Every finding on record at Center at Lincoln, LLC, The

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of five residents reviewed for accidents out of five sample residents.Resident #1 was admitted on [DATE] for postoperative left knee replacement rehabilitation services and physical therapy. Resident #1 was determined to be a high fall risk related to her postoperative status and history of falls. On 10/17/25 Resident #1 sustained an unwitnessed fall when she was left unattended in the bathroom.On 10/24/25 Resident #1 sustained an additional fall when she was left unattended in the shower. She sustained a left femur fracture that was deemed inoperable for repair. Specifically, the facility failed to ensure fall interventions were consistently implemented for Resident #1, which resulted in a fall with major injury. Findings include:I. Facility policy and procedureThe Fall Prevention policy, revised 7/24/23, was provided by the nursing home administrator (NHA) on 11/5/25 at 4:50 p.m. It read in pertinent part, Falls in the skilled nursing setting represent one of the most potentially devastating occurrences that can negatively impact a patient's recovery. In facility, falls directly cause tens of thousands of bone fractures, intracranial hemorrhages, re-hospitalizations and deaths every year in the United States. It is because of these unfortunate events that The (name of facility) are implementing its comprehensive program to prevent falls and injury. Any patient deemed to be high risk by nursing and/or therapy staff will have the following interventions at least considered: Thorough physical therapy and occupational therapy evaluation, routine toileting schedule throughout shift and line of sight as needed. If an unwitnessed fall occurs, risk management to be completed and determine what interventions need to be implemented to prevent further falls. II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included fracture to the left femur with surgical intervention, difficulty walking, muscle weakness and a history of falls prior to admission. The 10/14/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The 10/28/25 MDS assessment revealed Resident #1 required supervision or touching assistance with toileting hygiene and showers and bathing. She required supervision or touching assistance with sit to stand transfers, toileting transfers and shower transfers. B. Resident #1's representative interviewResident #1's representative was interviewed on 11/5/25 at 9:26 a.m. The representative said the evening shift staff informed her of Resident #1's fall. She said the staff only gave Resident #1 Tylenol as ordered for pain and could not exceed the resident's dose of Tylenol due to potential liver damage. She said she asked the staff if they had called the doctor and the staff did not have an answer for her. She said the staff continued to transfer the resident improperly. She said the resident had pain from her hip to her foot. She said she was told by nursing staff that the resident's left knee prosthetic fracture was displaced and was now non-surgical. She said the Resident #1 was discharged home from the hospital with hospice care. She said the resident told her the staff had assisted her into the shower, set the water temperature and left the room. She said Resident #1 had finished her shower and was cold and wet, so she activated her call light. The representative said the resident waited a while and decided to try to get up by herself and fell.C. Record reviewResident #1's fall care plan, initiated 10/8/25 and revised 10/26/25, revealed the resident was at a high fall risk related to the need for increased assistance from others, decreased functional activity tolerance, fall in the last month prior to admission, hypertension (high blood pressure), pain, recent falls, recent surgery and lung cancer. The care plan indicated the resident had an unwitnessed fall on 10/17/25 and 10/24/25. Pertinent interventions included placing a Call Don't Fall sign in the resident's room to remind the resident to call for assistance (initiated 10/18/25), four P's: Did the resident have to use the restroom? Did the resident need to be repositioned? Were all commonly used belongings within reach of the resident? Was the resident having pain? (If Yes, Please report to nurse as soon as possible) (initiated 10/18/25), utilizing a fall bracelet if appropriate and as needed related to high fall risk (initiated 10/9/25), monitoring the resident's activities (initiated 10/8/25), transferring and changing the resident's position slowly (initiated 10/8/25), reinforcing the need to call for assistance (initiated 10/8/25), placing the call bell within reach (initiated 10/8/25), encouraging the resident to use positioning bars (initiated 10/8/25) and ensuring the environment was free of clutter and well lit (initiated 10/8/25). Resident #1's activities of daily living (ADL) care plan, initiated 10/8/25 and revised 10/26/25, revealed the resident was at a high fall risk due to self care deficits and decreased functional mobility secondary to fall, left femur fracture, lung cancer and a fracture of the distal femur on 10/24/25. Interventions included ensuring upper side rails were in position to help with bed mobility (initiated 10/8/25), ensuring the call light was within reach (initiated 10/8/25), preferred scheduled shower days were Tuesday and Friday nights (initiated 10/8/25) and encouraging the resident to do as much for herself as able and praising for effects with self-care (initiated 10/8/25). Resident #1's transfer care plan, initiated 10/8/25, revealed she needed assistance with transfers/toileting related to fall, left femur fracture, lung cancer and an acute displaced periprosthetic fracture of the distal femur on 10/24/25. Interventions included checking the resident frequently and assisting with toileting as needed (initiated 10/8/25), keeping call light within reach and reminding the resident to call for assistance (initiated 10/8/25) and providing incontinence care after each incontinent episode and applying barrier cream as needed (initiate 10/8/25).The physical therapy treatment and counter note, dated 10/23/25, revealed Resident #1 was at risk for falls and was weight bearing as tolerated on the lower left extremity. The resident was also to be transferred from chair to chair with