible for making sure the order that is in the electronic health record matches what is on the form. HUC L indicated, yes. Surveyor asked HUC L what she does if it doesn't match. HUC L indicated that she gives it to the nurse manager. Surveyor asked HUC L what she does if the form does match the order in the system. HUC L indicated if it matches it is just scanned into the system. Surveyor asked HUC L if she could recall receiving or what she did with the facility form for R181. HUC L indicated, she could not recall. On [DATE] at 1:19 PM, Surveyor interviewed R181's RCM V and asked if she recalled anyone giving her R181's facility labeled Resident Advance Directive Regarding CPR form and telling her that the code status listed did not match what was in the electronic health record. RCM V indicated her understanding was that they had a state DNR form for R181. On [DATE] at 11:21 AM, Surveyor contacted FM I (Family Member) via telephone and asked if she recalled the facility talking with her about a code status form where it says I do want CPR, I do not want CPR. FM I indicated she did recall this and that do not want CPR should have been marked. On [DATE] at 11:48 AM, MDS Coordinator K (Minimum Data Set) came to the conference room to speak to surveyor. MDS Coordinator K showed surveyor a WI State DNR form that indicates R181's code status as DNR. The form is signed by FM I and includes a date and time by FM I's signature of [DATE] at 11:18 AM. This form is also signed by a provider on [DATE]. Of note, no time is documented by the provider signature. MDS Coordinator K indicated that on [DATE] when R181 was admitted she called FM I and let her know that he was here and confirmed his DNR status. MDS Coordinator K provided a progress note dated and timed [DATE] at 12:49PM that includes, in part, .Did confirm that DNR status was desired. Of note, the facility Advanced Directive Form that has I do want CPR marked is dated [DATE] with no time. The interview with AA/QA J indicated that she forwarded the signed from she received from FM I to the upstairs HUC on [DATE] at 2:40 PM. Surveyor put the facility form which indicated, I do want CPR, and the state DNR form she provided next to each other and asked MDS Coordinator K how the nurses on the floor would know which form to use for code status. MDS Coordinator K indicated she would use what was in the banner in the electronic health record. The facility had an unrecognized discrepancy between R181's code status between the paper forms and the electronic health record.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication rates of five percent or greater for 2 residents (R3 and R2) of six residents observed during medication pass. The facility had 28 opportunities and 2 medication errors resulting in 7.14% error rate. R3 has Physician Orders to receive Carvedilol with meals for hypertension. Surveyor observed RN C (Registered Nurse) administer R3's Carvedilol before the evening meal. This resulted in a medication timing error. R2 has Physician Orders to receive Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop into both eyes as needed for dry eyes admin QID prn (4 times per day as needed). Surveyor observed RN D (Registered Nurse) complete his checks during medication pass and voiced he was ready to administer medications. R2's artificial tears were expired. Evidenced by: The facility's policy, Medication and Treatment Administration, revised 1/2020, indicates, in part, the following: It is the policy of the Company that administration standards for the delivery of medications and treatments will be adhered to by all staff responsible for providing these services. Medications and treatments shall be administered as prescribed. The Seven Rights of medication administration shall be observed. i. Right Resident, ii. Right Drug, iii. Right Dose, iv. Right Time, v. Right Route, vi. Right Manufacturer/Pharmacy Recommendations/Right Documentation i.e give with food. vii. Right Documentation Example 1 R3's hospital admission orders, signed 10/3/23, indicate the following: 6.25 mg (milligrams) - Give 1 tablet by mouth with meals for HTN (hypertension). R3's Carvedilol blister pack indicates administer with morning and evening meal On 10/3/23 at 4:08 PM, Surveyor observed RN C (Registered Nurse) administer R3's Carvedilol. Dinner is served on R3's floor between 5:00 - 5:30 PM. The Carvedilol was not administered with a meal and was given approximately 50 minutes - 1 hour 20 mins before R3 would receive dinner. This resulted in a timing error. On 10/3/23 at 4:36 PM, Surveyor reported this medication error to DON B (Director of Nursing). On 10/5/23 at 10:54 AM, Surveyor spoke with DON B (Director of Nursing). DON B stated, after we spoke regarding the medication error on 10/3/23, she checked with R3 to see if he had any chest pain or shortness of breath. DON B stated, R3 stated, no. R3 voiced to DON B that he normally takes his Carvedilol with a meal when at home. DON B stated, dinner isn't served until 5:00-5:30 PM. DON B stated she changed his order to 9:00 AM (breakfast is served around 8:30 AM) and 6:00 PM that way he can take it with food. Surveyor asked DON B, would you expect R3's Carvedilol to be administered with food per the Physician Order and pharmacy recommendation. DON B stated, I would expect it was administered at supper time (clarified with the meal.) DON B stated, RN C told her it was within 1 hour before 1 hour after, however, that's not how the order is written. DON B stated, she checked with the Pharmacist and she said it should be given with food. Example 2 R2 has Physician Orders to receive Artificial Tears Opthalmic Solution (Artificial Tear Solution) Instill 1 drop into both eyes as needed for dry eyes admin QID prn (4 times per day as needed). On 10/4/23 at 8:59 AM, Surveyor observed RN D (Registered Nurse) prepare R2's morning medications and Goodsense Artificial Tears. R2's Goodsense Artificial Tears have an Opened 9/1/23 documented and Expiration 10/1/23 documented. Surveyors observed RN D (Registered Nurse) lock his cart, pick up all medications including the eye drops, and turned to walk towards R2's room. Surveyor asked RN D if he is ready to administer R2's medications. RN D stated, Yes. Surveyor asked RN D, are R2's Goodsense Artificial Tears expired. RN D looked at the eye drops/label stated, Yes. RN D stated he will need to order new eye drops as the facility does not keep them on hand. RN D stated he should not administer expired medications. On 10/5/23 at 10:54 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if she expects staff to follow Physician Orders. DON B stated, yes. Surveyor asked DON B, should staff check medication expiration dates to confirm they are not administering expired medication. DON B stated, yes.

Based on interview and record review, the facility did not ensure that they had all assessments and behavioral interventions in place for 1 of 5 residents reviewed for unnecessary medications out of a total sample of 16 Residents (R133). R133 does not have resident-centered behaviors for the Certified Nursing Assistants (CNA) staff to monitor. R133 receives antipsychotic medication and does not have an assessment for tardive dyskinesia AIMS (Abnormal Involuntary Movement Scale) or Discus. R133 receives medication for insomnia and does not have a sleep assessment completed. This is evidenced by: The Facilities Policy and Procedure entitled Psychotropic Medication Management dated 10/2023, documents, in part: .To ensure that resident drug regimen is free from unnecessary drugs. An unnecessary drug is any drug when used .without adequate monitoring .A psychotropic drug is any drug that affects the brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: - Anti-psychotic, -Anti-depressant, - Anti-anxiety, and - Hypnotic .1. Indications for Use of Psychopharmacological Medications .k. Set up a monitoring system. 2. Monitoring for Efficacy and Adverse Consequences .f. For Antipsychotics: Abnormal Involuntary Movement Scale (AIMS) form will be completed upon initiation of therapy and every six months thereafter. g. Antipsychotic/Anxiolytics/sedatives/Hypnotics/ Antidepressants and other psychopharmacological drugs: Behavior assessment and monitoring of target behavior and monitoring for side effects will be completed during the duration of therapy .d. New Admissions .2. For residents who do not require a PASARR (Preadmission Screening and Resident Review- is a federal requirement established to identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement in the community or a nursing facility) screening and are admitted on an antipsychotic medication, the facility must re-evaluate the use of the antipsychotic medication at the time of admission and/or within 2 weeks of admission (at the time of the initial MDS) (Minimum Data Set- which is a comprehensive assessment of the resident)) and consider whether or not the medication can be reduced or discontinued . [SIC] R133 admitted to the facility 9/18/23 for short term rehabilitation. R133 has the following diagnoses that support the use of the psychotropic medications he is prescribed: bipolar disorder, major depressive disorder, anxiety, and insomnia. R133 receives the following psychotropic medications: buspirone 15 mg (milligrams) BID (twice a day), clonazepam 0.5 mg 2 tabs QHS (every bedtime), desvenlafaxine succinate ER (extended release) 50 mg QD (every day), olanzapine 15 mg QHS, olanzapine 2.5 mg with meals (TID- three time per day), and paroxetine HCL (hydrochloride) ER 15 mg QD. Buspirone is classified as an anti-anxiety medication. Clonazepam is classified as a benzodiazepine medication which is approved to treat anxiety. Desvenlafaxine succinate ER is classified as a SNRI (serotonin and norepinephrine reuptake inhibitor) which is a type of anti-depressant medication. Olanzapine is classified as an anti-psychotic medication. Paroxetine HCL ER is classified as a SSRI (selective serotonin reuptake inhibitor) which is a type of anti-depressant. Example 1 R133's care plan includes the following targeted behaviors to monitor for the medications that he receives: anxiety/nervousness, insomnia/inability to sleep, and restlessness/agitation. R133's CNA (Certified Nursing Assistant) care plan does not list any type of behaviors to monitor for. R133's CNA documentation in the computer under the Task section includes an array of behaviors (i.e., hitting, kicking, biting, etc.) that are not resident specific, therefore, the CNA's do not have an area to document resident specific behaviors. R133 receives anti-psychotic medication, Olanzapine, and has not had an assessment (AIMS or Discus) for tardive dyskinesia. It is important to note this is to be assessed on admission to obtain a baseline and then every six months thereafter. R133 receives medications at bedtime that are not classified as hypnotic medication but are being utilized to treat his insomnia, and he has not had a sleep assessment. It is important to note this too should be assessed on admission to obtain a baseline and then quarterly with MDS. On 10/5/23 at 4:25 PM, Surveyor interviewed CNA E (Certified Nursing Assistant) Surveyor asked CNA E how they know what behaviors to report for R133, CNA E said he doesn't have behaviors, he's been really good so far, no problems. Surveyor asked CNA E how she would know what behaviors to monitor for individual residents, CNA E replied we can tell they're agitated or something. On 10/5/23 at 4:17 PM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F how the CNA's know what behaviors to report to the nurse for R133, LPN F replied he doesn't have any behavior issues, has bipolar, never see behavior issues. Surveyor asked LPN F who completes the tardive dyskinesia assessments for residents on antipsychotic medications, LPN F said nurses do the assessment, everyday each shift charts, it alternates odd and even rooms. Surveyor asked LPN F who completes the sleep assessment or sleep diary for residents receiving medications to induce sleep, LPN F stated the night shift nurse. On 10/5/23 at 4:22 PM, Surveyor interviewed LPN G. Surveyor asked LPN G how the CNA's know what behaviors to report to the nurse for R133, LPN G stated I've not seen any behaviors. Surveyor asked LPN G who completes the tardive dyskinesia assessments for residents on antipsychotic medications, LPN G said the MDS coordinator. Surveyor asked LPN G who completes the sleep assessment or sleep diary for residents receiving medications to induce sleep, LPN G replied staff monitor his sleep at night, will document hours he slept when the EMR (Electronic Medical Record) asks for it. On 10/5/23 at 4:25 PM, Surveyor interviewed LPN H. Surveyor asked LPN H how the CNA's know what behaviors to report to the nurse for R133 or other residents, LPN H explained there's a behavior report, in general if a resident is having behaviors, they would report them to the floor nurse. The CNA's have a spot in their charting where it talks about behaviors, and it would get charted there also. Surveyor asked LPN H who completes the tardive dyskinesia assessments for residents on antipsychotic medications, LPN H said usually the Social Worker does that. Surveyor asked LPN H who completes the sleep assessment or sleep diary for residents receiving medications to induce sleep, LPN H stated the CNA's chart every shift how many hours they slept that shift. Surveyor asked LPN H who is responsible to review the hours/documentation that the CNA's record, LPN H stated we have weekly meetings as part of the behavior meetings, sleeping medications are looked at during that meeting. On 10/5/23 at 4:40 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how do the CNA's know what behaviors to report to the nurse for R133 or other residents, DON B explained that the CNA's have a task that is assigned for them to do, we do huddles that we just started this week - a group huddle at the beginning of the shift to monitor for behaviors or changes, as well as a communication tab (i.e. UTI (urinary tract infection signs/symptoms)) that the nurses and CNA's are required to read. Surveyor asked DON B should an assessment for tardive dyskinesia be completed for residents that are on antipsychotic medications, DON B said yes, on admission, with change of condition, with a decrease/increase in medication, and with MDS schedule. Surveyor asked DON B should a sleep assessment be done for residents that are receiving sleep inducing medications, DON B replied anyone who has an initial diagnosis of insomnia or medications that state insomnia or if noticing any trends during the night- like they're up during the night to rule out delirium. Surveyor asked DON B if that should be documented somewhere, DON B said under nursing assessments in EMR. Surveyor asked DON B how often the sleep assessment/diary should be done, DON B replied when we have a new admission; I would need to refer to the Policy and Procedure to be sure but initially, then probably 30 days after because after 30 days a resident has become long term, with change of condition, and with change in medication. Surveyor asked DON B to open up R133's record; Surveyor then asked DON B if he has a sleep assessment, DON B stated no he doesn't have one. Surveyor asked DON B if R133 should have an assessment for tardive dyskinesia, DON B stated yes, it should be under the misc. tab in the EMR. Surveyor asked DON B who is responsible for doing the tardive dyskinesia assessment (AIMS or Discus), DON B said their pharmacist, who has been off at a conference. Surveyor asked DON B who is responsible for the tardive dyskinesia assessment to be done in the Pharmacists absence, DON B said we would need to find someone who could. Surveyor asked DON B if R133 should have an assessment for tardive dyskinesia, DON B stated yes. Surveyor asked DON B if R133 should have a sleep assessment, DON B said if he has diagnosis of insomnia or is on a medication for sleep, then yes, he would need one.

Based on interview and record review, the facility did not ensure that the resident's physician was consulted when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 35 residents (R1.) R1 had a change of condition during the night shift on 3/29/23 following a fall that occurred on the late afternoon of 3/28/23. The facility did not consult R2's physician in a timely manner. This is evidenced by: The facility policy entitled, Change in Condition, with revision date of 6/21, states, in part: . PROCEDURE: . The Licensed Nurses will notify the physician, the resident and or resident's responsible party when there is a change of condition and will document such notification in the health record . .following examples of (but not limited to) changes in condition: 1. Any significant change in resident's vital signs . 7. Complaints of pain, or any change in pain level . 9. Any injury resulting from incident, accident, or error. The facility policy entitled, Physician Services, dated 1/20, states, in part: POLICY: .The medical care of each resident is supervised by a physician and physician services must be available 24 hours a day. If an emergency occurs and the personal physician or NP (nurse practitioner) is unavailable, the facility will secure medical care from the alternate physician, Medical Director, or an Emergency Physician Call List. If a physician cannot be reached in a timely manner, and the resident's needs are urgent and immediate, 911 will be called . The physician or NP shall be alerted by the facility of changes in condition and changes in level of care required . Per AMDA (American Medical Directors Association) guidelines, it states, in part: .an ACOC (acute change of condition) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death .When reporting information to a practitioner about a patient's condition, a nurse should not assume that the practitioner knows the patient well or can remember relevant details such as previous lab abnormalities or the patient's current medication regimen .Examples of Staff Roles and Responsibilities in Monitoring Patients With ACOCs .Staff nurse *Recognize condition change early, *Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms, *Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame, *Report patient status to practitioner as appropriate . R1 was admitted to the facility on [DATE], following hospitalization for a fractured left hip from a fall that occurred at her residence at an assisted living facility. R1's diagnoses include: fracture of unspecified part of neck of left femur, presence of artificial left hip joint, history of falling, and Alzheimer's disease with late onset. R1's progress notes: On 3/28/23 at 7:17 PM, notes document: Resident was found in her room sitting on the floor beside the bathroom, she self-transferred from the room recliner. Complaints of L (left) elbow pain, ROM (range of motion) WNL (within normal limits), ice applied to L elbow and prn (as needed) pain med given. MD (medical doctor) and daughter notified. Will update MD tomorrow if pain does not improve or worsens. On 3/29/23 at 4:42 AM, it documents: CNA (certified nursing assistant) noted, and writer assessed resident's right hip. Noted bruise dark purple in color 9cm (centimeters) x 1cm. Resident with onset of increased pain in right hip with movement. Due to resident's cognitive ability, she is unable to articulate exact location of pain, but gently ROM (Range of Motion) to right leg and resident was moaning with pain. Call placed to resident's APOA (activated power of attorney) at this time to update. (Important to note: Note does not mention MD updated, only APOA at this time.) On 3/29/23 at 5:25 AM, it documents: Call placed and spoke with resident's daughter emergency contact #2 as unable to reach her daughter (APOA). Updated on call to (Clinic Name) and that they will update PCP (primary care physician) with a call expected when the clinic opens. Important to note facility left message with triage nurse at clinic and did not consult with an on-call physician. MD has not been updated. Change in condition noted at 4:42 AM. On 3/29/23 at 5:30 AM, it documents: Subject: Change in Condition: Post PM fall: - new onset of right hip pain with right hip bruise - follow up. Call placed to clinic Clinic-Triage Nurse updated on residents change of condition, new onset of pain to right hip area and right hip bruise this shift. Updated that family would prefer that resident have an x-ray here if one is ordered - Nurse stated she would send this message to the PCP (Primary Care Provider), and they will call when the clinic opens at 8 am. Important to note: Facility updated a triage nurse not a physician, and triage nurse to give message to a physician when clinic opens at 8 AM. On 3/29/23 at 9:48 AM, it documents: Type: Change of Condition Note. Writer came in to assess pt. (patient) around 6:30 AM this morning and pt. was moaning and groaning throughout the whole interaction. Writer asked pt. where it hurt and pt. would not respond, she mumbled here and there only and was unable to have a conversation w/ (with) writer. Writer noted continued bruising to pt.'s R (right) hip and intact dressing to pt.'s L hip w/no drainage. CNA then collected pt.'s vitals and it was noted her O2% (oxygen) was only steady between 89 - 90%, all other VSS (vital signs stable). Writer applied 1.5L (liters) of O2 on pt. and got her saturation up to 92%. Writer then called clinic at 8:00 AM to report change of condition and got an order to send resident out to ER (emergency room ) for an eval. (Important to note: Change of condition occurred at 4:42 AM of increased pain with movement to right leg; R1 admitted 4 days prior with a left hip repair. R1 is post-surgical.) On 3/29/23 at 9:58 AM, it documents: Type: Change in Condition. Writer called clinic at 8:00 AM to report change of condition and got an order to send resident out to ER for an eval. Writer then contacted (ambulance name - nonemergent service) and they were able to pick resident up around 9:30 AM. POA, updated on all of this. RCM (resident care manager) aware. Important to note: Resident had change in condition at 4:42 AM with increased pain with movement of right leg and purple bruising to right hip. Facility updated a physician at 8:00 AM (3 hours and 18 minutes after onset of increased pain). Resident did not get transferred over to hospital until 9:30 AM (an hour and a half after the order was received to send R1 to ER.) Since onset of increased pain at 4:42 AM four hours and eighteen minutes have passed. On 3/29/23 at 1:01 PM, it documents: Type: Alert Note. Per ER nurse, resident admitted to the hospital for a broken R hip and bladder infection. Resident to have surgery tomorrow, per nurse. R1's telephone order, dated 3/29/23 at 08:45 AM, states, may send to ER for eval post fall with new bruising to R hip and increased pain, altered mental status & O2 saturation. R1's hospital discharge summary dated 4/6/23, states, in part: . admitted : 3/29/23 10:10AM discharge date : 4/6/23 Disposition: Back to ALF (assisted living facility) with hospice . Primary Discharge Diagnoses: 1. Fall 2. Right Hip Fx (fracture) 3. Comfort Cares . Per H & P . She presented to the hospital with complaints of unwitnessed fall. Patient has dementia and is not able to provide medical history. POA/daughter is present and able to provide history .it sounds like the patient had an unwitnessed fall around 3 pm afternoon yesterday, was found on the floor of the bathroom around 5:30 PM .ER physician warranted pan-scan for unwitnessed fall . showed right hip fracture . Hospital Course: Fall & Right Hip Fracture Comfort Cares Left hip fracture 3/16/23 and now admitted w/subsequent fall and right hip fx which was surgically repaired 3/30 . Given advanced age and significant co-morbidities, she is at very high risk for complications and prolonged recovery . R1's Care Plan, dated 3/24/23, with a target date of 6/22/23, states, in part: . Problem: At risk for Falls r/t (related to) recent fall with fracture. Goal: The resident will not sustain serious injury through the review date . On 6/22/23 at 2:15 PM, Surveyor interviewed RN C (Registered Nurse) and asked if she was R1's nurse on 3/28/23 and RN C indicated yes. Surveyor asked RN C if she could recall the time R1 had fallen on 3/28/23 and RN C indicated it was before supper. Surveyor asked RN C what time supper was, and she indicated 5:00 PM. RN C indicated R1 was observed on the floor in her room on 3/28/23. Surveyor asked RN C what she did at the time R1 was found on the floor and RN C indicated she assessed R1 for pain and injury. RN C indicated she performed ROM to R1's upper and lower extremities. Surveyor asked RN C if R1 showed any signs of pain or indicated pain and RN C indicated R1 was not grimacing or yelling out and R1 did not say anything during the assessing of ROM. RN C indicated R1 was confused, and Surveyor asked in what way. RN C indicated R1 was saying she had to get home. RN C indicated she did not get the feeling R1 had broken anything. On 6/22/23 at 3:05 PM, Surveyor interviewed RN E and asked if she was R1's nurse on 3/29/23 and RN E indicated yes. RN E indicated she went in to assess R1 in the morning and R1 was in pain, moaning and groaning, and not herself by not responding. RN E indicated R1 normally responds OK. RN E indicated the CNA retrieved vital signs and all were normal except for R1's O2 saturation was low, and she put O2 on R1 at 1.5 L. R1's O2 saturation level came up. Surveyor asked RN E if she updated the MD and RN E indicated she called the clinic at 8:00 AM and received orders to send to the ER. Surveyor asked RN E why the facility called for non-emergent transfers versus calling 911. RN E indicated because R1 was stable except for R1's O2 saturation. Surveyor asked RN E what the process is to call and notify physician of change in condition and RN E indicated the facility is to call clinic and speak to receptionist and the receptionist relays message to triage nurse. The triage nurse relays the message to the physician and then the physician calls back. Surveyor asked how long it typically takes to get a call back and RN E indicated it depends on how emergent the problem is. Surveyor asked RN E if she has ever had to call the facility's medical director due to no call back and RN E indicated a few times when they got no response back from the clinic. On 4/6/23, at 4:06 PM, Surveyor interviewed DON B (Director of Nursing) and reviewed progress notes together. Surveyor asked DON B when she would expect a call back from a physician after leaving a message with the triage nurse to update on R1's new onset of increased pain with movement of right leg and purple bruising to right hip area. DON B indicated within 30 minutes. DON B indicated the clinic will not let the facility speak directly to the physician; they must update the triage nurse and the triage nurse sends the message to the physician and then the physician gets back to you. Surveyor asked DON B if an onset of increased pain with movement, R1 moaning in pain, and purple bruising to right hip was noticed at 4:42 AM, would notifying a physician at 8:00 AM be appropriate and DON B indicated no. Surveyor asked DON B what options does the facility have when they do not receive call back from a physician or they have to wait until the clinic opens for physician to be notified. DON B indicated the medical director or herself could be called. Surveyor asked what DON B's expectation would be and DON B indicated after this she would have the nurse send R1 to the ER. On 6/22/23 at 4:25 PM, Surveyor interviewed RN D and asked what the process is to notify a physician of change of condition. RN D indicated she has to talk to the triage nurse at clinic and the triage nurse will relay the information to the physician and then the physician phones facility back. Surveyor asked how long is acceptable to wait for a call back and RN D indicated she would not wait more than half an hour. On 6/22/23 at 12:13 PM, Surveyor spoke with ALA F (Assisted Living Administrator). ALA F indicated R1 admitted back to the assisted living facility on 4/6/23 with admitting diagnosis of right hip fracture from a fall at Skilled Nursing Facility. Surveyor asked the facility for a fall incident report for R1 from 3/28/22; this was not provided. Surveyor left messages for R1's PCP's nurse with no return call. R1 was admitted to the facility following hospitalization for a fractured left hip repair from a fall that occurred while residing at an ALF. R1 had a fall on 3/29/23 before supper and had a significant change in condition at 4:42 AM on 3/29/22 that consisted of onset of increased pain with movement to right leg, moaning and groaning out loud with pain, and purple bruising noted to right hip area. Facility did not notify physician until 3/29/23 at 8:00 AM. The facility received orders at that time to send R1 to ER. Facility did not transfer R1 to ER until 9:30 AM. R1 was admitted to the facility with a fractured right hip and underwent surgery to repair. R1 returned to ALF on hospice on 4/6/23 and passed at ALF.

