Every finding on record at Center at Centennial, The

Based on record review and interviews, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#25 and #31) of three residents reviewed for antibiotic use out of 33 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #25 and Resident #31. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Antibiotic Prescribing and Usage in Hospitals and Long-term Care, dated 2019, was retrieved on 10/24/24 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html. It read in pertinent part, Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections. II. Facility policy and procedure The Antibiotic Stewardship Program (ASP) policy and procedure, revised 2/8/21, was received from the director of nursing (DON) on 10/23/24 at 12:43 p.m. It revealed in pertinent part ASP will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting. It is mandatory that all antibiotics are tracked using a facility spreadsheet. McGeer Criteria Surveillance Data Collection is to be used for all patients that are prescribed an antibiotic and determine if the patient meets criteria. The Infection Criteria Checklist, undated, was received from the infection preventionist (IP) on 10/23/24 at 11:35 a.m. It revealed in pertinent part, Symptomatic urinary tract infections (UTI) must have three of the following: fever (greater than 100.4 degrees fahrenheit), new or increased pain on urinations, frequency or urgency, new flank or suprapubic pain or tenderness, change in character of urine (bloody, foul smell, sediment, pyuria), worsening of mental or functional status (may be new or increased incontinence). III. Resident #25 A. Resident status Resident #25, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included compression fracture of vertebra (bone in the spine), urinary tract infection and hypertension (high blood pressure). The 10/1/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview of mental status (BIMS) score of 11 out of 15. The resident was incontinent of urine and prescribed an antibiotic. B. Resident interview Resident #25 was interviewed on 10/21/24 at 10:55 a.m. Resident #25 said she was on her second round of antibiotics for a UTI since coming to the facility. Resident #25 was not sure why she required another round of antibiotics for the same UTI. C. Record review Review of Resident #25's October 2024 CPO revealed the following physician's orders: Urinalysis (UA - a urine test) for urinary frequency, ordered 10/9/24. Keflex (antibiotic) 500 milligrams (mg) three times a day for three days for UTI, ordered 10/10/24. Bactrim DS (antibiotic) 800-160 mg, give two times a day for five days for UTI, ordered 10/18/24. The preliminary UA test result dated 10/12/24 read sensitivity report (a report which indicates what antibiotics a bacteria is susceptible to) was to follow. The UA sensitivity results report, dated 10/14/24, revealed Resident #25 had two microorganisms in her urine. According to the report, one organism was resistant to Keflex, the first antibiotic prescribed on 10/10/24 prior to the results report being completed (see physician's orders above). -Keflex was not the correct antibiotic to treat the whole infection. According to the UA sensitivity results report, both microorganisms were susceptible to the Bactrim that was started on 10/18/24. -Due to the facility's failure to wait for the UA sensitivity report results prior to starting Resident #25 on an antibiotic to treat her UTI, the resident was prescribed an antibiotic that was not effective for treating both microorganisms, which required a second antibiotic to treat the infection effectively. D. Staff interview Registered nurse (RN) #1 was interviewed on 10/23/24 at 8:58 a.m. RN #1 said if a resident presented with a new onset of symptoms, such as dark, cloudy urine or confusion, she suspected a possible UTI. RN #1 said she would contact the physician to obtain a UA test with culture and sensitivity. RN #1 said, depending on the physician, some would start a resident on an antibiotic before the culture and sensitivity test results were back from the laboratory (lab). RN #1 said when the culture and sensitivity test results came back, the physician would sometimes have to change the resident to a different antibiotic. 40960 IV. Resident #31 A. Resident status Resident #31, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnosis included fracture of the neck of the left femur (thigh bone), dementia, cirrhosis of the liver, chronic viral hepatitis C, acute kidney failure, personal history of other infectious parasitic diseases and long term current use of antibiotics. The 10/8/24 MDS assessment revealed, the resident had severe cognitive impairment with a BIMS of five out of 15. He used a walker and a wheelchair and had impairment to one side of his lower extremities. He required maximal assistance with toilet hygiene and was dependent on staff for lower body dressing and putting on/off footwear. He was frequently incontinent of bowel and bladder. He had a surgical wound and moisture associated skin damage. He received an antibiotic. B. Record review A nurse's note dated 10/3/24 at 10:24 a.m. revealed Resident #31 had dark urine and an order was received to collect a urine sample via straight catheter and send it to the lab for evaluation. A 10/3/24 physician's order read to collect a urine sample for a UA and C&S (culture and sensitivity) if indicated due to dark urine. A 10/4/24 physician's order read Amoxicillin (antibiotic) oral tablet 875 mg (milligrams) give one tablet by mouth two times a day for urinary tract infection for six days. A 10/4/24 physician's risk/benefit assessment revealed the antibiotic use did not meet the McGeer criteria. -However, Resident #31 was prescribed the antibiotic despite the antibiotic use not meeting the criteria. A 10/15/24 physician's order read to collect a UA with culture and sensitivity. -The facility failed to identify any symptoms or reason for the request of the urinalysis. A 10/17/24 physician's order read Keflex (antibiotic) oral capsule 500 mg by mouth three times a day for UTI for three days. A nurse's note dated 10/18/24 at 2:17 p.m. revealed Resident #31t was started on Keflex 500 mg three times a day for five days while awaiting the sensitivity results. A 10/20/24 physician's order read Levaquin (antibiotic) oral tablet 500 mg by mouth one time a day for UTI for six days. -The facility failed to follow the Mcgeer Criteria when obtaining urinalysis and treating suspected urinary tract infections, which resulted in Resident #31 being prescribed three different antibiotics. C. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 10/22/24 at 9:40 a.m. LPN #1 said the nurses assessed the residents everyday. She said if the resident had a history of UTIs or symptoms, they would call the physician. She said if the physician ordered a urinalysis, the nurse would report it to the IP who would ensure it met the Mcgeer Criteria. LPN #1 said the nurse did not follow the McGeer Criteria when requesting an order for a urinalysis from the physician for Resident #31. V. Additional interviews The infection preventionist (IP) and the DON were interviewed on 10/23/24 at 11:05 a.m. The IP said the facility used Mcgeer criteria for UTIs before prescribing an antibiotic for a resident. The IP said staff looked for a change in the character of urine, such as color, smell, burning, frequency, incontinence, fever, or change in a residents' mental status. The IP said it was the responsibility of the nurse to observe, or if a certified nurse aide (CNA) reported any changes, to call the physician to be able to send out a UA. The IP said the nurse who collected the UA on 10/9/24 for Resident #25 only documented urinary frequency as a symptom, so the nurse did not follow Mcgeer criteria for Resident #25. The IP said Resident #25's antibiotic had to be changed when the culture and sensitivity came back in order to treat the UTI effectively. The IP said Resident #31 did not meet the criteria for antibiotic treatment on 10/4/24 and should not have been treated with an antibiotic. The DON said physicians could choose to start an antibiotic or wait for the culture and sensitivity results to come back. However, the DON said starting an antibiotic before the culture and sensitivity results came back did not follow the antibiotic stewardship program the facility had in place. The DON said the facility would immediately educate the nurses and physicians on following the Mcgeer Criteria for antibiotic use. The physician (PH) was interviewed on 10/25/24 at 11:20 a.m. The PH said he followed Mcgeer criteria most of the time if the resident was symptomatic for a UTI. The PH said he had to change the antibiotic after the culture and sensitivity results came back for Resident #25 in order to effectively treat her UTI because he had prescribed an antibiotic that was not effective to treat both microorganisms prior to receiving the sensitivity results. The PH said Resident #31 was symptomatic for a UTI on 10/3/24, with dark urine and altered mental status, so he ordered a urinalysis and started the resident on Amoxicillin on 10/4/24 while awaiting the culture and sensitivity results. The PH said Resident #31 was started on an antibiotic a second time after the UA was collected on 10/15/24 before receiving the sensitivity results. The PH said after the sensitivity results from the 10/15/24 UA were received, Resident #31's antibiotic had to be changed to effectively treat the bacteria growing in the urine.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 15 sample residents received adequate supervision and services to prevent an accident. Resident #1 was admitted to the facility on [DATE] with a traumatic subdural hemorrhage with loss of consciousness (intracranial bleeding between the brain and the skull), muscle weakness, aphasia (loss of the power of speech), hemiplegia (paralysis affecting one side of the body), Parkinson's disease (a condition that affects muscle control and movement), acute pain due to trauma and a history of falling. Resident #1 was status post burr holes (small holes that a neurosurgeon makes in the skull to help relieve pressure on the brain when fluid, such as blood, builds up and compresses brain tissue) of subdural hematoma with surgical incision on the left side of his head with staples in place. On 4/15/24, certified nurse aide (CNA) #1 and CNA #2 transferred Resident #1 via the hoyer lift (mechanical lift). During the transfer, Resident #1 fell from the lift to the floor, striking his head. Resident #1 began vomiting after the fall and was immediately transferred to the hospital where he was diagnosed with a large posterior scalp hematoma (bleeding under the skin) and left ankle trauma with pain and mild soft tissue swelling. The facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review the use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. Due to the facility's failure to transfer a dependent resident safely, Resident #1 sustained a new head injury and required hospitalization for three days. Resident #1 was discharged from the hospital to his home on hospice care due to the families concern for the resident's safety at the facility. Findings include: I. Facility policy and procedure The Mechanical Lifts policy and procedure, revised 2/1/23, was provided by the nursing home administrator (NHA) on 7/31/24 at 10:22 a.m. It read in pertinent part, (Facility name) utilizes mechanical lifts when appropriate to ensure safe patient handling during transfers and employee safety when providing patient care. Direct care staff will receive training upon hire and as needed for proper preparation of the patient, equipment, and environment during utilization of mechanical lifts. II. Mechanical lift manual The user manual for the Span model: F500P full body patient lift was provided by the NHA on 7/31/24 at 10:35 a.m. It read in pertinent part, Special care must be taken with users/patients who cannot themselves provide assistance while being lifted (patients who are comatose, spastic, agitated, or otherwise severely handicapped). The patient lift should be used solely for transferring a user/patient from one utility (beds, chairs, toilets) to another. The patient lift should not be used for transporting or moving any patient from one location to another location. During lifting or lowering, whenever possible, always keep the base of the lift in the widest position. The base of the lift should be closed before moving the lift. Do not roll casters over any object while the user/patient is in the sling. Do not lock casters during lifting. While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lifter. Never leave the user/patient unattended during lifting. III. Resident # 1 A. Resident status Resident #1, age 65, was admitted on [DATE] and discharged to the hospital on 4/15/24. According to the April 2024 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness, muscle weakness, aphasia, hemiplegia Parkinson's disease, acute pain due to trauma and history of falling. The 4/15/24 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). The staff assessment for mental status was completed and revealed the resident had short and long-term memory problems and had severely impaired cognitive skills for daily decision making. He was dependent on staff for transfers, and required substantial/maximal assistance with bed mobility. The MDS assessment indicated the resident had one fall since admission and documented there was no injury. -However, the resident sustained a head injury with a hematoma, per the hospital records. B. Facility investigation of Resident #1's fall on 4/15/24 The fall investigation was provided by the director of nursing (DON) on 7/30/24 at 5:29 p.m. The 4/16/24 post fall investigation revealed the following in pertinent part: On 4/15/24 at 6:30 p.m. licensed practical nurse (LPN) #1 heard a loud bang and ran into the resident's room. Resident #1 was on the floor. CNA #1 and CNA #2 were using the hoyer lift to transfer the resident when Resident #1 slipped through the middle of the sling. Resident #1 hit the back of his head. The resident's vital signs were within normal limits.The physician and the resident's daughter were notified of the fall. The resident was evaluated by registered nurse (RN) #1 and she made the decision to send the resident to the emergency department (ED) as he had hit his head. The resident's vital signs were stable when the resident left the facility with emergency medical services via stretcher to the hospital ED. An undated statement was obtained from CNA #1. CNA #1 said she was sitting at the computer charting and giving a report to the next oncoming shift. She had asked CNA #2 if she would like her to help lay Resident #1 down and she replied sure. CNA #1 said the hoyer lift sling appeared to be properly in place. CNA #1 said she hooked the resident's sling up to the hoyer lift and began to lift him to the bed. She said Resident #1 suddenly began to slip out of the sling and onto the floor. An undated statement was obtained from CNA #2. CNA #2 said she worked on the night shift at (facility name). CNA #2 said she started her shift at 6:00 p.m. on 4/15/24. CNA #2 said after report was given from the day shift, one of the day shift CNAs offered to help get Resident #1 into bed before she left for the day. CNA #2 said they went to Resident #1's room and he was sitting in his wheelchair by the window side and was leaning towards his right side. CNA #2 said they adjusted Resident #1 the best they could. CNA #2 said they tucked in the hoyer lift sling and criss-crossed the sling between his legs and moved the wheelchair closer to the hoyer lift machine. CNA #2 said they then lowered the hoyer lift machine down to wheelchair level and proceeded to hook up the sling to the machine. CNA #2 said they used the first hook on all six hookups (three on left, three on right). CNA #2 said she had control of the hoyer lift and the other CNA (CNA #1) was guiding Resident #1 towards the bed. CNA #2 said the wheelchair was removed once he was high enough, then she proceeded to move towards the bed. CNA #2 said they were in position moving towards the bed when Resident #1 slipped out of the sling through the bottom. CNA #2 said Resident #1's bottom went through the sling and he landed on his bottom, and then fell backwards and hit his head. CNA #2 said at that point she was in a state of shock. CNA #2 said she had been doing that job for more than [AGE] years and that had never happened. CNA #2 said they went to Resident #1 and he was still awake, aware and trying to speak. CNA #2 said the nurse rushed in and called 911. CNA #2 said she stayed with Resident #1 until the ambulance and fire department came to help him off the floor. She said Resident #1 was then sent out to the hospital for further evaluation. An undated statement from the DON said CNA #1 and CNA #2 had both been through skills check-offs to include mechanical lifts, and both followed facility protocol for hoyer lift use. The statement said this had been an unfortunate, isolated event. The resident was evaluated at the hospital and the head computed tomography (CT) scan did not show any new bleeds. -However, according to the emergency progress note Resident #1 sustained a large posterior scalp hematoma (see record review below). C. Record review The baseline (admission) care plan, dated 4/13/24, revealed the resident required two person assistance with transfers, bathing, grooming, locomotion and toileting. The resident was at risk for falls related to impaired mobility secondary to weakness and debility and related to current drug regimen.The resident had acute and chronic pain. The 4/13/24 admission skin assessment revealed an actual surgical wound with dressing changes per physician orders. A review of the April 2024 CPO revealed a physician's order was set up to follow up with a neurological surgeon to remove the staples from the resident in five days, ordered on 4/14/24. The 4/16/24 nursing progress note, documented at 1:49 a.m., revealed the nurse heard a loud bang and the nurse ran into Resident #1's room. The resident was on the floor. The CNAs were using the hoyer lift and the resident slipped through the middle of the sling. The resident hit the back of his head. RN #1 came and evaluated the resident. The 4/16/24 change in condition note, documented at 2:42 a.m., revealed the resident's vital signs were within normal limits. The resident was vomiting after the fall. The note documented the physician and family were notified of the fall at 6:30 p.m. on 4/15/24. The 4/16/24 bed hold progress note, documented at 8:18 a.m., revealed the DON spoke with the resident's spouse who stated the resident would not be returning to the facility. The post fall evaluation, completed by the DON on 4/16/24, revealed the resident sustained a witnessed fall on 4/15/24. The resident hit his head and was transferred to the hospital. Neurological checks were initiated per facility protocol. A skin evaluation was not completed. The resident did not have pain from the fall and did not receive pain medication. The resident fell during a transfer in the resident's room with a hoyer lift and sling. The assessment documented the probable cause of the fall was the resident's buttocks slid through the sling onto the floor and the staff expressed that it was properly placed and the appropriate size sling was used. The IDT (interdisciplinary team) discussed the resident's fall. The resident was on the fall program with his bed in a locked and low position, received assistance from two persons at all times for hoyer lift transfers and to assure the sling fit correctly. The evaluation documented the care plan was revised on 4/16/24. It documented the physician and family were notified on 4/15/24. The 4/15/24 hospital progress note documented a [AGE] year old male with a history of Parkinson's disease and recent subdural hemorrhage status post burr holes brought in to the emergency department from a rehabilitation facility after he was accidentally dropped out of a hoyer lift and hit his head once again. He was not on an anticoagulant and was nonverbal at baseline. He was noted to have a large posterior scalp hematoma that was new since prior exam. A review of the resident revealed he had pain to his left ankle with mild soft tissue swelling. X-rays were obtained and were negative. The hospital progress note documented the plan was for the resident to return to the rehabilitation facility, however the patient's wife had serious concerns about the safety of this facility and did not wish him to go back there. The note documented the resident's spouse was going to contact hospice and palliative care services tomorrow morning as her desire was to take him home on hospice care. The resident was discharged home on hospice from the hospital on 4/17/24. -Following Resident #1's fall on 4/15/24 from the hoyer lift, the facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. D. Staff interviews The DON was interviewed on 7/30/24 at 5:05 p.m. The DON said Resident #1 sustained a fall on 4/15/24 at 6:30 p.m. The DON said CNA #1 and CNA #2 witnessed the fall. She said CNA #1 and CNA #2 alerted LPN #2 after the fall. The DON said CNA #1 and CNA #2 were transferring Resident #1, via a hoyer lift, from his wheelchair to the bed and had lifted the resident up in the sling and out of the wheelchair and began to lift him to the bed and that was when Resident #1 fell . The DON said she felt it was a freak accident. The DON said the hoyer lift sling was placed correctly because staff had expressed that it was properly placed and the appropriate size. She said when the CNAs started moving Resident #1 toward the bed, he slipped through the sling. The DON said since Resident #1's admission he had required two person assistance with the hoyer lift. The DON said the comprehensive care plan was still being developed on the day the resident sustained the fall. She said the resident's care plan was not updated after the fall because the resident did not return to the facility. The DON said there was a communication board in the resident's room to let the caregivers know what assistance level the resident required. The DON said no further re-education training was provided to CNA #1 and CNA #2 after the fall because they were both very competent with transfers and she did not know what further instruction or information she could have told them on how they could have corrected the situation. The DON reiterated that she had never seen this type of accident before so there had not been specific training or corrective action given to the direct care staff after the fall. The DON said CNA #1 and CNA #2 had had training on the hoyer lift in February 2024 and had completed the skills competency checklist. The DON said the facility did not do any other training for all the staff after the fall on 4/15/24 because she did not think it was needed as they had just completed the annual skills checklist and there was nothing identified in the fall incident that could have improved the situation. CNA #2 was interviewed on 7/30/24 at 5:40 p.m. CNA #2 said Resident #1 fell on [DATE] when she had just come on shift. She said Resident #1 was in his wheelchair and CNA #1 had offered to help put him into bed. CNA #2 said it was dinner time and sometimes it got busy, so she was glad for the help. CNA #2 said the hoyer lift sling was under Resident #1 and the moment she moved the hoyer lift away from the wheelchair, the resident fell and hit his head on the floor. CNA #2 said she screamed and could not believe what happened. CNA #2 said she ran and got the nurse and the resident was sent to the hospital. CNA #2 said she could not pinpoint what went wrong with the transfer since the sling was already under him. CNA #1 was interviewed on 7/30/24 at 5:44 p.m. CNA #1 said she and CNA #2 went in to transfer Resident #1 on 4/15/24 via a hoyer lift. She said he fell out of the sling during the transfer. CNA #1 said Resident #1 was in his wheelchair and she and CNA #2 went to hook the hoyer lift sling up and put him to bed for the evening. CNA #1 said she hooked up the sling and he slipped out of the sling. CNA #1 said she and CNA #2 had put the hoyer lift sling underneath the resident. CNA #1 said she remembered that because she had been working with Resident #1 all day on the day shift. CNA #1 said Resident #1 had just finished eating his dinner. CNA #1 said when Resident #1 was lifted up with the hoyer lift, they were turning the hoyer lift to go to the bed and that was when Resident #1 slid out of the sling and hit the floor. CNA #1 said she was completely shocked and did not know what could have gone wrong. CNA #1 said she was trying to be extra careful with the hoyer lift transfers she was now doing but said she did not receive any new training after the resident's fall. LPN #2 was interviewed on 7/30/24 at 5:55 p.m. LPN #2 said when she entered Resident #1's room on 4/15/24, he was on his back on the floor. She said the resident was conscious. LPN #2 said she checked his vital signs and went to get RN #1. LPN #2 said Resident #1 started vomiting when the emergency medical technicians (EMT) arrived. RN #1 was interviewed on 7/30/24 at 6:00 p.m. RN #1 said another RN, who had since retired, came in to assess Resident #1. RN #1 said the nurse on the floor would typically complete a fall progress note. RN #1 said a progress note was not documented by the RN in the resident's EMR. RN #1 said she decided not to move the resident until the EMT's arrived. RN #1 said she came in later to check on the situation, the resident was still on the floor and the EMTs had arrived. RN #1 said she heard the CNAs say they had hooked the hoyer lift up and they were not sure what had happened or how he fell . She said the CNAs did not say the hooks fell off but the resident fell out of the sling. The DON was interviewed again on 7/30/24 at 6:13 p.m. The DON said she had put an education book about the different types of hoyer lift slings to use, how to know which size to use as a guide and placed them at the CNAs desk stations. The DON said she was not sure if any of the CNAs had looked at it or read it. The DON said the facility had not had any further incidents of hoyer lift falls, but said she had not done any official education with staff following the fall. E. Facility follow-up On 7/30/24 at 6:04 p.m. the DON provided documentation that CNA #1 had completed a skills competency checklist on 2/13/24 and CNA #2 had completed skills competency checklist on 2/17/24. The competency nurse aide skill checklist included 53 personal care skills, including hoyer use, with a date passed by demonstration and a signature. -However, the facility did not have CNA #1 and CNA #2 complete a new skills competency checklist following Resident #1's fall from the hoyer lift on 4/15/24. On 7/31/24 at 10:30 a.m. the NHA provided documentation that the facility had conducted weekly ongoing maintenance and hoyer lift inspections from January 2024 to present. On 7/31/24 at 1:09 p.m. the DON provided documentation of an audit that was performed by therapy on 7/31/24 (during the survey) to ensure residents who required hoyer lifts had the appropriate sling sizes and types and felt safe with them. The audit included five residents who were currently transferred by nursing staff using the hoyer lifts. On 8/2/24 at 9:45 a.m. the NHA sent an email which revealed in pertinent part, the NHA further reviewed the case (of the hoyer lift fall with Resident #1) with the facility medical director and the DON. The NHA said the chart reflected that when Resident #1 was returned to acute care post-fall, no significant changes from the prior studies were identified (attached were the before and after CT/neurology consult notes). The NHA said, specifically, Resident #1 had a previous history of brain injury/bleeds and that the staples identified in Resident #1's head were present upon admission to the facility. The NHA said no additional injuries or signs and symptoms of pain were noted by staff as a result of the fall. The in-services, audits sheets began and he would provide (see below). -However the hospital notes revealed after the facility fall Resident #1 sustained a new large posterior scalp hematoma (not subdural), and a new left ankle trauma with pain and mild soft tissue swelling (see record review above). In addition Resident #1 exhibited vomiting after the fall. On 8/2/24 at 2:21 p.m. the DON provided a signature page for the hoyer lift in-service. The hoyer lift in-service was dated 7/31/24 (during the survey). -However, the document revealed CNA #1 had the in-service emailed to her and CNA #2 did not participate in the in-service. -Additionally, the facility only provided the signature page, not the curriculum for the hoyer lift in-service.

Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for two (#2 and #3) of three residents reviewed for medication errors out of 15 sample residents. Specifically, the facility failed to ensure Residents #2 and #3 received medications as scheduled according to the physician's orders which resulted in significant medications errors. Findings include: I. Facility policy The 6 (six) Medication Administration Rights policy, undated, was received from the nursing home administrator (NHA) on 7/30/24 at 1:28 p.m. It read in pertinent part, Medications should be administered at the time indicated by the prescribing physician. Acceptable practice is to use a one-hour window time frame. Medications can be given one hour before or one hour after the prescribed time. II. Resident #2 A. Resident status Resident #2, age 72, was admitted to the facility on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body), muscle spasms, and anxiety. The 7/1/24 minimum data assessment (MDS) assessment revealed the resident was moderately cognitively impaired. A brief interview for mental status (BIMS) was not conducted as the resident was rarely or never understood. The resident was dependent for all activities of daily living (ADL). B. Record review The July 2024 CPO revealed a physician's order for Alprazolam (anti-anxiety medication) 0.25 milligrams (mg) with instructions to give one tablet via PEG-tube (percutaneous endoscopic gastrostomy feeding tube) three times a day for anxiety, ordered on 7/16/24. The 6/18/24 care plan, revised 7/11/24, revealed Resident #2 could experience adverse reactions from his psychotropic medications, including Alprazolam for his anxiety. Pertinent interventions included monitoring Resident #2 for mood disturbances and using non-pharmacological interventions. The 7/19/24 care plan revealed Resident #2 was at risk for adverse side effects from the use of anti-anxiety medication. Pertinent interventions included administering medications per physician's orders. Resident #2's July 2024 medication administration record (MAR) revealed the resident's Alprazolam 0.25 mg was not administered timely on the following dates: -On 7/17/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:21 p.m. (21 minutes after the allowed administration time). -On 7/18/24 the medication was scheduled for administration at 3:00 p.m. and administered at 5:24 p.m. (one hour and 24 minutes after the allowed administration time). -On 7/18/24 the medication was scheduled for administration at 9:00 p.m. and administered at 10:07 p.m. (seven minutes after the allowed administration time). -On 7/19/24 the medication was scheduled for administration at 9:00 a.m. and administered at 10:20 a.m. (20 minutes after the allowed administration time). -On 7/21/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:23 p.m. (23 minutes after the allowed administration time). -On 7/22/24 the medication was scheduled for administration at 9:00 a.m. and administered at 10:48 a.m. (48 minutes after the allowed administration time). -On 7/23/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:52 p.m. (52 minutes after the allowed administration time). -On 7/26/24 the medication was scheduled for administration at 9:00 a.m. and administered at 11:20 a.m. (one hour and 20 minutes after the allowed administration time). -On 7/28/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:46 p.m. (46 minutes after the allowed administration time). -On 7/29/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:33 p.m. (33 minutes after the allowed administration time). III. Resident #3 A. Resident status Resident #3, age 70, was admitted on [DATE] and discharged on [DATE]. According to the June 2024 CPO, diagnoses included malignant neoplasm (cancer) of the lung, lower back pain, and epigastric pain. The 6/18/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required supervision to partial/moderate assistance with most activities of daily living. The resident was on a scheduled pain medication regimen and had pain almost constantly that interfered with her day-to-day activities. B. Resident interview Resident #3 was interviewed via phone on 7/31/24 at 10:39 a.m. Resident #3 said the morphine to treat her pain associated with lung cancer was administered later than it was scheduled. She said occasionally it was over two hours late. Resident #3 said the delay in administration had caused her to be in pain. Resident #3 said she had laid in bed and suffered. Resident #3 said she had used her call bell to alert the certified nurse aides (CNAs) that she was in pain but the CNAs had told her they had already alerted her nurse. C. Record review The June 2024 CPO revealed a physician's order for morphine sulfate oral solution 20 mg/milliliter (ml) with instructions to give 0.5 ml by mouth every four hours for pain management, ordered on 6/12/24. The 6/12/24 care plan, revised 6/13/24, revealed Resident #3 had acute/chronic pain risk due to her conditions, which included neoplasm of the lung, lower back pain, epigastric pain, and headaches. Pertinent interventions included administering pain medications per physician order and noting effectiveness. Review of Resident #3's June 2024 MAR revealed the resident's morphine sulfate 0.5 ml was not administered timely on the following dates: -On 6/14/24 the medication was scheduled for administration at 4:00 a.m. and administered at 5:27 a.m. (27 minutes after the allowed administration time). -On 6/15/24 the medication was scheduled for administration at 4:00 a.m. and administered at 5:12 a.m. (12 minutes after the allowed administration time). -On 6/15/24 the medication was scheduled for administration at 8:00 a.m. and administered at 10:09 a.m. (one hour and nine minutes after the allowed administration time). -On 6/21/24 the medication was scheduled for administration at 8:00 a.m. and administered at 10:15 a.m. (one hour and 15 minutes after the allowed administration time). Review of Resident #3's June 2024 pain level summary revealed the following: -On 6/14/24 at 5:23 a.m. Resident #3's pain was rated as a 6 out of 10 on a scale of 1-10; -On 6/15/24 at 10:09 a.m. Resident #3's pain was rated as an 8 out of 10; and, -On 6/21/24 at 10:15 a.m. Resident #3's pain was rated as a 6 out of 10. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/31/24 at 9:37 a.m. LPN #1 said medication administration was conducted each day by splitting the residents between two nurses and going down each hall, leaving about 20 residents for each nurse to administer medications to. LPN #1 said the facility's computer system notified nurses one hour before each medication cycle was due. He said, for example, for 10:00 a.m. medications, the computer system alerted them at 9:00 a.m LPN #1 said the nursing staff had a one hour window before and after a medication was due to administer the medication on time. LPN #1 said it was important to administer medications as scheduled in order to avoid interactions with other medications and to have an appropriate interval before or after meal times. LPN #1 said pain medications needed to be administered when they were scheduled to avoid over-sedating the resident. The director of nursing (DON) was interviewed on 7/31/24 at 11:11 a.m. The DON said medication administration was divided between the nurses, and that each hall had staggered medication administration schedules in order to keep the nursing staff on schedule. The DON said medications were considered to be given on-time if they were administered within an hour window before or after the medication was scheduled. The DON said most medications, especially pain medication, needed to be administered as scheduled. The DON said unforeseen circumstances could come up that could cause delays. The DON said Resident #2 may have had some delays in medication administration on the dates his medication was late due to being out of the facility for an appointment. The DON said, for Resident #3, on 6/21/24 the nurse who had administered the resident's pain medication over an hour late had been overwhelmed during the shift. The DON said the nurse in question had been counseled on timely administration of medications and later left the facility. The DON was interviewed again on 7/31/24 at 11:45 a.m. The DON said Resident #2 did not have any appointments scheduled on the days in which his medications were not administered as scheduled.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on hand held showers in 12 private shower rooms, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 4/12/23 at 1:03 p.m. revealed: The hand held shower head in rooms #227, #237, # 223, #219, #202, #203, #208, #340, #326, #331, #319 and #307 did not have a backflow prevention valve on them. The hand held showers were long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pans. II. Staff Interview The housekeeping supervisor (HKS) was interviewed on 4/13/23 at 9:50 a.m. He acknowledged he was not familiar with the backflow valve protocol. He said the hand held showers in all showers should have had a backflow prevention valve on them. He said he would install them immediately.

Based on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning on four resident hallways. Findings include: I. Observations An observation of the resident environment was completed on 4/12/23 at 1:03 p.m. Exhaust fans were installed in the ceiling of each bathroom. Bathroom fans in all rooms located on four of four hallways were not audible and did not create air movement with the switch turned on. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans did not function properly. Urine odors were observed during multiple observations in all halls, between 4/10/23 and 4/13/23. The bathroom exhaust fans were not functioning in all restrooms of the facility. II. Staff Interview The environmental tour was conducted with the housekeeping supervisor (HKS) and director of nursing (DON) on 4/13/23 at 9:50 a.m. The HSK confirmed the exhaust fans in all restrooms were not functioning. The HSK said the ventilation fans had been worked on previously. The HSK said he would have to check the motors on all halls to see why they were not functioning correctly. The HSK said the ventilation fans in every resident room should be in good working condition.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled, dated, and monitored in refrigerators; -Ensure the kitchen equipment were clean and sanitary; -Ensure staff were utilizing proper personal hygiene practices; -Ensure holding temperatures of food were within the safe range; and, -Ensure systems were in place to prevent compromised food safety through proper staff training. Findings include: I. Failure to ensure food was labeled, dated and monitored correctly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved 4/17/23). B. Facility policy and procedure The Food Storage policy, revised 2/8/21, was provided by the director of nursing (DON) on 4/13/23 at 1:58 p.m. It revealed in pertinent part, Food from outside sources are to be stored in the refrigerators located on floors two and three with the correct date. Outside food sources should be labeled properly with the correct date and room number of the patient. C. Observations On 4/12/23 at 4:19 p.m. a tour of the second floor nursing floor refrigerator was conducted with dietary manager (DM) #1 and the following was observed: -In the employee break room, a resident refrigerator containing a take-out food box with a resident room number was undated. -A kitchen bowl of oatmeal was undated. -An outside food container was dated 4/11/23 but not labeled. On 4:12 p.m. at 4:34 p.m. a tour of the third floor nursing floor refrigerator was conducted with DM#1 and the following was observed: -In the employee break room, a resident refrigerator containing an outside food container was dated but not labeled. D. Staff interviews DM #1 was interviewed on 4/12/23 at 4:34 p.m. He stated foods kept inside of containers should have a date and a label. These food items should be thrown away after 24 hours. He said that the dietary clerks were responsible for maintaining and cleaning the resident refrigerators in the employee break rooms. II. Failure to ensure the kitchen equipment were clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, For sanitation of equipment, food-contact surfaces and utensils, a contact time of at least 7 seconds for a chlorine solution or a contact time of at least 30 seconds for other chemical sanitizing solutions. Unless used immediately after sanitization, all equipment and utensils shall be air-dried. (Retrieved 4/17/23) B. Observations On 4/10/23 at 9:10 a.m. a stack of steam table pans on a shelf were wet in between the pans. On 4/12/23 at 12:10 p.m. cook (CK) #2 took a sharp knife out of the knife box and she went to the three compartment sink and rinsed it under water. She proceeded to go to the third sink and pumped out some sanitizer onto the knife, and immediately rinsed the knife off, not allowing the sanitizer to sit on the knife in order to sanitize it properly. She then used it to cut ham for lunch. At 1:42 p.m. a stack of steam table pans on a shelf were wet in between the pans. On 4/13/23 at 8:33 a.m. dietary aide (DA) #2 was observed pouring liquid from coffee and juice cups into a red sanitation bucket. At 1:25 p.m. two stacks of steam table pan on a shelf were wet in between the pans. C. Staff interviews DA #2 was interviewed on 4/13/23 at 8:33 a.m. She said the kitchen staff used a designated red sanitation bucket to pour drink liquids into before putting them into the dishwasher. She said she had been employed with the facility less than a month and did not know how to fill the sanitation buckets with the chemical, how often the buckets should be changed or what chemical was used. DM #1 was interviewed on 4/13/23 at 10:30 a.m. He stated the kitchen had red sanitation buckets filled with an ammonia chemical solution and green buckets filled with a soap and water solution for cleaning the kitchen. The ammonia solution should be maintained between 300-400 parts per million (PPM) and tested every week to three days. He said the red sanitation bucket DA #2 was used for pouring liquids, such as coffee and juice, into the dishwasher. It was emptied down the drain when full. DM #1 was interviewed again on 4/13/23 at 1:35 p.m. He said dishes that come out of the dishwasher were still wet and set on a rack or on a cart to air tray. He was unaware there were steam table pans stacked while still wet and warm from the dishwasher. He acknowledged this was unsanitary due to the moisture between the pans could create bacteria. The registered dietitian (RD) was interviewed on 4/13/23 at 3:00 p.m. She stated the kitchen staff should be using the red sanitation buckets only for the sanitation chemical and not to drain liquids. She said that the chemical should be tested every two hours, as needed, and when changed out. III. Failure to ensure staff were utilizing proper personal hygiene practices A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view. It revealed in pertinent part, Epidemiological outbreak data repeatedly identify a major risk factor related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: Poor personal hygiene. Food employees shall clean their hands and exposed portions of arms for at least 20 seconds, using a cleaning compound in a handwashing sink. Food employees shall clean their hands and exposed portions of their arms after touching bare human body parts other than clean hands. (Retrieved 4/17/23) B. Facility policy and procedure The Handwashing for dietary staff policy, revised 2/8/21, was provided by the DON on 4/13/23 at 1:58 p.m. It revealed in pertinent part, Hands should be washed after touching bare human body parts other than clean hands. Hand washing procedure is a 20-second process. C. Observations Continuous observations from 11:10 a.m. through 1:50 p.m. on 4/12/23 revealed: -At 11:45 a.m. DM #1 began washing dishes with gloves on. -At 12:36 p.m. DM #1 picked up clean trays and separated them out to dry while wearing the same gloves he wore to wash dirty dishes. -At 12:48 p.m. DM #1 moved clean blender parts with the same dirty gloves. -At 1:20 p.m., DM #1 put dirty dishes into the dishwasher and then pulled the clean rack out of the other side of the machine wearing the same gloves he wore to wash and load the dirty dishes. -During lunch service, CK #2 touched her surgical mask with her bare hands five separate times and failed to perform hand hygiene. -During lunch service, DA #1 touched his surgical mask with his bare hands seven separate times and failed to perform hand hygiene. On 4/13/23 at 10:08 a.m. CK #2 was observed washing her hands for less than ten seconds during meal preparation and after touching her surgical mask twice with her bare hands. At 10:47 a.m. DA #2 was observed touching her bare face with bare hands without performing hand hygiene. D. Staff interviews DM #2 was interviewed on 4/10/23 at 9:00 a.m. She stated that the staff were to only use the designated hand washing sink to wash their hands and needed to wash for no less than 20 seconds. The staff were to wash after using the bathroom, touching unclean body parts and any other time when their hands were exposed to bacteria. IV. Failure to ensure holding temperatures of food were within the correct range A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41 F (fahrenheit) or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control. (Retrieved 4/17/23) B. Observations Continuous observations from 11:10 a.m. through 1:50 p.m. on 4/12/23 revealed: -At 11:30 a.m. cold sandwiches and salads were brought out and held on a pan rack next to the steam table and tray line. There were nine sandwiches (tuna, chicken and ham) and eleven chef salads (some containing egg and ham). The sandwiches and salads were covered with saran wrap but were not kept on ice or with any other means to maintain a cold temperature. The sandwiches and salads were left out on the rack during the entire lunch service without any mechanism to keep them cold. -At 11:37 a.m. temperatures were taken at the start of lunch service by CK #2. The temperatures were as follows: Puree hot corn- 115 F Puree hot ham- 111 F Cold tuna salad sandwich- 56 F Cold chef salad- 55 F Cottage cheese- 48 F -At 11:40 a.m. CK #2 made another batch of puree corn and the temperature read at 129 F. -Service started at 11:58 a.m. -At 12:46 p.m. the chicken salad sandwich temperature was 67.4 F. -At 1:50 p.m. at the end of lunch service, the salad temperature was 76.9 F. On 4/12/23 at 4:19 p.m. a tour of the second floor nursing floor cart and refrigerator was conducted with DM #1 and the following was observed: -The second floor nursing medication cart held a metal container for dietary supplements and soft foods for medication administration. Within the metal container was an open six ounce cup of yogurt. The yogurt ' s internal temperature was 66 F and was sitting in water with no ice. -The second floor nursing floor refrigerator failed to contain a thermometer for the freezer section. The temperature inside the refrigerator section showed the internal temperature was 52 F. On 4:12 p.m. at 4:34 p.m. a tour of the third floor nursing floor refrigerator was conducted with DM #1 and the following was observed: -The third floor nursing medication cart held a metal container for dietary supplements and soft foods for medication administration. Within the metal container was an open 3.9 ounce cup of applesauce. The applesauce ' s internal temperature was 71 F and was sitting in water with no ice. -The third floor nursing floor refrigerator failed to contain a thermometer for the freezer section. C. Staff interviews CK #1 was interviewed on 4/12/23 at 11:37 a.m. She said the internal holding temperature for hot foods should be no less than 135 F and no more than 41 F for cold foods. If hot foods such as pureed items did not meet that temperature, she would remake the puree. She did not know the procedure when the food was not within hot holding range. CK #1 stated that if cold foods exceed 41 F, she would put the item in the refrigerator to bring the temperature down. DM #1 was interviewed on 4/12/23 at 4:34 p.m. He stated food items kept on the nurses cart for residents should be kept on ice at a holding temperature of 41 F or below. Food kept inside of the employee break room resident refrigerator should have a holding temperature of 41 F or below. DM #1 did not know who was responsible for ensuring the nursing staff understood the holding temperatures. Licensed practical nurse (LPN) #2 was interviewed on 4/12/23 at 4:40 p.m. She stated the nurse filled the metal container on the medication cart with ice at the beginning of the shift. She stated she did not know what the holding temperature should be for food items inside the metal container. Registered nurse (RN) #2 was interviewed on 4/13/23 at 9:12 a.m. She stated the overnight nurse would restock the items in the metal container on the nurse ' s medication cart and fill the container with ice at the end of the shift. RN #2 would dump the container after her medication pass at 9:30 a.m. She stated she did not know what the holding temperature should be for food items inside the metal container. RN #3 was interviewed on 4/13/23 at 9:15 a.m. She stated she did not know what the holding temperature should be for food items inside the metal container. DM #1 was interviewed on 4/13/23 at 9:48 a.m. He stated cold foods, such as sandwiches and salads, should be kept at a holding temperature of 31 F. The kitchen staff should maintain the temperature by covering the food or using it immediately. V. Failure to ensure systems were in place to prevent compromised food safety through proper staff training. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The designated person in charge shall ensure that: -Food employees are properly trained in food safety. (Retrieved 4/17/23) B. Staff interviews The DON was interviewed on 4/13/23 at 1:10 p.m. She stated that the dietary manager consultant was the RD. The DON said she would produce proof of kitchen staff training on hand hygiene, sanitation and testing, and temperatures. The RD was interviewed on 4/13/23 at 3:00 p.m. She stated she only provided consultation to the dietary manager on the clinical and nutritional needs of the residents, not areas like sanitation or holding temperatures. The DON was interviewed again 4/13/23 at 3:23 p.m. She stated that she was unable to find any proof of kitchen staff training on sanitation, hand hygiene or temperatures. She was not able to provide proof of training in those areas for DM #1. DM #1 had started staff in-serving in those areas on 4/13/23. DM #1 was using the facility policies to in-service the kitchen staff. The DON acknowledged that the facility did not have a policy on sanitization or testing. C Facility follow-up A facility policy on kitchen temperature control was requested from the DON on 4/13/23 at 10:39 a.m. At time of exit, this policy had not been provided. Documentation of the kitchen staff in-service was requested from the DON on 4/13/23 at 4:15 p.m. An email was received on 4/13/23 at 4:43 p.m. from the DON stating an in-service to the kitchen staff regarding temperature testing, hand hygiene, and kitchen sanitation was initiated 4/13/23 and would be completed by 4/14/23. Documentation of this was not provided after exit date 4/13/23.