standby assistance. The 10/17/25 facility post fall assessment for Resident #1's fall was received from the NHA on 11/5/25 at 1:30 p.m. The investigation documented that on 10/17/25 Resident #1 had an unwitnessed fall in her bathroom. The assessment documented that a staff member went to check on the resident in the bathroom and found the resident sitting on the floor with her legs facing the bathroom door. The resident was assessed for injury and reported no pain or injuries.The resident denied hitting her head and was able to move all extremities. The resident was assisted back to her wheelchair by two staff members. Neurological checks were started and were within normal limits. The interdisciplinary team (IDT) reviewed the resident's fall and education for the resident was completed on proper use of her call light and waiting for assistance. Staff continued to work on strength and safety and a fall band falling star was put in place and signage added in the room to remind the resident to use her call light for needs.The 10/24/25 facility investigation for Resident #1's fall was received from the NHA on 11/5/25 at 1:30 p.m. The investigation documented that on 10/24/25 Resident #1 had an unwitnessed fall in her bathroom while taking a shower after certified nurse aide (CNA) #2 left the resident alone in the shower. Resident #1 tried to get out of the shower without calling for assistance. The resident said she tried to get out of the shower and did not call for help. The resident was assessed by a registered nurse (RN). The physician checked on the resident and decided to delay the resident's discharge for a few days to monitor. Xrays of the resident's ankle and knee were ordered. The physician's orders included elevating the resident's left leg and to apply ice to the swelling. The director of nursing (DON) and the family were notified. Neurological checks were initiated. Resident #1 was assisted from the floor using a gait belt. CNA #2 was provided education on 10/24/25 regarding the importance of supervision and adherence to care plan, safe transfer and bathing techniques, reporting and documentation requirements after a fall and emotional and physical impacts of falls on a resident. The Xray results revealed a fracture to the neck of Resident #1's left femur bone. The resident was sent to the hospital for further treatment. The 10/25/25 hospital documentation indicated Resident #1 sustained a femur fracture that was inoperable due to the residents' comorbidities. It was decided the resident would transition to hospice and comfort care made by the resident and her family. The IDT facility discharge summary on 10/23/25 revealed Resident #1 had a planned discharge scheduled for 10/24/25 to go home with family supervision. The summary documented physical therapy recommended the resident should initially have supervision for all functional tasks and mobility upon discharge using an assisted device to decrease risk of falls. The resident should continue with outpatient skilled therapy services to increase strength and improve functional performance with tasks. III. Staff interviewsCNA #3 was interviewed on 11/5/25 at 11:29 a.m. CNA #3 said if a resident was a fall risk, he did not leave them alone in the shower. He said residents could fall very quickly so it was very important to stay close by any resident while providing care assistance. He said the nursing staff knew what care to provide to residents based on the electronic medical record (EMR). He said Resident #1 was a fall risk and was in a room close to the nurses' station. He said her assistive needs were also written on the white board in her room. CNA #1 was interviewed on 11/5/25 at 12:05 p.m. CNA #1 said the falling star symbol on a resident's door indicated the resident was a fall risk. CNA #1 said Resident #1 was a fall risk, as she frequently ambulated by herself. CNA #1 said the resident had tried to get up by herself six or seven times and had to be redirected. CNA #1 said the resident was difficult to redirect, as she was fixated on getting back in bed and did not want the staff to help her wipe or pull her pants up. CNA #1 said the resident was on frequent checks to help with fall prevention.Licensed practical nurse (LPN) #1 was interviewed on 11/5/25 at 12:14 p.m. LPN #1 said she was Resident #1's assigned nurse on 10/24/25 when Resident #1 fell and sustained a femur fracture. LPN #1 said Resident #1 was admitted to the facility for rehabilitation because she had fallen and had surgery. She said the resident had a wristband that indicated she was a fall risk and had fall signage in her room. She said the fall on 10/24/25 occurred at 10:20 a.m. She said she was passing medication to other residents when she was notified by another staff member that the Resident #1 was on the floor in her bathroom. LPN #1 said when she arrived to the resident's room, she noticed Resident #1 was on the floor in the shower. She said Resident #1 was covered in water and had a towel around her. LPN #1 said the resident was assessed and a physician's order was obtained for an Xray. LPN #1 said CNA #2 was assisting the resident with a shower and left the resident unsupervised to get supplies. LPN #1 said CNA #2 should not have left the resident in the shower alone because she was a fall risk and had fallen in the past while in the bathroom. LPN #1 said CNA #2 should have utilized the call light to have another staff member bring the supplies to Resident #1's room. LPN #2 said the resident had pain in her right knee and ankle after her fall and was given her scheduled Tylenol. LPN #2 said the results of the Xray confirmed a new fracture to the resident's left femur and she was sent out to the hospital. LPN #1 said she thought the resident was trying to get out of the shower by herself and that was the reason she fell. CNA #4 was interviewed on 11/5/25 at 1:39 p.m. CNA #4 said residents at risk of falling typically received frequent checks and resided in rooms that were closer to the nurses' station. She said if a resident was at risk for falls, their doors and windows that opened to the hallway were left open, unless the staff were providing care. CNA #4 said the residents' abilities were assessed on admission by physical therapy and occupational therapy. She said the residents' needs were written on the communication board in