Based on staff interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 3 sampled resident (R1) out of 35. The facility did not thoroughly assess R1's pain according to standards of practice. This is evidenced by: The facility policy entitled, Pain Management, dated 6/21, states, in part: POLICY: To maintain each resident's right to have pain prevented or controlled adequately. PROCEDURE: . 7. Residents will be assessed (through interviews) at least once per shift so pain medications can be administered. 8. Complaints of pain and need for medication will be considered a STAT (immediate) intervention for administration of pain medication. If the resident currently does not have an order for pain medication, the physician will be notified for a medication order. For residents currently receiving pain medication regimen that is noted to be ineffective or have break through, the physician will be notified for further medication orders . R1 was admitted to the facility on [DATE] and has diagnoses that include fracture of unspecified part of neck of left femur, presence of artificial left hip joint, history of falling, and Alzheimer's disease with late onset. R1's Care Plan dated 3/24/23, states, in part: . Problem: Functional Status Interventions: Transfer of Assistance Level: Assist of 1 with standing lift Bed Mobility Assistance Level: Assist of 1 History of Falls . Problem: Services Date Initiated: 3/24/23 . Interventions: Pain Medication, Location of Pain, and Prescence/Characteristics of Pain: (specify) . Important to note: R1 was admitted to facility after having repair of left hip fracture. R1 has nothing in care plan regarding pain and pain interventions. R1's physician orders dated 3/27/23, states, in part: . Pain Monitoring every shift: Rate the pain level between 1-10 with 1 being the least amount of pain and 10 being the highest. Document location of pain Rate the intensity of pain using the following descriptors: A= Aching, B= Burning, C= Cramping, D=Dull, L= Localized, R=m Radiating, S= Sharp/Stabbing, T= Throbbing, O=Other every shift for Pain Non- Pharmacological Interventions Attempted: 0=not applicable, 1= distraction, 2= relaxation, 3= superficial massage, 4= breathing, 5= spiritual practices, 6= environmental modifications, 7= positioning/repositioning . -Acetaminophen Oral Tablet 500 mg (milligrams) (Acetaminophen) Give 2 tablets by mouth three times a day for pain Max daily dose 4000mg from all sources. Order date: 3/24/23 -Oxycodone HCI (hydrochloride) Oral Tablet 5 mg (oxycodone hci) Give o.5 tablet by mouth every 4 hours as needed for pain Order Date: 3/24/23 -Oxycodone HCI (hydrochloride) Oral Tablet 5 mg (oxycodone hci) Give 1 tablet by mouth every 4 hours as needed for pain Order Date: 3/24/23 . R1's March Medication Administration Record (MAR) shows: Acetaminophen Oral Tablet 500 mg (Acetaminophen) Give 2 tablets by mouth three times a day for pain max dose 4000 mg from all sources Start Date: 3/24/23 -3/24/23 shows the 4pm & 8pm doses were administered with no pain ratings or effectiveness noted - 3/25/23 - 3/28/23 shows the 6 am, 4pm & 8pm doses were administered with no pain ratings or effectiveness noted -3/29/23 shows the 6am dose not administered R1 in hospital On 3/24/23: Pain Monitoring every shift: Evening Pain Level- 0 Night Pain Level- 0 On 3/25/23: Pain Monitoring every shift: Day Pain Level- 0 Evening Pain Level- 2 Night Pain Level- 0 On 3/26/23: Pain Monitoring every shift: Day Pain Level- 0 Evening Pain Level- 1 Night Pain Level- 0 On 3/27/23: Pain Monitoring every shift: Day Pain Level- 5 Evening Pain Level- 0 Night Pain Level- 0 On 3/28/23: Pain Monitoring every shift: Day Pain Level- 3 Evening Pain Level- 3 Night Pain Level- 4 On 3/28/23: Pain Monitoring every shift: Day Pain Level- 3 Evening Pain Level- 3 Night Pain Level- 4 On 3/29/23: Pain Monitoring every shift: Day Pain Level- 6 Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI) Give 0.5 tablet by mouth every four hours as needed for pain Start Date: 3/24/23 . On 3/28/23 MAR shows administration at 4:03 PM for Pain Level- 3 Marked E for effective with no time On 3/28/23 MAR shows administration at 11:38 PM for Pain Level- 4 Marked E for effective with no time On 3/29/23 MAR shows administration at 5:20 AM Pain Level- 4 Marked U for unknown for effectiveness R1's Progress Notes: 3/29/23 at 4:42 AM, it documents: Change of Condition Note CNA (certified nursing assistant) noted, and writer assessed resident's right hip. Noted bruise dark purple in color 9cm (centimeters) x 1cm. Resident with onset of increased pain in right hip with movement. Due to resident's cognitive ability, she is unable to articulate exact location of pain, but gently ROM (Range of Motion) to right leg and resident was moaning with pain. Call placed to resident's APOA (activated power of attorney) at this time to update. Important to note: R1 moaning in pain no administration of pain medication until 5:20 AM. On 3/29/23 at 9:48 AM, it documents: Type: Change of Condition Note. Writer came in to assess pt. (patient) around 6:30 AM this morning and pt. was moaning and groaning throughout the whole interaction. Writer asked pt. where it hurt and pt. would not respond, she mumbled here and there only and was unable to have a conversation w/ (with) writer. Writer noted continued bruising to pt.'s R (right) hip and intact dressing to pt.'s L (Left) hip w/no drainage. CNA (Certified Nursing Assistant) then collected pt.'s vitals and it was noted her O2% (oxygen) was only steady between 89 - 90%, all other VSS (vital signs stable). Writer applied 1.5L (liters) of O2 on pt. and got her saturation up to 92%. Writer then called Clinic at 8:00 AM to report change of condition and got an order to send resident out to ER (emergency room ) for an eval. Important to note- R1 was administered pain medication at 5:20AM and now at 6:30AM R1 continues to moan and groan in pain. Nothing is done for R1 at this time for continued pain to include non-pharmacologic interventions such as ice. Physician not updated until 8:00AM. On 3/29/23 at 9:58 AM, it documents: Type: Change in Condition. Writer called clinic at 8:00 AM to report change of condition and got an order to send resident out to ER for an eval. Writer then contacted (nonemergent ambulance service) and they were able to pick resident up around 9:30 AM. POA (power of attorney), updated on all of this. RCM (resident care manager) aware. Important to note: Resident had change in condition at 4:42 AM with increased pain with movement of right leg and purple bruising to right hip. Oxycodone 0.5 mg was administered at 5:20 AM and ineffective. Facility updated a physician at 8:00 AM (three hours and 18 minutes after onset of increased pain). Resident did not get transferred over to hospital until 9:30 AM (an hour and a half after the order was received to send R1 to ER). Nothing is done for R1's pain since administration of the oxycodone at 5:20AM and R1 continues to be in pain. On 3/29/23 at 1:01 PM, it documents: Type: Alert Note. Per ER nurse, resident admitted to the hospital for a broken R hip and bladder infection. Resident to have surgery tomorrow, per nurse. R1's hospital discharge summary dated 4/6/23, states, in part: . admitted : 3/29/23 10:10AM discharge date : 4/6/23 Disposition: Back to ALF (assisted living facility) with hospice . Primary Discharge Diagnoses: 1. Fall 2. Right Hip Fx (fracture) 3. Comfort Cares . Per H & P . She presented to the hospital with complaints of unwitnessed fall. Patient has dementia and is not able to provide medical history. POA/daughter is present and able to provide history .it sounds like the patient had an unwitnessed fall around 3 pm afternoon yesterday, was found on the floor of the bathroom around 5:30 PM .ER physician warranted pan-scan for unwitnessed fall . showed right hip fracture . Hospital Course: Fall & Right Hip Fracture Comfort Cares Left hip fracture 3/16/23 and now admitted w/subsequent fall and right hip fx which was surgically repaired 3/30 . Given advanced age and significant co-morbidities, she is at very high risk for complications and prolonged recovery . On 4/6/23, at 4:06 PM, Surveyor interviewed DON B (Director of Nursing) and reviewed progress notes together. Surveyor asked DON B when she would expect a call back from a physician after leaving a message with the triage nurse to update on R1's new onset of increased pain with movement of right leg and purple bruising to right hip area. DON B indicated 30 minutes. DON B indicated the clinic will not let the facility speak directly to the physician; they must update the triage nurse and the triage nurse sends the message to the physician and then the physician gets back to you. Surveyor asked DON B if an onset of increased pain with movement, R1 moaning in pain, and purple bruising to right hip occurring at 4:42 AM, would notifying a physician at 8:00AM be appropriate and DON B indicated no. Surveyor asked DON B after administering a pain medication when a nurse should reassess if pain medication was effective. DON B indicated within 30-60 minutes. What else could you expect a nurse to do if a resident's pain was not controlled after reassessing. DON B indicated the nurse could see what other medications could be administered, non-pharmacological interventions, and call on call physician. R1 had pain post fall and the facility did not attempt other interventions when R1's pain was not well controlled.

Based on observation, interview and record review, the facility failed to ensure 1 resident (R13) of 13 sampled residents were reviewed for self-administration of medications. R13 was observed to have a Ziploc bag with a bottle of Tums tablets on R13's chair next to bed. R13 was observed to have an [MEDICATION(S)] Aerosol Solution inhaler and Nicotine inhaler at bedside. This is evidenced by: The facility's policy, Medication- Self Administration, with a revision date of 7/21, states, in part: . Policy: The facility will assure that a resident wishing to self-administer his/her own medications will be evaluated, determined as capable of doing so and have a safe storage area that prevents other residents from gaining access to the medication. Procedure: 1. Once the resident has been evaluated and determined to be capable of safely administering his/her own medications, the physician will be contacted, and a written order of approval will be obtained. 2. A Self-Administration of Medication Assessment will be completed by a licensed nurse. 3. Medications will be stored in a secure and lockable compartment in the resident's room. 4. Resident education will include: No sharing of medications. Not bringing medications into common areas of the facility. Giving discontinued medications to the licensed nurse for proper destruction. Reporting adverse reactions. Taking as directed. Not transferring into different containers. Keeping the facility appraised of changes. A change in condition status will require another Self-Administration of Medication assessment and possibly having to relinquish the medications to be dispensed by the licensed nurse. 5. Ask the resident for a return demonstration of his/her medication routine. 6. Continually evaluate the resident for status change which may indicate an inability to safely manage his/her own medication. Occurrences which may be of concern include Re-ordering medication too often or not often enough. Increased confusion and forgetfulness. Newly prescribed [CONDITION(S)] medications. Cognitive or medical instability. R13 was admitted to the facility on [DATE] and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/10/22 indicates R13's cognition is intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. R13's Physicians orders, dated 5/3/22, states, in part: . [MEDICATION(S)] Aerosol Solutions 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours as needed . *R13's Physicians orders, dated 5/5/22, states, in part: . Nicotine Inhaler 10 MG inhale orally as needed for smoking cessation. Will use own supply-RX do not send from Pharmacy. *R13 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Important to note: an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's current Care Plan does not indicate self-administration of any medications. R13's Self-Administration of Medication screen, created on 8/9/22 at 5:58 PM, indicates R13 is safe to self-administer medications. Important to note: Date of Assessment. Surveyor had requested a self-administration assessment for R13 prior. On 8/8/22, around 3:00 PM, Surveyor introduced self to R13. Surveyor asked R13 if R13 had any concerns or questions for Surveyor. R13 voiced concern that someone had taken her inhaler from her bedroom the morning of 8/8/22. R13 thought it was a Registered Nurse that took it but was not sure. R13 stated that they took her inhaler and didn't explain why just that she couldn't have it in her bedroom. R13 stated she had the inhaler in her bedroom and will use it when she needs it. Surveyor asked R13 about the Tums that were on her chair. R13 indicated the Tums on the chair were hers. R13 indicated she has a Nicotine inhaler in her bedroom that she will use, but that it doesn't really do much. R13 showed Surveyor her Nicotine inhaler that was by bedside. On 8/9/22, at 3:23 PM, RN L (Registered Nurse) indicated R13 had wanted to keep the [MEDICATION(S)] inhaler in her bedroom, but that it was not currently in her bedroom. Surveyor asked if the Nicotine inhaler is in her bedroom. RN L indicated the Nicotine inhaler is in R13's bedroom. Surveyor asked RN L if RN L could show Surveyor R13's Self-Administration of Medication screen. RN L looked in R13's medical record on the computer and stated, I'm sorry, I don't see it. On 8/9/22, at 3:45 PM, R13 indicated to Surveyor R13 had an [MEDICATION(S)] inhaler and Nicotine inhaler at bedside. Surveyor observed bottle of Tums in a Ziplock bag still on chair in bedroom. On 8/11/22, at 9:30 AM, DON B (Director of Nursing) and RN M indicated a Self-Administration of Medication screen should be completed before a resident self-administers medications. RN M indicated R13's screening was completed as soon as the facility learned about the medications being in R13's bedroom. R13's family is very involved and brought in the medications without the facility knowing. RN M indicated the [MEDICATION(S)] Aerosol Solution inhaler and Nicotine inhaler now have orders and the screening process was complete. RN M indicated R13 has two [MEDICATION(S)] Aerosol Solution inhalers. An RN picked up one of the inhalers on 8/8/22 because the RN thought it was left at bedside. The facility was unaware that R13 has two [MEDICATION(S)] Aerosol Solution inhalers. RN M indicated they did not know R13 had Tums in her bedroom, but now that they do, they will work on getting a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review the facility did not ensure that every resident has the right to make choices about aspects of their life in the facility that are significant to them for 2 of 13 residents (R6 and R289) residents reviewed for choices. Resident (R6) requested her bedtime to be around 10:00 PM, staff will place items to get ready for bed after supper. R6 has been told by staff that she needs to go to bed because staff needed to leave work. Resident (R289) requested her bedtime to be around 9:00 PM, R289 reports that staff will get out her evening items to get ready for bed after supper and feels it is a hint to go to bed early. This is evidenced by: The Facility's Policy entitled Notice of Resident Rights Under Federal Law with an unknown last revision date, documents, in part: Self-Determination: 14. You have the right to self-determination, including but not limited to the following rights: a. The right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with your interests, assessments, plan of care and as otherwise set forth here . Example 1: R6 is a long-term resident of the facility. R6 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's admission Minimum Data Set (MDS) assessment on 5/20/22 indicates R6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating her cognition is cognitively intact. Daily Preferences Assessment of bedtime indicates it is very important to choose her own bedtime. R6's care plan states Problem: Impaired Functional Status r/t (related to) s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: Will be able to propel w/c (wheel chair) independently . R6 will be able to choose the time that she will get up for the day where to have her meals. Encourage her to be up in her w/c for all meals . Please note: no bedtime routine of time or cares are indicated in the care plan. R6's Resident Preferences Evaluation, effective date of 5/19/22 states, in part: Daily Preferences . 5. How important is it to you to choose your own bedtime? a) Very Important . On 8/8/22 at 2:12 PM, Surveyor interviewed R6. R6 reports They wanted me to get ready for bed after dinner because the staff told me they had to leave by 8:00 PM. Surveyor asked who the staff member was and provided the name to the Surveyor. R6 reported to Surveyor that she did Not want to be rushed, I don't like how that feels, I have a whole page of diagnosis. I have a bad shoulder, a-fib, arthritis, and heart failure and I like to stay up late. On 8/10/22 at 2:45 PM, Surveyor performed follow up interview with R6. R6 reports to Surveyor, the same staff member Makes me go to bed right when she picks up my dinner tray. I do say no and then she just says fine she will help other people and does not come back until she wants to. She tells me I have to go to bed. I have always gone to bed at 10 PM. It makes for a long night. I get itching while I lay there awake, I get bored, and end up awake more when I have to go to bed early like that. On 8/10/22 at 3:40 PM, Surveyor interviewed CNA S (Certified Nursing Assistant). Surveyor asked CNA S what time residents go to bed, she replied Usually we put them down after dinner, we let them sit for 30 minutes if they want to. Surveyor asked CNA S what time does R6 prefer to go to bed at night, she replied around 3:00 PM, even before supper. Surveyor asked CNA S is she would let R6 go to bed for a nap, she replied that R6 won't do it, she wants to be in bed. On 8/11/22 at 2:46 PM, Surveyor interviewed RN R (Registered Nurse). Surveyor asked RN R R6's bedtime routine, she replied R6 likes to get cleaned up, cream on arms and itchy areas, R6 gets her meds around 8:00 PM-9:00 PM, goes to bed about 9:00 PM. Surveyor asked RN R when does CNA S's shift normally end, she replied CNA S shift ends normally around 10:00 PM, sometimes she leaves early about 9:30 PM. Surveyor asked RN R the reasoning for CNA S to leave early, she replied that CNA S may have another job and will put R6 down early, CNA S gets her work done, if she is leaving early, the resident will be in bed. Surveyor asked RN R if R6 ever complained about going to bed early, RN R stated, Not really. On 8/11/22 at 3:15 PM, Surveyor interviewed DON B (Director of Nursing) if there are any bedtime requirements for residents, she replied, no. Surveyor asked DON B if a resident should get to choose what time to go to bed, she replied, yes. Example 2: R289 is a long-term resident of the facility. R289 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R289's admission MDS assessment on 8/5/22 indicates R289 had a BIMS score of 15 indicating her cognition is cognitively intact. Daily Preferences Assessment of bedtime indicates it is very important to choose her own bedtime. R289's care plan does not provide any preferences of bedtime routine. On 8/11/22 at 2:01 PM, Surveyor interviewed R289. Surveyor asked R289 if there was a certain bedtime, she replied that Right after supper they start bringing in the bedtime stuff like toothbrush, toothpaste, and my gown; it's kind of a hint. I don't usually want to get ready for bed until 9 PM. So, when the bring the stuff in, I take that as a hint. Surveyor asked R289 do staff make you go to bed prior to 9 PM. R289 stated yes.