Based on observations and interviews, the facility failed to maintain emergency patient care equipment in safe operating condition and remove expired medical supplies from three of three emergency response crash carts. Specifically, the facility failed to perform daily quality readiness checks on the emergency response cart, to ensure the carts contained emergency equipment and expired items were removed and replaced. Findings include: I. Facility policy The facility policy for maintaining patient care equipment was requested [DATE] at and was not received by exit on [DATE]. II. Observations A. On [DATE] at 4:15 p.m. the second and third floor emergency response carts were observed with the director of nursing (DON). The DON acknowledged the following: Third floor emergency response cart: -Four pairs sterile examination gloves, expired [DATE] days prior; -Four 100 militer (ml) Medline Sterile Water Solutions, expired [DATE] days prior; and, -Three Medline Non-Conductive Suction Tubing - Sterile, expired [DATE] days prior. There was a daily checklist on the cart that indicated facility staff failed to check the cart every day. The cart was not covered and was stored in the staff break room adjacent to the dining table. Second floor: -Two Medline Non-Conductive Suction Tubing - Sterile, expired [DATE] days prior; and, -Five pairs of sterile examination gloves, expired [DATE] days prior. B. On [DATE] at 11:15 a.m. the first floor emergency response cart was observed with the assistance director of nursing (ADON). The ADON confirmed the cart contained the following expired items: -Four sterile gloves, expired [DATE] days prior; and, -Three 100 ml Medline Sterile Water Solutions, expired [DATE] days prior. There was no inventory/quality checklist on the medication cart and it was missing a sterile oral suction yankauer and collection canister. The oxygen cylinder on the cart did not have a flow regulator properly attached for immediate use. The cart was not covered and was stored in a room and adjacent to the table where facility staff completed their individual COVID-19 testing. III. Interviews The DON was interviewed on [DATE] at 4:51 p.m. She stated it was the responsibility of the night shift nurse to check the items on the cart and ensure the oxygen canister was ready for use. She replaced the expired items on the second and third floor and had a staff member cover the carts with a bed sheet. The ADON was interviewed on [DATE] at 11:30 a.m. She acknowledged the first floor oxygen flow regulator was assembled incorrectly, where the flow regulator was not attached to the oxygen canister correctly. It took the ADON several attempts to adjust the regulator so that it was operational. The ADON acknowledged expired items were present. She said that it was the responsibility of the nursing department to maintain the equipment. She was unable to locate the daily checklist for the cart. She said the crash carts were to be checked after every use.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 10 of 25 resident rooms in four hallways. Specifically, the facility failed to ensure walls, halls, ceilings, and floors were repaired, painted and properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 4/12/23 at 1:03 p.m. revealed: room [ROOM NUMBER]: The toilet paper holder in the resident's restroom was falling off the wall with two dime sized holes. The wall next to the entrance had two dimes sized holes. The transition from the resident's room to the hallway was missing room [ROOM NUMBER]: The resident's thermostat had been moved with the outline of the old thermostat visible. room [ROOM NUMBER]: There were two quarter sized holes on the wall next to the room's entrance. The ceiling outside of room [ROOM NUMBER] had two large water stains approximately 24 inches by 24 inches and the other was 20 inches by 20 inches. room [ROOM NUMBER]: The toilet holder was hanging off the wall in the resident's restroom. There were two nickel sized holes from the damaged toilet paper holder. room [ROOM NUMBER]: The toilet paper holder was hanging off the wall in the resident's restroom. room [ROOM NUMBER]: The toilet paper holder was hanging off the wall in the resident's restroom. room [ROOM NUMBER]: The floor tile next to the shower had an area approximately 12 inches long, which was lifted. The strip in front of the shower was missing a section approximately 36 inches long by three inches wide. The ceiling outside of room [ROOM NUMBER] had large water stains approximately 25 inches long by 14 inches wide. room [ROOM NUMBER]: The wall in the restroom had two quarter sized holes next to the commode. II. Environmental tour and staff interview The environmental tour was conducted with the housekeeping supervisor (HKS) and director of nursing (DON) on 4/13/23 at 9:50 a.m. The above detailed observations were reviewed. The DON documented the environmental concerns. The HKS said the facility utilized a computer system to identify environmental issues. The HKS said the maintenance supervisor (MS) was out on vacation and he was just filling in for MS while he was on vacation. The HKS said he did not have any repair requisition requests for the above-mentioned items. The HKS said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on record review, observations and interviews, the facility failed to ensure the facility was free from accidents and hazards. Specifically, the facility failed to ensure the exit doors to the second and third floor balconies were locked from the outside without allowing building re-entry if locked outside. Findings include: I. Facility policy The Facility Assessment Tool, dated 10/19/22, was received on 4/10/23 from the director of nursing (DON). -The assessment tool did not include information on facility patio-balcony safety for exit and entry. II. Observations On 4/10/23 at 1:15 p.m., on the third floor west hallway the patio door was propped wide open with a metal patio chair. There was a letter size notice at standing eye level on the inside wall to notify patio users the door would lock from the outside if the door was fully closed. A portable, wireless, doorbell button was observed at standing height attached to the outside door frame. On 4/11/23 at 8:45 a.m. the third floor west hallway patio was propped wide open with a metal patio chair. The third floor west hallway patio was observed outside to have no signage by the door frame to notify the door would lock after entering the patio area and was fully closed. The patio contained a standing height portable, wireless, doorbell button. At 1:27 p.m. a female resident was observed on the third floor, self-propelling her wheelchair using her lower extremities. She moved towards the elevator every time the elevator doors opened. Staff were observed three times as they re-directed the resident away from the elevator. The resident was heard telling the staff that she wanted to go home. At 1:38 p.m., the exit door to the patio on the west 200 hall was propped open with a metal patio chair. There was a remote, wireless, doorbell button attached to the door frame. The remote doorbell was pressed but no bell could be heard in the west hall. At 1:48 p.m., the exit door to the patio on the east 200 hall was propped open with a metal patio chair. The patio area did not have a sign that identified the door locked if closed. There was no doorbell outside attached to the metal door frame. At 2:00 p.m. the exit doors to the patios on the third floors were observed propped wide open with a metal chair. The east patio had a remote doorbell attached to the outside door frame but no signage that identified the door would lock when closed. The exit door on the west patio was propped wide opened with a metal chair. The west patio did not have signage that identified the door would lock when closed. The west patio did not have a remote door bell attached to the outside door frame. All remote doorbells were tested with no chime heard on receiver or located receiver at the nursing station or certified nurse station on all halls. The doorbell transmitter was pressed for one and a half minutes with no response from any facility staff. This was done on all three patios and no facility staff responded to an activated doorbell transmitter. III. Resident interview Resident #28 was sitting alone outside on the patio and was interviewed on 4/11/23 at 1:30 p.m. The resident said he had to leave his rollator walker inside the facility in the hallway because he could not push it around the metal chair in the doorway that held the door open. He said to access the chair he was sitting on he sort of hobbled along, holding on to the doorway and back of the metal patio chairs. The resident said he was aware the door would lock if it closed because he saw the sign on the wall and he watched the door because it was a windy day and wanted the door to remain propped open. He said that he was unaware a doorbell button was attached to the exterior door frame. IV. Staff interviews Certified nurse assistant (CNA) # 9 was interviewed on 4/10/23 at 1:27 p.m. CNA #9 said anyone was allowed to use the patio when they desired. She said all residents were told that they should notify a staff member prior to using the patio. CNA #9 said if a resident was locked out on the patio it would not be for long because a lot of staff members use the adjacent stairs during the day and they look to see if anyone was on the patio. She said a lot of staff members were in the hallways during the day and would hear or notice anyone locked out on the patio. CNA #1 was interviewed on 4/11/23 at 1:43 p.m. She said staff propped the patio doors open as it got too hot in the facility. She said the facility did not have residents that wandered. She said if any resident would go out the patio doors it would automatically lock behind them. She said if a resident would get locked out on the patio, I wouldn't really check as it was at the end of the hall and I could not see if a resident was in the patio area. She said she did not know the location of the chime receiver or that the patio had a doorbell transmitter. CNA #2 was interviewed on 4/11/23 at 1:52 p.m. She said she did not know the patio doors would lock automatically when they were closed and she said she did not know they had doorbells. She said, I have never really checked to see if any residents were using the patio area. She said she did not know where the doorbell receiver was located. Registered nurse (RN) # 4 was interviewed on 4/11/23 at 2:05 p.m. She said not just anyone was allowed to use the exterior patio balconies. She said the activity and therapy staff members took residents outside after they cleared the activity with the assigned registered nurse. RN #4 said they keep wandering residents in line of sight with the staff and no wandering residents would be able to make their way unattended outside. RN #4 was unaware where the doorbell transmitter was located and was unaware the patios had doorbell buttons outside. RN #4 said she was not concerned that the doorbells did not ring because she was unaware the facility had any incidents with residents or staff trapped outside. The director of nursing (DON) was interviewed on 4/11/23 at 3:48 p.m. She was told of observations above. She said the facility had an issue with their air conditioners. The DON said she had never seen any residents out on the patios as no residents went out there. She said the facility did not admit residents who wander to the facility. She said, I suppose it would be possible a resident could get stuck out on the patio but not injured. She said the maintenance supervisor was out on vacation and she would have the housekeeping supervisor look into it immediately. -However, observations revealed there was a female resident that was trying to leave the facility to go home (see above). The housekeeping supervisor (HS) was interviewed on 4/12/23 at 10:01 a.m. He said he did not know why the patio doors locked automatically but he said the nursing home administrator (NHA) had said it was because of the high winds the facility had. He said all four patio areas have new signage on them and they were getting new doorbell transmitters and doorbell receivers. He said he did not know how often the doorbell transmitters and doorbell receivers were tested prior to yesterday, and he did not know if there were any logs documenting the monitoring of the doorbell devices. V. Record review A request was made for the battery monitoring logs of the patio doorbells and location of doorbell chime receivers on all floors, as well as follow up staff training on monitoring the patio areas. At time of exit on 4/13/23, no information requested was provided.

Based on observations, record review and interviews, the facility failed to ensure the kitchen provided food that accommodated resident preferences for three (#27, #28 and #229) of six residents of 20 sample residents. Specifically, the facility failed to ensure Resident #27, #28 and #229 were receiving their menu choices. Findings include: I. Resident #27 Resident #27, age 79, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included osteoarthritis and irregular heartbeat. The 4/4/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview of mental status (BIMS) score of 14 out of 15. B. Resident interview Resident #27 was interviewed on 4/11/13 at 10:15 a.m. She said during her stay, she completed menus with her food choices but she rarely received the food that she requested. She said when she received food items she did not want, certified nursing assistants (CNA) were not helpful to replace the items. She stated she finally told a CNA she would accept any entree except fish and then she received tilapia. She ordered scrambled eggs and a muffin for breakfast and instead received two boiled eggs and sausage, and when she requested a replacement she did not receive the breakfast items until lunchtime. She began to save her meal sheets that were included with each meal to show what she ordered was not the same as what she was receiving. One meal she received roasted turkey, poultry gravy, mashed potatoes, glazed carrots, baked roll, and cranberry crunch bar. What she ordered were pears, carrots, herb roasted potatoes, roll, and a cookie. Another meal she identified included lemon baked fish, orzo pilaf, vegetable blend, chocolate pudding, and tomato juice when she ordered carrots, pasta, pear, gravy and pound cake. C. Record review The nutrition care plan dated 4/4/23 revealed the resident had the potential for an inability to maintain nutrition due to lactose intolerance and decreased appetite. Interventions were to provide and serve the resident ' s diet as ordered. The resident required the assistance of one staff member to set up her meals and she was independent with eating. The nutrition assessment dated [DATE] revealed the resident had a moderate decrease in food intake with a regular diet texture thin consistency. II. Resident #28 A. Resident status Resident #28, age 82, was admitted on [DATE]. According to the April 2023 computerized CPO, diagnoses included cellulitis (skin infection) and hypertension. The 3/23/23 MDS assessment revealed the resident had no cognitive impairments with a BIMS score of 15 out of 15. B. Resident interview Resident #28 was interviewed on 4/10/23 at 1:50 p.m. The resident stated she had problems with receiving the food she ordered four times a week for the last four weeks. She said she had complained to the dietary aides and CNAs but the issue has not improved. The resident said the dietary staff had told her it had to do with their new computer system for taking orders and they were working on it. C. Record review The nutrition care plan dated 4/4/23 revealed the resident had potential for an inability to maintain nutrition due to underweight body mass index (BMI), decreased appetite with weight loss and meets criteria for malnourishment. Interventions were to provide and serve the resident ' s diet as ordered. The nutrition assessment dated [DATE] revealed the resident had a severe decrease in food intake, underweight body mass index (BMI), decreased appetite with weight loss and met criteria for malnourishment with a regular diet texture thin consistency. III. Resident #229 A. Resident status Resident #229, age 94, was admitted on [DATE]. According to the April 2023 CPO, diagnoses included fracture and kidney failure. The 4/5/23 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 13 out of 15. B. Resident interview Resident #229 was interviewed on 4/10/23 at 1:10 p.m. She stated she was not sure what she would get for her meals because she did not always get what she ordered. She filled out the menus provided to her by the kitchen staff but the kitchen would make substitutions and she would not know until she received her meal tray. C. Record review The nutrition care plan dated 4/3/23 revealed the resident had the potential for an inability to maintain nutrition due diagnosis and past medical history of swallowing difficulty. Interventions were to provide and serve the resident ' s diet as ordered. The nutrition assessment dated [DATE] revealed the resident had occasional swallowing difficulty and met criteria for malnourishment with a regular diet texture thin consistency. IV. Observations On 4/12/23 the tray line was observed from 12:01 p.m. through 1:50 p.m. The starch of the regular meal that day was southern style squash. This was substituted with zucchini. At 1:32 p.m cook (CK) #2 ran out of the zucchini and substituted it with a vegetable blend (zucchini, carrots, and cauliflower). At 1:32 p.m. the kitchen ran out of the puree dessert, cherry crisp. This was substituted with cherry Jello for the last six puree orders. V. Staff interviews The registered dietitian (RD) was interviewed on 4/13/23 at 9:38 a.m. She stated her role was to focus on clinical but was not involved in the meal planning. She would provide individual recommendations for residents and would review substitutions and sign off if appropriate. The RD did not know if the residents were notified when a menu item was replaced with a substitute. She acknowledged the substitutions from the 4/12/23 lunch were not ideal. The kitchen manager was using a new system for taking resident orders and the system was still not running smoothly. The food items on the menu provided to the facility by the distribution company did not always match what they wanted to serve to the residents. The meal tickets had the distribution companies menu items on it and this did not always match what the residents received on their order form to choose from. Dietary manager (DM) #1 was interviewed on 4/13/23 at 9:48 a.m. He stated the food items on the menu provided to the facility by the distribution company did not always match what they wanted to serve the residents. The dietary aides would go to the resident rooms and provide the residents with menus for the entire week to fill out. The dietary aides would return every day to enter that order into a tablet that would go into the kitchen system. He stated the RD did sign off on the substitutions for the 4/12/23 lunch but the kitchen had no system to notify residents of menu changes. He had been working with the distribution company daily for two months to resolve the discrepancies. DM #1 provided recipes on 4/12/23 at 3:00 pm. for the puree vegetables, chicken salad/tuna salad sandwiches, and the chef salad. He provided documents with the recipe typed up and he said he typed the recipes up that same day. -The recipes failed to show portion or scoop sizes. The RD interviewed on 4/13/23 at 3:34 p.m. She stated there were official recipes for the puree vegetables, chicken salad/tuna salad sandwiches, and the chef salad that included exact portions and measurements. She was not aware the dietary manager did not know about the recipes.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 in one of four halls including an isolation room. Specifically, the facility failed to ensure appropriate personal protective equipment (PPE) while providing care for Resident #136 who was positive for COVID. Findings include: I. The Centers for Disease Control (CDC) recommended guidelines The CDC, Preparing for COVID-19 in Nursing Homes, updated 9/27/22, retrieved on 4/19/22 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. It read in pertinent part, HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). In general, patients should continue to wear source control until symptoms resolve or, for those who never developed symptoms. II. Observations and interviews On 4/11/23 at 11:36 a.m. the activity director was observed entering Resident #136's room, who was on isolation for COVID-19. The AD was observed donning a gown and gloves. She was observed wearing a cloth mask and then placing a surgical mask over her cloth mask. She then walked into Resident #136's room. She stayed in the room approximately seven minutes and exited the room. She doffed her PPE inside the room and opened the door removing the second surgical mask and placing it in the trash can with her bare hand, which was overflowing in the resident's room. She then went into another resident's room and did not hand sanitize her hands prior to entering the room. She did not wear a N-95 mask and she did not wear a face shield or eye protection prior to entering Resident #136's room. She did not hand sanitize her hands after placing the second surgical mask into the trash can. At 1:57 p.m. an unknown staff member entered Resident #136's room. She was observed putting on a gown, gloves and placed a new surgical mask over her original surgical mask. She was in the room for approximately seven minutes. She exited the room wearing her surgical mask. She did not hand sanitize her hands prior to donning her PPE prior to entering the resident's rooms. She did not wear a N-95 mask or face shield or eye protection. At 2:13 p.m. a hospice caseworker was observed entering Resident #136's room. She donned her gown and gloves prior to entering the resident's room. She was in the room for approximately 15 minutes. She exited the resident room and doffed her PPE outside of the resident's room. She bent into the resident's room and placed the PPE in the trash can pushing her used PPE into the trash can as it was overflowing. The hospice caseworker (HCW) said she had received her PPE training and doffing from her hospice provider. She said she visited various facilities completing hospice assessments. The HCW did not hand sanitize her hands prior to donning her PPE. She did not wear an N95 mask or wear a face shield or eye protection. She doffed her PPE outside of the resident's room. At 3:02 p.m. registered nurse (RN) #1 was observed entering Resident #136's room. She donned her gown and gloves. She was in the resident's room for approximately five minutes. She exited the resident's room and returned to her medication cart. RN #1 said she did not have on a N95 mask and she did not wear a face shield or any eye protection when entering the resident's room. On 4/12/23 at 9:09 a.m. certified nurse aide (CNA) #4 was observed entering Resident #136's room. She donned her gown, gloves and N95 mask but placed the N95 mask over her surgical mask. She was in the resident's room for approximately five minutes. CNA #4 doffed all her PPE in the resident's room and exited with the resident's meal tray. CNA #4 walked to the CNA station on the east hall with the room tray and her face shield on. While CNA #4 was placing the meal tray into the meal cart. She spilled the resident's milk while picking up the glass. She placed the uncovered meal tray back into the meal cart. She then removed her face shield placing it into a lower drawer in the CNA station. CNA #4 said she should have not worn her N95 over her surgical mask and she should have sanitized her hand and face shield after removing the room tray from the COVID room, and she should have placed them into a bag. III. Administrative interviews The director of nursing (DON) was interviewed on 4/13/23 at 9:14 a.m. She said staff should wear full PPE, which would be a gown, gloves, N95, face shield or eye protection. Staff should hand sanitize prior to entering the residents' room. She said then staff should be doffing all PPE prior to exiting residents' rooms and placing their face shields into a paper bag. The DON was told of the observations above. She said all staff have been trained on doffing and donning PPE, and they know better than that. She said a negative outcome could be getting themselves sick and spreading COVID. The infection control nurse (ICN) was interviewed on 4/13/23 at 11:00 a.m. She said staff should wear full PPE, which would be a gown, gloves, N95, face shield or eye protection. Staff should hand sanitize prior to entering the residents' room. She said then staff should be doffing all PPE inside the residents' room prior to exiting residents' rooms. She said then staff should sanitize their face shield or eye protection placing them inside of a bag. She said staff should know better than that because they have all been trained on donning and doffing PPE.

Based on observations, record review and interview, the facility failed to ensure a residents' who were unable to carry out activities of daily living (ADLs) receives the necessary services and assistance during showers and baths for three (#7, #8 and #2) of four residents reviewed for hygiene assistance of nine sample residents. Specifically, the facility failed to provide scheduled showers and baths or offer an alternative for Resident #7, #8 and #2. Findings include: I. Facility policy The Activities of daily living (ADLs), and Mobility Care Need policy, reviewed on 2/8/21, was provided by the director of nursing (DON) on 1/6/23 at 8:51 a.m. The policy read in part, Patient communication boards will be utilized to communicate assistance levels and important precautions/restrictions to enable direct care staff to promote functional independence while maintaining patient safety when providing care. II. Resident #7 A. Resident status Resident #7, age 93, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included wedge compression fracture, muscle weakness, acute kidney failure, chronic kidney disease, and history of falling. According to the 12/25/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming, bathing and toilet use. B. Observation/resident interview On 1/4/23 at 10:13 a.m., Resident #7 was sitting in her recliner with her pajamas on. She said I get tired of being in my pajamas. She said, I prefer a shower but I have to get a sponge bath out of the sink. I have only received two showers since I have been here (12/22/22). C. Record review The care plan, initiated 12/23/22 and revised 1/3/23, identified the resident was okay with receiving a shower, bed bath, and/or sponge bath per her preference. Interventions include the resident preferred showers. Bathing frequency was two times a week. The December 2022 point of care (POC) documentation utilized by the certified nurse assistants (CNAs), identified the bathing task to occur two times a week. The documentation identified the resident receiving one shower on 12/24/22 at 12:08 p.m. The occupational therapy shower sheets provided by the nursing home administrator (NHA) on 1/5/23 at 11:42 a.m. The shower sheets from the last 30 days documented one shower was given on 12/26/22, and 1/4/23 with no time given. III. Resident #8 A. Resident status Resident #8, age 80, was admitted on [DATE]. According to the January 2023 CPO, diagnoses included metabolic encephalopathy (altered mental status), abnormal gait, dysphagia (swallowing difficulty), altered mental state, and history of falling. According to the 12/15/22 MDS assessment, the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming, bathing, and toilet use. B. Observation/resident interview On 1/4/23 at 11:30 a.m., Resident #8 was lying in her bed talking with her daughter. Resident #8's hair was disheveled and uncombed. Resident #8 and the resident's daughter were interviewed on 1/4/23 at 11:30 a.m. The daughter said Resident #8 was getting a shower once a week. She said, I had to ask the staff to give her a shower on 12/20/22. The daughter said, I requested she get a shower on 12/31/22 and again on 1/1/23 and requested again on 1/2/23. She said staff told her there were drain issues this weekend so no showers were given. C. Record review The care plan, initiated 12/22/22 and revised 12/28/22, identified the resident was okay with receiving a shower, bed bath, and/or sponge bath per her preference. Interventions include the resident preferred a shower. Bathing frequency was three times a week. -The care plan did not identify interventions if Resident #8 refused a shower, or did not receive a shower since it was documented the resident refused (see below). The December 2022 POC documentation utilized by the CNAs, identified the bathing task to occur two times a week. The documentation identified the resident received zero showers or sponge baths in the last 30 days. The occupational therapy shower sheets provided by the NHA on 1/5/23 at 11:42 a.m. The shower sheets from the last 30 days documented one shower on 12/20/22, and two refusals on 12/16/22 and 12/30/22. IV Resident #2 A. Resident status Resident #2, age 82, was admitted on [DATE]. According to the January 2023 CPO, diagnoses included encephalopathy (brain disease), pneumonitis (lung inflammation) due to inhalation of food, dysphagia, diabetes mellitus, and Parkinson's disease. According to the 12/12/22 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming, bathing and toilet use. B. Observation/resident interview On 1/4/23 at 12:13 p.m. Resident #2 was sitting in his wheelchair next to his bed. Resident #2 was wearing a white t-shirt and pajama bottoms. He had just finished washing up in his sink. He said showers were a big problem when it comes to showers. He said his scheduled showers were on Wednesdays and Saturdays. He said his last shower was on 12/28/22 and he did not get his shower on Saturday. He said, I like to take showers regularly because I sleep a lot better when I am clean. He said, I wash myself in the sink daily. C. Record review The care plan, initiated 12/6/22 and revised 12/29/22, identified the resident was okay with receiving a shower, bed bath, and/or sponge bath per his preference. Interventions include the resident preferred showers. Bathing frequency two times a week. The December 2022 POC documentation utilized by the CNAs, identified the bathing task to occur two times a week. The documentation identified the resident received three showers or sponge baths on 12/20/22, 12/21/22 and 12/28/22 in the last 30 days. The occupational therapy shower sheets provided by the NHA on 1/5/23 at 11:42 a.m. The shower sheets from the last 30 days documented two showers on 12/21/22 and 12/27/22. V. Staff interviews CNA #1 was interviewed on 1/4/23 at 9:45 a.m. She said each resident was scheduled for two showers. She said resident showers were missed because occupational therapy (OT) also provided showers and there was a miscommunication of who was giving the showers and when they were given. Licensed practical nurse (LPN) #1 was interviewed on 1/5/23 at 9:34 a.m. She said all residents were scheduled for two showers a week unless they requested extra. She said CNAs provided showers and they documented in the POC documentation. She said she did not know if OT documented when they gave the residents showers. She said if a CNA reported a refusal or a problem with showers, she would make a progress note. She said all residents should be given showers according to their preference. CNA #4 was interviewed on 1/5/23 at 9:55 a.m. She said staff we were all responsible for resident showers. She said the problem was with OT and communication since the CNAs did not know when they were providing showers. She said the lack of communication caused residents to not get showered when they were scheduled. She said the facility had a drain problem this weekend (12/31/22 to 1/1/23) but the showers had not been provided to residents that were missed. The DON was interviewed on 1/5/23 at 12:15 p.m. She said the staff documented the showers in the POC in the resident's electronic medical record and the OT shower sheets. She said each resident was scheduled for two showers a week. The DON was told of the observations and interviews above. She said, I know there's a problem with showers and I am working on trying to correct it. She said residents should be receiving their scheduled shower.