the resident's rooms. CNA #4 said for residents who were alert and oriented but were at a fall risk, they relied heavily on the resident to communicate their needs. CNA #4 said they let the residents do as much as they were capable of doing without intruding on their privacy.The director of nursing (DON), the nursing home administrator (NHA) and the regional nurse consultant were interviewed together on 11/5/25 at 3:51 p.m. The regional nurse consultant said the fall care plan for Resident #1 was created on 10/8/25. The DON said Resident #1 was evaluated on admission for individual fall interventions, and was at an increased risk for falls. The DON said the resident had a yellow fall band, a Call Don't Fall sign and required observation checks in the task section for the nursing staff. The DON said after her fall, the facility had an IDT meeting to discuss the resident's needs. The NHA said Resident #1 was impulsive and confused. The NHA said Resident #1 was admitted in an observation room near the nurses' station with fall interventions including Call Don't Fall signage and the four- P's were added after fall. The DON explained that the four - P's were frequent assessments of needs to keep the resident content and decrease their fall risk. The DON said the fall happened because CNA #2 left the resident during her shower to retrieve a towel. The DON said CNA #2 should have called another staff member for the towel instead of leaving the resident by herself because she was impulsive and confused. The DON said the resident had reached her maximum functional level for discharge but was not independent with ADLs and still required assistance. The DON said the facility educated CNA #2 on fall interventions on the spot to call for instructions when assisting residents with showers. The DON said they had not done education specifically regarding the incident for the facility staff but planned to do so as soon as possible. The NHA said they had done their annual nursing staff training since the incident, included correct ADL and transfer techniques. CNA #2 was interviewed on 11/5/25 at 4:46 p.m. CNA #2 said she was assigned to assist Resident #1 with her shower the day of the fall (10/24/25). CNA #2 said she left the resident alone to get some towels and socks. She said when she left the room, Resident #1 fell out of the shower chair. CNA #2 said she knew she should not have left the resident alone in the shower. She said she could have called another staff member for supplies instead of leaving the resident to get supplies herself. CNA #2 said this was the first time she worked with the resident and she thought it was okay to leave her alone for a few minutes because the resident was getting discharged that day. CNA #2 said every resident in the facility was at a fall risk because it was a rehabilitation facility. She said she remembered the resident having on a yellow wrist band indicating she was a fall risk.

Based on record review, observations, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#53) one resident out of 60 sample residents. Resident #53 was admitted to the facility for rehabilitation services on 10/4/24 with a diagnosis of fracture of the left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/5/24 admission skin assessment indicated the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. The assessment did not indicate that the resident had any abdominal wounds. On 10/24/24 the resident was noted to have two facility acquired moisture associated skin disorder (MASD) wounds to her abdominal folds. The facility failed to provide the resident with showers per her preferences. Due to the facility's failures, observations revealed the resident had developed three MASD wounds to her abdomen. Through observations, the facility failed to follow infection control practices when providing wound care and failed to document the third MASD wound. Additionally, the facility also failed to communicate the worsening of the abdominal wounds to the primary care physician and ensure a timely referral to a wound physician. Findings include: I. Resident #53 A. Resident status Resident #53, age less than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of left femur, end stage renal disease, type two diabetes, and morbid obesity. The 10/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, bathing, and lower body dressing and was partially dependent for all other activities of daily living (ADL). The assessment indicated that the resident did not have any skin conditions. B. Resident interview Resident #53 was interviewed on 11/18/24 at 11:24 a.m. Resident #53 said she had wounds underneath her abdominal fold that she had developed when she was admitted to the facility. She said the abdominal wounds were very painful. She said the pain was what caused her to ask the staff to look under her abdominal fold. She said she did not understand how the wounds developed so quickly and when she asked the nurse they said that they did not know either. Resident #53 was interviewed again on 11/20/24 at 8:06 a.m. She said the facility gave her bed baths instead of showers because she was unable to sit in the shower chair comfortably. She said she preferred to receive a bed bath in the morning, however she often refused her bed bath because the certified nurse aide (CNA) would come between 7:00 p.m. and 8:00 p.m., which she had told them repeatedly was too late. She said she had requested to be moved to the day shift for her bed baths to ensure she received it during the day, but her request had still not been honored. Resident #53 said when the facility the staff did give her a bed bath, they did not lift up her abdominal fold and clean underneath. She said she had full feeling in her abdominal fold and underneath it, and she would have felt if they had cleaned underneath it. Cross reference F561: The facility failed to ensure Resident #53's preference to have her bed bath done during the day shift was honored. C. Observations On 11/21/24 at 8:40 a.m. the certified wound nurse (CWN) and the director of nursing (DON) were observed providing Resident #53's wound care and dressing change. The CWN cleared off the resident's bedside table and wiped it down with a disinfectant wipe, applied a barrier pad and placed her bag of resident wound care supplies on top. The DON entered the room as