Based on observation and interview the facility did not provide privacy during personal care and medication pass on 1 of 14 sampled residents (R6) and 1 of 8 supplemental residents (R289). R6 stated during an interview that staff do not put the blinds down when doing cares. R289 stated during an interview that she has to ask staff to close the door or windows, Surveyor observed application of a [MEDICATION(S)] with the window blinds open and another staff present without providing privacy. This is evidenced by: Example 1: R6 is a long-term resident of the facility. R6 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's admission Minimum Data Set (MDS) assessment on 5/20/22 indicates R6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating her cognition is cognitively intact. On 8/9/22 at 8:35 AM, Surveyor interviewed R6. Surveyor asked R6 about any concerns with her privacy, she reported Sometimes they do not put down the blinds, I can see the offices next door. On 8/10/22 at 9:55 AM, Surveyor followed up with R6 about privacy during cares last night. R6 reported She didn't put my blinds down or wash my stockings, I had to ask the nurse the close the blinds when she brought me my medicine. Example 2: R289 is a long-term resident of the facility. R289 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R289's admission MDS assessment on 8/5/22 indicates R289 had a BIMS score of 15 indicating her cognition is cognitively intact. On 8/10/22 at 9:32 AM, Surveyor observed RN H (Registered Nurse) administering a [MEDICATION(S)] to R289. RN H walked into the room and asked R289 where she would like her patch applied and R289 lifted the left side of her shirt that is facing the open window with nearby buildings. Surveyor observed another facility staff in the room. RN H did not offer privacy for the windows or if the presence another staff member was permissible. On 8/11/22 at 2:01 PM, Surveyor interviewed R289. Surveyor asked R289 How she felt about her privacy when staff was placing the patch on with the windows open and showing skin, she replied I do have a concern with the blinds open. I have to ask them to close the door before I undress or to do private cares. I don't want to give any freebies. On 8/10/22 at 8:39 AM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F is the window blinds and doors should be closed prior to cares, she replied yes. On 8/10/22 at 10:08 AM, Surveyor interviewed DON B (Director of Nursing), Surveyor asked DON B if staff should close the window blinds and doors prior to cares, she replied yes.

Based on interview and record review, the facility did not ensure that the facility is able to provide emergency basic life support immediately when needed, including Cardiopulmonary Resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel for 2 of 13 residents (R12 and R286) reviewed for advance directives. R12's Medical Record contained conflicting code status/advanced directives on a signed form, face sheet, and the dashboard. Staff did not follow through on the paperwork needed to change R12's code status to DNR as he wished. Staff reported they would look in different areas of the chart for R12's code status. R286 Medical Record contained conflicting code status/advanced directives on a signed form, face sheet, and the dashboard. R286's printed face sheet in his hard chart indicates he is full code. R286's signed form and dashboard indicate he is DNR. Evidenced by: Facility policy, entitled Advance Directives, reviewed ,d+[DATE], includes, in part: . if a resident has completed an updated advanced directive ., the social services director or designee will document in chart and include a copy of the advanced directive in medical record . The facility will document and communicate the resident's choices to the interdisciplinary team . Example 1 R12 was admitted to the facility on [DATE]. R12's Advanced Directive Form, dated [DATE], signed by RR G (R12's Activated Power of Attorney/Resident Representative), a witness, and a Nurse Practitioner, indicates R12 wishes to be a full code status. R12's MD Progress Note, dated [DATE], include in part: I saw that his code status in point click care was full code and this is the paperwork RR G signed upon admission to the skilled nursing facility upon admission . In the past he has been a DNR (Do Not Resuscitate). I called RR G and discussed. R12 should be a DNR. R12's Physician Orders, includes, [DATE] code status: DNR. On [DATE] at 10:00 AM Surveyor reviewed R12's Electronic Medical Record. R12's Dashboard indicated R12 is a DNR. R12's Face Sheet indicated R12 is a DNR. R12's signed Advanced Directives form indicated R12 was a full code. R12's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 10:56 AM during an interview, RN I indicated if R12 was found pulseless and nonbreathing he would look at R12's dashboard to verify his code status which is DNR. Surveyor asked RN I about the signed advanced directive form in R12's medical record. RN I indicated R12's dashboard should reflect R12's signed advanced directive sheet. On [DATE] at 11:01 AM LPN J indicated if she found R12 pulseless and nonbreathing she would verify R12's code status by looking at the signed sheet in his chart, indicating R12 is a full code. Surveyor showed LPN J R12's dashboard indicating his code status is DNR. LPN J indicated she would follow the signed advanced directive sheet if saw the discrepancy. On [DATE] at 11:11 AM RN D indicated if she found R12 pulseless and nonbreathing she would look at R12's dashboard to verify his code status with indicates R12 is a DNR. Surveyor and RN D reviewed R12's signed advanced directive sheet together, indicating R12 wishes to be a full code. On [DATE] at 11:20 AM LPN F and RN H indicated if they found R12 pulseless and nonbreathing they would look on the computer at R12's dashboard and if their computer was not open, they would look at the signed advanced directive form. Surveyor, LPN F, and RN H reviewed R12's dashboard and then R12's advanced directive form, noting the discrepancy. LPN F and RN H indicated these documents should reflect each other. LPN F also showed Surveyor R12's Face Sheet that indicated R12 is a DNR. On [DATE] at 11:21 AM ADON E indicated it is her expectation that staff would look in chart first and then look in the resident dashboard when verifying code status. Surveyor and ADON E reviewed R12's medical record, including the Face Sheet, signed advanced directives, and R12's dashboard. ADON E indicated the signed advanced directive is the document that the staff should follow if there is a discrepancy like this. ADON E indicated Surveyor should consult with DON B for sure though. On [DATE] at 12:39 PM RR G indicated she believes R12 would want to be a DNR. RR G indicated the facility has asked her today to sign a document that indicates this. RR G indicated all areas in R12's record should reflect his wishes. On [DATE] at 1:20 PM Surveyor interviewed DON B, DON B indicated staff should look at the residents' dashboard on PCC (electronic health record) to verify code status and they can look in the hard chart too at the advanced directive form. DON B indicated these documents should all reflect the wishes of that resident and each other. DON B and Surveyor reviewed R12's medical record. DON B indicated in December of 2021 R12's Nurse Practitioner asked R12's POA if R12's wished to be a DNR. Surveyor reviewed R286's medical record also, noting on R286's dashboard it indicated he should be a DNR and on his Face Sheet it is noted he should be a Full Code. DON B stated R286 was admitted on [DATE] and was a full code. On [DATE] his wishes changed, and the paperwork was completed, but the Face Sheet was not reprinted in his chart. DON B indicated all documents in R286's chart related to code status should reflect R286's wishes and each other. Example 2 R286 was admitted to the facility on [DATE]. R286's Advanced Directive Form, dated [DATE], signed by R286, a witness, and a Nurse Practitioner, indicates R286 wishes to be DNR. On [DATE] around 10:00 AM Surveyor reviewed R286's hard chart. R286's Face Sheet in hard chart indicates R286 is full code. On [DATE] at 1:20 PM Surveyor interviewed DON B, DON B indicated staff should look at the residents' dashboard on PCC (electronic health record) to verify code status and they can look in the hard chart too at the advanced directive form. DON B indicated these documents should all reflect the wishes of that resident and each other. Surveyor reviewed R286's medical record also, noting on R286's dashboard it indicated he should be a DNR and on his Face Sheet it is noted he should be a Full Code. DON B stated R286 was admitted on [DATE] and was a full code. On [DATE] his wishes changed, and the paperwork was completed, but the Face Sheet was not reprinted in his chart. DON B indicated all documents in R286's chart related to code status should reflect R286's wishes and each other. On [DATE] Surveyor reviewed R286's Face Sheet. The Face Sheet now matched the Advanced Directive Form, Physician order, and dashboard indicating R286 is DNR.

Based on observation, interview, and record review, the facility did not ensure 2 (R13 and R3) of 13 sampled residents were free from accident hazards and provided supervision and assistive devices to prevent avoidable accidents. R13 had multiple falls after admission. The facility failed to identify and implement interventions to reduce fall risk. R3 was transferred via a Hoyer lift on 5/19/22 with the assist of 2, using a different style Hoyer sling, fell out of the Hoyer lift during a transfer and struck her head. The fall caused 3 abrasions and a hematoma on the back of R3's head and was witnessed by staff of R3 hitting her head. This is evidenced by: The Facility's Policy and Procedure entitled Fall Reduction and Management Program- SNF with a last revised date of 02/21, documents, in part: Policy: It is the policy of the Facility that every effort be made to reduce or minimize serious injury if a fall should happen . Care Planning and Implementation: Based on resident fall evaluation, an individualized care plan with the goal to prevent falls and/or minimize serious injury if fall occurs will be developed, implemented, monitored, and modified as needed. Licensed Nurse and/or Interdisciplinary Team will: 1. Develop an individualized care plan that addresses the risk factors identified, formulate goals that promote resident safety and prevention/reduction of falls and minimize serious injury if fall occurs . 4. Review, evaluate, revise, or modify the care plan on a quarterly basis and as needed . III Ongoing Monitoring . General Staff: . 4. Managers/Supervisors: Manager/Supervisors will be vigilant to potential/actual environmental hazards and will ensure resident environment is free of accident/fall hazards as possible . Example 1 R13 was admitted to the facility on [DATE] and has a diagnoses that include other intraarticular fracture of lower end of right radius subsequent encounter for closed fracture with routine healing, malignant neoplasm of unspecified part of right bronchus or lung, [CONDITION(S)], [CONDITION(S)], essential hypertension, anxiety disorder, vitamin D deficiency, [CONDITION(S)], depression, asthma, hypertensive urgency, pain in right wrist, muscle wasting and atrophy, other lack of coordination, cognitive communication deficit, dizziness, weakness, unspecified open wound of toe with damage to nail, other reduced mobility, personal history of other mental and behavioral disorders, personal history of nicotine dependence, and history of falling. R13's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/10/22 indicates R13's cognition is intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. R13's Care Plan noted: Problem: At risk for falls r/t recent fall with fracture. Goal: Will not sustain serious injury through the review date. Interventions: Be sure call light is within reach and encourage to use it for assistance as needed. Created on: 5/3/2022. Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Created on: 5/3/2022. Ensure that she is wearing appropriate footwear when ambulating or mobilizing in w/c. Created on: 5/3/2022. Staff to provide frequent checks, for safety and needs, encourage her to wait for staff to assist. Created on: 5/16/2022. Transfer Assistance Level: Assist of 1 and walker. Toileting Assistance Level: Assist of 1, encourage her to use the bathroom in frequent intervals while awake and before going to bed. Revision on: 5/11/2022. On communication tool between the Therapy Department and Nursing it states, R13 should be checked on every 30 minutes. It is important to note this is not on R13's Care Plan. It is important to note all of the above interventions were put in place at the time of R13's admission to the facility. There was only one new intervention put in place until R13's fifth fall. R13's falls: On 5/12/22 at 4:30 PM R13 slid off her wheelchair and onto the floor in resident bedroom. Incident Report: R13 stated she was going from her wheelchair to bed with assistance from daughter. R13 felt unsteady so she went to sit back down in w/c but did not make it all the way onto the wheelchair and started to slide off the chair and onto the floor. R13 stated that she did not hit her head or obtain any injuries from the fall. No injuries observed at time of incident. Staff assessed the resident, obtained v/s, and assisted her to bed. VSS, neuro check WNL, denies pain. Other info: Resident was wearing gripper socks. She had returned to facility from outpatient surgery a few hours prior. No interventions discussed in incident report. On 5/13/22 at 3:43 PM R13 fell in bedroom. Incident Report: Team member communicated to writer that patient was sitting on the floor right outside of her doorway. When I approached the patient, she was sitting upright with knees bent. It did not appear that she hit her head or made hard contact with the floor. Resident said she had waited 10 minutes after pressing her call light and slid out of her chair when self-transferring to her wheelchair. Stated that it was hard to do things independently while only having one arm available. Stated that she was in no pain d/t fall. No interventions discussed in incident report. In R13's Progress notes it states frequent checks will be started on R13. On 6/25/22 at 8:00 AM R13 fell in R13's bathroom. Incident Report: Was found lying in the bathroom leaning against the right hand. Stated she was trying to use the toilet, fell and could not get up. Assessed for injuries. Assisted to the toilet and stayed with patient. Other info: Does not understand limitations, self-transfers, does not call for help. No interventions discussed in incident report. On 6/26/22 at 7:45 PM R13 fell in bedroom. Incident Report: Found on the floor sitting next to the bed. No injuries noted. Stated she was transferring from her wheelchair to the bed, lost balance and fell . Vitals obtained, assessed for injuries, assisted to the bed. Other info: Does not utilize call light or call for help, does not understand own limitations. No interventions discussed in incident report. On 7/15/22 at 9:30 PM R13 fell in bedroom. Incident Report: Staff heard the noise from resident room and immediately provided help. When staff entered the resident room and found the resident lying on the floor on her back. Patient is a fall risk patient. She's on 30-minute checks. Between the 30-minute checks, stated attempted to get her own diaper out of the closet without calling for help. She lost her balance kneeled down and fell backward bumping her head on the door. Assessed the resident for pain and any injury. No apparent injuries. ROM WNL. helped resident to get up and walk to bed. Message left for NP (nurse practitioner). Daughter updated on the phone. No injuries observed at time of incident. Other info: Resident transfer and ambulation one assist use walker but resident forgetful. Ambulates herself without assistance. Interventions and root cause analysis was completed for 7/15/22 fall. Risk and Benefit discussed with R13, and NP monitoring BP. Medication change took place at 7/19/22 appointment. On 8/8/22, around 3:00 PM, Surveyor introduced self to R13. Surveyor asked R13 if R13 had any falls while at the facility. R13 indicated that she had multiple falls while at the facility and it was all stupid stuff as to why she had fallen. R13 declined to discuss her recent falls any further. Surveyor observed R13 to be wearing grippy socks and call light was next to her. R13 had a walker and wheelchair in her bedroom. Surveyor observed no other fall interventions in place in R13's bedroom nor any staff completing frequent checks on R13. On 8/9/22, at 2:56 PM, LPN O (Licensed Practical Nurse) indicated when a resident falls an Incident Report should be completed. Surveyor asked what is in place for R13's fall interventions. LPN O indicated R13 is at risk for falls. R13's call light should be within reach; this is a given for all residents at the facility. Staff should encourage R13 to participate in activities, to wear proper footwear, and for staff to check on R13 frequently. Surveyor asked LPN O how often is frequently? LPN stated, a minimum of every two hours. On 8/9/22, at 3:56 PM, Surveyor asked CNA N (Certified Nursing Assistant) what is R13's fall interventions? CNA N indicated R13 likes doing things on her own. Staff provide reminders to use the call light if she needs something. Surveyor asked CNA N if there were any other interventions in place and CNA N stated, not really anything else. On 8/11/22, at 9:30 AM, Surveyor interviewed DON B (Director of Nursing) and RN M (Registered Nurse) indicated R13 is at risk for falls. RN M indicated she had a discussion with R13 on risk and benefits after R13's fall on 7/15/22. (R13's fall on 7/15/22 was R13's fifth fall while at the facility.) RN M indicated after R13's fall on 7/15/22 R13 had stated she had felt dizzy. RN M stated they updated the NP, and they are monitoring R13's blood pressure as this fall seemed to be more medical related. RN M indicated R13's fall interventions include staff try to make her feel like they are here to help, frequent checks, NP monitoring, and R13's family goes outside with her once or twice a day. RN M indicated her family involvement is the best intervention. R13 doesn't really want to do things with us or any activities at the facility. Example 2: R3 is a long-term resident of the facility. R3 was admitted on [DATE] with a diagnosis history that indicates: [CONDITION(S)] Disease, Unspecified Dementia without Behavioral Disturbance, Spinal Stenosis, Pain unspecified Joint, Generalized Anxiety Disorder, Generalized Muscle Weakness, History of Falling, Wedge Compression Fracture of First Thoracic Vertebra, Subsequent Encounter for Fracture with Routine Healing. R3's quarterly MDS (Minimum Data Set) assessment on 5/17/22 indicates R3 had a BIMS (Brief Interview for Mental Status) score of 99 indicating severe cognitive impairment. R3's cognitive impairment is rarely or never understood and sometimes understands responding adequately to simple, direct communication only. R3's Functional Assessment: total dependence assistance with two+ persons for physical assist with transfers. R3's moving from seated to standing position assessment was not performed. R3's functional limitation assessment indicates no impairment in the upper extremity and impairment on both sides in the lower extremity. Devices that R3 uses are a wheelchair. Pain assessment for R3 indicates that resident is receiving scheduled pain medication and is not receiving PRN (as needed) pain medication, and unable to answer for a rating of pain level. Fall assessment for R3 indicates no falls since admission. R3's care plan documents the following, in part: Problem: ADL (Activities of Daily Living) Self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Dementia, Limited Mobility. Goal: R3 will maintain current level of function in regards to ADLs and accept staff assistance with all cares. Interventions: . Transfer: R3 uses a broda chair and requires total assist with mobility. She requires 2 assist and a mechanical lift for all transfers . This care plan is initiated on 2/14/20, revision on 3/04/21. Problem: At risk for falls: Confusion, Incontinence, Poor communication/comprehension, Unaware of safety needs, R/T [CONDITION(S)], anxiety and depression. Goal: R3 will have no fall related injuries. Interventions: . Mechanical Lift for transfers . This care plan is initiated on 2/14/20, revision on 8/24/21. Please note, the care plan does not indicate which sling to use, where the sling is located and has not been updated. Problem: Potential risk of impairment to skin integrity R/T incontinence B&B (bowel and bladder), cognition, wounds to hammer toes, hx (history) of pressure and decrease nutritional intake. Goal: Will maintain or develop clean and intact skin by the review date. Interventions: . Use caution during transfers, bed mobility and when propelling in broda chair to prevent striking arms, legs and hands against any sharp or hard surface . This care plan is initiated on 6/8/21. On 5/19/22 at 7:30 AM, Incident Description Note states Resident being transfered via Hoyer lift w/a (with assist) of 2 staff per protocol. Resident slipped from Hoyer sling landing on the floor. 