Based on observations, record review and interviews the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and and does not develop pressure ulcers unless the individual's clinical condition demonstrates that the were unavoidable for one (#24) of four residents out of 40 sample residents reviewed for pressure ulcers. Resident #24 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24 skin was assessed at admission on 12/12/21 as not having any pressure areas identified. The facility identified the resident at low risk for developing pressure ulcers, however per the 12/17/21 minimum data assessment, he was identified at risk for developing pressure ulcers. The facility failed to have preventative interventions in place to ensure Resident #24's feet were offloaded, failed to provide showers as preferred (cross-reference F561) and failed to complete all ordered weekly skin and foot assessments. Due to the facility's failures, the resident developed an avoidable, facility acquired unstageable pressure ulcer to his left heel, which was discovered by the resident's wife on 1/10/21. Furthermore, the resident indicated the pressure ulcer caused the resident pain and discomfort. Findings include I. Professional reference A. The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (2/4/18) Accessed 1/27/22. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .). Cambridge Media: Osborne Park, Western Australia 2/14/18, accessed 1/27/22: Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, periwound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor. II. Facility policy The Pressure Ulcer policy, revised 2/8/21, provided by the director of nursing (DON) on 1/24/22 at 2:00 p.m., read in pertinent part: The facility will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice. -Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin. -The physician will assist the staff with reviewing current orders when wounds are not healing as anticipated or new wounds develop despite existing interventions. III. Resident status Resident #24, age 73, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/17/21 minimum data set (MDS) assessment revealed Resident #24 had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. (However, according to the nursing note 1/1/22 he was alert and oriented to person, place and time.) He did not have mood or behavior symptoms and was not resistant to care. He required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use. He required extensive assistance of one staff member for personal hygiene. Bathing had not occurred. He was not steady and only able to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet and with surface to surface transfers. He had impairment on one side of upper and lower extremities. He used a wheelchair for mobility. He did not have any pressure ulcers upon admission but was at risk for developing a pressure ulcer. The treatments indicated were pressure relieving devices in his chair and bed, turning and repositioning, however application of dressing to feet was not indicated. IV. Resident/wife interview and observations Resident #24's wife was interviewed on 1/12/22 at 1:57 p.m. She said the staff were now treating a pressure ulcer on his left heel that she brought to their attention a couple days ago. She said she was applying lotion to his feet when she felt something hard on his heel and notified the nurse, who then notified the wound care nurse. She said he did not have any pressure ulcers when he was admitted to the facility. She said, I have no doubt they did not know it was there because he had not received a bath or shower for the last month until I mentioned that to them as well and no one had been assessing his skin routinely. Resident #24 was interviewed and an observation of his left heel was done on 1/24/22 at 1:39 p.m. He was lying on his back in bed on a standard mattress, not an air mattress. He was wearing non-skid socks and his feet were not elevated off the mattress. The heels up pad which would have elevated his feet off the mattress was propped against the wall across from the foot of the bed. He said he did not have the pressure sore to his heel when he was admitted to the facility. He said the nursing staff had not completed full skin assessments on a weekly basis since his admission. He said the pressure sore on his left heel was painful at times and felt as if it was swollen. He said he had not refused to be turned, repositioned or have his heels elevated off the mattress. He said they left a soft boot (pressure relieving device) for him to wear on his foot but it was not on his foot, it was in a chair under a pillow. Resident #24's son was at the bedside and removed the sock from his left foot. The pressure ulcer was covered in a thick black skin and the surrounding skin had a rim of dark brownish skin as well. There was no bandage on the area and no drainage was observed. -At 5:11 p.m., Resident #24 was seen seated in his wheelchair being transported to the main dining room on the first floor. He did not have the pressure relieving soft boot on his left foot. He was wearing non-skid socks and his feet were resting directly on the foot pedals of the wheelchair without any protection/cushion. On 1/25/22 at 10:00 a.m. Resident #24 was again observed lying in his bed. He was not wearing the soft boot to his left foot nor were his feet elevated (floated) off the bed. -At 2:00 p.m. Resident #24 was seen in his room seated in his wheelchair interacting with a therapy staff member. He was wearing non-skid socks and his feet were resting on the foot pedals of the wheelchair. He was not wearing the soft boot on his left foot. V. Record review Review of the care plan, initiated 12/11/21 and 12/12/21, revealed Resident #24 required assistance with activities of daily living (ADLs) related to self care deficits and decreased functional mobility secondary to cerebral infarction and metabolic [CONDITION(S)]. He had actual/potential decline in his ability to perform ADLs. He had a potential for skin breakdown related to impaired mobility secondary to weakness and debility, decreased functional mobility, cerebral infarction and cognition deficits. Interventions included: to reposition patient throughout shifts as needed and see CNA (certified nurse aide) tasks and documentation for ADLs. Provide assistance as needed with grooming, bathing, and personal hygiene and per patient's preferences. Braden scale every week per protocol, and skin evaluation as ordered and as needed. Monitor/reminding/assist to turn/reposition frequently, as needed or requested. Pressure-relieving mattress per facility protocol and as ordered. Skin treatment per physician order. Review of the December 2021 CPO revealed an order dated 12/11/21 for skin prep (skin protectant) to bilateral heels every other day (QOD) at bedtime and orders dated 12/17/21 for weekly pain assessments, weekly pressure sore risk assessments and weekly skin and foot assessments. Review of the weekly pain assessments revealed the following: The 12/17/21 assessment indicated he was unable to answer but staff indicated he had pain when moving. The 12/31/21 assessment indicated he had occasional pain rated at 5 out of 10 (with 10 being the worst pain the scale). The 1/8/22 assessment indicated he had frequent pain rated at 4 out of 10. -Pain assessments were not completed on 12/24/21 or 1/14/22. Review of the Braden Scale for Predicting Pressure Sore Risk assessments completed on 12/31/21, 1/7/22 and 1/21/22 indicated Resident #24 was at low risk for developing a pressure sore with scores of 17, 18 and 17 respectively out of 23 with low numbers indicating higher risk. -The nursing staff had orders to assess the resident more frequently and should have completed four pressure sore risk assessments prior to the discovery of the unstageable ulcer on his left heel. Braden scale assessments were not completed on 12/17/21, 12/24/21 or 1/14/22. In addition, the 12/17/21 MDS assessment (see above) indicated the resident was at risk for developing a pressure ulcer. Review of the admission assessment and weekly skin assessments revealed the following documentation: The 12/12/21 nursing admission assessment, documented by registered nurse (RN) #5, indicated Resident #24 was oriented only to himself, he was bedfast, he was very limited in his ability to change or control body position and no pressure ulcers were documented. The 12/31/21 skin evaluation documented no pressure areas. The 1/7/22 skin evaluation documented no pressure areas. -Weekly skin assessments were not completed on 12/17/21, 12/24/21 or 1/14/22 and 1/21/22. The nursing staff should have completed five weekly skin assessments prior to the discovery of the unstageable left heel ulcer. Review of the daily skilled nursing notes, documented by RN #6 on 1/8/22 at 4:55 p.m. and on 1/9/22 at 5:11 p.m., one and two days prior to discovery of the pressure ulcer, revealed no documentation of an issue with Resident #24's heel. The 1/10/22 Skin/Wound Note-Late Entry, documented by licensed practical nurse (LPN) #3 at 6:13 p.m. read in part: This nurse notified of dark area to patients left heel. Immediately came to room and evaluated with charge RN, wife at bedside. Patient has foam wedge under his legs at this time. Dark, softly hardened tissue noted to site, soft perimeter of area noted as well. Patient does not complain of pain at this time. Using clean technique, area was cleansed, dried well, [MEDICATION(S)] applied. Physician notified of new incident; no signs or symptoms of infection noted. Educated patient and wife related to benefits of offloading boney areas. Have spoke to patient recently and at times he is resistive to repositioning, prefers supine positioning. Assistant director of nursing (ADON) and charge RN updated. Will continue to monitor. Wound physician (WP) notified of new skin concern; he will evaluate 1/12. Orders to float heels while in bed and interventions in place. -The orders to float heels when in bed and for the heels up pad were not added to the chart or the CNA task list until after the discovery of the heel ulcer on 1/10/22. The order, If patient refuses to use heels up positioning pad in bed, place elevating heel offloading bootie as patient will tolerate to left foot was not added to his chart until 1/20/22, which was 10 days after the heel ulcer was identified. There were no measurements of the wound identified on the skin/wound note. The 1/12/22 Skin/Wound note documented by LPN #3, at 7:25 a.m., read in part: Wound care evaluation today with the wound care team and WP related to the patients skin concerns to left heel. WP documentation to follow in chart. Wounds are progressing as expected, not worsening. Eschar (dead tissue) hardened, perimeter less pink, still no pain to area. Using clean technique, wound care was done on patient as they were lying in bed. Treatments were then done per recommendation of WP. Patient did tolerate the wound care well and was then repositioned after to comfort with heels up pad in bed. Treatment orders are now up to date in chart as well as care plan. We discussed with patient the benefits of wound care and also the importance of regular skin treatment regimen. We educated related to the importance of protein and good caloric value needed to help their skin heal. Patient voiced no concerns at this time; wife is aware and updated. Attending physician, nursing and dietitian have been updated - all satisfied at this time with their plan of care. The 1/12/22 Wound Care evaluation, documented by the WP read: Date of onset 1/10/22, left heel pressure is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 3 cm length x 3.1 cm width with no measurable depth, with an area of 9.3 square centimeters (sq cm). The patient reports a wound pain of level zero out of 10. Wound bed has 100% eschar. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Wound Orders: Cleanse wound with normal saline, apply [MEDICATION(S)] to area twice daily (BID). Preventive Measures: offloading. The 1/19/22 Skin/Wound care evaluation, documented by LPN #3 at 2:30 p.m., read in part: Skin and wound care evaluation today with the wound care team and the WP related to the patient's skin concerns to left heel. Measurements are length 3.4 cm x width 5.0 cm x depth undetermined-unstageable. Upon entry into room, no pad on bed to float heels. Patient states he kicked it out sometime earlier. WP discussed risks and benefits of offloading heels; pt (patient) voices understanding. This writer discussed offloading booties, will evaluate and place today. Wounds are progressing as expected. Eschar hardened, perimeter soft, discolored, suspected deep tissue injury initially, may appear larger. Using clean technique, wound care was done on patient as they were lying in bed. Treatments were then done per recommendation of WP. Patient did tolerate the wound care well and was then repositioned after to comfort with heels up pad in bed. Treatment orders are now up to date in chart as well as care plan. We discussed with patient the benefits of wound care and also the importance of regular skin treatment regimen. We educated related to the importance of protein and good caloric value needed to help their skin heal. Patient voiced no concerns at this time. Will continue to monitor closely. Staff updated. -From the discovery of the heel ulcer on 1/12/22 to 1/19/22 it had increased in size. VI. Staff interviews CNA #1 was interviewed on 1/24/22 at 3:00 p.m. She said Resident #24 was pleasant and cooperative and she had not had any issues with him being non-compliant with using the heels up pad once it had been started. He had not refused care at any time. RN #6 was interviewed on 1/24/22 at 5:00 p.m. She said Resident #24 had no pressure ulcers when he was admitted and she had not known him to be non-compliant with any care (however, this was not indicated in the resident's care plan, see above). She said if there were orders for weekly skin/foot, pain and Braden scale assessments, those were to be done by the nurse and a skin/foot assessment was to include examining all the skin, head to toe and documenting any abnormal findings. The DON was interviewed on 1/25/22 at 12:25 p.m. She said when a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she thought Resident #24's heel area had initially started as a blister, however, there was no documentation to that effect. She said if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged that if the weekly skin assessments and his scheduled showers had been completed as they should have been the heel ulcer could have been caught earlier than it was and not have progressed to an unstageable pressure ulcer.

Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#221) of two residents out of 40 sample residents. Resident #221, who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated she had back pain and did not like to get out of bed much because she had more pain when she moved. The resident also stated that she ate most of her meals lying down in her bed because she had less pain when she was lying in bed. The comprehensive pain assessment completed upon admission to the facility documented the resident had sharp, continuous left flank pain which worsened with movement and made activities of daily living (those skills required to manage one's basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating), physical activity, and mobility more difficult. Furthermore, the pain assessment documented the resident's acceptable level of pain was a 3 on a scale of 1-10, with 10 being the worst possible pain. Daily skilled nurse's notes revealed the resident experienced a pain level greater than her stated acceptable pain level of 3 on 13 out of 20 days (between 1/5 and 1/24/22), with a pain level greater than 5 on several of those days. The resident received as needed pain medication, however, review of the follow-up pain levels after pain medication administration revealed the resident's pain frequently remained above her stated acceptable pain level of 3 and no further pain medication was administered. The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to notify the physician that the resident was occasionally refusing her pain patch or that her pain levels remained greater than her stated acceptable level of pain following administration of pain medication. In addition, the facility failed to conduct weekly Comprehensive Pain Evaluation assessments per physician orders, and the physician, as well as the facility, did not address the resident's acceptable pain level until the pain concerns regarding the resident were brought to their attention. Due to the facility's failures, Resident #221 experienced pain greater than her stated acceptable pain level and stated she did not want to get out of bed because movement increased her pain. Findings include: I. Facility policy and procedures The Analgesia (pain) policy and procedure, last revised 2/8/21, was provided by the director of nursing (DON) via email on 1/25/22 at 1:37 p.m. It read in pertinent part, Upon admission, all patients will be evaluated for pain. Pain level will also be evaluated every shift. Once a patient expresses the perception of pain or makes a request for pain medication, the patient will be provided with a dose of analgesic pain medication or non pharmacological intervention will be initiated. It is the responsibility of the individual staff member that heard the complaint to follow up and make sure that some intervention (pharmacological or otherwise) is initiated. If a patient has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Any scheduled pain medications should be given as close as time stated in Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .). -The policy did not address the need to follow-up with the physician if pain medications were ineffective in managing a resident's pain. II. Resident status Resident #221, age 85, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/9/22 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 12 out of 15. She required one-person limited assistance for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The 1/9/22 MDS assessment further revealed that the resident received scheduled and as needed pain medications. She also received non-medication interventions for pain. She had moderate pain occasionally over the five day look back period of the assessment. III. Resident observations and interviews On 1/12/22 at 11:00 a.m., Resident #221 was lying in bed in a hospital gown. Resident #221 said she was admitted to the facility from the hospital and her back was broken. She said she experienced a lot of pain if she moved. Resident #221 said the nurses did give her pain medication but she still had pain when she moved. She said she did not like to get out of bed because of the pain. She said she ate most of her meals lying down in the bed, curled on her side because her back did not hurt so much when she was in that position. On 1/13/22 at 9:23 a.m., the resident was lying in bed curled on her left side. She said she was having pain in her back and she had not been out of bed much that morning. She said she did not want to get up because her back hurt when she moved. On 1/13/22 at 3:27 p.m., Resident #221 was again lying in her bed, curled on her left side. She said her back was hurting and she was waiting on the nurse to bring her pain medication. On 1/24/22 at 3:46 p.m., the resident was lying on her left side in bed. She said she did not hurt much as long as she did not move. As she rolled to her back she grimaced and reached toward the left side of her body. On 1/25/22 at 8:50 a.m., Resident #221 was lying in the bed on her back. The head of the bed was elevated and the resident was lying closer to the foot of the bed. She said she had just walked to the bathroom. She said she had pain in her back. She said she would rest for a few minutes to decrease the pain before she moved herself up toward the head of the bed. She was wincing and grabbing at her left side while she talked. Resident #221 said she was not sure if she had received pain medication that morning, but she thought the nurse had given her some. She said she saw a doctor on the prior day (1/24/22). She said the doctor told her she needed to get up and move more. IV. Record review Resident #221's history and physical completed by the hospital physician on 1/2/22 documented the following in pertinent part, Principal problem is intractable back pain. New thoracic compression fracture. Patient with pain radiating from back to left lower chest wall. Patient has been given a brace in the past but declines to wear the brace. Will focus on pain control. Tylenol and [MEDICATION(S)] ([MEDICATION(S)]) for pain control. [MEDICATION(S)] patch as needed. Previous medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient states it feels okay if she lays still and doesn't move but anytime she moves the pain is magnified. It is a dull pain. The January 2022 CPO revealed Resident #221 had the following orders for pain management: -[MEDICATION(S)] HCl tablet 50 milligrams (mg) one tablet by mouth every six hours as needed for pain levels of 5-10. The order date was 1/4/22; -Tylenol Extra Strength tablet (Acetaminophen) 500 mg two tablets by mouth every six hours as needed for pain levels of 1-4. The order date was 1/4/22. The order was discontinued on 1/9/22. -Acetaminophen tablet 650 mg by mouth every four hours as needed for pain. The order date was 1/9/22; -[MEDICATION(S)] Patch 4 %. Apply to the affected area topically one time a day for pain management and remove per schedule. The order date was 1/4/22. The order was discontinued on 1/20/22; -[MEDICATION(S)] Patch 5 %. Apply to the affected area topically one time a day for pain management, remove each night per schedule. The order date was 1/20/22; -Offer non-pharmacological interventions throughout the shift to include: ice, re-positioning, elevation, relaxation, rest, etcetera. The order date was 1/4/22. (The January 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Evaluation of pain every shift and document for routine screening. The order date was 1/4/22; and, -Comprehensive Pain Evaluation every week for routine screening. The order date was 1/4/22. Review of Resident #221's comprehensive care plan, initiated 1/5/22, revealed she had acute/chronic pain related to spinal fractures. Pertinent interventions included acknowledging the presence of pain and discomfort, listening to the patient's concerns as needed, administering pain medications per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain section of the Nursing Comprehensive Admission Data Collection assessment dated [DATE] documented Resident #221 had sharp, continuous left flank/back pain upon admission. The resident rated her pain at 5 out of 10 on the numeric pain scale (on a scale of 1-10, with 10 being the worst pain). The 1/4/22 admission assessment further documented the resident's pain was alleviated by pain medication, rest, and repositioning. The resident's pain worsened with movement and made activities of daily living (those skills required to manage one's basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating), physical activity, and mobility more difficult. Further review of the 1/4/22 admission comprehensive pain assessment revealed Resident #221 stated her acceptable pain level was 3 out of 10 on the numeric pain scale. Review of Resident #221's January 2022 EMAR revealed she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The order was not signed off on the EMAR to indicate the assessment had been completed on 1/11/22 and there was no Comprehensive Pain Evaluation assessment found in the resident's electronic medical record (EMR) for 1/11/22. -The order was signed off on the EMAR to indicate the assessment had been completed on 1/18/22, however there was no Comprehensive Pain Evaluation assessment found in the resident's EMR for 1/18/22. -Review of Resident #221's January 2022 EMAR from 1/5/22 through 1/24/22 revealed the daily pain assessment was not documented as completed on the day shift on 1/5, 1/10, 1/11, and 1/23/22. Review of Resident #221's Daily Skilled Nurses's Notes from 1/5 through 1/24/22 revealed the following, in pertinent part: 1/5/22: There was no daily skilled nurse's note documented. 1/6/22: Pain rating out of 10: 7. 1/7/22: Pain rating out of 10: 6. 1/8/22: Pain rating out of 10: 7. 1/9/22: Pain rating out of 10: 8. 1/10/22: Pain rating out of 10: 7. 1/11/22: Pain rating out of 10: 5. Patient reports that if she is not moving she has no pain, but any movement causing increased pain. 1/12/22: Pain rating out of 10: 6. Patient reports when moving around in bed. 1/13/22: Pain rating out of 10: 4. 1/14/22: Pain rating out of 10: 4. 1/15/22: Pain rating out of 10: 0. 1/16/22: Pain rating out of 10: 6. 1/17/22: Pain rating out of 10: 4. Does not want to move much due to pain issues. 1/18/22: Pain rating out of 10: 4. Goes up with movement. 1/19/22: Pain rating out of 10: 0. It only hurts when I move. 1/20/22: Pain rating out of 10: 0. 1/21/22: Pain rating out of 10: 0. 1/22/22: Pain rating out of 10: 0. 1/23/22: Pain rating out of 10: 5-10. Moving increases pain. 1/24/22: Pain rating out of 10: 2. Unless moving around. -The above documentation revealed Resident #221 experienced a pain level greater than her stated acceptable pain level of 3 on 13 out of 20 days. -Despite documentation that movement increased the resident's pain, there was no documentation of the physician being notified to request additional orders for pain control. Further review of Resident #221's electronic medical record revealed the following progress notes: 1/7/22: A progress note from the facility's physician documented in pertinent part: Back pain has improved. Pain level 6 out of 10. -The pain level documented in the progress note was greater than the resident's stated acceptable pain level of 3. 1/14/22: A progress note from the facility's physician documented in pertinent part: Back pain has improved. Pain level 6 out of 10. -The pain level documented in the progress note was greater than the resident's stated acceptable pain level of 3. 1/15/22: A progress note from the facility psychologist documented in pertinent part: Subjective: 'I cannot move it hurts right here; I have an ulcer.' I asked if she was hungry, and she tells me she is but could not sit up. She turns slightly on her side and wants her plate on the bed. I set-up breakfast for her and she was eating when I left. I went back to check on her and we talked about what happened. I told her per her chart she fell and where it hurts, she has a fracture. She tells me she is not sleeping well. 1/19/22: A progress note from the facility's physician documented in pertinent part: Back pain. Pain level 0 out of 10. Patient reports it only hurts when she moves. -Despite the resident stating it only hurt when she moved, there was no documentation to indicate the physician addressed the need for more effective pain management in order to enable the resident to be more active. 1/21/22: A progress note from the facility's nurse practitioner documented in pertinent part: Today she reports minimal to moderate back pain at times. Pain level is 5. She stated it only hurts when she moves. -The pain level documented in the progress note was greater than the resident's stated acceptable pain level of 3. -Despite the resident stating it only hurt when she moved, there was no documentation to indicate the nurse practitioner addressed the need for more effective pain management in order to enable the resident to be more active. 1/22/22: A progress note from the facility psychologist documented in pertinent part: Subjective: I told her she looked good walking today. ' Yes, but it still hurts. My side really hurts now. I really want to go home so I hope in four or five days it is better and does not hurt so much. ' She went on to tell me her son can not visit as he has COVID-19. Review of Resident #221's January 2022 EMAR for pain medication administration from 1/5 through 1/24/22 (20 days) for pain levels 4 and above, revealed 11 days with failures for ineffective pain management. The findings were as follows: 1/5/22 at 7:32 p.m: As needed (PRN) Tylenol 1000 mg was administered for a pain level of 4. The medication was documented as ineffective with a follow-up pain level of 6, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/7/22 at 7:15 a.m: PRN [MEDICATION(S)] 50 mg was administered for a pain level of 7. The medication was documented as effective, however the follow-up pain level was documented as a 6, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/9/22 at 10:48 a.m: PRN Tylenol 1000 mg was administered for a pain level of 8. The medication was documented as unknown effectiveness (indicating the resident's pain was not assessed following the pain medication administration). -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/9/22 at 1:28 p.m: PRN [MEDICATION(S)] 50 mg was administered for a pain level of 8. The medication was documented as unknown effectiveness (indicating the resident's pain was not assessed following the pain medication administration). -There was no further pain medication administered to the resident until 10:28 p.m. 1/13/22 at 4:30 p.m: PRN [MEDICATION(S)] 50 mg was administered for a pain level of 7. The medication was documented as effective, however the follow-up pain level was documented as a 5, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/14/22: The resident's daily pain assessment was documented as a pain level of 4, which was greater than the resident's stated acceptable pain level of 3, for both the day shift and the night shift. -Despite the resident's pain levels being greater than her stated acceptable pain level of 3, there was no PRN pain medication administered on 1/14/22, and the resident had also refused her scheduled [MEDICATION(S)] patch. 1/16/22 at 5:30 a.m: PRN [MEDICATION(S)] 50 mg was administered for a pain level of 5. The medication was documented as unknown effectiveness (indicating the resident's pain was not assessed following the pain medication administration). -There was no further pain medication administered to the resident until 7:21 p.m. 1/16/22 at 7:21 p.m: PRN [MEDICATION(S)] 50 mg was administered for a pain level of 8. The medication was documented as effective, however the follow-up pain level was documented as a 4, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/18/22: The resident's daily pain assessment was documented as a pain level of 7, which was greater than the resident's stated acceptable pain level of 3, for both the day shift and the night shift. -Despite the resident's pain levels being greater than her stated acceptable pain level of 3, there was no PRN pain medication administered on 1/18/22. 1/21/22 at 2:50 p.m: PRN [MEDICATION(S)] 50 mg was administered for a pain level of 8. The medication was documented as effective, however the follow-up pain level was documented as a 5, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/22/21 at 11:52 a.m: PRN [MEDICATION(S)] 50 mg was administered for a pain level of 7. The medication was documented as effective, however the follow-up pain level was documented as a 4, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/23/22: The resident's daily pain assessment was not documented, however the Daily Skilled Nurse's Note documented Pain rating out of 10: 5-10. Moving increases pain. -Despite the nurse's note documenting the resident was experiencing pain levels of 5-10, there was no pain medication administered to the resident on 1/23/22. 1/24/22 at 5:23 p.m: PRN Tylenol 650 mg was administered for a pain level of 8. The medication was documented as effective, however the follow-up pain level was documented as a 5, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #221's eMAR for pain medication administration for 1/5 through 1/24/22 revealed the resident refused application of her [MEDICATION(S)] patches on 1/11, 1/12, 1/14, and 1/24/22. -The [MEDICATION(S)] patch was documented as no coverage needed on 1/13 and 1/15/22. -There was no documentation which indicated the physician had been notified the resident was refusing her [MEDICATION(S)] patches on occasion. V. Interviews The certified occupational therapy assistant (COTA) was interviewed on 1/25/22 at 8:59 a.m. The COTA said it required good timing with Resident #221 to encourage her to get up and participate with therapy. She said the resident did not like to get up much, but sometimes she was willing to get up. The COTA said the resident had pain when she moved, but she said a lot of the time patients had pain memory. She said patients thought it was going to hurt so they did not want to move, but once the patient got moving, he or she discovered it did not hurt as much as they thought it was going to hurt. The COTA said she thought Resident #221 received pain medication, but she did not know what medication she received or how often she received it. Certified nurse aide (CNA) #9 was interviewed on 1/25/22 at 9:03 a.m. CNA #9 said Resident #221 did not like to be out of bed much, however she would get up and sit in her recliner at times. She said the resident would usually put herself back into bed though. She said the resident had pain in her left side and she had more pain when she moved. CNA #9 said when the resident complained of pain, she told the nurse and the nurse would give her pain medication. She said the resident would still have pain when she moved. CNA #9 said Resident #221 would often eat lying down in bed because it helped her pain not to be sitting up. Licensed practical nurse (LPN) #2 was interviewed on 1/25/22 at 12:22 p.m. LPN #2 said she would ask a resident if they were having pain when she administered their scheduled medications. She said if the resident indicated they had pain, she would ask them what their pain level was and administer PRN pain medication to them. LPN #2 said she would follow up with the resident about an hour after the pain medication was administered to see if the pain medication had been effective. She said if they were still complaining of a higher pain level than was acceptable for them she would consider the pain medication ineffective. She said she would see if the resident had another pain medication that could be given. LPN #2 said if they did not have another pain medication she would inform the charge nurse who would call the physician for orders for more effective pain medication. She said Resident #221 often complained of having pain mostly with movement. She said she received PRN pain medications. LPN #2 said the resident also had a pain patch but she sometimes refused it. She said had refused the patch that morning (1/25/22) because she was going to take a shower. Registered nurse (RN) #4 was interviewed on 1/25/22 at 10:04 a.m. RN #4 said residents should be assessed for pain whenever a nurse was in the resident's room. She said if a CNA noticed a resident was having pain they should alert their nurse so pain medication could be administered. RN #4 said a lot of the facility's residents came in with pain from surgical procedures, broken bones, etcetera, so managing pain was very important. She said if a resident was given pain medication, the nurse should follow up with them in an hour to an hour and a half and see if the medication was effective. RN #4 said pain levels were very individually based for residents, but a resident usually had a pain level that they said was acceptable. She said if the follow-up pain level was above that acceptable pain level, the nurse should administer another pain medication if the resident had one. RN #4 said nurses were supposed to let her know if pain medication was not effective for a resident and she would call the physician to see what type of new orders could be obtained for pain management. The DON was interviewed on 1/25/22 at 12:29 p.m. The DON said pain was different for individual residents. She said nurses completed an initial comprehensive pain assessment on every resident upon their admission to the facility. She said the assessment included documenting the resident's acceptable pain level. She said the facility utilized non-pharmacological interventions such as rest, ice, and heat, as well as opioid and non-opioid medications for effective pain management. The DON said nurses should follow up with a resident after administering a pain medication and if the resident's pain level continued to be above their acceptable pain level, the nurse should administer another pain medication if the resident had orders for one. She said if the resident did not have another pain medication order, and the resident needed better pain management, the charge nurse should call the physician for further orders. She said if a pain regimen was deemed ineffective, then a different pain regimen should be obtained in order to manage the resident's pain. The DON said she had been in Resident #221's room on several occasions and the resident did not complain very often. She acknowledged that just because a resident did not complain, that did not necessarily mean the resident did not have pain. The DON acknowledged the nurses had a responsibility to ensure they were properly assessing and managing residents ' pain, however she said the responsibility also belonged to the physician because they looked at the resident's medical record as well. VI. Facility follow up On 1/26/22, after the survey, the nursing home administrator (NHA) provided, via email, a physician's progress note dated and a handwritten note from RN #4. The physician's progress note was dated 1/25/22 at 1:50 p.m. (one hour and 21 minutes following the interview with the DON). The progress note documented the physician's visit with Resident #221. It documented in pertinent part, Pain rating 2 out of 10, 10 when moving around. Pain level is acceptable at 4 out of 10. Usual pain level has been 4 out of 10. Pain is getting better. On pain medications, will avoid extra narcotics, use Tylenol PRN. -The physician did not address Resident #221's acceptable pain level (which had been a 3 since admission on 1/4/22) until the pain management concern was brought to the facility's attention. In addition, the physician did not address when the resident's pain level was 5-10 and when PRN [MEDICATION(S)] was not administered according to the orders or when the scheduled [MEDICATION(S)] patch was refused by the resident, which was part of her pain management regimen. Furthermore, the physician did not schedule any additional pain medication, such as Tylenol after this visit on 1/25/22. The handwritten note from RN #4 was dated 1/26/22 and documented in pertinent part, I went to see the Resident #221 to ask her about her acceptable level of pain and her answer was 4. She said bad pain for her was 8 out of 10. The note was signed by RN #4. -The facility did not address Resident #221's acceptable pain level (which had been a 3 since admission on 1/4/22) until the pain management concern was brought to the facility's attention.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19. Specifically, the facility failed to: -Ensure staff and visitors wore the appropriate personal protective equipment (PPE) and performed appropriate hand hygiene when entering transmission-based precaution (TBP) rooms on one of four halls; -Ensure staff wore masks appropriately while in resident care areas on three of four halls; and, -Ensure residents were offered hand hygiene before meals on two of four halls. Findings include: I. Facility policy and procedures A. The Infection Prevention, Control, and Immunizations policy, last revised 2/8/21, was provided by the director of nursing (DON) via email on 1/13/22 at 4:57 p.m. It read in pertinent part, Staff will use standard precautions (hand hygiene and appropriate PPE equipment). Staff will follow appropriate hand hygiene practice. PPE equipment to be worn for contact with blood, body fluids, [MEDICATION(S)] membranes, or non-intact skin. Appropriate PPE to be worn for infections/ illnesses. Staff will implement appropriate TBP. The facility will follow the Centers for Disease Control (CDC) Guidelines and recommendations. B. The PPE During the COVID-19 Pandemic policy, last revised 5/1/21, was provided by the nursing home administrator (NHA) via email on 1/24/22 at 3:08 p.m. It read in pertinent part, Gloves: Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns:· Don gown upon entry into the patient room. Doff gown prior to exit and dispose of gown inside of patient room. Masks: Masks may be worn continuously until visibly soiled or damaged throughout shift. N95/KN95 respirator masks: Staff that has the potential to come into contact with patients on quarantine or transmission-based precautions will wear an N95 or KN95 mask. Eye Protection: Eye protection should be cleaned when a staff member can not visibly see through. Cleaning must be done outside of patient care areas. Eye protection will be worn in quarantine rooms. If a county's two week positivity rate is greater than 10%, eye protection will be worn universally. II. Failure to ensure staff and visitors wore the appropriate PPE and performed appropriate hand hygiene when entering TBP rooms A. Professional reference The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 9/10/21), retrieved on 1/31/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part, HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. B. Observations 1/12/22 -At 3:17 p.m., a visitor was observed in room [ROOM NUMBER], which was a quarantine room. There was a sign on the door that stated a gown, gloves, N95 or respirator and face shield/goggles must be worn prior to entering the room. The visitor was not wearing any PPE except for a surgical mask. A nurse walked by the room, looked in, but did not ask the visitor to put on the proper PPE. -At 3:30 p.m., a female family member was seen in quarantine room [ROOM NUMBER]. She was seated on the resident's bed. She was not wearing any PPE at all, even though signage posted on the quarantine room door read: Quarantine with PPE: Must wear full PPE to enter room: gown, N95 mask or respirator, gloves, goggles or face shield. An unknown nurse was preparing to enter the resident room as well. The unknown nurse approached the isolation cart outside the room. She was wearing an N95 mask and did not perform hand hygiene. The nurse applied a gown, entered the room, applied a pair of gloves and closed the door. She was not wearing eye protection. She did not encourage the female family member to apply the appropriate PPE when entering the room. When the family member saw the nurse, she said, Oh I tried wearing all that stuff but I got too hot. 1/13/22 -At 8:20 a.m. an unknown certified nurse aide (CNA) was observed preparing to enter quarantine room [ROOM NUMBER] to deliver a breakfast tray. She was wearing an N95 mask. There was no alcohol based hand rub (ABHR) or gloves on or in the isolation cart as the sanitizer dispenser was located inside the room on the wall near the door. The gloves were located in a box in a dispenser mounted on the wall just inside the door to the room. The CNA did not perform hand hygiene. She donned a gown and stepped inside the room to don gloves. She then donned a face shield. When the CNA exited the room a few minutes later, she removed the face shield, tucked it under her arm and continued down the hall to another resident room. C. Interview The IP, SDC, and DON were interviewed together on 1/25/22 at 11:00 a.m. The IP said staff should be following the PPE guidelines which were posted on the doors of the isolation/quarantine rooms. She said all staff should wear an N95 mask, gown, gloves, and eye protection when entering the TBP rooms. She said staff should remind visitors about the recommended PPE guidelines and encourage visitors in the TBP rooms to wear the full PPE. The IP said she had spoken to the family member for room [ROOM NUMBER] several times regarding wearing the appropriate PPE for her safety and the safety of others. She said the family member chose not to wear any other PPE except for her surgical mask. III. Failure to ensure staff wore masks appropriately while in resident care areas A. Professional reference The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 9/10/21), retrieved on 1/31/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part, Source control refers to the use of respirators or well-fitting face masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for healthcare personnel (HCP) include: A NIOSH-approved N95 or equivalent or higher-level respirator, respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated), or a well-fitting facemask. Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. HCP should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors). B. Observations 1/12/22 -At 2:43 p.m. licensed practical nurse (LPN) #1 was seen standing behind the nurse's station on the second floor. Her N95 mask was under her chin. When she realized she was being observed, she raised it over her mouth and nose. -At 3:15 p.m., two unknown CNAs were standing next to each other in the middle of the hallway on 300 East. One CNA had her mask pulled down below her chin and was eating a piece of candy while the two CNAs were talking to each other. -At 3:25 p.m., LPN #1 was again observed seated behind the nurse's station with her N95 mask under her chin. LPN #1 was eating something while she was seated at the nurse's station. 1/13/22 -At 8:00 a.m., LPN #1 was seen repeatedly lowering her N95 mask below her nose and mouth. Her N95 mask only had one strap attached to it, and the strap was located around the middle of her head. -At 10:54 a.m., an unknown female dietary worker walked through the main dining room to the kitchen with a blue surgical mask on instead of an N95 mask. -At 11:05 a.m., another female dietary worker walked through the dining room to the kitchen. She was carrying an N95 mask in her hands, however she was not wearing a mask as she walked through the dining room. -At 2:20 p.m., LPN #1 was seated behind the nurse's station on the second floor working on a computer. Her N95 mask only had one strap that was positioned low on her head. A male visitor approached the desk and she lowered the mask below her mouth to speak to him. When she realized she was being observed she raised the mask. The mask was not tight fitting and moved as she talked. -At 2:21 p.m., the physician (PHYS) was sitting behind the nurse's station on the third floor typing on a computer. He was wearing a yellow surgical mask instead of an N95 mask. His mask was pulled down below his chin. There was a nurse seated within six feet of the PHYS. -At 2:49 p.m., LPN #1 was observed at the nurses station standing directly next to a CNA discussing a facility activity. LPN #1's mask was not well fitted to her face and was positioned below her nose. -At 3:11 p.m., LPN #1 was observed within arms' reach of a resident. LPN #1 pulled down her mask to speak to the resident who had come out of his room to ask a question. The resident was not wearing any face covering. LPN #1 pulled her mask up after answering the resident question, however she did not perform any hand hygiene after touching the mask on her face. 1/24/22 -At 3:20 p.m., the PHYS was seen seated behind the nurse's station on the second floor, near two other staff members. He was working on a computer. He was wearing a surgical mask instead of an N95 mask. The mask was pulled down below his chin and his hand was over his mouth. The PHYS touched his face/mouth multiple times then typed on the computer. An unmasked resident was observed in the lobby sitting area just in front of the nurse's station desk. -At 5:27 p.m., the DON was observed with both elastic straps of her N95 mask around the lower part of her neck. The top elastic strap was not around the crown of her head. 1/25/22 -At 9:15 a.m., an unknown CNA was observed on the second floor in the hallway. She had the top elastic strap of her N95 mask below her ears around her neck. The lower elastic strap of the mask was not around her head. Instead, the lower strap was dangling from the mask, under her chin. There was a gap between her face and the mask. An unknown housekeeping staff member was seen entering a resident room with the top elastic strap of her N95 mask above her head and the bottom strap under her chin. A kitchen staff member was observed delivering a breakfast tray to a resident room wearing a surgical mask instead of an N95 mask. -At 9:20 a.m., an unknown nurse was seen seated at the nurse's station on the second floor working on a computer. Both elastic straps of her N95 mask were around her neck below her ears. An unknown CNA was seen in the hallway on the second floor wearing a face shield situated high on her forehead and both straps of her N95 were around her neck below her ears. C. Interview The DON, NHA, and the infection preventionist (IP) were interviewed together on 1/24/22 at 5:17 p.m. The IP said all staff and providers should wear N95 masks while in the facility. She said staff should wear eye protection in the isolation/quarantine rooms. The IP said unvaccinated staff were required to wear eye protection at all times while working in the facility. She said masks should be worn appropriately and staff should ensure their mouth and nose were covered by the mask. The NHA said the facility's providers were encouraged to wear N95 masks while they were in the facility, however he said some providers chose to wear surgical masks despite the recommendation. He said he had spoken to the PHYS and he had chosen not to wear an N95 mask. The NHA said masks should cover the mouth and nose of the person wearing the mask and should not be pulled down below a person's chin. He said he would have a discussion with the PHYS regarding his improper mask use. IV. Failure to ensure residents were offered hand hygiene before meals A. Professional reference The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes (updated 9/10/21), retrieved on 1/31/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, Educate residents and families through educational sessions and written materials on topics, including information about [CONDITION(S)]-CoV-2, actions the facility is taking to protect them and their loved ones from [CONDITION(S)]-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene. B. Observations 1/13/22 -At 12:48 p.m., a CNA delivered Resident #63's lunch meal tray to his room. The resident had been sitting at his bedside table handling personal items on the table. The CNA did not offer to clean the table before setting the resident meal tray on the surface. The CNA did not offer or encourage the resident to perform any method of hand hygiene. 1/24/22 -At 5:32 p.m., CNA #10 was observed delivering dinner meal trays on the 200 East hall. CNA #10 delivered a meal tray to room [ROOM NUMBER]. The tray did not have a hand sanitizer wipe on the tray, and CNA #10 did not offer the resident an opportunity to perform hand hygiene prior to eating. -At 5:36 p.m., CNA #10 delivered a meal tray to room [ROOM NUMBER]. The tray did not have a hand sanitizer wipe on the tray, and CNA #10 did not offer the resident an opportunity to perform hand hygiene prior to eating. -At 5:42 p.m., CNA #10 delivered a meal tray to room [ROOM NUMBER]. The tray did not have a hand sanitizer wipe on the tray, and CNA #10 did not offer the resident an opportunity to perform hand hygiene prior to eating. C. Interviews The executive chef (EC) was interviewed on 1/25/22 at 9:20 am. The EC said the kitchen staff did not include hand sanitizer wipes for the residents on their meal trays. She said the facility had never used sanitizer wipes since she started in October 2021. She said she would look into ordering hand sanitizer wipes. The IP, SDC, and DON were interviewed together on 1/25/22 at 11:00 a.m. The SDC said residents should be provided hand hygiene prior to every meal. She said staff had been provided education regarding hand hygiene for residents on several occasions. She said the facility had not provided education on hand hygiene for residents since July 2021. The IP said all residents should have sanitizing wipes in their rooms. and staff should be offering those or hand sanitizer prior to meals. D. Additional information The DON provided a copy of two staff education packets regarding resident hand hygiene on 1/25/22 at 1:30 p.m. The first staff education was conducted on 11/16/2020. The education packet included a sign in sheet for staff who received the education and a memo which had a picture of hand sanitizing wipes and the following education: All patients should be offered hand hygiene prior to every meal. Meal trays will now include a sanitizing hand wipe for patient use. Staff who bring meal trays to patients are expected to open the hand wipe package and offer it to the patient while delivering the patient meal tray. The second staff education was conducted on 11/30/2020. The education packet included the facility's hand hygiene policy, handouts for proper hand washing technique and using ABHR, social distancing information, and a sign in sheet for staff who received the education. The copy of the policy included hand written reminders to offer hand hygiene to residents prior to meal service. The staff development coordinator (SDC) provided a copy of a staff re-education regarding resident hand hygiene which was conducted on 7/13/21. The education memo read: All patients should be offered hand hygiene prior to every meal. Meal trays will now include a sanitizing hand wipe for patient use. Staff who bring meal trays to patients are expected to open the hand wipe package and offer it to the patient while delivering the patient meal tray. Hand hygiene should be offered a second time (with ABHR) once the meal is completed as well. V. Facility COVID-19 status The DON and the NHA were interviewed together on 1/12/22 at 9:15 a.m. The DON said the resident census was 79. She said the facility was currently in an outbreak status which started on 1/4/22. She said the facility had 4 positive residents and 19 positive staff members. She said the facility was conducting polymerase chain reaction (PCR) testing of all staff and residents two times per week per the county public health department recommendations. She said all unvaccinated staff and residents were receiving daily rapid tests in addition to the twice per week PCR tests. The DON said the facility had conducted two rounds of all staff and resident testing on 1/6/22 and 1/10/22. She said the facility was still waiting for the results from both rounds of testing due to a backlog of COVID-19 tests at the lab where the facility's tests were sent.