well and put a clean chucks pad (disposable absorbent pad) under the resident's abdominal fold but below the wounds. Three dressings were observed on the resident, one on the right, one in the middle and one on the left. All of the dressings had the date 11/20/24 with a nurse's signature. Both the DON and the CWN completed hand hygiene and put on clean gloves. The CWN removed all three dressings, the right and left sides had moderate serosanguineous drainage (a thin watery fluid), the middle had a small amount of bloody drainage. The wound on the right was the largest of the three wounds. It was noted to have a ring of redness around it and the center had 20% eschar and 10% yellow slough the remaining tissue was red and it had no odors. The middle wound was the size of a nickel and had red tissue throughout and did not have an odor. The wound on the left was noted to be about the size of a quarter and had 80% slough and 20% red tissue and did not have an odor. The CWN changed her gloves to set up her supplies for the wound care. She set up a stack of gauze, a continuous spray can of saline solution and a lidocaine spray. She started on the left wound by taking one gauze she sprayed it with saline and wiped the wound, folded it over and wiped again three times with the same gauze, the wound was noted to have bloody drainage. The CWN then threw the gauze away and with her dirty glove touched the saline bottle and then re-sprayed all three wounds with lidocaine per the resident's request due to pain, with contaminated gloves. Using the same gloved hands the CWN then took another piece of gauze and sprayed it with the saline solution and moving from the left wound to the middle wound she wiped twice with the same piece of gauze. The CWN then moved to the wound on the right and wiped the wound three times with the same piece of gauze. She then collected a second piece of gauze moistened it with saline and wiped eight times over the wounds with the same piece of gauze, she then took another piece of gauze moistened it with saline solution and proceeded to wipe six more times over the wound areas. She took a third piece of gauze and dabbed the area three times due to bloody drainage. She threw away the gauze and changed her gloves and performed hand hygiene. The CWN conducted a wound culture to the right wound. She took the culture tubing out of the sterilized package. She swabbed the right wound. She then inserted the sample into the test tube. The CWN then changed her gloves, performed hand hygiene. She started on the left side of the wound, using gauze and saline to wipe, applied skin prep to the peri-wound and cut calcium alginate (highly absorbent dressing) sheet to size and applied it. She applied Medihoney (antimicrobial gel) and covered the wound with a border foam dressing. The CWN moved to the middle wound and used a saline-soaked gauze to wipe the wound four times, using the same gauze to apply the skin prep to the peri-wound. She cut another piece of calcium alginate and Medihoney and applied both to the resident's wound and covered it with the foam dressing. Using the same gloved hands, the CWN moved to the right wound, using saline soaked gauze, she wiped the wound four times with noted serosanguinous drainage coming out of the wound as she applied skin prep. She measured the right wound at this time 3.5 centimeter (cm) length by 9 cm width by 0.1 cm depth and said the wound was larger than last week. She took calcium alginate and Medihoney and applied it to the wound and covered it with a foam dressing. Cross-reference F880: the facility failed to follow proper infection control practices for wound care. D. Record review The potential for skin breakdown care plan, revised on 10/5/24, documented Resident #53 had a surgical incision on her left hip, brace to the left knee, double right chest port, folded abdomen and a hard abdomen. The interventions included applying antifungal powder beneath the pannus (abdominal fold) every shift, completing a Braden scale every week per protocol, providing prophylactic skin treatments as ordered, performing skin assessments as needed, wound nurse to evaluate and treat and the wound physician to evaluate and provide treatment as needed. -The comprehensive care plan did not include Resident #53's actual skin breakdown of three abdominal wounds. The 10/4/24 hospital discharge summary documented Resident #53's skin was warm, dry, intact and had no rashes. The 10/5/24 admission skin assessment documented Resident #53 had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. -It did not document Resident #53 had abdominal wounds upon admission. The 10/10/24 and 10/17/24 skin assessments documented the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. -It did not indicate Resident #53 had sustained any abdominal wounds. The 10/24/24 skin assessment documented the previously identified skin concerns and additionally a wound to the abdomen. It did not include any information regarding the wound to the abdomen. The 10/24/24 wound progress note documented the floor nurse requested the wound nurse to come and assess the abdominal wounds. The note indicated that there were two moisture-associated skin damage (MASD) wounds underneath the pannus. The right wound measured 2.5 cm in length by 4 cm in width by 0.5 cm depth with 50% granulation tissue (new connective tissue) and 50% slough (dead tissue) with little signs or symptoms of drainage. The wound was debrided with no complications. The left wound measured 1 cm length by 1.5 cm width by 0.2 cm depth with 70% granulation tissue and 30% slough with little signs or symptoms of drainage. The wound dressing order read: cleanse with wound cleaner, apply skin prep to peri-wound (skin surrounding a wound), apply collagen to the wound bed, cover with a foam border dressing every other day or as needed, replace the Interdry sheets (fabric to absorb moisture) beneath the abdomen every three days or as needed and monitor placement of the Interdry sheets every shift. The 10/31/24 wound note documented that the size of both wounds had not changed, however the right wound now had 20% gran and an increase of 80% slough with little signs or symptoms of drainage. The left wound was unchanged with 70% granulation tissue and 30% slough with little signs or symptoms of drainage. The wound dressing order was