1 staff operating the Hoyer, 1 staff assisting with WC (wheelchair) placement at this time, neither staff were in a position to assist her to the floor. It was witnessed that she did hit her head. Small amount of red drainage noted from the back scalp at this time. Resident alert and assessed with no know injury to rest of her body. VS's (vital signs) and Neuro's initiated. Family, hospice, NP (Nurse Practitioner) and DON (Director of Nursing) notified of the incident. On 5/24/22 at 11:14 AM, Incident Note written by DON B (Director of Nursing) state, in part: Root Cause Summary: Staff walked me through the process. A different sling was used for transfer, as the sling she uses was in the wash. Resident assessed, resident placed back into bed, neuro checks initiated to include VS. All slings have been checked and all slings are in good condition and no need of repair. Hoyer lifts have been checked and are in good condition and no need for repair. For resident using a Hoyer, 2 slings will be available for usage. On 8/11/22 at 2:33 PM, Surveyor interviewed LPN NM K (Licensed Practical Nurse, Nurse Manager). Surveyor observed slings on the floor in LPN NM K's office and asked LPN NM K where the slings were from, she replied they were from R3's room. LPN NM K then held up the white sling the staff used with R3 and demonstrated no physical concerns and that they are different than the others. LPN NM K reported R3 has an extra sling in her closet. Surveyor observed the sling did not have back support material. Surveyor noted another white sling on the floor noting 2 slings. On 8/22/22 at 8:09 AM, Surveyor interviewed DON B. Surveyor asked DON B if staff should have known not to use the sling, she replied, well, no, we have numerous kinds. Surveyor asked DON B if there should have been education on the correct sling, she replied, The staff development nurse initiated education of application of sling and Hoyers in general The facility did not ensure staff were trained on appropriate sling use for R3. R3 fell out of an alternate sling that was used by staff.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program that helped prevent the development and transmission of COVID-19, which has the potential to affect all 39 residents who reside in the home. The facility is in a COVID-19 outbreak 35 of 39 residents have contracted COVID-19. One resident (R1) died from COVID-19 and three residents (R4, R5 and R6) have been hospitalized with COVID-19. The facility failed to identify an outbreak on [DATE], [DATE], and [DATE] and did not implement aggressive measures to prevent further spread, including outbreak testing on both staff and residents according to current standards of practice. The facility failed to perform contact tracing of COVID-19 positive staff to identify staff that share a breakroom. The facility did not ensure all visitors are screened upon entering the facility as Surveyors were not screened upon entering. The facility did not keep room doors closed to have a barrier between residents who have not been infected and residents who were positive for COVID-19. The facility did not ensure soiled personal protective equipment (PPE) was stored in covered bins. The facility did not ensure staff were fit tested for the N95 masks they wore. Facility staff observed wearing face shield into multiple resident rooms without removing and disinfecting in between. Residents who tested positive for COVID-19 did not have a COVID-19 care plan in place. The facility's failure to implement infection prevent and control measures to prevent the spread of COVID-19 created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (NHA A) was notified of the immediate jeopardy on [DATE] at approximately 2:30 PM. The immediate jeopardy was removed by the facility on [DATE]. The deficient practice continues at a scope and severity of an F (potential for harm/widespread) as the facility continues to implement its action plan. Evidenced by: According to the Centers for Disease Control and Prevention (CDC), Among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die . In general, your risk of getting severely ill from COVID-19 increases as you get older. In fact, 8 out of 10 COVID-19-related deaths reported in the United States have been among adults aged [AGE] years and older. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/olderadults.html#:~:text=Among%20adults%2C%20the%20risk%20for,or%20they%20may%20even%20die. The Centers for Disease Control and Prevention notes that hospitalization rates per 100,000 people increase as one ages. hospitalization rates increased from 136.1 per 100,000 people aged 50 to 64 to 513.2 per 100,000 people aged 85 and above. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html Example 1: Outbreak not identified, line listing not completed, no contact tracing of shared areas (other than work areas). According to the Centers for Disease Control and Prevention, A single new case of [DIAGNOSES REDACTED]-CoV-2 infection in any HCP (healthcare personnel) or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html The Centers For Medicare and Medicaid Services' (CMS) Center for Clinical Standards and Quality/Survey and Certification Group, Memo QSO-,[DATE]-NH includes, in part: . Upon identification of a single new case of Covid-19 infection in any staff or resident, all staff and residents should be tested , and all staff and residents that test negative should be retested every 3 to 7 days until testing identifies no new cases of Covid-19 infection among staff or residents for a period of 14 days since the most recent positive result. Facility staff testing documentation, includes, in part: [DATE] - [DATE] staff are tested on ce a month or if they have signs and symptoms of COVID-19. Residents were tested on ly when they show signs and symptoms of COVID-19. Facility Line Listing for October and [DATE] include: DA D (Dietary Aide) exposure/Asymptomatic . date of collection: [DATE] . COVID-19 positive . symptom resolution [DATE] (It is important to note this one positive COVID-19 result would put the facility in an outbreak and outbreak testing should have begun.) FS E (Facility Staff) . symptom onset: [DATE] . date of collection [DATE] . COVID-19 positive (It is important to note this is the second staff member to test positive for COVID-19.) The facility did not implement outbreak testing. FS F . symptom onset: [DATE] . date of collection [DATE] . COVID-19 positive (It is important to note this is the third staff member to test positive for COVID-19.) CNA G (Certified Nursing Assistant) . symptom onset: [DATE] . date of collection: [DATE] . COVID 19 positive R3 . symptom onset: [DATE] . sore throat . COVID-19 positive . date of collection: [DATE] R7 . symptom onset: [DATE] . fever . COVID-19 positive . date of collection: [DATE] (It is important to note these are the first 2 positive resident cases, and they both had symptoms.) On [DATE] the facility tested on ly the residents on the wing where the two positive residents (R3 and R7) reside. Two more residents tested positive for a total of 4 total positive residents on [DATE]. On [DATE] the facility tested on ly the residents who reside on the floor where the four positive residents reside. These results were delayed by the lab until [DATE]. On second floor two residents presented with symptoms and were tested . Both results were positive. ([DATE] total of 6 residents positive). [DATE] through [DATE] all residents were tested / house-wide. Test results came back [DATE] and [DATE]. The total positive residents on [DATE] (including the 6 previous) is 33. (It is important to note, during interviews staff told Surveyor the total number of residents with COVID-19 positive test results was 35. The line listing does not reflect this total and there are no more entries added to line listing past [DATE]). On [DATE], a total of 10 staff had tested positive for COVID-19. NHA A provided a list to Surveyor, dated [DATE], entitled Staff Who Previously tested Positive. Of the 131 staff listed, 86 are marked for having tested positive previously. (It is important to note: the facility line listing does not include staff for the month of November.) On [DATE] at 1:29 PM, during an interview with Infection Preventionist C (IP) indicated the outbreak started on [DATE] when the first resident tested positive for COVID-19. IP C and Surveyor reviewed Centers for Medicare and Medicaid Services memo, QSO-,[DATE]-NH, definition of an outbreak. IP C indicated the facility should have started outbreak testing on [DATE] when the first staff member was positive. IP C indicated the facility had been testing staff monthly since [DATE] and testing only residents who had signs and/or symptoms of COVID-19. IP C indicated on ,[DATE]- ,[DATE] is when all residents and staff were tested and when weekly testing started. On [DATE] at 3:30 PM during an interview, NHA A indicated the facility should have started outbreak testing when they had the first positive staff member. NHA A indicated the Facilities staff do not have much if any contact with residents in the skilled nursing and the Dining Services staff has minimal contact with residents. NHA A indicated staff from Dining Services and nursing share a break room. NHA A also indicated staff from both resident floors share a breakroom. On [DATE] at 12:20 PM, during an interview, Medical Director N (MD) indicated she was aware of each positive test result but through discussion it was decided the staff had minimal contact with residents. MD N indicated she was unaware DA D was in resident areas. MD N indicated she was unsure if it was discussed where staff take breaks and if contact between staff could have occured in other areas than resident living areas. MD N was unsure where staff took their breaks. MD N indicated the facility should have began outbreak testing with the first positive staff member and not waited until a resident was positive. Facility list of discharges, deaths, hospitalization , includes in part: R1 expired [DATE] R4 hospitalized [DATE] with COVID-19 R6 hospitalized [DATE] with COVID-19 R5 hospitalized [DATE] with COVID-19 Example 2: Screening On [DATE] at 8:50 AM, Surveyors were standing in the facility parking garage donning PPE (personal protective equipment. Surveyor observed two women walk to the facility telephone, called someone on it, and then the door to the facility released. The two women entered the facility. Surveyor picked up the phone and it immediately rang. A staff member answered the phone and Surveyor introduced both Surveyors and relayed the purpose for the visit. The staff member told Surveyors she would open the door. Surveyors heard the door release and entered the facility. Surveyors did not observe any staff inside the doors and did not observe any signage with instructions for a screening process. Surveyors rode the elevator to plaza level and waited outside of the elevator door. While waiting, Surveyors observed a woman walking with a walker and donning a surgical mask. At 9:00 AM, Surveyors observed a staff member walking by and asked her if she would assist in connecting the Surveyors with the NHA A or DON B (Director of Nursing). NHA A met Surveyors at the elevator doors and led Surveyors to the conference room. (It is important to note: Surveyors entered the building without being screened and spoke with two staff members who did not prompt Surveyors to be screened. The facility did not provide a policy for screening visitors). On [DATE] at 9:25 AM, NHA A entered the conference room. Surveyor asked NHA A what the process was for screening staff and visitors. NHA A indicated staff should not have allowed Surveyors into the building without being screened. During this interview, NHA A indicated there is a screening station by another entrance to the building. NHA A gave Surveyors a thermometer and paperwork for screening and observed Surveyors take their own temperature and fill out the paperwork. On [DATE] at 5:00 PM, during an interview, NHA A indicated she had addressed the screening concerns with some additional signs and training for staff monitoring the doors. Example 3: Physical barriers between positive and negative residents: Facility policy, entitled Management and Care of Residents with COVID-19, dated ,[DATE], includes, in part: . Licensed nurse will promptly place the resident on contact and droplet precautions and isolate with door closed . On [DATE] between 2:00 PM, and 3:25 PM, Surveyor observed 16 room doors to be open on the third floor, including the one resident room staff told Surveyor had not been infected with COVID-19. During an interview CNA H indicated all residents on third floor were positive for COVID-19 except for one. CNA H indicated he was unsure if room doors should be opened or closed. During an interview, CNA H and Activity Therapy Assistant J (ATA J) indicated every resident on third floor is positive with COVID-19. AT J indicated she was unsure if the room doors were to be opened or closed. During an interview, ATA J indicated she was not sure if the one room with the resident who does not have COVID-19 should have her room door closed. Health Unit Coordinator K indicated all residents on third floor have tested positive, except for one. On [DATE] between 2:00 PM, and 3:25 PM, Surveyor observed 5 room doors to be open on the second floor, including three rooms with residents who had not been infected with COVID-19. During interviews, RN L and RN M indicated three rooms on this floor have not been infected with COVID-19 and they were unsure if the room doors should be closed for these residents. On [DATE] at 3:30 PM, during an interview, NHA A indicated room doors should be shut for all residents, but she has helped out on the floor in the last couple weeks and it was just easier to keep an eye on the residents and interact with them with the doors left open. On [DATE] at 12:20 PM, during an interview, MD N indicated she supports the decision to keep the doors open to maintain visualization, allow staff to interact with and keep track of residents. MD N indicated that the one resident on third floor who has not been infected with COVID-19 is her own person and makes her own decisions about her door. Example 4: Soiled PPE (personal protective equipment) bins not covered On [DATE] between 2:00 PM, and 3:25 PM, Surveyor observed a total of 6 garbage cans overflowing with used PPE, such as gowns, gloves, and masks in the hallways on 2nd and 3rd floors. Cans did not have covers, and soiled gowns and gloves were observed on the floor around the cans. On [DATE] at 3:30 PM, during an interview, NHA A indicated the soiled PPE should be contained in bins with covers and she would take care of this immediately. Example 5: Fit testing Without an adequate seal, air and small particles leak around the edges of the respirator and into the wearer ' s breathing zone. When properly fitted and worn, minimal leakage occurs around the edges of an N95 respirator when the user inhales, ensuring that the user ' s breathing air is being directed through the filter material. Staff that are required to use respiratory protection must undergo fit testing, medical clearance, and training, which are all required elements of a healthcare facility ' s written respiratory protection program. These are requirements of the Occupational Safety and Health Administration (OSHA) Respiratory Protection standard (29 CFR 1910.134). https://blogs.cdc.gov/niosh-science-blog/[DATE]/n95-preparedness/#:~:text=Annual%20fit%20tests%20ensure%20that,ensure%20the%20best%20fit%20possible. On [DATE] at 1:29 PM, during an interview, IP C indicated she and NHA A have made calls in an effort to try to get someone in the building to perform fit testing of N95 masks and were unsuccessful. IP C indicated she trained staff to mold the mask to their face, but staff have not been properly fit tested for the use of the masks they are wearing. On [DATE] at 3:30 PM, NHA A indicated she purchased a webinar to learn fit testing and the webinar did not contain the training for fit testing. NHA A indicated staff are trained to mold their N95 mask to their face, but are not fit tested . Example 6: Face shields not disinfected. Facility policy, entitled Infection Control Standard Precautions, revised ,[DATE], includes, in part: . ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned, disinfected, and reprocessed . (It is important to note, Facility did not provide a policy that gives instructions for how to disinfect face shields.) On [DATE] between 2:00 PM, and 3:25 PM, Surveyor observed CNA I enter a COVID-19 positive room with all PPE on. Upon leaving room CNA I removed gown, gloves, and did not remove her shield or mask. CNA I then donned a new gown and gloves. Then CNA I entered into a room with a resident who has not been infected with her same mask and face shield. CNA I indicated she was going to assist resident with a video call. (It is important to note CNA I did not disinfect her face shield between a COVID-19 positive resident and a COVID-19 negative resident). Example: 7 Care Plans On [DATE] at 5:00 PM, NHA A indicated residents who are positive for COVID-19 should have a care plan. NHA A indicated IP C was working on this. (It is important to note, Surveyors obtained copies of current care plans for R1, R2, R3, R4, R5, R6 and R7. These care plans did not contain goals or interventions related to testing positive for COVID-19.) The facility's failure to implement infection prevention and control measures to prevent the spread of COVID-19 created a finding of immediate jeopardy because of the ease with which [MEDICAL CONDITION] can spread and because of the serious effects it can have on the elderly and those with compromised systems. The immediate jeopardy was removed on [DATE] when the facility took the following action: -All personnel will be re-trained by Executive Director or designee prior to their next working shift that all visitors must be screened before allowed into the building. This included the parking level entrance. This will be audited at random times under the direction of the Resident Services Director or designee three times per week for four weeks, with results reported to monthly Quality Assurance Performance Improvement (QAPI) Committee for further recommendations. -The IP will begin the CDC Infection Control Training related to outbreak. NHA has re-educated IP on what constitutes as a COVID-19 outbreak, on COVID-19 outbreak policies and procedures, on immediate testing in a Covid-19 outbreak, and together reviewed the contents of QSO-,[DATE]. Outbreak testing will be monitored by NHA A on an ongoing basis and updates reported to monthly QAPI Committee for further recommendations. -All staff will be re-trained by the nurse manager prior to their next working shift on the need for barriers on the transmission-based precaution rooms, including COVID-19 positive rooms. This will be monitored by nurse managers and audits completed daily until all residents test negative for COVID-19 and this is no longer applies, with observations reported monthly to QAPI Committee for further recommendations. -Temporary PPE disposal bins have been removed from the unit and lidded bins redistributed throughout. All staff will be re-trained by the nurse manager prior to their next working shift that PPE must be disposed of in bins with lids. These will be audited by DON or designee to ensure no PPE is exposed daily for one week with results reported monthly to QAPI Committee for further recommendations. -All staff will be re-trained by nurse manager prior to their next working shift to disinfect face shields with appropriate EPA-approved disinfectant when leaving resident rooms. This will be audited daily by DON or designee for one week with results reported to QAPI Committee for further recommendations. -All affected residents have current COVID care plans. Minimum Data Set Coordinator or designee will ensure these are completed as necessary. DON or designee will audit with each new COVID-19 positive case to ensure a care plan is completed and report findings to QAPI Committee.