Based on observation and interviews, the facility failed to follow infection control measures to prevent the potential cross contamination of [CONDITION(S)]-CoV-2 COVID-19, during testing procedures while the facility was in outbreak. Specifically, the facility failed to: -Disinfect surfaces within six feet of the collection/handling area thoroughly after each specimen test; and, -Disinfect the testing/specimen collecting area on an hourly basis. Findings include: I. Professional reference The Centers for Disease Control (CDC) Guidance for [CONDITION(S)]-CoV-2 Point-of-Care and Rapid Testing, (updated 1/19/22), retrieved on 1/31/22 from https://www.cdc.gov/coronavirus/2019-ncov/lab/point-of-care-testing.html#anchor_ 947, read in pertinent part: Disinfect surfaces within 6 feet of the specimen collection and handling area before, during, and after testing and at these times: -Before testing begins each day -Between each specimen collection -At least hourly during testing -When visibly soiled -In the event of a specimen spill or splash -At the end of every testing day. II. Observations The facility conducted COVID-19 rapid and PCR testing of staff in a closed room located off the main dining room. Staff conducted their own specimen collection. There was a bedside table near the entrance to the room with a basket of PCR testing kits sitting on it.There was a sign posted on the door which said: COVID-19 Self-testing Guidelines: 1. Grab a pre-made test kit outside of room 2. Please keep the door closed at all times. 3. Only one person testing at a time. 4. Please maintain social distancing. 5. Perform hand hygiene with hand sanitizer before and after testing. 6. Wipe testing area with a sanitizing wipe when you are done. Registered nurse (RN) #2 was sitting in the room at a desk with a computer. She was wearing an N95 mask. The COVID-19 testing station was located across the room from RN #2 at a distance of greater than six feet. A continuous observation of the facility's COVID-19 testing room was conducted on 1/13/22 from 10:21 a.m. through 11:56 a.m. Observations during that time were as follows: At 10:25 a.m., restorative aide (RA) #1 entered the testing room. She went to the testing table and obtained a rapid test kit. The table had a chair sitting at it, however RA #1 did not sit down. She completed the test while standing behind the chair and reaching over it to sanitize her hands and swab her nostrils. She sanitized her hands with alcohol based hand rub (ABHR), removed her N95 mask and placed it on the table (with the inside of the mask facing up), and swabbed her nostrils. After swabbing, she placed the swab in the specimen transport tube. She labeled the tube with her own pen and placed the specimen tube in the biohazard bag. She sanitized her hands, then put her mask back on. (She did not change to a different mask). She did not sanitize the table area. As she opened the door to leave the room with her rapid test, RN #2 got up from the desk and walked over to the testing table. RN #2 told RA #1 she would wipe the table down. RA #1 said Oh, you're going to wipe it? I've never had to do that before. RN #2 proceeded to wipe the table with a disinfectant wipe. RN #2 did not wipe down the chair that was in front of the testing table. At 10:44 a.m., the housekeeping supervisor (HSKS) entered the testing room. There was no one else in the room besides RN #2 who was greater than six feet from the testing area. He took a pre-made PCR testing kit off of the table outside the door of the room. He went over to the testing table in the room and sanitized his hands with ABHR. He did not sit in the chair at the table. He stood over the chair as he proceeded to perform his testing. After sanitizing his hands, the HSKS removed his N95 mask and set it on the table with the inside of the mask facing up. He took a pair of white handled scissors out of a container and used them to cut open the swab package. He placed the scissors back in the container without wiping them with a disinfectant wipe. The HSKS took the swab and swabbed both of his nostrils and placed the swab in the specimen transport tube. He wrote his information on the label on the transport tube with his own pen and placed the tube in the biohazard bag. He proceeded to place the biohazard bag containing his swab in a styrofoam container that was sitting on the testing table with a lid on it. The cooler had a black plastic bag in it that he had to open with his bare hands to put his specimen into. After placing his specimen in the cooler, the HSKS put his same N95 mask back on without sanitizing hands. After replacing his mask on his face, he sanitized his hands with ABHR. The HSKS walked toward the door to exit the room without wiping down the table. RN #2 got up and wiped the table down with a disinfectant wipe. She did not wipe off the scissors the HSKS had used or the chair that he had been standing over while he performed his swab. At 11:15 a.m., certified nurse aide (CNA) #8 entered the testing room. There was no one else in the room besides RN #2 who was greater than six feet from the testing area. CNA #8 walked over to the testing table and sat down in the chair in front of the table. She labeled her specimen transport tube with her own pen. CNA #8 sanitized her hands then proceeded to pull her N95 mask down below her chin and swab both nostrils with the swab from the pre-made PCR testing kit. She placed the swab in the transport tube and placed the tube in the biohazard bag. CNA #8 pulled her N95 mask back over her nose and chin before sanitizing her hands. After sanitizing her hands, she put on a pair of gloves and wiped the table down with a disinfectant wipe. She wiped down the seat of the chair and one arm of the chair with the disinfectant wipe before discarding the wipe and her gloves in the trash. CNA #8 placed her specimen swab in the styrofoam container and re-sanitized her hands with ABHR before exiting the testing room. At 11:24 a.m., a female dietary worker walked from the kitchen and entered the testing room to get something out of the room. There was no one else in the room besides RN #2 who was greater than six feet from the testing area. As the dietary worker entered the room, she had a black surgical mask on which was pulled down below her chin. She pulled the mask up over her mouth and nose after the door closed behind her once she was in the room. She retrieved what she needed from the testing room, then exited the room and returned to the kitchen. At 11:31 a.m., RN #1 entered the testing room. There was no one else in the room besides RN #2 who remained greater than six feet from the testing area. RN #1 did not sit down in the chair, but stood at the table next to the chair. She labeled her specimen transport tube. RN #2 proceeded to sanitize her hands with ABHR, remove her N95 mask, and discard it in the trash can. She swabbed her nostrils while standing over the chair at the testing table. She placed the swab in the transport tube and then into the biohazard bag. She sanitized her hands, then put on gloves and wiped down the table with a disinfectant wipe. RN #2 did not wipe down the chair with the disinfectant wipe. After disinfecting the table, she placed her swab in the styrofoam cooler. She re-sanitized her hands and put on a new N95 mask before leaving the room. At 11:49 a.m., the executive chef (EC) entered the testing room. There was no one else in the room besides RN #2 who remained greater than six feet from the testing area. The EC stood next to the chair while she performed the swabbing portion of the test. She did not sanitize her hands before pulling her N95 mask below her chin. After pulling her mask down, she sanitized her hands. She proceeded to swab her nostrils and placed the swab in the specimen tube. The EC then sanitized her hands and wiped the table down with a disinfectant wipe. She did not wipe down the chair with the disinfectant wipe. She placed her swab specimen in the bag inside the cooler. She did not re-sanitize her hands after placing the specimen in the cooler. The EC pulled her N95 up from below her chin so the mask covered her mouth and nose before she left the room. -During the one hour and 35 minute continuous observation of the COVID-19 testing room, the following failures occurred: -Staff did not thoroughly disinfect all surfaces within 6 feet of the specimen collection and handling area; and, -Housekeeping did not conduct an hourly disinfection of the testing area. III. Interviews RN #2 was interviewed on 1/13/22 at 11:20 a.m. RN #2 said staff should wipe down the table with a disinfectant wipe after they performed their swabs. She said the sign on the door and the sign posted above the table both stated that they should wipe the table down. She said she always made sure to disinfect the table if someone did not do it. She said the entire room got disinfected by housekeeping at least once a day. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 1/13/22 at 12:54 p.m. The IP said the testing room was used for rapid and PCR testing. She said unvaccinated staff performed a daily rapid test. She said the facility was in outbreak status, so all staff were performing PCR tests two times per week. The IP said the rapid tests were located on the testing table in the room, and the PCR tests were on the table outside of the room for staff to take into the room with them and perform their test. She said only one person testing was allowed in the room at a time. She said staff performed their own swab tests at the testing table. She said staff should sanitize their hands before and after performing the swab. The IP said staff should disinfect the table and the chair after they performed the swab test. She said the housekeeping staff disinfected the room at least one time per day, however she did not know what the cleaning schedule was. The IP said she did not think the testing area was disinfected on an hourly basis. The IP, DON, and staff development coordinator (SDC) were interviewed together on 1/25/22 at 11:00 a.m. The DON said the chair at the testing table had been removed from the COVID-19 testing room. She said the facility had implemented disinfecting the room on a more frequent basis. IV. Facility follow-up On 1/27/22 at 2:12 p.m., after the survey, the nursing home administrator (NHA) provided copies via email of the facility's cleaning testing room schedule for the dates of 1/17/22 through 1/25/22. The copies of the cleaning schedules that were provided by the NHA documented the COVID-19 testing room had been cleaned on an hourly basis between 6:00 a.m. and 6:00 p.m. on 1/17, 1/18, 1/19, 1/20, 1/21, 1/22, 1/23, 1/24, and 1/25/22. There was no documentation on the cleaning schedules for the hours between 6:00 p.m. and 6:00 a.m. for any of those dates. V. Facility COVID-19 status The facility was in outbreak status starting on 1/4/22. As of 1/12/22, 19 staff members and 4 residents had tested positive for COVID-19 via rapid testing procedures. The facility began conducting polymerase chain reaction (PCR) testing of all staff and residents two times per week per the county public health department recommendations on 1/6/22. All unvaccinated staff and residents continued to receive daily rapid tests in addition to the twice weekly PCR tests. As of 1/12/22, the facility had conducted two rounds of all staff and resident testing on 1/6/22 and 1/10/22. However, due to a backlog of COVID-19 tests at the lab where the facility specimens were sent, the facility was still waiting on results from both rounds of PCR testing.

Based on interviews and record review the facility failed to ensure the resident's right to be informed of, and participate in his or her treatment for one (#24) of four residents out of 40 sample residents reviewed for the right to be informed and make treatment decisions. Specifically, the facility failed to include Resident #24's wife in his care planning decisions. Findings include: I. Facility policy The Care Plan policy, dated 8/23/18, revised 2/8/21, provided by the director of nursing (DON) on 1/24/22 at 2:00 p.m. read in pertinent part: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident. -The care plan will be patient centered emphasizing the resident's and/or family's goals. -The facility will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. To the extent that is practical, the resident and/or family will be involved in the development of their care plan. II. Resident status Resident #24, age 73, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/17/21 minimum data set (MDS) assessment revealed Resident #24 had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He did not have mood or behavior symptoms. He required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use. He required extensive assistance of one staff member for personal hygiene. He was not steady and only able to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet and with surface to surface transfers. He had impairment on one side of upper and lower extremities. He used a wheelchair for mobility. III. Spouse interview Resident #24's wife was interviewed on 1/12/22 at 11:08 a.m. She said she had not had a care conference, a phone call or a meeting with anyone from the facility since his admission on 12/11/21. She said, I have no idea what the plan is for his care or a discharge plan. The resident's wife was again interviewed on 1/25/21 at 12:30 p.m. She said she finally approached the social services director (SSD) on 1/13/22, because after a month, I still did not know what was going on. She said Resident #24 was confused and out of it when he was admitted and apparently told the SSD that we were getting a divorce. For some reason she believed him. If she had a question about that she should have called my son or daughter to get the correct information because they were listed as contacts as well. IV. Record review The care plan, initiated 12/12/21, revised 1/4/22 indicated Resident #24 had a cognitive deficit related to cerebral infarction (stroke) with a BIMS score of six, indicating severe cognitive impairment Resident #24 wanted to establish goals for himself and to be involved in his discharge planning process and when he discharged he wanted to go home with his spouse. Interventions included to communicate with patient and/or family as needed related to progress, goals, and plans. Review of the social history documented by the SSD on 12/16/21 at 2:12 p.m., indicated Resident #24 was admitted from the hospital on 12/11/21. He declined ancillary services and a mental health consult at that time. His mood was stable. He appeared to be able to make simple things known and appeared to have no behavior issues. Plan: Short-term placement-wishes to return home with spouse with home health therapy. After the initial social history there was no discharge planning or progress notes until 1/13/22, which was 33 days after admission, when the resident's wife approached the SSD. The social services progress note, documented by the SSD on 1/13/22 at 11:44 a.m., read in part: Patient continues to participate and make progress with therapy. Discharge plan is to return home with spouse. No discharge date set. The social services progress note documented by the SSD on 1/13/22 at 3:59 p.m., read in part: Discharge planning: Social services met with spouse and discussed: only bathroom in the home is on main level, with 2-3 steps to that level. Spouse stated patient was confused when he said that he was divorced during initial assessment. Spouse requests home health referral upon discharge. Patient owns front-wheeled walker, will need platform attachment and wheelchair upon discharge. V. Staff interview The SSD was interviewed on 1/25/22 at 11:23 a.m. She said when Resident #24 was admitted he told her that his wife had left him and he and the wife were getting a divorce. She said she honored the resident's wishes and did not contact the wife for a care conference because of what the resident said about their relationship. Although, she did not say the resident told her not to call his wife. His wife was listed on his profile as the #1 contact as well as a son and daughter. She said his wife approached her on 1/13/22 and asked about how he was doing and asked about discharge planning. His wife said she and the resident were not getting a divorce. She said social services normally did an initial baseline care plan within 24 hours of admission and within 48-72 hours they conducted a care conference with family as well. This did not happen with Resident #24's wife until 1/13/22. She had no explanation as to why the wife was not contacted for over a month regarding his care conference. She said there was no policy for conducting care conferences. She said there was a form the social services department used called Summary of Interdisciplinary Care Conference that listed the different departments involved in the care conference and what areas were covered and the form was to be signed by the resident and family member. She said she had not completed this form for Resident #24.

Based on observations, record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for two (#24, #49) of two residents reviewed for shower preferences out of 40 sample residents. Specifically, the facility failed to honor Resident #24's shower preference of twice weekly and the offer of a bath daily, and Resident #49's shower preference of every other day. Cross-reference F686, pressure ulcer for Resident #24. Findings include: I. Facility policy A bathing/shower policy was requested on 1/24/22 at 1:00 p.m. from the director of nursing (DON) but was not provided. II. Resident #24 A. Resident status Resident #24, age 73, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/17/21 minimum data set (MDS) assessment revealed Resident #24 had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. (However, according to the nursing note 1/1/22 he was alert and oriented to person, place and time.) He did not have mood or behavior symptoms and was not resistant to care. He required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use. He required extensive assistance of one staff member for personal hygiene. Bathing had not occurred. He was not steady and only able to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet and with surface to surface transfers. He had impairment on one side of upper and lower extremities. He used a wheelchair for mobility. B. Resident/wife interview Resident #24's wife was interviewed on 1/12/22 at 11:07 a.m. She said her husband had only received one bath since he was admitted on [DATE]. She said she had to bring it to their attention after a month went by with no one bathing him. She said she was not informed of any schedule for bathing. Resident #24 was interviewed on 1/24/22 at 1:54 p.m. He said he had not had a shower for close to two months. He said he did not receive a bath of any kind until his wife brought it to their attention. He thought he was supposed to receive a shower twice a week but had not gotten them. He said, I haven't had so much as a spit bath let alone a real shower. He said he felt so dirty and a shower would definitely make him feel better. C. Record review Review of the care plan, initiated 12/11/21 and 12/12/21, revealed Resident #24 required assistance with activities of daily living (ADLs) related to self care deficits and decreased functional mobility secondary to cerebral infarction and metabolic [CONDITION(S)]. He had actual/potential decline in his ability to perform ADLs. He had a potential for skin breakdown related to impaired mobility secondary to weakness and debility, decreased functional mobility, cerebral infarction and cognition deficits. Interventions included: Provide assistance as needed with grooming, bathing, and personal hygiene and per patient's preferences. See choices and preference in care on task list, preference sheet and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the shower schedule, provided by the DON on 1/24/22 at 4:00 p.m., Resident #24 was to receive a shower twice weekly on Mondays and Thursdays. The certified nurse aide (CNA) shower documentation revealed Resident #24 received his first shower on 1/11/22 (31 days after admission on 12/11/21). He received another shower on 1/14, a sponge bath on 1/16, 1/18 and a shower on 1/22/22. Documentation indicated he refused a shower on 1/19 and 1/25/22 although there was no nursing documentation indicating he refused the showers or what alternatives were offered. Out of 12 scheduled showers/baths he received five. III. Resident #49 A. Resident status Resident #49, age 74, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/28/21 minimum data set (MDS) assessment indicated Resident #49 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She did not have mood or behavior symptoms. She required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use and required extensive assistance of one staff member for personal hygiene. She was dependent on one staff member for bathing. She was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, when moving on and off the toilet and with surface to surface transfers. She used a wheelchair for mobility. It was very important to her to be able to choose between a tub bath, shower, bed bath or sponge bath. B. Observation and resident interview On 1/12/22 at 12:00 p.m. Resident #49 was seen in her room seated in a wheelchair. She was wearing a hospital gown and her hair appeared oily and unkempt. She said she had not been given a shower since she was admitted . She was not sure when she was supposed to get them and was not aware of a shower schedule. She said she had tried to do what I can at the sink by myself but it sure isn't like a good shower. She said she would feel so much better if she could get showers routinely. C. Record review The care plan, initiated 1/5/22, indicated Resident #49 had actual/potential decline in ability to perform activities of daily living (ADLs). She required assistance with ADLs related to self care deficits and decreased functional mobility secondary to hypoxemia (low oxygen), dyspnea (difficult breathing) and pneumonia. Interventions included: Encourage to do as much as possible for self as able. Provide assistance as needed with grooming, bathing, and personal hygiene and per patient's preferences. She was okay with receiving a shower, bed bath, and/or sponge bath, and wanted to take shower, bed bath, and/or sponge per facility schedule-she prefered a shower and bathing frequency every other day. According to the shower schedule, provided by the DON on 1/24/22 at 4:00 p.m., Resident #49 was to receive a shower twice weekly on Mondays and Thursdays. The CNA shower documentation indicated Resident #49's preference for showers was every other day. According to the documentation, since her admission on 12/22/21, she had refused a shower on 1/13/22 but received it on 1/14/22. No showers were documented after 1/14/22. Out of twice weekly scheduled showers she should have received nine and per her preference of every other day she should have received 17 showers and had only received one shower since admission. There was no nursing documentation, other than on 1/13/22, that indicated she refused any showers or what alternatives were offered. IV. Staff interviews CNA #1 was interviewed on 1/24/22 at 3:29 p.m. She said when a resident was admitted to the facility, they had a CNA admission packet that had a shower preference form in it and they had a shower schedule for each room which indicated showers twice a week. If a resident wanted a shower more or less often they indicated their preference on the sheet. If a resident refused a shower they would sign a refusal form and the form was placed in the assistant director of nursing (ADON's) box and she addressed the refusal from there. They were also to offer a different day or time if a resident refused. CNA #2 was interviewed on 1/24/22 at 3:34 p.m. She said upon admission a resident was asked when they preferred a shower and if it was apart from the normal two day a week, per the shower schedule per room, they indicated their preference on the admission packet form. If a resident refused a shower they were to sign a form and were encouraged to accept the shower and they were offered a different day or time. She said the DON received the shower refusal paper so she could address it. The DON was interviewed on 1/25/22 at 12:25 p.m. She said showers should be given per the resident's preference. She acknowledged there was an issue with showers being completed as scheduled or per resident preference. She said they had a plan in place for showers and they had adjusted their staff and were providing a shower aide every day to address the issue. She said if a resident refused a shower they were to sign a refusal form. She provided a copy of the plan to address the shower issue dated 1/13/22. It read: Documentation not always done in point of care (POC), shower refusals forms not always filled out, showers documented do not always match what is on the care plan, sometimes with no explanation of why. Showers that are done by CNAs, occupational therapy (OT) or otherwise are charted on the day of. If patient refuses, a refusal form is signed by patient and uploaded to medical records (MR). Not applicable (NA) is not used in bathing charting. Will institute dedicated shower aide for each floor. The facility will assign dedicated CNAs to do showers.

Based on observations, record review and interviews the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (#131) of two residents reviewed for professional standards out of 40 sample residents. Specifically, the facility failed to have a physician's order in place for intravenous (IV) fluid that infused continuously for four days for Resident #131. Findings include: I. Facility policy The Medication Administration policy, dated 7/1/17 and revised 2/8/21, provided by the director of nursing on 1/24/22 at 2:00 p.m. read in pertinent part: It is the policy of this facility that medications are to be administered as prescribed by the attending physician. -Medications must be administered in accordance with the written orders of the attending physician. -All current drugs and dosage schedules must be recorded on the patient's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -The staff administering the medication must record the administration on the patient's MAR/TAR. II. Resident status Resident #131, age 91, was admitted [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/9/21 minimum data set (MDS) assessment indicated Resident #131 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required extensive assistance of two staff members for bed mobility, transfers and toilet use. He received three out of seven days of a diuretic. He did not receive IV fluids/medications. IV. Observations On 1/12/22 at 11:47 a.m. Resident #131 was observed lying in bed asleep. He had IV fluids infusing with the flow rate set to 60 milliliters (ml) an hour. On 1/13/22 at 2:20 p.m. Resident #131 was observed again lying in bed with the IV infusing at 60 ml an hour. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] V. Record review Review of the January 2022 physician orders revealed the following: -An order dated 1/5/22 at 6:24 p.m. read, Dextrose Solution 5 percent (%) use 60 milliliters (ml)/hour (hr) intravenously every shift for high blood urea nitrogen (BUN) (abnormal kidney function lab result) for two days. This fluid infused on the sixth and seventh and should have been stopped after the two day infusion. There was no further order entered indicating the IV fluid was to continue. The following physician orders were entered after the facility was made aware of the above issue: -On 1/13/22 at 2:39 p.m. Daily weights, notify physician if weight gain of three pounds per day or five pounds in five days and weight loss of greater than five pounds in five days. -On 1/13/22 at 3:58 p.m. Discontinue (D/C) IV fluids dextrose solution (D5W) at 60ml/hr til further notice per physician to restart. Review of the nursing notes revealed the following entries: On 1/13/22 at 2:20 p.m. registered nurse (RN) #1 documented, Patient has been educated about his IV flow rate. Patient has been observed changing his rate on his IV. Writer corrected patient IV flow rate and re-educated patient on his IV flow rate. Licensed practical nurse (LPN) #1's documentation on 1/13/22 at 4:04 p.m. read, Physician notified to request basic metabolic profile (BMP) for IV fluid follow-up along with urinalysis (UA) with culture and sensitivity (C&S) for complaints of (?) painful/difficult urination (dysuria). Also reported weight gain information from registered dietitian (RD). Received order to stop IV fluids at this time pending further orders. Continue to encourage fluids. Staff reports patient will turn dial-a-flow thinking that he's helping to get fluids in. Patient teaching provided-voices understanding. Will request IV pump for future administration. Son updated. On 1/13/22 at 4:29 p.m. LPN #1 documented: Noted patient was continuing IV fluids D5W at 60ml/hr per verbal order from physician. Order update had not been done in computer system. Physician and son notified. New order to stop fluids pending lab results then notify physician to continue or D/C. Patient also observed per staff adjusting dial a flow-see progress note. VI. Staff interviews RN #1 and LPN #1 were interviewed on 1/13/22 at 2:20p.m. RN #1 said Resident #131 had IV fluids running at 60 ml/hour. She acknowledged there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 provided a copy of a BMP lab result dated 1/9/22. At the bottom of the form next to an asterisk it read patient had significant weight gain and severe pitting [CONDITION(S)] to legs-lungs are clear and next to another asterisk was per physician continue fluids. There was no order to indicate what type of IV fluid, the rate at which it was to be infused, or for how long. LPN #1 said it was her responsibility to enter the new orders that were received when the physician was notified of lab results. She acknowledged no order was entered that indicated to the nurses that the IV should continue. RN #1 said she just continued to hang the same IV fluid that had been ordered on 1/5/22 and ended 1/8/22 even though no order was entered on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The DON was interviewed on 1/25/22 at 12:25 p.m. She said it was the responsibility of the unit manager (LPN #1) to enter physician orders when they were notified of lab results. Those orders were to be entered into the computer system and onto the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She said LPN #1 notified her of the above observation and the IV order having not been entered into the resident's chart and she commented she knows better than that. She said the nurses should not assume that a previous IV order, that had a stop date, could be resumed without an official order entry. She said a medication error had been completed for this incident.