changed and read as: cleanse with wound cleaner, apply skin prep to the peri-wound, apply medihoney and then collagen to the wound beds, cover the wound with a foam border dressing everyday and as needed, replace the Interdry sheets beneath abdomen every three days or as needed and monitor placement of the Interdry sheets every shift. The 11/13/24 provider note documented that the nurse practitioner (NP) saw Resident #53 to follow up on her abdominal wound and her lab work. It documented the NP saw the wounds via picture. It documented that the wound team was following the MASD open wounds. The 11/14/24 wound progress note documented there were no changes to both wounds. -The wound progress notes did not reveal accurate documentation of the wounds in describing the eschar (scab-like dead tissue covering the wounds) observed to the right wound and that Resident #53 had three abdominal wounds (see observations above of wound care during the survey process), not only two wounds. Review of the record revealed that the resident's primary care physician or her nurse practitioner did not physically see the abdominal wounds except for via photograph which was noted on 11/13/24 (see NP interview below). II. Staff interviews The CWN was interviewed on 11/21/24 at 9:11 a.m. The CWN said Resident #53 had abdominal wounds upon admission and were caused from moisture. -However, according to the facility admission skin assessment, Resident #53's she had a surgical incision on her left hip and scattered bruises on her upper extremities upon admission to the facility. The CWN said the wound physician had not been referred to see Resident #53's wounds, but she had referred the resident that week, during the survey process, since the wounds had gotten worse and were not healing. She said she observed Resident #53's wounds weekly. The CWN said she was notified from the floor nurse yesterday (11/20/24), that Resident #53's wound had deteriorated. She said she contacted the wound physician and received an order to culture one of the wounds. The CWN said her cleaning technique with the gauze was to move from clean to dirty and then discard the gauze. She said she had not realized she had used the same gauze up to eight times to wipe the wound. She said she should have changed the gauze in between each wipe to decrease the risk of infection. She said she should have changed her gloves in between each wound site to decrease the risk of infection. Primary care physician (PCP) #1 was interviewed on 11/21/24 at 11:55 a.m. PCP #1 said she was the PCP for Resident #53. PCP #1 said Resident #53's skin was clear from any wounds upon admission, except for the surgical incision. She said she observed the wounds on 10/25/24, but had not observed the wounds since because the wound nurse was following and she expected the wound nurse to provide her with updates. She said the NP was following the wounds more closely for this resident. She said she had not been informed Resident #53's wound had deteriorated to include eschar and slough. She said she would assume the wound physician ordered a wound culture because there was concern about a potential infection of the wound. She said she would have expected the CWN to have referred Resident #53's wounds to the wound physician sooner, who was an expert in that area. NP #1 was interviewed on 11/21/24 at 12:21 p.m. NP #1 said she was the NP for Resident #53. She said she had not directly observed Resident #53's abdominal wounds. She said she hated to take off the bandage to look at the wound because of Resident #53's pain and creating more work for the floor nurse. She said she had asked the CWN for pictures of the wounds. She said she was not informed Resident #53's wounds had deteriorated to include eschar and slough, just that they had increased in size. NP #1 said an increase in measurements did not necessarily mean the wounds were deteriorating. She said if she had been provided more information and informed of the eschar and slough, she would have acted differently, to ensure the wound physician was involved sooner. NP #1 said the presence of eschar and yellow slough meant the wound was deteriorating. She said that using the same gauze to wipe the wound multiple times could spread bacteria as well as not changing gloves, which had potential to lead to an infection. She also said that by not debriding the wound before getting a culture of the wound could potentially cause inaccurate test results. NP #1 said she was unaware the wound physician was not already following and involved in the wound care for Resident #53's abdominal wounds. The CWN was interviewed again on 11/21/24 at 4:32 p.m. The CWN said she was not concerned about Resident #53's abdominal wounds until yesterday (11/20/24), when the floor nurse informed her the wound had gotten worse. She said by the time she had been notified of the worsening of the wounds, the wound physician had already left for the day. The CWN said it was up to her discretion as to when a wound required the wound physician's expertise. She said the wound physician would see Resident #53's abdominal wounds next week.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure foods were appealing and palatable in temperature and seasoning. Findings include: I. Facility policy and procedure The Food Palatability policy and procedure, revised 8/22/22, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, Food and drink each resident receives and the facility provides foods prepared by methods that conserve nutritive value, flavor, and appearance. In addition, the food is palatable, attractive, and served at a safe and appetizing temperature. The dietary staff prepares foods according to the menu and recipes available in the dietary department. Foods are sampled daily by designated staff to ensure the taste and quality of the foods remain at a high level. Use of seasonings and proper cooking methods are followed to ensure the food is appealing and palatable. II. Resident interviews Resident #221 was interviewed on 11/18/24 at 9:30 a.m. Resident #221 said some of the food at the facility tasted okay. Resident #221 said she had received a thick slice of turkey for dinner that she could not even cut into, much less chew. Resident #224 was interviewed on 11/18/24 at 10:05 a.m. Resident #224 said the food at the facility was served cold and that