Based on observation, interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as possible and/or that each resident receives adequate supervision and assistive devices to prevent accidents for 4 (Residents 4, 1, 6, and 7) of 5 residents reviewed for falls. Resident 4 had 4 falls from her electric wheelchair in a 4-month period. Resident 4 sustained fractures on two separate occasions related to falling from the wheelchair and getting caught on the wheelchair seatbelt. The facility did not assess the safety of the seatbelt, did not identify the root cause of 2 falls, did not document assessments related to the safety of the wheelchair, and did not document interventions and/or change the care plan to prevent future falls. Resident 1 sustained a fall with injury and the fall was not fully investigated to determine the root cause and fall interventions were not in place or used per manufacture's instructions to prevent additional falls. Resident 6 was observed being transfered to the shower chair. This shower chair is on casters and can be positioned over the toilet commode giving the resident a higher seat. During this observation the shower chair did not have all four casters locked as per manufacturer's recommendation. Resident 7 was observed to be in bed without the use of a motion sensor as is indicated on her plan of care. This is evidenced by: Example 1 Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4 was first admitted to this facility on 2/4/14. Admission notes on 2/4/14 indicate that she was admitted "following a stay at (name of hospital) for a R (right) distal/fib (fibula) fx. (fracture) from a car accident...Resident works for UW Clinics and uses an electric wheel chair to get around. Resident is hoping to return to prior residence following therapies." Resident 4 completed rehab and was discharged to an assisted living facility on 4/4/14. A Discharge Summary from (name of hospital) - Orthopedic Surgery dated 4/8/14 indicates that the discharge [DIAGNOSES REDACTED]." It also states in part that: "...because of her broken leg she was NWB (non-weight bearing) and was at a rehab facility. They were transferring from the bed to the wheelchair and the Hoyer (mechanical lift) tipped and fell on top of her." (Note: This incident with the Hoyer occurred at the Assisted Living Facility and resulted in a right hip prosthetic fracture.) Upon re-admission on 4/8/14, the facility completed a "Falls - Contributing and/or Risk Factors" form for Resident 4. This assessment indicated (with a check mark in box) that Resident 4 had "3 or more falls in past 6 months, major injury, hip." Two other check boxes are also marked in the section for "Gait/Balance" and "Medications." The form notes: "If ANY of the above checked the Resident is considered at Risk for falls. Immediate interventions must be initiated and a Care Plan developed." Facility "Event Reporting" and/or "Incident Report" forms show the following falls with investigation in the facility for Resident 4: Fall #1 - 5/8/14 5:00 PM - the report states: "...Resident calling out for help and upon entering room found lying prone on floor with electric w/c (wheelchair) directly behind her. Resident stated she thought she may have fallen asleep and fell forward out of chair. Resident remained awake and alert talking to staff while awaiting help (Blood visible-reported was coming from nose after ER (emergency room ) eval (evaluation.)" Injury is noted as: "R (right) eye lid and forehead hematoma." Follow-up indicates "911 notified for immediate assist and transport." The "Event Investigation Summary Report" dated 5/8/14 indicates: "Conclusion/Root cause: fell asleep and leaned forward in chair." The "Plan of Correction: Remind (Resident 4) to wear seat belt-she agrees." Fall #2 - 6/21/14 2:30 PM - the report states: "...Resident was leaning to ground with w/c at 14:30 (2:30 PM.) C/O (complaint of) pain on right thigh and right knee. Pain level is 8-9. VSS (Vital Signs Stable.) Notified on call Dr (name of doctor.) Received order and sent to ER for evaluation. The "Event Investigation" form notes: "Resident fell asleep in chair-seat belt on and secure." A witness statement notes: "I heard someone screaming for help went to (Resident 4)'s room. She was leaning completely forward hands touching the ground. Seatbelt on. Me and another aide sat her up. Then put (Resident 4) in bed with maxi lift." This witness statement is not signed or dated. There is no indication as to who completed the statement or when. A second witness statement states in part: "...we found patient still seat belted in electric w/c but bent down to the floor. We both grabbed a side and eased her back into a sitting position..." This statement was signed by Witness (does not indicate job title) C and dated 6/22/14. An Event Investigation Summary dated 6/21/14 states in part: Conclusion/Root Cause: "incorrect w/c fit and falling asleep in chair." Was this event Avoidable/Unavoidable: "Unavoidable due to resident falls asleep in middle of day and w/c fit." Plan of Correction: "Will talk to resident when back from hospital regarding w/c fit." (Note: There are no documented discussions that can be found in the medical record regarding the w/c fit or assessments of the wheelchair and seatbelt after this fall.) Nurses Notes dated 6/26/14 at 19:56 (7:56 PM) state in part: "...readmitted to Capitol Lakes with dx (diagnosis) of right distal femur fx (fracture). Plans to receive OT/PT. Alert, oriented x 3." Fall #3 - 8/5/14 6:00 PM - The "Incident Report" form states: "Location" "Parking/Loading Area...Resident family getting back from Dr. appointment and resident chair tipped on her ramp coming out and she was still in her chair. Resident sister called the front desk to report she needed help getting resident chair tipped back up with resident in it. Resident states she didn't bump her head on the ramp or hurt herself. Resident when asked why she didn't tell the nurse when it happened she commented she didn't want anybody to know but when asked if she was hurting anywhere she did comment her left hip and her knees were sore." The report indicates that Resident 4 was sent out to the hospital via ambulance. Interdisciplinary Notes dated 8/5/14 at 10:48 state: "Writer placed call to (first name), GHC (health plan) case manager regarding f/u (follow-up) on w/c positioning. They have not received an order from PCP (Primary Care Physician.) Writer left voice mail for (name of doctor)'s nurse about order. (Resident 4) is seeing her today." (Note: The writer of this note is Registered Nurse (RN) D who is RN supervisor for Resident 4's unit.) An interdisciplinary note in the medical record, dated 8/6/14 at 8:29 AM, states: "(Resident 4) was sent back to facility around 0700, no injuries. (Resident 4) was carrying groceries when the w/c tipped over. She denied injuries. Writer updated (name of w/c manufacturer) about incident in order to expedite the process of a better fitting w/c." (Note: the writer is RN D.) The section for "Investigation/Notes" on the 8/5/14 Incident Report is blank. There are no witness statements, no root cause analysis, and no plan of correction. (Note: The facility switched to a new computer system in this period and the investigation reports are now fully computerized. There are no sections in the new report format for root cause or plan of correction as previously.) Fall #4 - 9/12/14 3:00 PM - The Incident Report States: Describe incident - "therapy heard a yell and found resident laying forward with upper body/chest on floor. Resident fell asleep while sitting in w/c with her seat belt and fell forward. (Resident 4) was stopped by the seat belt. (name of CNA), (name of PT/Physical Therapist), (name of PT student), and writer were able to get the w/c pulled back and (name of medical records staff) undid the seat belt. (Resident 4)'s left leg was flexed at the hip and her lower leg was bent laterally and upward. Her right foot was turned inward. Both extremities were restricted by the w/c. Upon the release of the seat belt, writer was able to straighten (Resident 4)'s legs. (Resident 4) reported pain in her left knee. (Resident 4) was laying prone and a pilow (sic), she stated she was comfortable. Writer waited with (Resident 4) until parametics (sic) and EMT (Emergency Medical Technicians) came." Investigation/Notes - "(Resident 4) fell asleep in chair with the seatbelt and leaned forward. The chair did not fall on her, but she was unable to get herself off the floor. Due to the seat belt being on, her legs were restricted and bent..." Note: The investigation notes do not indicate any root cause analysis, interventions added, or changes to the care plan. Interdisciplinary Notes dated 9/17/14 at 6:39 PM state: "readmitted to (name of facility) after a fall with left femur fx. Alert and oriented x 4. PT/OT to eval and treat." Interdisciplinary Note dated 9/17/14 at 12:17 PM states: "late entry from 9/16/14: writer spoke with (first name) at (w/c manufacturer) regarding the most recent incident with resident. He did not think there was much he could do with the chair in order to fit her better. Writer explained the dangerous seating position for (Resident 4) and how it is not safe. He will come out Monday to re-evaluate the chair." This note was written by RN D. (Note: there are no further records of the manufacturer representative visit.) On 10/6/14 at 1:00 PM, Surveyor interviewed Physical Therapist (PT) E regarding any therapy evaluations of Resident 4's wheelchair or seatbelt. PT E stated that there was so much going on with (Resident 4) and that she was falling asleep in the wheelchair. PT E stated that the wheelchair is really more of a scooter and has no tilt and just a plate at the bottom to rest feet. PT E stated that Resident 4 has a large girth and her pannus (abdominal area) was far forward in front of her while in the scooter. PT E stated that, after the fall with fracture on 6/21/14, they did try a different wheelchair that could tilt back more. PT E stated that Resident 4 did not like the new wheelchair because it was not electric and took away her mobility as the chair was too wide to reach the wheels for self-propelling. PT E stated that she (PT) and the nursing staff made a "contract" with Resident 4 to help her be safer in the electric wheelchair. PT E stated that the contract was signed by the resident as an agreement that she would not stay up in the electric wheelchair for more than 2 hours at a time so as not to fall asleep in it. PT E stated that she and RN F had discussed the agreement with Resident 4. When asked to see the contract, PT E stated that Nursing should have it. When asked when it was signed, PT E stated around 7/3/14 (based on notes she had in her calendar.) PT E stated that she had not documented in the therapy notes any of her evaluation of the wheelchair or these discussions with Resident 4. PT E stated that she never did a formal PT evaluation of the wheelchair and has no documentation regarding the electric wheelchair or regarding the non-electric wheelchair that Resident 4 used for a short time. PT E provided her "PT Evaluation and Plan of Care" for the certification period from 5/18/14 to 8/7/14. There is no evaluation of the wheelchair position or fit in the PT documentation. On 10/6/14 at 1:15 PM, Surveyor interviewed RN F. RN F stated that he works on day shift on Resident 4's unit. RN F stated that he recalls working with therapy to have Resident 4 sign a consent form because therapy did not want her sitting at the edge of the bed because she was falling asleep sitting up. RN F stated that the consent also spoke about only sitting up in the electric scooter for 90 minutes at a time. RN F stated that he was there when therapy talked to Resident 4 about the plan. RN F stated that he did monitor Resident 4 after that to see if she was falling asleep in wheelchair and encourage her to be in bed. RN F stated that it went pretty good for a while. The consent/contract cannot be found in the medical record. There is no documentation in the medical record to indicate what the actual terms of the safety agreement were. The only reference to it that the facility was able to provide was a Nurse's Note dated 7/8/14 at 4:11 PM that states: "16:05 late entry: Spoke with (PT E) on 7/3 to review safest transfer for resident. (Resident 4) is requesting to be transferred with the maxi-lift, and use her wheelchair. The therapists and the nurse reviewed with (Resident 4) on 7/4 the risks of using a maxi-lift and sitting in her chair rather than the reclining w/c. (Resident 4) is aware of the risks and signed a managed care agreement form." The managed care agreement is not in the medical record and the facility was unable to locate it upon request. On 10/6/14 at 1:30 PM, Surveyor interviewed RN D, the nurse supervisor. RN D stated that after the 6/21/14 fall, she talked to the company that dealt with the wheelchair. They came out and looked at the fit of the chair. RN D stated that, when Resident 4 first got back after the 6/21 fall, she did not use the electric wheelchair because of hip precautions from her fracture. RN D stated that they had discussions with the surgeon about which chair to use. RN D stated that it was OK with the surgeon to have limited amount of time up in the electric wheelchair. There is no documentation of these discussions. When asked for an assessment of the seatbelt used in the wheelchair, The facility provided a computerized note dated 5/9/14 at 4:28 PM that states: "(Resident 4) was found after falling asleep in her w/c and falling forward, hitting her eye. She was not wearing her seat belt for the w/c and has been wearing it since the fall. She has demonstrated that she is able to release the seat belt, she needs some assistance to put the seat belt on. But if given time, she is able to don the seat belt independently." There is no safety assessment of the seatbelt and no re-assessment after the 6/21/14 fall. Resident 4's Care Plan for Falls dated 9/17/14 contains the following interventions: - OT (Occupational Therapy)/PT eval and treatment to increase functional mobility and safety. - See Basic Needs and Preferences care plan for transfer and mobility needs. (The mobility care plan states in part: Wheelchair locomotion: Electric Wheelchair.) Place commonly used/personal items within reach. - Call light within reach. - Assist with transfers. When asked evidence that the safety recommendation made by PT in the "contract" had been added to the Care Plan, the facility provided CNA care guides (not a part of the permanent medical record.) The Care Guide for 8/22/14 had an entry: "Up in power w/c 90 min (minutes) w/2 hrs in bed between periods of being up in power w/c." This entry had been discontinued on the 8/25/14 CNA care guide. When asked why this had been discontinued, the facility provided an Interdisciplinary note dated 8/25/14 at 12:00 PM that states: "Per PT in care conference, 3 person transfer with Hoyer lift can be changed to two person. (Resident 4) can now be up for an unlimited time in w/c." On 10/6/14 at 2:50 PM, Surveyor interviewed Physical Therapy Aide (PTA) G who was the therapy staff person who attended the 8/25/14 care conference. PTA G stated that he is aware of Resident 4's history of falls but was not involved in any of the assessments (post-fall). PTA G stated that he did address the transfer status at the care plan meeting on 8/25 in terms of going back to her previous assist level of 2 for the Hoyer lift. PTA G stated that he does not recall any discussions and did not make any recommendations regarding the time spent up in the wheelchair. Resident 4 had significant pain following her return to the facility after the 9/12/14 fall. Nurse's notes indicate: 9/17/14 11:27 PM -"C/O pain to LLE (left lower extremity.) rated pain at 8/10. Resident reported that off and on her left leg spasms..." 9/18/14 11:13 10:11 PM - "Resident requested morphine medication to give at bedtime...left leg prn (as needed) pain medication given." 9/19/14 5:51 AM - "...rated her pain a 9 to her left casted leg..." 9/19/14 11:12 PM - "...C/O severe pain...L (left leg) with cast..." 9/20/14 12:57 AM - "Resident awake at 2300 (11:00 PM) with complaints regarding the overlay mattress-stated it is very uncomfortable and makes her lean to one side...also it makes her sweat and it is hard for her to reposition herself in bed...staff did remind resident that she is more bed bound now...but still requested to have overlay mattress removed..." 9/20/14 3:21 PM - "Resident was given prn oxycodone for pain 6 to left leg and was effective..." 9/20/14 11:13 PM "...c/o 7-8/10 pain LLE..." 9/21/14 3:33 PM - "Resident complained of 10/10 pain received prn oxycodone x 2 4 tablets each time. Resident had cast removed to do dressing on left leg and resident wanted it off d/t (due to) pain and writer had nowhere in orders to keep it off so placed it back on and made sure foot was to the bottom of the cast. CMST (Circulation, Motion, Sensation, Temperature) checks within normal limits. Did check foot and heel on left when cast was off to make sure no pressure areas and no areas of concerns were noted." 9/22/14 12:04 AM "...Crying and complaining of pain to left leg. Top of left foot has multiple dark discolorations and left heel has dark red. Applied optifoam for protection. Called on-call Ortho..." 9/22/14 11:33 AM - "Medicated only once for pain at end of shift. left leg in cast. CMST WNL (within normal limits). skin is pink warm and dry..." 9/24/14 3:22 PM - Resident requested pain meds 1 time this shift at 11:20 and states it was effective. Changed dressings to left top of foot and left heel. Purple areas are dry and no drainage noted on old dressings." 9/25/14 3:06 AM - Resident was awake at the start of the shift with pain to her left foot-PRN medication given for pain and spasms at that time...states she will be seen by MD today regarding pain to her left foot. Weepy at times in conversation regarding her health issues..." A consultation form from the visit to the Orthopedic Surgeon on 9/25/14 states in part: "Patient f/u (follow-up) L distal femur fracture. Has been in FRC (Focused Rigidity Cast) cast - developing further skin breakdown, leg spasming. Radiographs - increased displacement of femur fx. Also new non-healing fx of left periprosthetic hip fracture (not previously seen). Also L proximal tibia fracture-nondisplaced crack. On exam, new ulcerations noted of dorsal foot, heel...Plan-discussed with patient treatment options. Do not feel that continued cast is working. Recommend surgery for [REDACTED]. NOTE: Resident 4 was out to the hospital during survey on 10/6/14 and was not available for observation or interview. On 10/6/14 at 3:50 PM, Surveyor spoke with Nursing Home Administrator (NHA) A, Director of Nursing (DON) B, and RN D. RN D stated that she did the seatbelt evaluation on 5/9/14 and there are none after that date. RN D stated that she has been in contact with the manufacturer several times to re-evaluate the wheelchair. RN D stated that Resident 4's sleepiness (prior to the 9/12 fall) was better because she was using her CPAP (Continuous Positive Airway Pressure) machine more. RN D stated that Resident 4 had been treated for [REDACTED]. RN D stated that this may have been the reason for going back to unlimited time up in the wheelchair. If so, that assessment and the reason for the change was not documented. RN D stated that Resident 4 is currently out of the facility having an amputation of her leg. RN D stated that Resident 4 was admitted with wounds to her legs and had stasis wounds that were horrible. NHA A stated that Resident 4 was completely alert and oriented and made her own decisions. NHA A stated that Resident 4 could be up an unlimited amount of time in the wheelchair per her own choice. NHA A stated that they know that Resident 4 completed a managed care agreement form (to discuss risks/benefits and refusal of treatment) but that they are unable to locate it. NHA A and DON B stated that the amputation is due to the fractures sustained prior to her admission here and to the skin issues that were present on admission. They provided the following documentation related to the amputation: Office Visit Orthopedics 9/30/14 states in part: "History of Present Illness: (Resident 4) has a history of multiple fractures sustained in low-energy mechanisms, with the most recent being a displaced fracture of her left distal femur and now findings radiographically of nondisplaced fractures of the left hip and left proximal tibia. Since January of 2014, she has suffered a right hip fracture, right distal femur treated with fixation, right distal tib/fib fractures, right proximal tibia fracture. All fractures have occurred with little to no significant trauma. She also has had ongoing management of a chronic wound with underlying fistular osteo[DIAGNOSES REDACTED] to the lateral lower leg for the last two years...Secondary to high risk of infection of her total hip arthroplasty on the ipsilateral side with any attempts of ORIF (Open Reduction Internal Fixation) of the distal femur fracture (due to her chronic osteo[DIAGNOSES REDACTED] and medical comorbidities), patient will instead proceed with above knee amputation..." Example 2 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's care plan includes the following fall interventions: remind to call for assist prior to transferring, monitor safety each shift by encouraging to be out in common areas, maintain bed at standard height and keep wheelchair at bedside at night, slipper socks over his socks in bed. Per facility incident report, on 8/31/14 Resident 1 was found on the floor in the bathroom. Resident 1 was sent to the emergency room and noted to have right rib fracture and iliac crest fracture. The fall investigation report does not indicate an investigation was conducted to try and determine the root cause of how Resident 1 got to the bathroom and why he fell . On 9/3/14, Resident 1's Care Conference Summary indicates a motion sensor will be added and staff will try to keep in line of vision as much as possible. It also indicates a urinal was added the past few weeks. On 10/6/14, at 8:33 AM, Surveyor observed Resident 1's room. Surveyor noted the chair over Resident 1's toilet did not have any wheels locked and moved easily; however Resident 1 was not in the room at the time. On 10/6/14, at 9:51 AM, Surveyor observed Certified Nursing Assistant (CNA) K assist Resident 1 into bed. CNA K removed Resident 1's shoes and Resident 1 did not have non-skid socks on. CNA K lowered Resident 1's bed to the floor. Following cares Surveyor interviewed CNA K who stated Resident 1 is constantly up and down all day. By 9:58 AM, Resident 1 was sitting at the edge of his bed and the motion sensor triggered the call light. Assistant Director of Nursing (ADON) H responded to the light and offered to help Resident 1 lay down. Resident 1 responded he was just lying down. ADON H encouraged Resident 1 to lie back down. By 10:10 AM, Resident 1 had been incontinent and CNA I was in the bathroom providing cares. Following cares CNA I walked with Resident 1 to a chair as the bed needed to be changed. CNA I changed the bed linens then offered to assist Resident 1 back into bed. Resident 1 stated he was alright sitting up in the chair. CNA I encouraged Resident 1 to lay down by stating "You look tired." Resident 1 complied and laid down. Resident 1 did not have non-skid socks on when in bed. During this time Surveyor noted the chair over the toilet had four locking casters/wheels and only the front two were locked. Surveyor also noted the sheetrock was missing from the bottom of the closet corner just outside of the bathroom. The metal drywall strip and a screw were exposed. At 10:51 AM, Surveyor observed ADON H respond to Resident 1's call light, Resident 1 was lying in bed. ADON H lowered Resident 1's bed to the floor and adjusted the motion sensor alarm. Resident 1 stayed in bed until lunch. At 1:39 PM, Surveyor observed CNA I ambulate with Resident 1 out of the bathroom. Surveyor noted only the front two casters were locked on the toilet chair. CNA I assisted Resident 1 into bed and again Resident 1 did not have non-skid socks in place. Surveyor interviewed CNA I who stated Resident 1 spends most of his day in bed. On 10/6/14, at 1:45 PM, Surveyor interviewed ADON H and Registered Nurse/Resident Care Manager (RN) J. RN J stated Resident 1's care plan indicates to monitor safety which means to encourage Resident 1 to be out of his room. RN J also stated per the plan of care Resident 1 should have his bed at standard height, wheelchair placed next to his bed and non-skid socks over his socks. RN J stated following the fall on 8/31/14 the interdisciplinary team would have reviewed the fall the following working day. RN J was not able to find any documentation regarding this review or the outcome. ADON H acknowledged that she adjusted Resident 1's bed height and then checked with CNA I and went back and put the bed at standard height. RN J, ADON H and Surveyor then went to Resident 1's room. Resident 1 was in bed without non-skid socks and the wheelchair was not next to his bed, RN J also stated she had put a work order in for the closet corner to be fixed. RN J placed non-skid socks over Resident 1's socks and moved the wheelchair next to his bed. Example 3 Resident 6's [DIAGNOSES REDACTED]. On 10/6/14 at 1:13 pm Surveyor observed CNA (Certified Nursing Assistant) M assist Resident 6 to the toilet. With a gait belt in place, CNA M transferred Resident 6 from her wheel chair to the shower chair. This shower chair was on casters and was positioned over the toilet commode to provide a higher seat for Resident 6. As Resident 6 moved from her wheel chair to the shower chair, the shower chair moved approximately 2 - 1/2 inches. When CNA M had completed her task of assisting Resident 6 to the toilet, and had Resident 6 resting in bed, Surveyor asked CNA M if the shower chair casters were to be locked. CNA M was in the bathroom at this time and stated: "Yes, we lock them." As she said this she placed her hand on the chair and moved the chair. The chair moved as it was not secured in place. CNA M stated: "Well, this one isn't" and locked the front right caster with her foot. The manufacturer's instructions for the Shower Chair Commode includes: Toileting - Lock all locking casters. Example 4 Resident 7's [DIAGNOSES REDACTED]. On 9/30/14 at 9:15 pm Resident 7 sustained a fall. A new intervention was added to ensure Resident 7's safety which was a "motion sensor call light as resident does not put her call light on to notify staff what she needs but tries to do it herself." The motion sensor is not noted on Resident 7's plan of care. On 10/6/14 at 1:22 pm Surveyor observed CNAs I and K assist Resident 7 into bed with the use of a mechanical lift. Resident 7's motion sensor was noted on the bedside dresser. While CNA I was settling Resident 7 in bed, OT (Occupational Therapist) N entered the room stating he was going to work with Resident 7 when CNA I was finished. OT N left the room until CNA I had finished settling Resident 7. CNA I did not engage Resident 7's motion sensor when she left the room at approximately 1:28 pm. At approximately 1:30 pm OT N entered resident 7's room and began working with her. On 10/6/14 at 1:39 pm OT N left Resident 7's room stating to Surveyor that Resident 7 was too tired to do therapy. Resident 7 did not have her motion sensor alarm in place when OT N left Resident 7's room. On 10/6/14 at 1:43 pm Surveyor stopped RN (Registered Nurse) Manager J as she passed by Resident 7's room. Surveyor asked RN Manager J if she would enter Resident 7's room to check if the motion sensor was in placed and engaged. RN Manager J entered resident 7's room, picked up the motion sensor that was on the bedside dresser and stated: "It's not on." RN Manger J then turned the senor alarm on and placed it on the floor atop the floor mat next to Resident 7's bed.