Based on resident interviews, staff interview, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance, and temperature. Findings include: I. Resident interviews All residents were identified by the facility and assessment as interviewable. Resident #31 was interviewed on 1/12/22 at 10:35 a.m. She said the food was not served hot. She said some of the food was served hot when it should have been cold. She said she did not know if the staff would heat up her food. Resident #274 was interviewed on 1/12/22 at 12:31 p.m. He said the food was cold when he was served. He said he could get an alternative of a sandwich if he did not like what he ordered. He said he asked his family to bring him food. Resident #40 was interviewed on 1/12/22 at 12:47 p.m. She said the wrong meal had been delivered to her on multiple occasions. She said she would order the alternative meal but it did not arrive. She said the food that was served was cold and she asked her daughter to bring her food. Resident #19 was interviewed on 1/13/22 at 1:26 p.m. She said her food was delivered cold. She said the food had minimal flavor. Resident #56 was interviewed on 1/13/22 at 1:36 p.m. She said the food was overcooked. She said when the food arrived it was cold and dry. Resident #53 was interviewed on 1/13/22 at 1:50 p.m. He said the food was cold and not palatable. He said if he ate in the dining room it was warm but when he received a room tray it was not. II. Tray line and test tray On 1/24/22 at 4:34 p.m., tray line service began in the kitchen. The meal was an Italian sausage sandwich with French fries and orange sherbert. The restorative dining room was served first followed by the four wings. Plates were placed on a plate warmer and tray. A lid was placed on top of the plate before being placed in the food cart. Salt, pepper, and ketchup were not placed on the trays. Ketchup was sent up in a separate container to two of the four wings. A test tray was sampled on 1/24/22 at 5:55 p.m. The test tray was received after the last resident was served on the second floor east unit. The meal was an Italian sausage sandwich with French fries and orange sherbert. No salt, pepper, and ketchup were served on the tray. The consensus among the four surveyors was that the bread was tough and difficult to cut with a knife and chew. The sandwich was bland and without any additional toppings. The meat of the sandwich was measured at 122.5 degrees fahrenheit. The French fries were cold, bland, and were not crisp. III. Executive chef interview The executive chef (EC) was interviewed on 1/25/22 at 9:20 a.m. She said she had been the EC for the facility since November 2021. She said the dietary staff had received numerous complaints regarding the food. She said the complaints had been hard to manage. She said the dietary staff did not have control over the temperature of the food once the carts were brought to the units. She said the nursing staff should pass the trays when the food carts were ready and on the unit. She said certain foods dropped in temperature quickly which made it difficult to serve hot. She said the dietary staff received numerous calls during or after meal service for alternative meals or a la carte options. She said salt and pepper should be included on every tray and ketchup should have been served with French fries.

Based on observations, record review, resident and staff interviews, it was determined that the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for three of 31 sample residents (#430, #479 and #15). Specifically, 1. the facility failed to ensure pain was addressed and assessed timely by staff when resident #430 complained of pain during a therapy session. The resident experienced unrelieved pain at a level 7/10; and 2. The facility failed to identify and assure effective pain relief was achieved for sample resident #479. 3. The facility failed to thoroughly assess the resident's pain to ensure an acceptable comfort level was achieved for sample resident #15. The findings include: I. Policy: Review of the facility pain policy documented in pertinent part, "I. Facility Pain Management Policy The facility's pain policy states that the center ensured that all attempts be made to keep residents as pain free as possible. The procedure included in pertinent part that -All residents be assessed at regular intervals for the presence of pain. -Resident's shall be asked to classify their pain on a scale of 1-10. -Reassessment of pain shall be performed after each method of pain relief is tried to assess the effectiveness of the method. -Attempts to control pain shall be employed until the resident reaches an acceptable comfort level. -Residents shall be instructed to report reoccurrence of pain and previously effective methods of pain control." 1. Resident observations and interview with sample resident #430. The resident expressed she was in pain: On 11/05/2013 at 3:45 p.m., during the initial resident interview, the resident stated, "My arm and back hurt all the time. The medication takes the edge off but does not take care of all the pain (Indicating that the resident was still in pain after pain medications were administered)." On 11/7/13 at 9:40 a.m., the resident was observed in therapy room as she received therapy. IV fluids/medications were observed hanging on a pole. The resident was observed ambulating with one staff guiding the resident and another staff holding the IV pole. The resident was guided into the elevator and guided back to her room. At 9:50 a.m., the resident was observed in her room as she sat in wheelchair (WC). During that observation, the resident voiced that she was in pain. In a brief interview with the resident at that time, she stated that on a scale of 1-10, her pain level was at 6/10. The resident further stated, "Therapy is going well I hope it will help something ... My knee is starting to hurt again." On 11/7/13 at 9:52 a.m., with the surveyor present, the COTA (Certified Occupational Therapy Assistant) came into room and stated that she was going to give therapy to the resident. During observations at that time, the COTA administered OT treatment to the resident's left side arm and hand. During the OT session at that time, the resident periodically stated, "It hurts...Right now it's at (pain level) about 5-6 ...I took the pain pill (MARs indicated administration of [MEDICATION NAME] 5 mg at 8:14 a.m., instead of the ordered 10 mg) at about seven this morning ...Right now it hurts." The resident continued to complain of pain periodically throughout the therapy session. During that therapy session, the resident also stated, "I have pain in my hand." Then the COTA answered, "OK ...moves your hand to the front and back," as she (COTA) assisted the resident with those movements. During those movements of the hand the resident further stated, "That hurts but I expect it to hurt." During those observations, at about 10:20 a.m., in the surveyors' presence, the resident asked the COTA to ask the nurse for provision of pain medication. During this session, the COTA did not stop treatment or ask if the resident required anything for pain relief. The treatment ceased at 10:20 a.m. On 11/7/13 at 10:44 a.m., as no staff member had been in to assess the resident yet, the resident stated, "My knee (left knee) is probably at a 7 (pain level of 7/10) ...I guess I can't have any more pills for about 6 hrs ...I try to wait till 12 (12:00 p.m. I don't know if they (nurses) can give me anything in between ...(COTA's name) was going to catch up with the nurse to see if there is anything (pain medication) I can get ....(Name of COTA) was going to report to the nurse that my knee was hurting ...She (COTA) left about 25 minutes ago ...Maybe they will call the doctor to see if there is something else they can do ...I'm gonna (going to) wait a little bit then I will tell (Name of charge nurse on duty that date) myself." At that time, the resident was observed to be teary and stated, "This whole situation ...I ' m not getting well ... What I want to know is what's wrong with my left knee ...I want to know if they found out what is contributing to the pain in my knee ...today the knee started hurting so bad this morning when I first got up ...I had pain pill ([MEDICATION NAME] see above) about seven ([MEDICATION NAME] was last administered to resident at 8:14 a.m.)." Staff was alerted at 11:05 a.m. of the resident's pain by the surveyor. A. Resident #430, [AGE] years old, was initially admitted to facility on 9/27/13. Her primary admission [DIAGNOSES REDACTED]. The resident received rehabilitation therapy and aftercare for a healing traumatic fracture. The resident's Minimum Data Set (MDS), dated [DATE], was reviewed and revealed the following: -The resident scored 15 on her brief interview for mental status (BIMS), indication of no cognitive deficits. The resident had no short-term or long-term memory impairments. The resident understood others and was usually understood by others as she had clear speech. The resident had no behavioral symptoms. The resident needed limited assistance of one to two staff for all activities of daily living (ADL's). The resident had limitations with range of motion (ROM). The MDS indicated that the resident had limited ROM on one of her upper and lower extremities. The MDS indicated that the resident received scheduled pain medication regimen, PRN (as needed) and was on a pain regiment and non-medication interventions for her pain. The MDS indicated that the resident experienced constant pain. The numerical pain rating scale was documented as "5" on a scale of 1 to 10, 10 being the worst pain. The "Verbal Description Scale," for pain on the MDS was left blank. The section entitled, "Staff Assessment for Pain," on that MDS, was also left blank. The MDS indicated that the resident received Occupational Therapy (OT) five days a week and Physical Therapy (PT), six days a week. 1. Pain Management a. The resident's facility care plan which was initiated on 10/4/13 and revised on 10/31/13, was reviewed. The care plan read in pertinent parts, "(Resident #430's name) has pain r/t (related to) a fall at home having left shoulder and foot pain, left wrist pain ...has back pain, pain interferes at times with ADLs, dx (diagnosis) of polymyalgia, compression fx (fracture) hx (history) of LE (lower extremity) [MEDICAL CONDITION]." The goals read in pertinent parts, "Reduced pain ...frequency and/or intensity ...over the next 90 days ...Pain will be resolved within 1 hour of intervention over the next 90 days ...Target Date: 2/5/2014." Approaches to the care plan read in pertinent parts: "Compressive pain assessment weekly...Monitor pain level every shift and prn ...Notify MD of any change in condition ... Administer pain medication per MD orders and note the effectiveness ...Give prn pain medications for breakthrough pain per MD orders and note the effectiveness ...Acknowledge presence of pains and discomfort. Listen to resident's concern ... Document/Report complaints & non-verbal signs of pain ...Notify physician if interventions are not consistently effective." b. Pain Medications as ordered by the Physician (MD) Review of the 11/13 (November 2013) computerized physician (CPO) orders and 11/13 Medication Administration Records (MARs): Orders initiated on 9/28/13 that read in pertinent parts, "[MEDICATION NAME] 650 mg (milligrams) PO (by mouth) ... PRN (as needed) PO q (every) 4 hr (hours). [MEDICATION NAME], (anti-[MEDICAL CONDITION]) 0.6 mg ...PO ...PRN ...take one tablet PO q4hr for left ankle pain." On 11/5/13, the physician's ordered, "[MEDICATION NAME] HCL (opioid [MEDICATION NAME]) 10 mg PO q 4 Hr (by mouth every 4 hours) PRN. Use [MEDICATION NAME] for L (left) ankle/foot pain first. Then may give [MEDICATION NAME] if pain not relieved." Review of the November MARs, dated 11/13, revealed staff failed to transcribe this 11/5/13 order onto the MAR. Instead, the 11/13 MARs erroneously indicated a physician's order dated 9/28/13 and updated on 10/4/13 which read in pertinent parts, "[MEDICATION NAME] HCL -By mouth (PO) ...5 mg every 6 hrs as needed for pain ...Use [MEDICATION NAME] for (L) ankle/foot pain first. Then may give [MEDICATION NAME] if pain not relieved." Although the order was changed on 11/5/13, staff continued to administer 5 mg of [MEDICATION NAME] and the resident continued to express she was in pain. There were no physician orders for discontinuation of [MEDICATION NAME] 10 mg PO q 4 hrs as ordered on [DATE]. 11/7/13 On 11/7/13, review of the MARs indicated nursing staff administered 5 mg of [MEDICATION NAME] at 8:14 a.m. There was no assessment of the resident's pain level prior to administration or after to ensure pain relief was achieved. Staff did not offer [MEDICATION NAME] as indicated on the physician's order. At 9:40 a.m., as noted above, the resident stated her pain level was a 6/10 and the pain continued. As the 11/5/13 physician's order had not been transcribed onto the MAR, nursing staff could have administered 10 mg every four hours versus 5 mg of [MEDICATION NAME] every six hours. A Nurse's notes, dated 11/7/13 at 12:00 p.m., read in pertinent parts, "Spoke with pt (patient/resident) ...left knee pain. Pt states her knee feels better with ice and elevation, she's (she is) not sure if the Tylenol administered at 11:30 (11:30 a.m./11:21 a.m.) was effective or not." B. Interview and Follow up On 11/7/13 at 11:05 a.m., the unit (Licensed Practical Nurse) LPN was interviewed. In that interview, the LPN stated that she was unaware that the resident requested pain medication at about 10:20 a.m. The LPN stated, "No, (name of COTA) did not tell me that the resident was in pain ...No she (COTA) did not tell me (LPN) that the resident was in pain, she (COTA) just told me of her (resident #430's) swelling in the wrist but that the swelling was no different from yesterday ...She (COTA) told me about five minutes ago (11:00 a.m.)." As stated above, the resident asked the COTA to tell the nurse about her pain at about 10:20 a.m., on that date. On 11/7/13 at about 11:07 a.m., the LPN went into the resident's room. At that time, the resident confirmed to the LPN that she (resident #430) told the COTA to tell the LPN about her pain. The resident stated to the LPN, "It hurts ...I told (COTA name) to tell you." The LPN stated, "I don't know if you can have anymore medications, I will check." The resident stated, "I do not want this (pain) to get worse ...the pain is increased ...I did therapy ...I walked back ...If I can have two pills (10 mg [MEDICATION NAME]) then I will take those ...Can I even have one (pain pill/[MEDICATION NAME]) now ...I had it ([MEDICATION NAME]) at 7:30 (7:30 a.m.)." The LPN checked the resident MARs and returned to the resident's room and stated to the resident that it was not time for the resident's [MEDICATION NAME] (the last dose was given at 8:14 a.m.). The LPN stated to the resident, "It's not time yet (indicating that the LPN was unaware of the new physician's order to administer [MEDICATION NAME] 10 mg every four hours, instead of [MEDICATION NAME] 5 mg every 6 hours PRN)." The nurse did not offer the other pain medication [MEDICATION NAME]. The LPN offered the resident Tylenol and an ice pack for her pain. At 11:15 a.m., the resident further stated to LPN, "I don't know how much I can have ...If someone knows what to give me to stop it (left knee/left arm) from hurting...I will take it." The resident was teary at that time. At about 11:15 a.m., without assessing the pain level, the LPN stated, "I'm gonna see if she is due for pain meds ...I will check if you can have it now." At about 11:16 a.m., the LPN stated, "She (resident #430) got [MEDICATION NAME] at eight (8:00 a.m.) she cannot have anymore ... I will try some Tylenol ... She walked to therapies today." The LPN stated that the resident stated to the LPN in pertinent parts, "She (resident) stated that it (pain to left knee /arm) felt like I (LPN) kicked her." The LPN was observed to fill an ice pack which she administered to the resident's knee. At about 11:22 a.m., the LPN administered Tylenol 650 mg to the resident and told the resident what she was administering. The resident then asked when she could get her [MEDICATION NAME]. The LPN answered in pertinent parts, "You can have it at two (2:00 p.m.)." The LPN stated that she would return at 2:00 p.m., to administer the [MEDICATION NAME] (six hours after the 8:00 a.m., dose was administered) for a resident who was ordered [MEDICATION NAME] every four hours prn, and [MEDICATION NAME] was not offered or administered to the resident as ordered. Record review revealed that 5 mg [MEDICATION NAME] was administered at 3:44 p.m. on 11/7/13. Review of the MARs revealed that the resident was not administered any [MEDICATION NAME] on that date for pain. There was no assessment of the resident's pain prior to administration or afterwards to ensure effective pain relief was achieved. C. Failures: Although the resident was medicated with Tylenol on 11/7/13 at 11:21 a.m., (see above observations) for the complaint (C/O) pain with no relief by 11:30 a.m./12:00 p.m. (see above), there was no further assessment to indicate that the resident's pain level was re-assessed for relief or lack of relief after Tylenol was administered, as indicated by her care plan. Record review showed no indication or documentation of a nursing assessment related to the administration of [MEDICATION NAME] 5 mg, which was administered on 11/7/13 at 8:14 a.m. to ensure relief was obtained. On that date, by 10:50 a.m., the resident rated her pain level as 7/10 and had only been medicated with [MEDICATION NAME] 5 mg that morning when 10 mg was prescribed. The resident was not offered or reassessed for pain when lack of documentation indicated that all the other combinations of pain medications had not been offered to the resident on 11/7/13. The resident was still in pain at 10:00 a.m. (see nurses' notes above). No further medications were given and no physician notification was initiated for further instructions, as indicated. During the treatment session, although the resident expressed she was in pain, the treatment was not stopped to ensure pain relief was obtained. Rehabilitative staff did not communicate the resident's concern or complaint that she was in pain and requesting a pain pill. There was a delay in an assessment. Medications were not offered as ordered. Nursing staff did not transcribe the 11/5/13 physician orders onto the MAR. Although the resident could have been administered [MEDICATION NAME] or [MEDICATION NAME] on 11/7/13 at 12:00 p.m. with the last assessment of unrelieved pain at 11:30 a.m., those medications were not offered at that time. Review of the medical record revealed that the resident was not offered any [MEDICATION NAME] between 11/1/13 and 11/7/13, as indicated in the physician orders above. Review of the resident's MARs, dated 11/7/13, revealed that the resident received [MEDICATION NAME] 5 mg at 3:45 p.m. Nursing did not reassess within the hour to ensure there was pain relief, as indicated by the residents care plan. D. Staff interviews: On 11/7/13 at 11:22 a.m., the COTA was interviewed in presence of LPN. The COTA confirmed that she did not tell the LPN about the residents pain when the resident asked at 10:20 a.m. In that interview, the COTA stated, "I assumed that nurses knew that she (resident #430) was in pain." On 11/7/13 at 11:56 a.m., the COTA acknowledged that she did not tell the LPN of the resident's pain when the resident requested. The COTA stated, "I told her about swelling on her palm...in last two days ...I told her (LPN) ...it (swelling to palm) has not improved ...I assumed they (nurses) were aware of pain ...I did not think of mentioning the leg pain, she (resident #430) already had her pain medication." On 11/7/13 at 4:30 p.m., in a brief interview with the Director of Nursing (DON) about the medication transcription error found by the surveyor, the DON stated that it was an error on the physician's part as he did not intend to order those medications (However, record review on 11/7/13, revealed no discontinuation of physician orders in regards to the 11/5/13 [MEDICATION NAME] 10 mg by that date). No further comments were expressed by the DON regarding the above issues and the resident's pain. 2. Sample resident #479, [AGE] years of age, was admitted to the facility on [DATE]. According to the current face sheet, the resident had [DIAGNOSES REDACTED]. There was no minimum data set (MDS) completed as the resident was newly admitted on [DATE]. -hospitalization history of pain prior to admission to the facility: -Review of hospital admission history and physical (H&P) on 11/13/13 at 11:49 a.m. (during the survey), and dated 10/23/13, documented in part, "...at time of interview, the patient is moaning and groaning just about everywhere that I touch her...she refuses to interact fully with physical exam because she states it "hurts too much." When I ask her where she localizes the pain, she states everywhere ...when I ask her to be more specific, she states that her back hurts and cannot localize exactly where it is..." Under the physical examination section the following was documented in part, "...she is in no acute distress as long as she does not move, however; when we move essentially any part of her body, but especially her bilateral lower extremities, she cries out in pain. According to the nurse, when they would move her pillow, she would cry out in pain, when they tried to roll her over she would cry out in pain; when they tried to move her arm, she would cry out in pain...she cannot localize the pain to me. She cannot describe it. She does not know anything that makes it better or worse, other than pretty much any movement. She states her entire body hurts, but she localizes it more to her back. She states it is her entire back." Further documentation found in the admission H&P revealed the resident received x-rays as follows: "Pertinent imaging": "plain films of back show no evidence of fracture, subluxation, or other acute process..." Under the "Plan" section documented in part the physician discussed informally with Neurosurgery about further diagnostics to include imaging of the spine (MRI, Cat Scan) but due to the residents limited H&P and diffuse complaints it seemed more musculoskeletal in nature as opposed to spine and the risk/benefit ratio of using the imaging contrast and MRI of back was weighed more towards risk than benefit. -Care plan Review of a care plan provided for review on 11/6/13 (during the survey) for pain and initiated 11/5/13, documented the Focus as "Pain related to impaired mobility and weakness." The goal was: "reduced pain (frequency and/or intensity) over the next 90 days, pain will be resolved within 1 hour of intervention over the next 90 days." Interventions: " ...comprehensive pain assessment weekly, monitor pain level every shift and prn (as needed), notify MD of any change in condition, administer pain medication per MD orders and note the effectiveness, give prn pain medications for breakthrough per MD orders and note the effectiveness, acknowledge presence of pains and discomfort listen to resident's concerns, document/report complaints and non-verbal signs of pain, notify physician if interventions are not consistently effective, reposition frequently, implement non-pharmacological interventions when able ..." -Observations and Interviews with resident: On 11/7/13 at 12:22 p.m., the resident was interviewed. The resident stated she was having pain in her lower back and that laying in bed and not moving helped. The resident stated she was getting [MEDICATION NAME] now for her pain and that she was on the edge of her pain flaring up again. The resident confirmed she was receiving therapy and she was medicated beforehand. The resident's facial expression appeared strained and sad. Her brow was furrowed. On 11/12/13 at approximately 11:00 a.m., the resident was interviewed a second time. The resident was sitting up in her chair. The resident's facial expression appeared strained and her brow was furrowed. The resident stated she was still having a lot of pain in the buttocks that radiated all the way around her body. The resident confirmed she was still receiving [MEDICATION NAME] a couple of times a day and a pain patch on her back but the patch only worked for a little while. The resident stated she did receive some Tylenol but it doesn't do anything (as noted on the physician's 11/5/13 note below the Tylenol was not effective). The resident stated she had not seen a doctor for a week. The resident stated she was given a [MEDICATION NAME] about an hour ago and that it helped some but no one had come to check to see if it had helped her. The resident expressed her pain level was currently a 5/10 and her preferred level of pain would be a "1." A. Pain medications orders and assessments At the time of discharge from the hospital, the medications prescribed for pain were: -[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 mg (milligram) 1 tab by mouth Q (every) 4 hr PRN (as needed) pain 1-5. Order date 11/4/13. Discontinued 11/5/13. -[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5/325 mg (milligram) 2 tabs by mouth Q (every) 4 hr PRN (as needed) pain 6-10. Order date 11/4/13. Discontinued 11/5/13. With the resident's admission to the facility, on 11/4/13 these above medications were discontinued and changed to Tylenol prn: -Tylenol ([MEDICATION NAME]) 500 mg (milligram) tablet by mouth, PRN (as needed), 1-2 tabs Q (every) 6 hours. Dx (diagnosis): Pain. Start date 11/4/13; -"Assess pain q (every) shift and document. Pain monitoring. Start date: 11/4/13;" Review of a comprehensive nursing admission assessment, dated 11/4/13 documented the resident with a pain intensity of "6" on a numeric rating scale of (0-10) and described by the resident as "moderate." The location, "back." The onset/duration was documented as "chronic." The assessment further documented that relaxation and position change alleviated the pain, however; sitting up for long periods of time and movement was documented as making the pain worse. The resident's assessment identified her pain as moderately affecting her ADL'S (activities of daily living) and physical activity/mobility. Review of an initial physical therapy (PT) assessment, dated 11/4/13 documented in part the resident was referred due to new onset of decrease in strength, decrease in functional mobility ...pain." The initial assessment further documented the following impairments: "pain at rest; intensity- 6/10, constant in lower back and buttocks (ache). Pain with movement; intensity-9/10, constant in lower back and buttocks (spasm/sharp). The assessment summary documented in part, "skilled justification; to increase LE (lower extremity) ROM (range of motion) and strength, decrease complaints of pain ..." Risk factors: "...increased pain ..." 11/5/13 Review of a physicians admission history and physical (H&P), dated 11/5/13, documented in part the chief complaint as "back pain." History of present illness: " ...the patient notes that she has had multiple falls over the last month ...she is still having low back pain ...states she has had low back pain since she was a child ...states she has had sciatica ...she does say that she has pain down both legs, although the left does seem to be worse, the pain radiates down into the left thigh, she also does have a history of [MEDICAL CONDITION] secondary to type 2 diabetes ...she notes no relief with Tylenol." The H&P further documented under the section "musculoskeletal," the resident complained of muscle aches along with her back pain. The physician assessed the residents back and documented in part the resident had tenderness to palpation over the ischial region bilaterally without any soft tissue swelling. The physician's plan/impression documented in part, "acute on chronic low back pain secondary to [MEDICAL CONDITION] disc disease. Mild to moderate stenosis. Will add scheduled [MEDICATION NAME] ([MEDICATION NAME]) 50 mg (milligram) bid (twice daily); avoid narcotics due to her risk of false (falls)." -[MEDICATION NAME] HCI 50 mg (milligram) tablet by mouth twice daily at 8:00 a.m. and 8:00 p.m. every day. Dx: pain. Start date 11/5/13. A skilled nurse note entry, dated 11/5/13 at 11:08 p.m., documented the resident was medicated per her request for pain in leg at a 5/10 pain level. There was no further documentation regarding effectiveness of the medication. -11/5/13 PT note; " ...pt (patient) presents with crouched posture with inability to stand upright with c/o (complaint of) bil (bilateral ) buttock pain at 8/10 despite pre-medication..patient states pain in bil (bilateral) LE's (lower extremities) from knee down is due to [MEDICAL CONDITION], states pain/spasms in buttocks and lower back is chronic but more intense at this point with 8-10/10 pain level with movement. MD in to see pt (patient) during eval, is prescribing alternate pain meds asap (as soon as possible)." 11/6/13 A skilled nurse note entry dated 11/6/13 at 1:52 a.m., documented the following: "Tylenol 1-2 tabs PO (by mouth) Q 6H (hour) PRN (as needed): medication effective for pain, level reduced to a 0." The MAR, below, revealed the resident with a pain level of 5; however, there was no documentation on the MAR indicated [REDACTED]'s pain was located or the description of the resident's pain. -11/6/13 PT note; "pt continues with complaint of bil buttock and lower back spasms with supine ex (exercise) and all aspects of mobility. Pt was pre-medicated before session with [MEDICATION NAME] ([MEDICATION NAME]). Pt offered cold/heat modalities but declined." 11/7/13 Review of the electronic record revealed a daily skilled progress note and dated 11/7/13 at 11:03 a.m., documented in part the resident complained of 8/10 pain to lower back and pelvis that was sharp when moving or standing. The physician was notified. The resident was medicated twice on this day per the MAR (see below). There was no documentation in the nurse's note what the resident was medicated with or if the medication was effective. At this time, the physician adjusted the resident's pain management program: Review of a physician progress notes [REDACTED]." The assessment/plan for the acute on chronic back pain secondary to degen ([MEDICAL CONDITION]) disk disease and disk bulging, on [MEDICATION NAME] 1.3% patch, add [MEDICATION NAME] 25 mg (milligram) q (every) hs (bedtime), max 50 mg (milligram)/d (day), b/c (because) of [MEDICAL TREATMENT]." -[MEDICATION NAME] (pregabalin) ([MEDICATION NAME] for neuropathic pain) 25 mg (milligram) capsule by mouth q (every) hs (bedtime). Dx: sciatica. Start date 11/7/13; -Flector ([MEDICATION NAME] epolamine) 1.3% patch topical, apply to sacral area bid (twice a day). Dx: pain. Start date 11/7/13. 11/8/13 -11/8/13 PT note; " ...pt c/o severe back pain with bed mob (mobility) and transfers. Nursing notified and pt received pain meds..." 11/9/13 On 11/9/13, another physician's order was received and directed staff to perform comprehensive pain assessments every week-day shift on Fridays to monitor for pain. 11/11/13 -11/11/13 PT note; " ...pt having increased pain with sitting and standing; low back ..." Review of a pain assessment, dated 11/11/13, documented in part the resident had pain in the last five days, frequently making it hard for the resident to sleep at night, affecting her day to day activities. Her pain intensity was assessed at a "6" on a numeric rating scale of (0-10). The description of the pain was not documented (the area was left blank). In the section where staff assessed for indicators of pain or possible pain; was left blank. In the section titled: frequency of indicator of pain or possible pain; was left blank. In the section titled: pain management documented that Tylenol was effective for pain to lower back and that non-medication intervention for pain used was a k-pad (electronic heating device) and repositioning. The effectiveness of the interventions was not documented as indicated on the pain assessment form. 11/12/13 -11/12/13 PT note; "...patient states she is in pain at 4-6/10 at rest despite pre-medication and in room modalities provided by nursing ..." 11/13/13 Review of the in-house physician progress notes [REDACTED]. Subjective documentation revealed "the residents back pain not controlled well and hurts in the coccyx area. The resident fell x3 at home, wonders if could have broken. The resident's pain was down the legs, sometimes below knees when sitting and not much better after [MEDICATION NAME] (see above med list)." The medical physical exam documented the residents back/coccyx area was not tender to palpitation but positive (illegible word) to bilateral buttocks/ischial areas. The plan for the resident's back pain was to increase the scheduled [MEDICATION NAME], schedule Tylenol and referral to pain management; question ESI ([MEDICATION NAME] steroid injection). Review of a telephone order, dated 11/13/13 at 3:00 p.m., documented the following: "[MEDICATION NAME] 25 mg (milligram) one po (by mouth) q 6 hrs prn (as needed) pain in addition to scheduled. Schedule Tylenol 650 mg (milligram) one po (by mouth) QID (four times a day). Pain management referral ..." Review of a second pain care plan provided on 11/13/13 (during the survey) with an initiation date of 11/5/13 and revision date of 11/12/13 documented the Focus as "Pain related to impaired mobility, sciatica, back pain and weakness." The goals remained the same as on the above care plan. The interventions remained the same as above. The only thing different in the two pain care plans was the "Focus." B. Lack of consistent Pain monitoring: As noted on 11/5/13, the physician's note (above) referenced the resident reported that Tylenol offered no relief, Tylenol remained on the medication list for prn pain relief. Review of the electronic record skilled nursing notes from 11/4/13 to 11/11/13 and November MAR provided during the survey, revealed no consistent monitoring or detailed assessment of the resident's pain relief or location in each instance. -According to the 11/13 (November) MAR, there was an order to assess pain q (every) shift and document. There was a section for "day" and "night" shift to sign and a section to mark the "level" of pain. For the day shift the following was documented (scale of 1 - 10): 11/4/13 (blank), 11/5 (0), 11/6 (5), 11/7 (8), 11/8 (5), 11/9 (5), 11/10 (5), 11/11 (6). For the night shift the following was documented: 11/4 (blank), 11/5 (0), 11/6 (0), 11/7 (0), 11/8 (0), 11/9 (0), 11/10 (0), 11/11 (0). According to the 11/13 (November) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -11/5 Tylenol 1000 mg (milligram) administered at 11:08 p.m.; -11/6 no documentation of any Tylenol administered; -11/7 Tylenol 1000 mg administered at 10:47 a.m. and 2:11 p.m.; -11/8 Tylenol 1000 mg administered at 2:59 p.m. -1