he had yet to be served a hot meal. Resident #226 was interviewed on 11/18/24 at 10:13 a.m. Resident #226 said the food at the facility was not good. Resident #226 said the food at the facility was tasteless and that they served the same things over and over again. Resident #234 was interviewed on 11/18/24 at 10:19 a.m. Resident #234 said breakfast at the facility was always served cold. Resident #225 was interviewed on 11/18/24 at 11:14 a.m. Resident #225 said the food at the facility was bland. Resident #231 was interviewed on 11/18/24 at 11:21 a.m. Resident #231 said the food could be a bit warmer when served. Resident #53 was interviewed on 11/18/24 at 11:33 a.m. Resident #53 said the food served by the facility was not great. Resident #53 said the meat was very overcooked and the mixed vegetables seemed like they were microwaved too long. Resident #233 was interviewed on 11/18/24 at 1:42 p.m. Resident #233 said the food at the facility could be better and that it was served cold. Resident #232 was interviewed on 11/18/24 at 1:51 p.m. Resident #232 said the food at the facility was for the most part always cold and barely edible. Resident #232 said by the time the meals were served they were already cold. Resident #190 was interviewed on 11/18/24 at 2:04 p.m. Resident #190 said the food at the facility was cold and yucky. Resident #190 said it was especially cold if your room was at the last place on the delivery list. Resident #322 was interviewed on 11/18/24 at 2:20 p.m. Resident #322 said the food was awful when she first got to the facility. Resident #322 said her husband had to heat up her lunch in the microwave sometimes because the food arrived cold. Resident #322 said her coffee was rarely served hot and that the food was tepid in temperature. Resident #52 was interviewed on 11/18/24 at 3:25 p.m. Resident #52 said most of the meals at the facility were bland. Resident #52 said the meals at the facility were unseasoned. Resident #324 was interviewed on 11/18/24 at 3:44 p.m. Resident #324 said the food at the facility was served at room temperature. Resident #378 was interviewed on 11/18/24 at 3:48 p.m. Resident #378 said the food at the facility did not look good and that they had to have the staff reheat it a few times because it was served cold. Resident #126 was interviewed on 11/18/24 at 4:08 p.m. Resident #126 said he was not impressed with the food at the facility and that it did not taste right. Resident #388 was interviewed on 11/19/24 at 9:18 a.m. Resident #388 said their dinner a few days prior was a pork chop that was very thin and so overcooked and tough they could not eat it. Resident #388 said the pork chop hurt to chew. Resident #388 said they were supposed to be eating a lot of protein, and when they received protein that was inedible they were not able to have enough intake to help their wounds heal or help with their constipation issues. Resident #382 was interviewed on 11/19/24 at 10:27 a.m. Resident #125 said the quality of the meals at the facility had declined since his last stay. Resident #125 said the meals he received were barely warm. Resident #33 was interviewed on 11/19/24 at 10:30 a.m. Resident #33 said the food at the facility was not great and was served at room temperature. Resident #379 and their family member were interviewed on 11/19/24 at 1:42 p.m. Resident #379 ' s family member said the meals Resident #379 was served looked terrible and turned the resident ' s stomach. Resident #379 said she ordered over-easy eggs for breakfast but received overcooked and cold eggs. Resident #221 was interviewed a second time on 11/20/24. Resident #221 said her breakfast that morning was okay. Resident #221 said her eggs were so rubbery she could barely eat them. Resident #221 said eating the eggs was comparable to eating a rubber bouncy ball. III. Resident council minutes Resident council minutes, dated 11/11/24 at 2:00 p.m., revealed an unidentified resident reported the food at the facility lacked seasoning and that the portions of the desserts were too small. -However, there was no documentation that indicated these concerns were addressed by the facility staff. Resident council minutes, dated 10/7/24 at 2:00 p.m,. revealed an unidentified resident said the texture of the food at the facility was not good and that the food lacked flavor and seasoning. -However, there was no documentation that indicated these concerns were addressed by the facility staff. Resident council minutes, dated 9/9/24 at 2:00 p.m., revealed an unidentified resident said the food was sometimes served cold. -However, there was no documentation that indicated these concerns were addressed by the facility staff. Resident council minutes, dated 7/8/24 at 2:00 p.m., revealed an unidentified resident said the meal temperatures were sometimes cold. -Notes in the margins of the 7/8/24 resident council meetings revealed the facility staff recommended that the residents could have their food reheated. IV. Test tray observations A test tray for a regular texture diet was evaluated by six surveyors immediately after the last round of room trays were delivered at 12:37 p.m. The test tray consisting of beef fajitas served on a corn tortilla, fajita vegetables, refried beans, and cilantro lime rice: -The rice was overcooked. The rice had no flavor or seasoning and was gluey to chew. -The refried beans were dry in texture. -The beef was dry. The beef l had no seasoning or flavor. -The fajita vegetables were bland. -The tortilla was hard and gluey in texture. V. Staff interviews The executive chef (EC) was interviewed on 11/20/24 at 11:45 a.m. The EC said she was looking into getting different plate warmers, as the food was served hot on her line but was cold by the time it was served to the residents. The EC said some of the residents had complained about food temperature, especially with breakfast. The EC said she individually delivered meals for residents that complained about food temperature so the food had a chance of being served hot. The EC was interviewed a second time on 11/20/24 at 3:53 p.m. The EC said she only ever received complaints about the temperatures of the eggs served for breakfast. The EC said some of the residents had complained about the palatability of the food served at the facility because they wanted salt in their food and that they could not use salt