Based on interview and record review, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 17 sample residents (Resident 15) as it relates to receiving CPR (Cardiopulmonary Resuscitation). The facility has 23 active residents that choose to be a full code status. On admission [DATE] Resident 15's legal representative signed a document indicating that Resident 15 is to be a Full Code for Cardiopulmonary Resuscitation. On [DATE] Resident 15 had a change of condition and again it was re-iterated that Resident 15 was to be a Full Code status. On [DATE] the nurse practitioner wrote in her progress notes that the family requested that if Resident 15 had recurrent pneumonia he was to be re-hospitalized . Resident 15 was not re-hospitalized when his chest x-ray showed active pneumonia. Resident 15 received an order for [REDACTED]. On [DATE] Resident 15's vital signs were very abnormal and unstable and Resident 15 was having difficulty breathing. Staff called the family; the Activated Power of Attorney for Health Care (AHCPOA) indicated they wanted Resident 15 sent to the hospital for treatment. Instead of calling 911 and sending Resident 15 to the hospital for emergent treatment, the facility called the family and repeatedly questioned the family's decision for full code status and attempted to talk the family into keeping Resident 15 at the facility as he "was not going to make it." Staff subsequently left Resident 15 alone in his room, despite the fact that he was having respiratory distress and his oxygen was turned up as high as it would go. When the CNA entered the room a couple of minutes later, she noted that Resident 15 looked like he was gone and got the nurse. The nurse practitioner came upstairs and instructed staff not to initiate CPR as it was "technically" an unwitnessed arrest (although it would have been witnessed had staff, knowing his condition, remained in the room with him). When staff noticed minutes later that Resident 15 had expired, CPR was not initiated. The failure to provide the care needed by Resident 15, as requested by the family, negated Resident 15's only chance for survival. This created a finding of immediate Jeopardy situation that began on [DATE]. Immediate Jeopardy was identified on [DATE] and the facility administrator was notified on [DATE]. Immediate Jeopardy was removed on [DATE] after the facility began inservicing staff. Scope/severity continues at an E level (potential for harm that is not immediate jeopardy/pattern) as the facility has yet to fully implement and monitor the effectiveness of its action plan. Findings as follows: The facility policy and procedure dated [DATE] includes the following: Policy: It is the policy of the company to initiate cardiopulmonary resuscitation on any resident witnessed suffering from a cardiac or respiratory arrest unless otherwise specified by a physician's orders [REDACTED]. If the resident and/or family, and physician desires full resuscitation, the following procedure will be followed: a. The staff person finding the resident in need of CPR will verify if the resident is a "Full Code". b. The staff person will loudly call out for help and activate bedside or bathroom call system, if available, start CPR and simultaneously , alert somebody to call 911 and get a licensed nurse. c. The licensed nurse will respond "stat" with the Emergency Cart and help/direct resuscitation measures. d. The person calling 911 will request advanced life support assistance and say "CPR in progress".... Resident 15 was admitted to the facility on [DATE] with Dysphagia, Pneumonia, and Encephalapathy. Resident 15 It should be noted that the facility staff were keenly aware of Resident 15's full code status and yet staff exited the room not providing the monitoring that Resident 15 required during this event. It should be noted that the facility staff were keenly aware of Resident 15's full code status and yet staff exited the room not providing the monitoring that Resident 15 required during this event. was not his own legal decision maker. Resident 15's discharge summary dated [DATE] indicates that Resident 15 is to be a DNR (do not resuscitate). Resident 15's legal representative signed on [DATE] (admitted ) that Resident 15 would like to be a "Full Code". The form states, "I understand that I have the right to make decisions about my present and future health care. The issue of cardiopulmonary resuscitation (CPR) has been thoroughly discussed with me. Basic CPR is defined as rescue breathing, whether done mouth to mouth or with specific breathing mask and bag, and external cardiac massage, which is chest compressions; however, chest compressions alone may be performed based upon changing standards for Basic CPR. I have decided that in the event of a witnessed cardiac or respiratory arrest, I do want CPR." Resident 15's physician's orders [REDACTED]. Oxygen Saturation-Check PRN for respiratory distress or change in pt (patient) condition. admission orders [REDACTED]. (Please note that Resident 15's family request for Full Code status and physician's orders [REDACTED].) A fax that is not dated was sent to NP NN (Nurse Practitioner) indicating, "Family opted to be "Full Code" but is discussing~may change to DNR." There is no follow up physician's orders [REDACTED]." (Please note that Resident 15 has an admission order for a no code but family has signed that they wanted Resident 15 to be a full code and there is no clarifying information at the time of admission.) A nursing note dated [DATE] at 11:12 PM indicates that Resident 15's lung sounds are clear upon auscultation. A nursing note dated [DATE] at 2:46 AM indicates that staff, upon auscultation, heard abnormal crackles and congestion in the bilateral lower lobe but no cough noted. Resident 15 had a chest x-ray to rule out TB ([MEDICAL CONDITION]); the conclusion states: No acute cardiopulmonary disease seen. (It should be noted that the change in lung sounds, a symptom of pneumonia, was not called to the NP.) A nursing note dated [DATE] at 4:00 PM indicates Resident 15's lung sounds have faint crackles posterior. At 10:41 PM note states congestion heard in anterior lung fields. (Again, it should be noted that the congestion in the lung sounds, a symptom of pneumonia, was not called to the NP.) A nursing note on [DATE] at 4:05 PM states lung fields and clear anterior chest. A note at 9:45 PM states, "Resident was unresponsive to verbal stimuli in the beginning of the shift. NP NN was here and ordered stat chest x-ray and labs. NP notified his family. Staff assisted resident to bed and later got resident up for supper. Resident was awake and alert afterwards. Family visited resident sat up in wheelchair and watched television with his son." The radiology report dated [DATE] indicates that Resident 15 has slight right lower lobe and modest left lower lobe pneumonia new since [DATE]. A Nursing Home Acute Visit progress note dated [DATE] seen by Nurse Practitioner NN (NP) states, "A [AGE] year old male seen today for chief complaint of chest congestion and altered mental status as reported by staff. Physical therapist could not awaken pt for afternoon session; earlier today pt went to PT and visited with family. ...Pt has dysphasia with recent hospitalization for aspiration pneumonia altered mental status and generalized weakness. Stat CXR, CBC and BMP ordered. Exam: requires sternal rub to open eyes unresponsive except to sternal rub and cold water. Lungs with rhonchi both upper lobes and scattered wheezes anteriorly. 2 plus [MEDICAL CONDITION] up to ankle on right and left. Assessment: Dysphagia may have aspirated. Call to (Wife's name) to review advanced directives. Pt's spouse changed her mind when pt entered nursing home and wants FULL CODE. Explained that pt is not likely to survive a Code but will begin a work up this afternoon at nursing home. Family would want pt to be re-hospitalized if pt has recurrent pneumonia. Was much more alert 48 hours ago." A physician's Telephone Order dated [DATE] states "Family Requests FULL CODE". A nursing note on [DATE] at 3:00 AM indicates, Resident 15's respiratory rate was 20 and unlabored with lung sounds clear upon auscultation but diminished bilateral lower lobe. At 3:07 AM a notes states call returned from on call physician at 1:30 AM regarding chest x-ray report slight right lower lobe and modest left lower lobe pneumonia. New orders for [MEDICATION NAME] 500 mg po every day for a week were received. A note at 3:11 AM states message left at 1:40 to NP NN to update her on chest x-ray results and antibiotic order. (Please note that Resident 15 was diagnosed with [REDACTED].) A nursing note on [DATE] (Saturday) at 3:45 PM states that Resident 15's son was calling and requesting update. Writer updated son on recent fatigue and review plan of care to reduce time up in w/c and to limit attempting to feed food fluids and meds until when resident appears alert and sitting at 90 degree angle. A note at 3:48 PM states call to NP NN to request use of [MEDICATION NAME] per son's request. No return phone call from NP NN to discuss [MEDICATION NAME] use per family request. (Please again note that a message was left on NP NN voice mail and that is not answered on weekends.) On [DATE] (Monday) a Physician Telephone order states, "Daily weights-Call to NP on Wed, BNP for [MEDICAL CONDITION] today and BMP today. A telephone order received at 4:00 PM states [MEDICATION NAME] 40 mg po daily for [MEDICAL CONDITION], Repeat BMP on [DATE] dx: [MEDICAL CONDITION], and Daily weight every AM using same scale. (Please note that the [MEDICATION NAME] was not started until [DATE] and no evidence of a weight done to monitor for weight gain.) On [DATE] at 3:00 PM Surveyor interviewed MDS Coordinator EE regarding Resident 15's physician's orders [REDACTED]. MDS Coordinator EE stated, "I looked up the weights and the only ones that I found were weights on ,[DATE] and ,[DATE]. His last weight was #212 on [DATE]. There are no daily weights done after the physician's orders [REDACTED]. A review of Resident 15's BNP lab results (lab test to determine [MEDICAL CONDITION] status) dated [DATE], was 650 with the normal being ,[DATE] per lab ranges. The lab result states that a BNP level of over 400 but less than 2000 indicates likely moderate [MEDICAL CONDITION]. A nursing note dated [DATE] at 5:43 AM states that Resident 15's oxygen saturation level was at 87%. There is no follow up or report to an RN that Resident 15's oxygen saturation was 87% on this morning. It should be noted that the facility did not document what interventions they put in place to raise the oxygen saturation levels to the ordered 88%. A nursing note on [DATE] at 2:44 PM states that Resident 15 has crackles, congestion heard throughout all fields. BP ,[DATE] and O2 saturation at 98%. A nursing note at 4:59 PM states, Respiratory rate 18 using accessory muscles oxygen saturation 84% on 2 liters, 85% on 3 liters and 88% on 5 liters resident cued to cough and deep breathe, after verbal cues resident coughed weakly. Call placed to NP NN regarding need to increase oxygen to 5 liters and sats not coming up above 88%. New orders received from NP NN to increase [MEDICATION NAME] to 80 mg every day and a stat dose to be given now (3:00 PM). Additionally an order was received at 5:30 PM for [MEDICATION NAME] to be given 1 time now and 1 time on [DATE]. A nursing note on [DATE] at 3:57 AM states that Resident 15's blood pressure is ,[DATE] Respirations 16 and unlabored and no short of breath noted with congestion heard in lungs upon auscultation. A nursing note documented on [DATE] at 2:01 PM Resident 15's states, "Comments: at 8:30 AM residents lung sound upon auscultation abnormal and congestion heard throughout all fields, elevate HOB, encourage cough and breathe resident unable to cough and breathe, started scheduled nebulizer treatment oxygen saturation remained 86% drop to 77% on oxygen at 4 liters per minute vs. BP ,[DATE], P85 R 12 T98.6. At 8:50 called NP NN to update change of condition, at 9:00 AM during am cares CNA noted resident nose and mouth come out dark old blood, at 9:00 AM NP NN was in the building ass (assess) the pt stop breathing, at 9:20 AM called the family inform of death, at 9:48 (MD name) update to pronounce dead." (This note was written by an LPN) A nursing note documented on [DATE] at 3:50 PM Resident 15's states, "Respirations 32 breathing pattern is fast and labored, experiencing shortness of breath and labored breathing, congestion heard throughout all fields. Remains on antibiotic for pneumonia occasional productive congested cough. Large amount of green odorous purulent thick [MEDICATION NAME]. Oxygen saturation ,[DATE]% on oxygen at 4 liters. Head of bed elevated continue to observe. A note at 4:06 PM, written by RN states, "At approximately 9:00 CNA staff approached this writer and requested I assess (Resident 15) Upon entering the room he was noted to have labored breathing. His lungs were very congested. He had excreted what appeared to be vomit and or sputum from his mouth and nose. It was brown in color and very foul smelling. He was rolled to the side to help clear the excrement then the HOB was raised to 90 degrees to help with breathing. He did not appear to be in any pain or discomfort at this time. Family was notified of (Resident 15's) change in condition. Approximately 10 minutes later upon assessment of (Resident 15) he was found to have no detectable vital signs. NP NN assessed and confirmed his expiration and advised staff that CPR should not be performed as this was an unwitnessed cardiac/respiratory arrest. Family arrived a short time later and funeral home arrangements were made." A nurse practitioner progress note dated [DATE] and documented at 2:21 PM states, "Pt was to be seen by examiner this morning. Unfortunately pt was found pulseless and breathless by CNA at facility. Family had already been called to facility by head nurse per GNP request. GNP met face to face with family and explained that pt had not suffered, and family had been with pt last evening and pt appeared to be comfortable..." On [DATE] at 10:25 AM Surveyor interviewed RN T regarding the events of [DATE] with Resident 15. RN T stated that he remembered the events of that day. RN T stated, "I was notified that (Resident 15) had difficulty breathing and had increased secretions. I went to see (Resident 15) and noted that he had difficulty breathing and I increased his oxygen up to 5; it was the highest it would go. The CNAs finished cares and got him comfortable. The NP was called. I called the family and they wanted him sent to the hospital. I explained that he was probably was not going to make it and the family was resistant. I told them that we would make him as comfortable as possible so that would not be in any distress. I tried to get the family to keep him here because it would cause the resident increased distress moving him." Surveyor asked if any resuscitation equipment was brought in the room when he knew that Resident 15 was deteriorating and was a full code status. RN T stated, "No, a suction machine or other equipment was not brought in there as there was not time, I thought about an oxygen mask but did not have time to get one." (Please note: Resident 15 was a FULL CODE status and this was decided on admission and 911 should have been called so that Resident 15 could get the emergent medical interventions that were needed to increase his chances of survival.) On [DATE] at 10:45 AM Surveyor interviewed CNA BB regarding Resident 15 on [DATE]. CNA BB stated that she remembered the day well. Surveyor asked CNA BB to review the events of the day regarding Resident 15 starting in the morning when she got there. CNA BB stated, "First thing in the morning I checked on him and he was sleeping. Around 8:30 AM I went in to wash him up for the day. He was having a little bit of a hard time breathing, like gurgling/short of breath. I took his oxygen levels, but I don't remember what they were now but I would have told the nurse if they were low. I got a partner (CNA AA) to assist with rolling him over. When we rolled him over, out of his nose only came discharge so we cleaned that up and rolled the head of his bed up and CNA AA got the nurse LPN OO. LPN OO and RN T came into the room at the same time. When the nurses came into the room we (CNA's) left to assist other people. LPN OO poked her head out of the room and asked if I would sit with him, I had to finish putting a tray away and then I went in the room. I looked at Resident 15 and he did not look good at all I thought he was gone. I looked outside the room and seen CNA AA and told her to get the nurse right away and she did. I left the room and the family came in about 10 minutes after this. Surveyor asked CNA BB how long it was from the time LPN OO asked her to come in Resident 15's room and when she actually did so. CNA BB stated that it was 2 minutes at the most. When she got to the room no one was in there, the nurse had just left. On [DATE] at 11:24 PM Surveyor interviewed CNA AA. CNA AA stated that she remembered the incident. CNA AA stated, "CNA BB was getting him dressed and I came in to help, he was not breathing so well but was not a lot different than other days. We turned him over and he had black stuff coming out of his nose, we rolled him back and elevated the head of his bed. I went out and got the nurse and the nurses came in with the vitals cart and did vital signs and left. He was wheezy that morning but was able to say good morning to us when he was getting ready until we rolled him over, but after that he was not responding." On [DATE] at 1:19 PM Surveyor interviewed DON B regarding CPR status. DON B stated that a resident is screened on admission to identify Code status. A Full Code means that they want everything done, regarding CPR in a witnessed arrest. When an arrest happens, and the resident is a full code then CPR is started, If the staff is not trained in CPR (some aides are not) then they are trained to get a nurse to begin CPR. Staff is trained to Call 911 and start CPR for a Full Code. Surveyor asked DON B if a resident is deteriorating and appears to be going to expire would it be appropriate for the nurse to leave the room, and DON B stated it would be inappropriate. DON B stated that the facility did not follow their policy in the event of Resident 15's change of condition and arrest. Surveyor asked DON B if she had reviewed Resident 15's medical record and she stated yes. Surveyor asked DON B if she had any concerns with [DATE] the day that Resident 15 expired. DON B stated that she wasn't here at the time but had concerns that NP NN pronounced him dead. Surveyor asked DON B if she had talked with NP NN regarding the situation and DON B stated, "No." On [DATE] at 2:00 PM Surveyor interviewed NP NN via phone along with CMS surveyor present. NP NN stated that she didn't really remember the conversation with the son and wife. When I saw him (Resident 15) he was already gone. Did know it was unwitnessed they (staff) weren't with him they "just stepped out and said he was gone," there was just no point (to start CPR). I wasn't sure when I first came up but they told me what happened. "I get the policy thing but what we did was in his best interest for (Resident 15) he was in poor condition. If you're going to fault anybody at (Facility Name) fault me." "It was so unrealistic with his severe dysphasia and being a FULL CODE status he just would not survive." NP NN also stated, "The facility notified me and the family. Spoke with RN T directly don't remember what the conversation was but certainly he aspirated with materials coming out of his nose and mouth, I told him to call the family and see what they want to do. When I got to the room he was already gone the family was here a bit later and I talked with them and told them that he did not suffer it was peaceful and they were happy with that and thanked us for his care." On [DATE] at 9:55 AM via telephone Surveyor interviewed LPN OO regarding Resident 15 on [DATE]. LPN OO stated that she remembered the events of the day. LPN OO stated that she had first gone into the room with the RN Manager (RN T) to see Resident 15 as the aides said that he had coughed up brown stuff. LPN OO stated that Resident 15 was a sick man that he had [MEDICAL CONDITION] and aspiration pneumonia. LPN OO observed Resident 15 and described Resident 15 as having his oxygen on with difficulty breathing. CNA's reported to RN T and LPN OO that he had some brown substance come out of his mouth when they were getting him up for the day. The CNA's told RN T and LPN OO that they raised the head of his bed and repositioned him to assist with breathing and got the nurse. RN T went to call the family and I called NP NN. He was a full code, he was in respiratory distress and I called the supervisor. LPN OO stated that she asked a CNA to come into the room and stay with Resident 15 since he had trouble breathing. The CNA said that she would come right away to Resident 15's room. LPN OO stated that she found out that NP NN was in the building and the supervisor went to find her. LPN OO stated that NP NN came up to the floor before Resident 15 expired. LPN OO stated that NP NN stated "not to do CPR as it will not make a difference." On [DATE] at 2:20 PM Surveyor talked to RN T again to request clarifying information to other interviews. RN T stated that the process for a full code resident was to call 911 and start CPR. "In this case I thought he was stable enough to call the family and get them involved. RN T stated, "(LPN OO) called (NP NN) and did not get her to call back yet, then I found out that (NP NN) was in the building. I went downstairs and found (NP NN) with another resident and I told there that (Resident 15) is having a situation and I needed her upstairs ASAP. It was about ,[DATE] min later when she came up." Surveyor asked RN T what the family said when he contacted them about Resident 15's change of condition. RN T stated, "I called the family and explained his condition over the phone I was asking the POA what she wanted. I talked to them for 4 minutes and went to check on Resident 15 and he was not looking so hot like he was going to expire. The POA stated that she could not make that decision not to send him as "she wanted him sent." She put her son on, and I explained everything to him again, his initial response was to "send him to ER." Then I said "let me go check on him quick and I did. I told the son that I didn't think he was going to make it to the ER and this would cause him more distress to send him in an ambulance, because they could make him comfortable at the facility. The family said they would come to the facility now to see him before making a decision. I went to check on him a 3rd time and he had passed and I told the family." (It should be noted that during the time of this phone call RN T knew Resident 15 was a full code status and was "going to expire" and wasted time talking to the family when 911 should have been called per family wishes as time was of the essence.) Surveyor asked RN T how he was found expired. RN T stated that LPN OO was in the room monitoring him (Resident 15) and she asked an aide to come in and sit with him she was gone ,[DATE] to 1 minute and when the aide came in she thought he was gone and got told a nurse and she told me. NP NN and I went into the room at the same time and I asked if we should do CPR and NP NN stated "No, technically it was an unwitnessed arrest." The facility was aware that Resident 15 was experiencing a significant change of condition on [DATE] at 8:30 AM. Nursing was monitoring Resident 15 due to his significant change of condition, yet left Resident 15 unattended until a CNA came back into the room a couple of minutes later and felt that he had passed away. The staff should have not left a resident experiencing a significant change of condition so grave that he was "not going to make it" unattended and should have been prepared to initiate CPR as he was a Full Code. 911 should have been called especially when the family was updated and requested that he be seen in ER. This situation created an Immediate Jeopardy situation. The facility removed the Immediate Jeopardy when on [DATE] when: ~The facility began inservicing the nursing staff regarding the CPR policy and demonstrate understanding of the difference between a witnessed arrest and unwitnessed arrest. Education will start tonight and continue before each nurses shift. ~Residents who are a full code will have the proper order, a signed code status in place and code denoted on the face sheet.