Based on observation, record review, and interviews, the facility failed to provide one (#1) of six sample residents the necessary care and services to attain and/or maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to identify, assess, implement, accurately monitor and evaluate the resident's increase in pain after she experienced a fall. The resident, who had recently undergone back surgery, fell the day after she was admitted . A sacral fracture was not diagnosed for 21 days. The facility's failures contributed to a decline in resident #1's physical and psychosocial well being, as exhibited by the resident's repeated verbal expressions of pain, and as demonstrated by therapy refusals related to anxiety and pain with therapy. The findings include: A. PROFESSIONAL REFERENCE McCaffery, Margo and Pasero, Chris, Pain: Clinical Manual, 2nd edition, Mosby, St. Louis, 1999, pp. 5 and 36. In pertinent part relative to pain assessment/pain management: "Clearly, for many years clinicians have been placed in a challenging situation...they had no standards for assessment and treatment (of pain)...Critical to correcting this is establishing a standard for assessing the existence and intensity (of pain)...if caregivers do not agree on a standard for assessing pain intensity, each is likely to assess pain differently...the care of a single patient can vary from one caregiver to another, very likely resulting in unrelieved pain.. Many studies have shown that either lack of pain assessment or the existence of differences between the clinicians' pain ratings and those of patients is a major cause of inadequate pain management." B. FACILITY POLICY The facility policy on pain management was received from the Director of Nursing (DON) and reviewed at 11:23 a.m. on 8/23/11. The policy read in pertinent part: "-All patients are to be assessed for pain at least Q (every) shift using an appropriate scale. Nurses are to document pain ratings on MARS (Medication Administration Records). Follow-through is to be documented as well (was it effective/other interventions) -Nurses are to be aware of the differences between short acting and long acting meds (medications). -Non-pharmaceutical interventions are to be used as well. These include repositioning/ice (if ordered) hydrotherapy, massage, etc. -It is very important to medicate your patients prior to therapy if it is requested. -If you notice a patient taking a lot of PRNs, please notify the MD - a long- acting opiate or scheduled med may be more appropriate. -If the patient requests a pain med, they should be medicated ASAP (as soon as possible) before the pain escalates." C. RESIDENT #1 1. Resident #1, age 73, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The history and physical, dated 5/27/11, indicated the resident had a decompression and fusion of the lumbar spine and was sent to the facility for rehabilitation and care. The Minimum Data Set (MDS) assessment (6/10/11) indicated the resident was admitted from an acute hospital after back surgery. She had adequate hearing, had clear speech, was able to understand others and could make herself understood, and had no memory impairments. She required extensive assistance of two or more staff members with bed mobility, transferring, dressing, with toilet use, and with personal hygiene, and required limited assistance of two or more staff members with walking in the room and in the corridor. The facility's "Nursing Comprehensive Admission Data Collection" dated 5/26/11, included a pain assessment. The pain assessment included questions regarding the intensity of the pain, onset/duration of the pain, the quality of the pain, the coping of the pain and how it affected the lifestyle of the resident. The only documented answers were that the resident had moderate pain in her back. There was no description of the pain, what alleviated the pain, and what made the pain worse. There was no documentation that the resident was queried about her acceptable pain level. According to the admission orders [REDACTED]. The resident also was on 300 mg of [MEDICATION NAME] orally three times a day for nerve pain. The electronic point-and-click system included on the 5/11 and 6/11 Medication Administration Records (E-MAR), indicated the resident's pain was to be assessed each shift and documented. According to Pain Management Flow Sheet, the resident's pain was to be rated on a scale of 0 to 10, with 0 being no pain and 10 being the worst possible pain. 2. Fall 5/27/11 The nurses' notes revealed the resident fell in her bathroom on 5/27/11 at approximately 6:15 p.m. (the day after admission). -The Incident/Accident Report indicated the resident was found on the floor next to the toilet. The resident stated she bent over and stood up and lost her balance. She was found on her back with her head against the wall. According to the report, the resident stated she hit the back of her head on the right side and hit her mid-back on the hand rail. -The report also indicated the resident had complained of head and mid-back pain (6/10) and was given an as needed pain medication. The resident was assessed as having no injuries. A post fall comprehensive pain assessment was completed on 5/31/11. The results of the pain assessment were based on interviews with the patient, observations during rest, and observations during movement and activities. The assessment read: -Nonverbal signs that could indicate pain were documented as "None." -Mood or behavior that could indicate pain was documented as "None." -After the statement, "Based on questions above does this patient have any signs, symptoms, or verbalization of pain," the documentation entered was "No." 3. Escalating pain following fall 5/27/11 - facility response Review of resident #1's record from admission on 5/26/11, to the day of discharge on 6/17/11, indicated the resident had moderate pain on admission, which escalated to severe pain (intensity 10/10 and 20/10), as well as new symptoms of numbness, and anxiety/panic related to anticipated pain with therapy. a. MDS Review of the resident's MDS assessments reflected that her pain increased. -On 6/2/11, she had moderate pain occasionally. -On 6/10/11, she had severe pain almost constantly, pain continued and per resident interview, the pain made it hard for the resident to sleep at night and limited her day-to-day activities. -On 6/17/11, the MDS again documented that the resident had severe pain almost constantly that made it hard for the resident to sleep at night and limited her day-to-day activities. b. Nurses' notes, therapy notes, and physician orders [REDACTED]. These records revealed: 5/27/11: Moderate pain in her back, prn Tylenol given with moderate effect, [MEDICATION NAME] 5-500 mg tablet every four hours as needed was added, resident reported pain while in therapy of 5/10. 5/28/11: Moderate pain in her back, (6/10) prn medication effective. 5/29/11: Mild and moderate pain due to a migraine and pain in her left anterior leg. 5/30/11: Mild pain in her lower back, complained of tailbone soreness and intermittent numbness to both lower legs. 5/31/11: Although the post fall assessment completed 5/31/11 documented the resident had no complaints of pain (see above), the daily nurses' notes, therapy notes, and physician's orders [REDACTED]. [MEDICATION NAME] 5 mg added as needed for back spasms, complained of intermittent numbness to both lower legs, while in therapy reported severe pain that "grabs" her in her back when attempting to move in bed, reported her pain as 6/10 while resting and 10/10 when trying to move. 6/1/11: Complaint of severe pain in lower back while in therapy, "Pt's (Patient's) level of assist and progress is impacted by degree of pain at the time of therapy." 6/2/11: Moderate pain in her back (5/10), prn [MEDICATION NAME] effective. 6/3/11: Moderate pain in her back (8/10). 6/4/11: Moderate pain (8/10) in her lower back. 6/5/11: Moderate and severe pain in her back, will consult with (primary) physician in a.m. for pain control issues. 6/6/11: Severe pain in her back, wanted to stay in bed due to back discomfort, [MEDICATION NAME] 5-500 mg tablet two tablets every four hours as needed was added. 6/7/11: Patient with 8 to 9/10 pain, patient not ready for discharge in too much pain, complained of intermittent numbness to both lower legs. A comprehensive care plan was developed on this date for pain related to back surgery. The goal was to reduce pain times 90 days. Some of the interventions listed were: -Administer pain medication as ordered and note the effectiveness -Give PRN (as needed) medications for breakthrough pain as per MD orders and note the effectiveness. -Acknowledge the presence of pain and discomfort. Listen to the resident's concerns. -Document/report complaints and nonverbal signs of pain. -Notify the physician if interventions are not consistently effective. 6/8/11: Moderate back pain, resident reported she can't walk today, "I just can't do it," having tremors. 6/9/11: Reporting pain 9/10 at therapy, maximum encouragement for increased time in standing. After 20 seconds, patient reports, "I can't!" Patient educated regarding trying to do the activity instead of saying, "I can't!" Requesting more [MEDICATION NAME]. 6/10/11: Generalized bruising noted on upper and lower extremities, resident resistant to ambulation due to pain, refusing to get up to go to the bathroom wants to use the bedpan, bedside commode added due to pain, pain medications requested for pain (6/10), reported pain 9/10 in therapy even after receiving pain medication one hour before therapy. 6/11/11: Resident reports pain (10/10) [MEDICATION NAME] was ineffective. 6/12/11: Resident stated she cannot get out of bed due to pain, had pain meds this a.m. with some relief, [MEDICATION NAME] added one tablet every eight hours as needed for anxiety. 6/13/11: Increased anxiety noted, reported she had a panic attack anticipating therapy, [MEDICATION NAME] 200 mg two daily twice a day for pain and inflammation, resident with maximum complaints of pain in therapy, and stated she didn't get out of bed all weekend secondary to pain. 6/14/11: [MEDICATION NAME] given for anxiety, complained of intermittent numbness to both lower legs, therapy reported resident complained of 10/10 pain in her right hip, refusing to increase activity secondary to severe pain, 6/15/11: Therapy documented resident reported 10/10 pain while in bed with increased pain to 20/10 with movement, therapy reported resident stating, "I cannot do this, I cannot move," requesting to stay in bed to offset a new pain to hips, addressed with physician and new order received, social worker aware of mental health issues, complained of intermittent numbness to both lower legs, [MEDICATION NAME] 0.5 ml Solution sub lingual (SL) as needed every four hours for pain was added. 6/16/11: Therapy reported resident complained of numbness and tingling in bilateral legs, assessed for (name of behavioral health facility) for placement on Saturday, pain 10/10 in her lower back/hips, and [MEDICATION NAME] sulfate given, follow-up appointment with orthopedic surgeon, x-rays taken with possible sacral fracture below lumbar fusion, MRI and CT scan scheduled for 6/17/11. (The orthopedic surgeon on the follow-up appointment had scheduled the x-ray because of the resident's complaints of pain.) 6/17/11: MRI confirmed a "new fracture extending [MEDICATION NAME] through the S1 vertebrae along the inferior aspect of the vertebral body and obliquely through both sacral ala. There is 14 mm of anterior displacement of the superior aspects of the S1 with respect to the remainder of the sacrum, bouts of confusion, refusing therapy. 4. Facility failures in response to resident's pain (1) Failure to assess reason for increase in back and hip pain, no referral to orthopedic surgeon after the fall, and inaccuracy in documenting prn pain medications (Cross Reference F514 Inaccurate Medical Record). Assessments and Referrals: Notwithstanding the resident's recent back surgery at the time of her fall (5/27/11), there was no documentation the facility considered notifying the resident's orthopedic surgeon of her fall. And, there was no documentation the orthopedic surgeon was notified when the resident began to verbally complain of increased pain, refused therapy, refused ambulation, began having anxiety in anticipation of therapy, and repeatedly complained of numbness in her legs. On 8/31/11 at 8:26 a.m., the orthopedic surgeon was interviewed. He stated he had not been notified by the facility (prior to the resident's follow-up appointment) that the resident had fallen or of her increased complaints of pain, anxiety, or numbness. While the facility contacted the resident's primary physician 6/5 and 6/15/11 regarding pain management concerns, there was no documentation that staff requested the physician physically assess the resident's condition prior to 6/17/11. While interview revealed the medical director was aware of the resident's complaints of pain, there was no documentation that he assessed the resident from 5/27-6/17/11, or that staff requested that he assess the resident's condition. Finally, there was no documentation that nursing assessed the resident's complaints of numbness or considered a physiological basis for her increasing anxiety. Rather, anti-anxiety medication was administered and social services considered mental health interventions. In a telephone interview with the resident on 8/31/11 at 12:33 p.m., she stated, "They thought I was crazy (because she was requesting pain medication)." Pain Medication Documentation: Review of resident #1's 5/11 and 6/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s need for medication to manage her pain. These included: -Six doses of [MEDICATION NAME] were omitted from the PRN 5/11 MAR (5/26-5/31). -Twenty-three doses of [MEDICATION NAME] were omitted from the PRN 6/11 MAR (6/1-6/16/11). (2) Failure to monitor effectiveness of pain management plan The electronic point-and-click system included on the 5/11 and 6/11 Medication Administration Records (E-MAR) revealed an entry that read "Assess pain q (every) shift and document." There were dated squares for the day shift and dated squares for the night (12 hour shifts); however, nursing staff did not document her daily pain level. There was only a check mark in the dated squares with initials under the check mark. The Director of Nursing (DON) was interviewed at 9 a.m. on 8/24/11 and stated she expected the nurses to document pain level and assessment on the "Pain Management Flow Sheet" every shift because the pain flow sheet was not on the point-and-click system as of yet. Review of the Pain Management Flow Sheet showed no documentation of a pain level on 5/30 and only one shift documented a pain level on 5/29, 5/31, 6/1, 6/2, 6/3, 6/4, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/13, and 6/14/11. -The PRN pain medication that had been administered per the flow sheet documented the location of the pain only four of 35 times and the effectiveness of the documented pain medication 34 of 35 times. -However, comparing the narcotic sign-out sheet with the MAR PRN pain documentation and with the pain management flow sheet, over 20 doses of pain medication administered were not documented as given. The MAR PRN pain medication documentation and the pain management flow sheet did not give a accurate picture of resident #1 pain needs and the effectiveness of the pain medication. In an interview on 8/24/11 at 9:10 a.m., the Medical Director stated there needed to be some more work done with accurately documenting pain medications. (3) Failure to Manage the Resident's Pain Although in his interview on 8/24/11 at 9:10 a.m., the Medical Director stated that he felt they had kept the resident comfortable, interviews with the resident, her family, and the orthopedic surgeon indicated otherwise. Specifically: -On 8/23/11 at 10:32 a.m., a family member was interviewed over the phone. The family member stated the resident was in constant pain after a fall at the facility. The family member stated his only question was why no one further assessed the resident, such as doing an x-ray, when she complained of so much pain. The family member went on to say that, instead, the facility got a psychologist involved, thinking the resident might be seeking pain medications. -On 8/31/11 at 8:26 a.m., the orthopedic surgeon stated the resident came to the office for follow-up appointment on 6/16/11 and was in a lot of pain. -In a telephone interview with the resident on 8/31/11 at 12:33 p.m., resident #1 stated that therapy insisted she had to work out but she couldn't because she hurt. She said she suffered, and had to be sent to the hospital for pain control until surgery could be scheduled.