in the food at the facility. The EC said the dietary staff did not really follow specific recipes but would look up recipes on their phones or find a recipe if their food provider had one. The EC said the plate warmers used at the facility were able to hold temperatures but that the EC was looking for better solutions. The EC said there were a few complaints about breakfast temperatures but said it was for no more than five residents. The EC said the food delivery carts were new and closed so there was less air-flow that could cool the food down. Certified nurse aide (CNA) #2 was interviewed on 11/21/24 at 12:23 p.m. CNA #2 said the dietary aides and a few other facility staff members usually came to help him pass out meal trays. CNA #2 said it only took a few seconds to get all of the meal trays on his hallway passed out when other staff members came to help, and even when it was only him passing out trays it still only took a few minutes. CNA #2 said some of the residents thought the food was very bland and would ask him to get them seasoning packets.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen; and, -Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators. Findings include: I. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, ([DATE]), were retrieved on [DATE] from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B. Facility policy and procedure The Use of Gloves/Hairnets/Covering of Food policy and procedure, revised [DATE], was received from the nursing home administrator (NHA) on [DATE] at 8:38 a.m. It revealed in pertinent part, Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. C. Observations During a continuous observation of the lunch meal service on [DATE], beginning at 10:30 a.m. and ending at 12:37 p.m. the following was observed: At 11:07 a.m. cook (CK) #1 retrieved a plastic bag containing heads of lettuce. With his bare hands, CK #1 reached into the plastic bag and grabbed the lettuce and put it onto the cutting board. CK #1 washed his hands, then using his bare hands held the lettuce as he cut it. CK #1 then used his bare hands to move the lettuce to a steam table bin. -The lettuce was placed into a steam table bin on the line and was added to the carnitas without any further washing or modification. At 11:09 a.m. dietary aide (DA) #1 was wearing a pair of gloves. With her gloved hands, DA #1 handled a plastic bag of bread and the buttons on a toaster. Using the same gloved hands, DA #1 pulled two pieces of bread out of the toaster. DA #1 grabbed the handle and opened the lid for the cold storage preparation area and retrieved several condiment packets. DA #1 squeezed the contents out of the condiment packets and used the same gloved hands to stabilize the pieces of toast while applying the condiments. With the same gloved hands, DA #1 retrieved the plastic bread bag and took out two more pieces of bread and put them in the toaster. With the same gloved hands DA #1 grabbed pieces of lettuce and put them on the toasted bread with the condiments applied. DA #1 repeated this process with several slices of tomato while wearing the same gloves. DA #1 then pressed buttons on the toaster with her gloved hand. DA #1 then used her gloved hands to sort through a plate of bacon, select several pieces, then put them on top of the lettuce and tomato. With the same gloved hands, DA #1 grabbed the pieces of bread out of the toaster and put them on top of the sandwiches. At 11:22 a.m. CK #1 was wearing a pair of gloves. Using his gloved hands, CK #1 retrieved a plastic bag of tortillas, opened it, and placed several tortillas onto the grill. Using the same gloved hand, CK #1 held the stack of tortillas as he took them off the grill and placed them into a steam table bin. At 11:34 a.m. CK #2 used his bare hand to grab a handful of lettuce and place it onto a plate containing pork carnitas. The executive chef (EC) told CK #2 to use tongs when performing that task. -However, the plate was still served. At 11:36 a.m. CK #1 used tongs to place two tortillas onto a plate. CK #1 then used his bare hands to separate the tortillas, then used his bare hand to stabilize the tortillas as he scooped beef into them. At 11:40 a.m. CK #1 was handling tongs and serving utensils with his bare hands. Using his same bare hands, CK #1 reached into a container of parsley, grabbed a pinch of the herb, and sprinkled it onto a plate containing mashed potatoes. CK #1 then used his bare hand to stabilize two tortillas on the same plate as he ladled pork into them. -CK #1 used his bare hands to sprinkle herbs onto several plates prepared during the lunch service. At 11:51 a.m. CK #2 donned (put on) a pair of gloves. Using his gloved hands, CK #2 used tongs and serving utensils. CK #2 used the same gloved hands to grab lettuce and shredded cheese and put them onto a plate containing carnitas. CK #2 then used the same gloved hands to adjust two halves of a grilled cheese sandwich on a plate prior to setting it into the window to be served. At 12:01 p.m. a pea sized amount of mashed potatoes landed on the bare forearm of CK #1. Using his bare hands, CK #1 grabbed the piece of mashed potatoes and flung it back into the steam table bin of mashed potatoes. At 12:08 p.m. CK #2 donned a pair of gloves and retrieved a plastic bag of bread. Using his gloved hands, CK #2 opened the bag of bread, grabbed two pieces of bread and put them onto a cutting board. CK #2 grabbed a knife that was previously used to cut fish, retrieved a towel from a sanitizer bucket, and wiped the knife off. Using the same gloved hands, CK #2 opened several packets of peanut butter and held the pieces of bread to stabilize them as he spread peanut butter onto the bread with the knife. Using the same gloved hands, CK #2 pressed the two pieces of bread together. At 12:11 p.m. CK #1 used his bare hands to handle serving utensils. Using the same bare hands, CK #1 reached into the container of shredded cheese and sprinkled it onto the pork carnitas. At 12:16 p.m. the EC was wearing a pair of gloves and handling serving utensils and the lid to a pot. Using the same gloves, the EC grabbed two pieces of toast out of the toaster and set them onto a plate. At 12:18 p.m. CK #2 was wearing gloves and handling serving utensils and tongs. Using the same gloved hands, CK #2 grabbed a handful of shredded lettuce and placed it