Based on interview and record review, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 3 of 10 sample residents (Residents 36, 37, and 39) as it relates to receiving CPR (Cardiopulmonary Resuscitation). Resident 36 medical record was inconsistent in regard to advance directives related to resuscitation. Resident 37's medical record was inconsistent in regard to advance directives related to resuscitation. Resident 39 medical record was inconsistent in regard to advance directives related to resuscitation. This is evidence by: The facility policy titled "Cardio [MEDICAL CONDITION] Resuscitation (CPR), revision/review date of [DATE] / [DATE], indicates; policy It is the policy of the Company to initiate cardiopulmonary resuscitation (CPR) on any resident witnessed suffering from cardiac or respiratory arrest unless otherwise specified by a physician order. Procedure: 1. Upon admission to the facility, admission orders [REDACTED]. physician's orders [REDACTED]. It is important that the resident be easily identified as a Do Not resuscitate (DNR) in an emergency situation... The facility audit form titled "Advance Directive Audit, undated, indicates the following; Verify the following on the charts below, if an issue is identified please correct it and note action taken: 1. Code status form signed. 2. If DNR - Physician order. 3. Code status noted on face sheet. 4. Correct sticker on the front of the chart... Surveyor and Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B on [DATE] at 11:05 AM. DON B stated that the list of resident's and their code status that is maintained in the computer charting is updated by everyone. DON B stated that the facility obtains written consent from residents, there is a sticker on the front of each chart and that the facility added the information into ECS (the facility's electronic charting system). DON B stated that the face sheet in the paper chart should match the sticker on the outside of the chart, in regard to code status. DON B stated that the physician orders [REDACTED]. Surveyor asked DON B and NHA A who was in charge of ensuring that all of the documentation regarding code status matched. DON B stated that it was an interdisciplinary team effort and that the RCM reviewed this as well. NHA A stated that this duty was also added to the social worker's responsibilities to audit. On [DATE], at 9:50 AM Surveyor spoke with Registered Nurse (RN) C regarding the facility education on identifying a resident code status. RN C stated the nurses were educated to pull the resident clinical record and identify the code status on the orange sticker on the front cover of the clinical record. RN C also stated the nurse are also to identify the code status on the resident face sheet and the advanced directive CPR form placed in every resident's clinical record prior to making a decision to perform CPR. The facility education form titled Abatement plan implementation, dated [DATE], indicates the following;... Chart review: Charts of all patients currently listed as "wanting CPR imitated" were reviewed for appropriate documentation. A signed ode status form is the first entry under the legal document tab. The identifiable code status is boldly noted on the front of the chart in orange. Code status is noted on the face sheet... Example 1 On [DATE], at approximately 9:20 AM, Director of Nursing (DON) B provided Surveyor a resident code status listing. The listing indicates the resident name and resident code status "CPR" or "DNR". Resident 36 is listed on the code status listing as wanting CPR provided in the event of a cardiac or respiratory arrest. Resident 36 was re-admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]. On [DATE], at 9:45 AM Surveyor review Resident 36's clinical record. Resident 36's record review findings are as follows: 1. Resident 36's orange sticker on the outside front cover of Resident 36's clinical record states, "Code Status No Code". 2. Resident 36's Resident Advanced Directive Regarding CPR signed and dated [DATE], I have decided that in the event of a witnessed cardiac or respiratory arrest indicates an X mark through the statement written "do not want CPR". 3. Resident 36's face sheet is documented "Code Status: CPR (Cardiopulmonary Resuscitation)." Resident 36's face sheet does not indicate Resident 36 does not want CPR performed as documented on Resident 36's Orange sticker and Resident 36's Resident advanced directive form. 4. Resident 36's Physician orders, dated [DATE], documents "Code Status; CPR". Resident 36's Physician orders [REDACTED]. On [DATE], at 11:05 AM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 36's code status listed on the code status listing. DON B stated everyone is responsible for updating the code status form and reviewing the code status listing to be sure the accurate information is listed. DON B also stated no one person is responsible to be sure the listing is correct. On [DATE], at 11:05 AM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 36's documented code status. DON B stated the resident is expected to have an orange sticker on the front cover of the clinical record indicating Resident 36's code status. DON B also stated upon admission Resident 36's face sheet and physician order [REDACTED]. DON B continued to state the code status on the front cover of the clinical record, the face sheet, Resident 36's CPR form and Resident 36's Physician order [REDACTED]. DON B reviewed Resident 36's clinical record and stated Resident 36's CPR form does not match Resident 36's face sheet or Resident 36's Physician order [REDACTED]. On [DATE], at 11:15 AM Surveyor and director of Nursing (DON) B reviewed Resident 36's physician orders [REDACTED]. No further information was provided to Surveyor . Example 2 Resident 39 was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. On [DATE], at 10:00 AM, Surveyor review Resident 39's clinical record. Resident 39's record review findings are as follows: 1. Resident 39's orange sticker on the front of Resident 39's chart is documented "Code Status No CPR". 2. Resident 39's Resident Advanced Directive regarding CPR indicates a X mark through the statement documented "do want CPR" on the form. 3. Resident 39's face sheet is documented "Code Status:" No documentation is identified on the face sheet for the code status. On [DATE], at 11:05 AM surveyor spoke with Director of Nursing (DON) B regarding expectation for placement of the code status information on the resident clinical record. DON B stated every resident's code status is to be placed on an orange sticker, on the front of the resident clinical record. DON B also stated she expected the code status to be placed on the face sheet at the time of admission. No further information was provided to Surveyor . Example 3 The outside front cover of Resident 37's medical record states, "Code Status Full Code." Resident 37's Admitting and Discharge Record dated [DATE] states, "Code Status: DNR (do not resuscitate)." This document was located in the front of Resident 37's chart. Resident 37's "Capitol Lakes Health Center Resident Advance Directive Regarding Cardiopulmonary Resuscitation, signed and dated [DATE] states, "...I have decided that in the event of a witnessed cardiac or respiratory arrest, I (check one:) (checked) do want CPR ..." Resident 37's admission orders ...Code Status: DNR..." Physician Telephone Orders, dated [DATE] state, "Orders checked to this date."

Based on observation, interview, and record review, in 2 of 6 residents reviewed for falls (Residents 5 and 10), the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. Resident 5 was care planned to have a bed sensor device on her bed. The facility utilized a clip alarm (Tabs alarm) for Resident 5 instead. Resident 5 was not assessed to utilize this type of alarm. Resident 5 fell from bed and sustained bilateral intracerebral hemorrhages. Resident 5 expired 8 days later. On observation Resident 10's fall interventions were not in place. This is evidenced by the following: Example 1 Resident 5's [DIAGNOSES REDACTED]. Resident 5 expired on [DATE] and was reviewed as a closed record. Resident 5 had a care plan problem dated [DATE] which states: "Problem: Potential for Trauma - Falls /Impaired mobility Related to: Impaired vision, A - fib, HTN, CHF, chronic pleural effusion as evidenced by: Unsteady gait, weakness, low endurance." One intervention to this care plan problem, dated [DATE], states "Keep call light within reach and keep personal items in reach." Resident 5's CNA (Certified Nursing Assistant) care plans dated [DATE] and [DATE] state that Resident 5 is to utilize a "bed alarm." (Please note these care plans were the only CNA care plans the facility was able to provide to Surveyor that were in use just prior to, and on the day of Resident 5's fall.) Resident 5's Nurse Notes state the following: [DATE] 2:05 am - "Comments: CNA heard loud crash - entered room to find resident lying on the floor on back with large pool of blood from head. Pressure applied to head. Bleeding noted to be coming from ear. Call to 911 - call to resident's daughter and informed of injury and call to 911." [DATE] 3:42 am - "Received call from: 3:38...Nurse at (Hospital) ER (emergency room ). Resident does have a head injury with poor prognosis - with death expected. Residents daughter does not wish any treatments so resident will be returned to the facility with this prognosis. ..." [DATE] 7:13 am - "Resident returned from (Hospital) ER at 0430 (4:30 am) via ambulance transfer...Daughter stated that she would like resident to be kept comfortable and "let nature take its course." Resident 5's hospital ER notes state (in part): "The patient has bilateral intracerebral hemorrhages. Her condition may worsen and she may die from these hemorrhages." Surveyor reviewed the facility's investigation into Resident 5's fall on [DATE]. This typed report (summary) is not signed or dated. This report states (in part): "During change of shift, safety rounds were performed and bed alarm was found to be not working. Charge nurse instructed CNA to place tab alarm on resident until bed alarm could be obtained. (Date of this occurrence is not noted). "Night CNA continued to bring attention to charge nurse the discrepancy in care plan which continued to state bed alarm. Charge nurse did not follow up. Tab alarm continued to be in place and in working order. (Date of this occurrence is not noted.) "...Early morning of [DATE] at approximately 0200 (2:00 am) staff heard a loud bang coming from resident's room...resident laying by side of bed with moderate amount of blood coming from R (right) ear. Resident did not lose consciousness. 911 was called and resident was sent out immediately...." "...Investigation showed CNA care plan stated bed alarm instead of tab alarm and was not assessed for appropriateness (of tab alarm) nor followed up on by Nurse Supervisor. CNA had identified this on safety rounds and appropriately reported it to supervisor.....The alarm attached to the resident during the time of the fall was still attached and not sounding. The alarm and the box were found next to resident." On [DATE] at 2:15 pm Surveyor spoke with DON (Director of Nursing) B regarding Resident 5's fall on [DATE]. DON B stated the reference on the CNA's care plan for a "bed alarm" means a sensor alarm. It does not mean a tabs alarm. DON B confirmed that Resident 5 should have had a bed alarm or sensor alarm in place at the time of her fall, not a tabs alarm. Example 2 Resident 10's plan of care, dated [DATE], indicated the problem area of Potential for injury trauma-falls. Interventions include: "Personal alarm wheelchair to alert staff to attempt to get up without staff assistance." On [DATE], at 1:14 PM, Surveyor observed Resident 10 in the lounge. Resident 10 was sitting in his wheelchair and the tab alarm was not secured to him. There was no staff in the immediate area. At 1:22 PM, Surveyor interviewed Certified Nursing Assistant (CNA) I about the alarm. CNA I stated Resident 10 has a tab alarm for safety and it should be connected to him.

Based on interview and record review, the facility did not ensure that residents were free of any significant medication errors for 1 resident out of 2 reviewed for medication errors (Resident 18). On [DATE], Resident 18 was given [MEDICATION NAME] sulfate 100 mg instead of [MEDICATION NAME] sulfate 10 mg, which was ten times the ordered amount. This error occurred because the physician's orders [REDACTED]. Resident 18 received 5 cc and was supposed to receive 0.5 cc. Resident 18 was also given [MEDICATION NAME] 1 mg along with the [MEDICATION NAME] and it was ordered only to be given if the [MEDICATION NAME] was not effective. This was the first time in months that Resident 18 received [MEDICATION NAME] sulfate. Resident 18 was unresponsive around 9:34 AM the following morning ([DATE]) and was found breathless and pulseless at 1:10 PM. The significant medication error was not discovered until after Resident 18 expired. As a result, there were no interventions to reverse the effects from the [MEDICATION NAME] overdose. The administration of 10 times the ordered amount of [MEDICATION NAME] solution to Resident 18 created a situation of immediate jeopardy. The immediate jeopardy began on [DATE]. The NHA was notified of the immediate jeopardy on [DATE] at 1:45 PM. It was determined the facility removed the immediate jeopardy on [DATE]. The deficient practice continues at a scope/severity level D (potential for harm that is not immediate jeopardy/isolated) because the facility needs to complete staff training and evaluate the effectiveness of the training. Findings as follows: The United States Food and Drug Administration produced a safety letter related to [MEDICATION NAME] ([MEDICATION NAME] sulfate) dated [DATE]. The letter includes the following: Serious adverse events and deaths have resulted from accidental overdose of high concentration [MEDICATION NAME] sulfate oral solutions. In most of these cases [MEDICATION NAME] oral solutions ordered in milligrams were mistakenly interchanged for milliliters (mL) of the product, resulting in a 20-fold overdose. For example a prescribed dose of 5 mg was mistakenly administered as 5 mL (100 mg) of the [MEDICATION NAME] sulfate concentrated solution. To assure that your patient received the proper dose of [MEDICATION NAME] oral solution please write a prescription for [MEDICATION NAME] sulfate oral solution clearly by including the following: (1) the concentration of [MEDICATION NAME] sulfate oral solution to be dispensed AND (2) the intended dose of [MEDICATION NAME] in milligrams (mL) with the corresponding volume in milliliters (mL or cc) written out in the directions. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 18 was a no code and not her own decision maker. On [DATE] Resident 18 received an order for [REDACTED]. Resident 18's Individual Resident Controlled Substance Record states that on [DATE] the facility received a vial of 30 cc of [MEDICATION NAME] oral 20mg/1 ml. Take 10 mg (0.5mg) under tongue every hour as needed for terminal care. Resident 18's physician orders [REDACTED]. On [DATE] at 5:30 PM Surveyor interviewed CNA P regarding Resident 18 as she worked the night shift of [DATE]th. CNA P stated that Resident 18 asked for pain medications to another person first and then requested them from CNA P again. Resident 18 rang again and wanted a pain pill, something strong. CNA P stated that Resident 18 was in a rush to go to sleep and wanted a pain pill to sleep. CNA P stated that Resident 18 was not short of breath or sick, nothing unusual. Resident 18 is someone that can tell you what she wants and asks for things herself. On [DATE] at 10:30 AM, Surveyor interviewed RN J regarding Resident 18. RN J stated that Resident 18 is independent usually at night; Resident 18 is spunky. RN J came to work that night at 10:30 PM and received report and nothing was mentioned about (Resident 18). RN J counted (narcotics) with the nurses on PM shift and had to do 4 new assessments; it was busy. The staff came to me a couple of times and told me that Resident 18 wanted to see me. At about 11:30 PM the aide came to me and asked if I had been in there yet and if not I really should go see her she won't let up. Resident 18 was worked up, not in a rude way and said exactly what she wanted. RN J gave her [MEDICATION NAME] and she also wanted the pill. She was different she was restless for us. RN J indicated she should have called the supervisor and told her about Resident 18 as she was very different from usual. I have not given [MEDICATION NAME] to her before and wasn't comfortable with it. I would normally document in the nurses notes when a resident is out of their norm, but I had many other patients to deal with. RN J stated that Resident 18 told her what she wanted so she gave her the medication. Resident 18's MAR (medication administration record) indicates that on [DATE] at 11:45 PM [MEDICATION NAME] 10 mg is signed out as being given for restlessness. Resident 18's pain was a 1 on a ,[DATE] scale and the effectiveness after the medication is that she slept. On the back of the MAR indicated [REDACTED]. On [DATE] at 11:45 PM, RN J signed out as giving 5 cc and the amount remaining in the vial was 25cc. (Please note that per directions on the vial 0.5 cc should have been given not 5cc. A 5 cc dose is 100 mg, 10 times the dose ordered). On [DATE], RN J documented on the back of the medication administration form regarding the [MEDICATION NAME] dosage; the note states, "for med given [DATE] at 11:45 PM. Reason (Resident name) was unusually agitated when she spoke to this writer after having several encounters of requests from the CNA. Upon entry to her room she shouted "I need something to sleep...I need it to be strong. I want the pill and the drink." She also said "I am [AGE] years old and I should be able to have what I want." Subsequently I gave her 1 mg of [MEDICATION NAME]. (Please note that the [MEDICATION NAME] and [MEDICATION NAME] should not have been given at the same time due to the potential over sedation effects.) RN J did not recognize that she had made a medication error; consequently, no steps were taken to reverse the potential effects from the overdose. On [DATE] at 11:30 AM, Surveyor asked RN J if she went back to check on Resident 18 after she gave her medications. RN J stated, "Probably around 12:30 or 1:00 AM to see if she was okay, she was sleeping. I didn't do vital signs as she was just sleeping. I felt that she was normal just groggy from what I have seen before so no assessments were done." On [DATE] at 4:45 PM, Surveyor interviewed via phone CNA O. CNA O stated that she worked day shift on [DATE] and Resident 18 was in a deep, deep sleep and she decided to do other residents first. The second time CNA O went to wake her was around 8:15 or 8:30 as she was not up for breakfast yet and CNA O touched Resident 18's shoulder, but she did not wake up she was usually up around 8:15 or 8:30 AM. LPN M asked where she (Resident 18) was and CNA O stated that she wouldn't wake up, and the nurse eventually went in there around 9:00 AM or so. CNA O stated that she told LPN M once before she couldn't wake her but LPN M didn't say much at that time. On [DATE] at 10:25 AM Surveyor interviewed LPN Q regarding Resident 18. LPN Q stated, (I went into her room that morning ([DATE]) to give her pills and noted that she was not responding and she was coughing and rattling in her chest. Her daughter was called and I told her she was doing very poor and was in the dying process. The daughter wanted [MEDICATION NAME] drops for the congestion in her chest and wanted her to have another dose of [MEDICATION NAME] to make her breathing easier. A nursing note on [DATE] at 9:34 AM states, "Writer went to resident room to give AM medication and found resident with blue lips, unresponsive, and respirations 12. Call placed to daughter to update on resident change of condition. Put head of bed to 30 degree angle and resident color improved, respirations stayed at 12 with abdominal breathing." On [DATE] at 10:00 AM an additional dose of .05 [MEDICATION NAME] was given. (Please note that this dose is also wrong; it is to be 0.5cc) A nursing note at 10:30 AM states that at 10:25 AM physician on call to get order for [MEDICATION NAME] drops per daughter, and the MD called back and gave order for drops. ([MEDICATION NAME] drops are used to help decrease congestion) A nursing note at 1:10 PM states that Resident 18 was deceased . There is no documentation of any vital signs or assessments for Resident 18's change of condition. Administration of 10 times the ordered amount of [MEDICATION NAME] sulfate created a situation of immediate jeopardy. The facility removed the immediate jeopardy on [DATE], by which time the facility had contacted the pharmacy and any [MEDICATION NAME] sulfate will be sent in unit dose amounts. No other residents had any liquid [MEDICATION NAME] orders. Inservicing had begun regarding proper destruction of narcotics, appropriate medication pass techniques (checking the orders and drug label). On [DATE] at 9:45 AM Surveyor interviewed DON B regarding Resident 18's significant medication error. DON B stated that she was made aware of the potential overdose of [MEDICATION NAME] on [DATE]. On [DATE] the MD was made aware of the error and on [DATE] the daughter was made aware of the error. On [DATE] DON B spoke with pharmacy and made them aware of the error and set up a plan for unit doses of [MEDICATION NAME] to be given via pre-filled syringes to avoid another potential overdose. DON B stated that she did an audit on all the other narcotics to make sure that there were no issues. Resident 18 was the only resident on liquid [MEDICATION NAME]. DON B stated that they are planning a big inservice on [DATE], and DON B talked to the nurses involved but did not document it. We noted that RN J did not document or assess appropriately and committed the medication error, the 2 staff destroying medications did not complete it accurately, LPN N did not report the error timely and the pharmacy had a label on the medication that did not match the strength on the order.

Based on interview and record review the facility did not ensure that 1 resident (Resident 18) of 2 residents reviewed for medication errors received the care and services necessary to attain the highest practicable well-being. On [DATE], Resident 18 experienced a change in condition when she was much more restless than usual. The nurse did not assess the resident but, instead, gave Resident 18 the medications that she was requesting (erroneously giving 10 times the ordered amount of [MEDICATION NAME]). The nurse did not assess the resident through the night. The resident was unresponsive the following morning; the nursing assistant did not immediately report this change to the nurse. The nurse subsequently determined that the resident was dying and she was found pulseless and nonbreathing at 1:10 PM. Findings as follows: Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 18 was a no code and not her own decision maker. On [DATE] Resident 18 received an order for [REDACTED]. Resident 18's care plan for pain dated [DATE] states that Resident 18's pain comfort level goal is a 3 on a ,[DATE] scale within 60 minutes after intervention. The interventions listed are to administer medications as ordered, assess pain every shift and PRN (as needed), use non-pharmacological methods, report pain to nurse, and encourage rest periods. A review of Resident 18 MAR for April does not indicate that nursing assessed for pain every shift. A quarterly review dated [DATE] states that Resident 18 is alert and oriented to person and place and can make needs known. Mood has been stable since last quarter and has no behaviors. Resident 18's physician orders [REDACTED]. On [DATE] at 5:30 PM Surveyor interviewed CNA P regarding Resident 18 as she worked the night shift of [DATE]th. CNA P stated that Resident 18 asked for pain medications to another person first and then requested them from CNA P again. Resident 18 rang again and wanted a pain pill something strong. CNA P stated that Resident 18 was in a rush to go to sleep and wanted a pain pill to sleep. CNA P stated that Resident 18 was not short of breath or sick, nothing unusual. Resident 18 is someone that can tell you what she wants and asks for things herself. On [DATE] at 10:30 AM, Surveyor interviewed RN J regarding Resident 18. RN J stated that Resident 18 is independent usually at night; she is spunky. RN J stated that staff came to me a couple of times and told me that Resident 18 wanted to see me. At about 11:30 PM the aide came to me and asked if I had been in there yet and if not I really should go see her she won't let up. Resident 18 was worked up, not in a rude way and said exactly what she wanted. RN J gave her [MEDICATION NAME] and she also wanted the pill. She was different she was restless for us. RN J indicated she should have called the supervisor and told her about Resident 18 as she was very different from usual. I have not given [MEDICATION NAME] to her before and wasn't comfortable with it. I would normally document in the nurses notes when a resident is out of their norm, but I had many other patients to deal with. RN J stated that Resident 18 told her what she wanted so she gave her the medication, she did not think to do an assessment. On [DATE], RN J documented on the back of the medication administration form regarding the [MEDICATION NAME] dosage; the note states, "for med given [DATE] at 11:45 PM. Reason (Resident name) was unusually agitated when she spoke to this writer after having several encounters of requests from the CNA. Upon entry to her room she shouted "I need something to sleep...I need it to be strong. I want the pill and the drink." She also said "I am [AGE] years old and I should be able to have what I want." Subsequently I gave her 1 mg of [MEDICATION NAME]. (Please note that the [MEDICATION NAME] and [MEDICATION NAME] should not have been given at the same time due to the potential over sedation effects.) RN J gave 5 cc of [MEDICATION NAME], which was ten times the ordered amount of 0.5 cc. RN J did not recognize that she had made an error and did not call the physician so that immediate intervention (such as the administration of [MEDICATION NAME]) could begin. On [DATE] at 11:30 AM, Surveyor asked RN J if she went back to check on Resident 18 after she gave her medications. RN J stated, "Probably around 12:30 or 1:00 AM to see if she was okay, she was sleeping. I didn't do vital signs as she was just sleeping. I felt that she was normal just groggy from what I have seen before so no assessments were done." On [DATE] at 4:45 PM, Surveyor interviewed via phone CNA O. CNA O stated that she worked day shift on [DATE] and Resident 18 was in a deep, deep sleep and she decided to do other residents first. The second time CNA O went to wake her was around 8:15 or 8:30 as she was not up for breakfast yet and CNA O touched Resident 18's shoulder, but she did not wake up she was usually up around 8:15 or 8:30 AM. LPN M asked where she (Resident 18) was and CNA O stated that she wouldn't wake up, and the nurse eventually went in there around 9:00 AM or so. CNA O stated that she told LPN M once before she couldn't wake her but LPN M didn't say much at that time. LPN M told CNA O that Resident 18 was dying and when there is a change like that it should be reported sooner. CNA O stated that looking back now at to what her heavy breathing was she should have notified the nurse sooner. LPN M stated to CNA O if you ever see a patient breathing like that again you need to get the nurse right away. A nursing note on [DATE] at 9:34 AM states, "Writer went to resident room to give AM medication and found resident with blue lips, unresponsive, and respirations 12. Call placed to daughter to update on resident change of condition. Put head of bed to 30 degree angle and resident color improved, respirations stayed at 12 with abdominal breathing." A nursing note at 10:30 AM states that at 10:25 AM physician on call to get order for [MEDICATION NAME] drops per daughter, and the MD called back and gave order for drops. ([MEDICATION NAME] drops are used to help decrease congestion) On [DATE] at 10:25 AM Surveyor interviewed LPN Q regarding Resident 18. LPN Q stated, (I went into her room that morning to give her pills and noted that she was not responding and she was coughing and rattling in her chest. Her daughter was called and I told her she was doing very poor and was in the dying process. The daughter wanted [MEDICATION NAME] drops for the congestion in her chest and wanted her to have another dose of [MEDICATION NAME] to make her breathing easier. Resident 18 received an additional dose on [DATE] at 10:00 AM for shortness of breath. A nursing note at 1:10 PM states that Resident 18 was deceased . There is no documentation of any vital signs or assessments for Resident 18's change of condition.

Based on record review, the facility did not ensure that each resident was provided with sufficient fluid intake to maintain proper hydration and health for 3 residents out of 8 reviewed for hydration status (Residents 7, 13, and 14). Resident 7, 13 and 14's intakes were recorded by the facility for each meal. The facility documented fluid intakes that did not meet their estimated fluid needs. The facility did not alter the plans of care or inform the physician of the decreased intakes. The facility did have a [MEDICAL CONDITION] in the building at the time these residents became dehydrated. Findings as follows: The facility's policy and procedure for Hydration revised/reviewed [DATE] states that it is the policy of the facility to assist each resident in achieving and or maintaining acceptable parameters of dehydration unless the resident's clinical condition deems this is not possible. The procedure includes the following: Each resident will be evaluated for hydration status. Residents will be provided with water at bedside if diet order allows. Fluids will be encouraged as orders allow. A beverage bar is located in each dining room for resident and family use. The facility Hydration Protocol dated ,[DATE] states that newly admitted residents and those with a medical change of condition will be monitored for risk of dehydration. Additional fluids generally 90 cc with med pass four times daily will be initiated for those identified to be at risk. Interventions to be monitored are placed on the Nursing 24 hour report along with the timeline for monitoring. Staff will assist residents to access their water mug at each meal. 2 or more beverages are offered at each meal and water is offered with meals...Nursing staff and the dietitian will monitor overall progress of identified residents and document the effects of interventions and ongoing plan. Example 1 Resident 13 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 13's care plan for Potential for Alternation in Nutrition dated [DATE] has a goal of eating ,[DATE] % of each meal. The interventions listed are to monitor weights weekly (contact RD if +or - 5 pounds), offer replacement food, monitor food intake, and added [DATE] hydration program. A review of Resident 13's current monthly orders dated ,[DATE] indicates that Resident 13 is on [MEDICATION NAME] 40 mg by mouth to lower blood pressure and get rid of fluid. Resident 13 is also on the following medications scheduled for his bowels: [MEDICATION NAME] Sodium 2 times a day, [MEDICATION NAME] 1 scoop every day, Senna- Gen 2 tabs by mouth every day (this was increased on [DATE] to 2 times a day and Milk of Magnesia 15 cc every day. Resident 13 was also on 90 ml water with med pass 4 times a day, this began on [DATE]. Resident 13 ' s initial Comprehensive Nutritional assessment dated [DATE] states that Resident 13 should have water encouraged due to bowel functions and he weighs 170# per his son. Resident 13's total assessed fluid needs are ,[DATE] cc of fluids a day. Resident 13's appetite is assessed at "good off/on." Resident 13 functional status for feeding is independent after set up. Resident 13's son does identify that his dad takes a long time to eat and may need assistance with eating. The assessment also addresses that Resident is on Diuretics, many Bowel elimination products and on a 90 cc 4 times a day hydration program. Resident 13's Quarterly Review Nutritional Note dated [DATE] states that Resident 13 is able to feed himself adequately with limited vision after set up from staff. Resident 13 usually eats 100 % of most meals and will occasionally he will have a decrease of intake of ,[DATE]%. On [DATE] wt was 184.1 and 181.4 on [DATE]. The note states that Resident 13 ' s weight is stable and will monitor intake and weights with follow up as needed. On [DATE] a nursing note indicates that a weekly weight is 191.5 which is up 7 pounds from 2 weeks ago but slight pedal [MEDICAL CONDITION] was identified and the GNP was updated. A nursing note on [DATE] indicates that Resident 13 squeezed the hand of other residents during a confrontation and the GNP was updated and orders were received for lab work for his behaviors. On [DATE] Resident 13's BMP results for is BUN was 16 and Creatinine was 1.0 and that was within normal limits. On [DATE] it is documented that Resident 13's weight is 160 #. Resident 13's Resident Care Flow sheet for [DATE]-9th indicate that his meal intakes averaged 71% of each meal, [DATE]th-16th reveals his average intake was 61% of each meal and [DATE]th- 23rd Resident 13's average meal intake was 43% . The facility's 24 hour board where intakes of food and fluid were documented indicates that from [DATE]-9th his average food intake at each meal was 71% and his daily fluid intake was 1301 cc of fluids (this is including his 90 cc 4 times a day with med pass). Resident 13's average meal intake for ,[DATE]-,[DATE] was 47% of each meal and 1081 cc. Resident 13's average food intake at each meal for ,[DATE]-,[DATE] is 51% of each meal and 985 cc average each day of fluids. Please note that Resident 13's assessed estimated fluid needs are to be ,[DATE] CC a day. Resident 13 did not meet his fluid need in January. Please note that the documentation on the 24 hour board and the Resident Care sheet are not complete for the whole month, but the documentation clearly shows a decrease in food and fluid intake for the 3 weeks prior to his hospitalization . A review of Resident 13's medication administration record for [DATE]th -23rd it indicates that Resident 13 received his 40 mg of [MEDICATION NAME] every day even though his fluid intakes had remained below assessed need.. A nursing note on [DATE] at 3:26 AM states that Resident 13 was yelling intermittently at 1:30 AM and had a large loose stool at that time, but no emesis. Resident 13 had an additional loose stool at 5:30 AM and his temp was 99.3. Family was notified at 7:41 AM of GI symptoms. A nurse practitioner note dated [DATE] indicates that Resident 13 had an acute change of condition. Resident 13's temp was 102 pulse was 108 and respirations were 22. Large emesis x 2 and loose stools with other residents positive for norovirus on this floor. Oropharynx a bit dry [MEDICAL CONDITION] rate 110 lungs with wheezes throughout. Fever of unknown origin: suspect dehydration vs. aspiration pneumonia. A nursing note at 8:17 PM states that Resident 13 had experienced several large loose stools and emesis during the shift. Resident 13's temperature had elevated and his oxygen saturations levels had dropped into the 80's. The facility called the GNP and was transferred to the hospital around 3:15 PM. Resident 13's Internal Medicine Hospitalist ' s History and physical dated [DATE] indicates that the reason for transfer is [MEDICAL CONDITION], loose stools and emeses. Mucus membranes are slightly dry. BUN is 27 and creatinine is 1.1. Resident 13 is quite dehydrated at this time as well, with laxatives and stool softeners discontinued and [MEDICATION NAME] and Potassium held at this time. He will be given IV fluid hydration. Resident 13's Physician's Discharge Summary form from the hospital dated [DATE] states that Pt appeared quite dehydrated initially so maintained IV fluids. Example 2 Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's care plan dated [DATE] indicates a Potential for alteration in nutrition problem. With a goal of will accept food and fluids as she desires. Resident 14 prefers to drink liquids over eating solid foods. The interventions for Resident 14's nutrition problem are to Monitor weights weekly and contact RD if a 5 # weight gain or loss in 1 month, contact MD with significant weight change, Monitor food intake, nutritional supplement Ensure plus, Monitor intake of meals, be aware that resident would not aggressive nutritional support i.e.. No tube feedings. Resident 14's monthly physician's orders [REDACTED]. Resident 14's Resident care flow sheet for [DATE] indicates that from [DATE] to [DATE] there is no food intakes recorded every box is either blank, R-Refused, or has a zero with a line through it indicating no intake. Resident 14's 24 hour Report sheet where intake of meals and intake of fluids is recorded indicates many omissions of documentation and when documentation is entered it does not meet her estimated fluid needs. The documentation of the 24 board is as follows: Resident 14's intake ranged from bites to 20% of meal intake and fluid intake ranged from sips to 360 cc at a meal for the month of January. On [DATE] it is noted that Resident 14 received orders for a Hydration program 90 cc oral fluids qid, clear liquid diet to bland and resume general diet after GI sx subsides. A review of resident 14's MAR dated [DATE] there is not indication that the facility carried out the orders that were written on [DATE] for the hydration program. On [DATE] orders were written again for the hydration program for hydration until nausea, vomiting and loose stools subside. Additional orders for an antiemetic and intake and output to be monitored at this time. Resident 14's MAR indicates an entry that states I and O for 72 hours and it is signed off each shift but the facility was unable to find a intake and output sheet. The nurses notes from the 12th - 15th document some amounts of fluids and "adequate" intakes but there is not a total for each shift and a total for 24 hours to assess if Resident 14 is getting her fluid needs met. The facility did not implement the hydration program when they were aware that Resident 14's food and fluid intake was decreased due to signs and symptoms of the [MEDICAL CONDITION] were occurring, to assess if she was getting adequate food and fluids. A nursing note on [DATE] at 5:45 PM states that resident 14 had an emesis at 4:30 and diarrhea at 5:00 PM. At 5:52 PM the nurse practitioner was called to report the change in condition of vomiting and diarrhea. The orders were received to monitor vital signs every shift for 72 hours. On [DATE] the nurse practitioner was called again to update on Resident 14 ' s continued GI symptoms and orders were received to push fluids, monitor intake and output every shift for 72 hours. (These orders are written on the January MAR and signed off every shift but there is no evidence of an intake and output measurement every shift). The nursing notes contain intake and outputs sparsely documented but do not give an accurate assessment of Resident 14's total intake and outputs for the 24th -27th to ensure that she is getting adequate intakes. A nurse's note on [DATE] states that Resident 14 presented with severe left sided abdominal pain and was sent to the emergency room . In the emergency room her BUN was 64 and her creatinine was 2.3. Resident 14's [DIAGNOSES REDACTED]. diverticulitis, and the family wanted no aggressive measures. Resident 14 expired at hospital on [DATE]. The facility was aware that Resident 14 was not taking in fluids due to nausea and vomiting on [DATE] and again on [DATE]. On [DATE] the facility received orders for a hydration program and was not implemented until [DATE], and even though the facility had orders to monitor intake and outputs there is no evidence that this was completed completely enough to get a total every shift and every 24 hours to assess hydration status. Example 3 Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's care plan problem for nutrition dated [DATE] indicates a potential for altered nutrition due to varied po intakes; this is evidenced by taking extra time to finish a meal. The goal for Resident 7 is to continue to eat ,[DATE]% of meals offered. Handwritten on the goal, with no date was "as she desires." The approaches listed included are: Monitor weights weekly and contact MD and RD if 5# weight change in a month, monitor food intake, assist in dining room and set up meals, assist, supervise and encourage to complete meal, redirect as needed. Added to the care plan with no date noted is "comfort care per Md order." Resident 7's [DATE] physician orders [REDACTED]. Diet is general, and DNR comfort cares, no x-rays, diagnostic tests, tube feedings, IV's, or blood [MEDICAL CONDITION]. No hospitalization s. Resident 7 has an order for [REDACTED]. The facility has a form for comfort measures filled out by the health care decision maker. The health care decision maker indicates which comfort measure items that they wish and then it is signed by the decision maker. Resident 7 does not have a form filled out and signed in her medical record for comfort measures. Per DON B the form was sent to Resident 7's legal decision maker and was not returned. Resident 7's Initial Nutritional assessment dated [DATE] states that Resident 7's weighs 160.4# on [DATE] with a "fine" appetite after set up is independent with eating. The form addresses her medications including that she is on [MEDICATION NAME] (diuretic). The comments section states that Resident 7 could tell the dietitian her appetite was fine and her family filled out menus. The medical record contains no Physical/medical information, with no diet order will follow up with family and provide meals according to the information from family. The [DATE] assessment does not address height, hematologic and biochemical assessments, clinical observations of nutrition, nutritional intake, residents' eating habits and preferences, dietary restrictions supplements and use of appliances. The assessment does not address hydration status or risk nor estimated fluid/calorie/protein needs. On [DATE] a Nutritional Quarterly review dated [DATE] states that Resident 7 and daughter will go in conference room and have lunch together at times. Resident 7 eats slow and likes the variety of foods served. No changes requested. Wt 125.2 and stable. Good appetite but takes longer time to finish meals. Ensure plus at 60 cc 4 times a day per nursing med pass accepted. Comfort care continued as noted. Tolerating a general diet with consistent intakes of diet at 75% of diet. Weight stable. Goal is to eat and drink as she desires and to monitor intakes and weights. A nursing note on [DATE] states in the weekly summary for eating that Resident 7 needs set up, and supervised assist at times. Resident 7's weight was 125.6 on [DATE] per nursing notes. The facility uses Resident Care Flow Sheet to document meal intakes on each resident. Resident 7's average meal intake from [DATE]-7th was 34% of each meal taken. Resident 7's average meal intake from [DATE] th -14th is 25% of each meal. Resident 7's average meal consumed from ,[DATE]-[DATE] is 31% of each meal. The nursing assistants were to take the meal percents and transfer them to the 24 hour sheet where each resident has their food and fluid intakes measured each shift and ice water mug amount in cc's also. The fluid percent includes Resident 7's 60 cc 4 times a day Ensure. The 24 hour sheets documents Resident 7's average meal intake from [DATE] to [DATE] to be 22.6 % of each meal consumed and a daily average of 510 cc of fluids taken. From [DATE] to [DATE] Resident 7's average daily food intake for each meal is 37% and daily fluid intake is 391 cc's. Resident 7's average meal consumption from [DATE] to [DATE] is 39% and average daily fluid intake is 577 cc a day. (It is important to note that the 24 hour board and the Resident Care Flow sheets have many documentation omissions). On [DATE] a nursing note at 7:06 AM states emesis-resident with onset of emesis at 5:00 AM. Temp 97.6, no stools noted. Head of Bed elevated. A note at 7:38 AM states that the facility spoke with daughter informed of emesis at 5:00 AM and precautions taken for GI/SS. (Please note that the facility had a Norovirus outbreak all of in [DATE]). Resident 7's did not receive her AM [MEDICATION NAME] at 8:00 AM as she had an emesis. Resident 7's blood sugar documented at 9:15 AM states was 446. An order received at 10:40 AM was to give [MEDICATION NAME] 10 mg now and recheck blood sugar at 2 PM. Straight catheter urine spec to be done to rule out UTI. On [DATE], at 11:22 AM 11:11 AM writer updated (HCPOA name) about resident elevated blood sugar and change in alertness. Updated HCPOA on new orders from nurse practitioner for UA. Resident had order for comfort care with no diagnostic tests; HCPOA wants the order for comfort care discontinued. Resident 7 was sent to the emergency room for evaluation of acute change of condition and elevated blood sugars. Resident 7's Adult Hospital Medicine Discharge Summary form dated [DATE] states the following: There was a [MEDICAL CONDITION] at the facility and the family was told not to visit over the past few weeks. Overnight the patient had an emesis and this morning she was acutely changes in terms of her mentation. She was slow to respond and had more difficulty communicating. Initially at 6:00 AM she was able to follow simple commands. However this progressed throughout the day with increasing somnolence. With continued changes in mentation she was referred to the hospital where she was noted to have blood sugar of 534, Bun of 50 and creatinine of 1.2. Resident 7 did not have diarrhea or any GI symptoms. Resident 7's weight was 114 pounds (please note the on [DATE] her weight was 125# this is an approximately 11 pound loss 9 days). Physical Exam: She does not open her eyes but will retract all of her limbs to physical stimuli. Her mouth is extremely dry. Laboratory Data: Sodium 152, BUN 50, Creatinine 1.2 glucose is 534. Urinalysis was negative. Impression and plan. The impression and plan for Dehydration with acute kidney injury-Fluid resuscitation with normal saline. [MEDICAL CONDITION] which is likely secondary to Dehydration, elevated blood sugar with out diabetic ketoacidosis-aggressive fluid resuscitation, [MEDICAL CONDITION] versus acute stroke-represents acute metabolic [MEDICAL CONDITION] from the [MEDICAL CONDITION] dehydration and [MEDICAL CONDITION]. Resident 7's Adult Hospital Medicine Discharge Summary dated [DATE] indicates a the discharge [DIAGNOSES REDACTED].