onto pork carnitas. CK #2 used the same gloved hands to repeat this process with shredded cheese. At 12:19 p.m. CK #1 was handling serving utensils and tongs with his bare hands. Using his bare hands, CK #1 grabbed a stack of five plates and laid them out along the food service line. CK #1 then placed the entirety of his bare hand onto the top of one of the five plates prior to putting food onto the plate and serving it. At 12:21 p.m. CK #2 took the same knife that was used to cut cooked fish and spread peanut butter onto bread and wiped the knife with the same rag that was used to wipe the knife prior. CK #2 then used the knife to cut a veggie burger into bite-sized pieces. -The towel had been left on the counter between uses and had not been replaced in the sanitizer bin. D. Staff interviews The EC was interviewed on [DATE] at 11:45 a.m. The EC said the dietary staff were not allowed to use gloves during food service. The EC said she told her dietary staff not to use gloves. The EC said she told CK #2 to wear gloves if that was what felt more comfortable for him but that CK #2 needed to change his gloves whenever he left the food service line. The EC was interviewed a second time on [DATE] at 3:53 p.m. The EC said ready to eat foods should be handled with clean gloves and only after hands had been washed. The EC said gloves should only be used for one task before being changed. The EC said whenever the dietary staff left the line they needed to remove their old gloves and perform hand hygiene before donning new gloves. II. Failed to store food items correctly in the refrigerators A. Professional reference The Colorado Retail Food Establishment Regulations, ([DATE]), were retrieved on [DATE] from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (F)) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. B. Facility policy and procedure The Kitchen Sanitation policy and procedure, revised [DATE], was received from the NHA on [DATE] at 8:38 a.m. It revealed in pertinent part, The staff shall maintain the sanitation of the kitchen through compliance with an established cleaning schedule. Cleaning and sanitation tasks for the kitchen will be defined. Frequency of cleaning for each task will be defined. C. Observations On [DATE] at 8:50 a.m. an initial tour of the kitchen revealed the following in the refrigerator by the food service line: -A pitcher of tea, unlabeled and undated; -A pitcher of fruit punch, dated [DATE]; -A cup of juice, dated [DATE]; and, -A boat shaped reusable container with meat in it, unlabeled and undated. At 4:48 p.m. observations of the nourishment refrigerator on the 200 unit revealed the following: -An open carton of milk with a name written on it, with an expiration date of [DATE]; -A carton of yogurt, with an expiration date of [DATE]; -A container with an apple-based dessert with a room number written on it but no date; and, -A container of noodles with a room number and resident name but no date. At 4:52 p.m. observations of the nourishment refrigerator on the 300 unit revealed the following: -A milk carton, with an expiration date of [DATE]; -A milk carton, with an expiration date of [DATE]; -A protein shake, with an expiration date of [DATE]; -A protein shake, with an expiration date of [DATE]; -A protein shake, with expiration date of [DATE]; -Two yogurt containers, with an expiration date of [DATE]; -A bowl of an unidentified food substance, dated [DATE]; -A container of food from a fast food restaurant , unlabeled and undated; -A cup of juice, unlabeled and undated; -A cup of milk, unlabeled and undated; -A container of ranch, dated [DATE]; -A container of red liquid, dated [DATE]; -A bottle of lemon juice, with an expiration date of [DATE]; and, -A packet of sour cream, with an expiration date of [DATE]. -The freezer had a foul odor. On [DATE] at 10:25 a.m., the nourishment refrigerator on the 300 unit was reviewed again. The same contents listed above remained in the refrigerator. During the observation period, an unidentified resident and unidentified staff member were walking by. The resident said it smelled like something died in the freezer. The staff member then replied to the resident and said they needed to clean it out more. D. Staff interview The EC was interviewed on [DATE] at 9:05 a.m. The EC said the pitcher of tea was hers from that morning. The EC said the boat shaped container was the staff's personal food from yesterday. The EC said the staff brought in food every Sunday to share among the staff. The EC said she told her staff to make sure they took their personal food containers home with them but they had forgotten it. The EC said the pitchers of juice were good for seven days once prepared, so the [DATE] and [DATE] containers needed to be thrown out. The EC was interviewed a second time on [DATE] at 3:53 p.m. The EC said the nourishment refrigerators were cleaned out twice a week on both units by the dietary staff. The EC said the process for cleaning out the refrigerators was to throw away any food without a name or date on it. The EC said the third floor refrigerator was last cleaned out the Tuesday ([DATE]) prior to observations taking place, and the second floor refrigerator was cleaned out that Wednesday ([DATE]) prior to observations taking place. The EC said food items prepared by the facility needed to be thrown out three days after the date written on them.

Based on observations, record review and interviews, the facility failed to develop and implement an effective discharge plan for nine (#376, #378, #380, #371, #388, #382, #10, #185 and #225) of 10 residents reviewed for discharge planning out of 60 sample residents. Specifically, for Residents #376, #378, #380, #371, #388, #382, #10, #185 and #225, the facility failed to: -Ensure residents and their representatives were involved in the development of the discharge plan; -Ensure the discharge plan of care was updated with the residents' discharge goals; and, -Ensure the discharge planning process was documented in the residents' electronic medical records (EMR). Findings include: I. Facility policy and procedure The Admissions, Readmission, Transfers, and Discharge Process policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part, It is the policy of this facility to permit each resident to remain in the facility, and not mandate a transfer out of the facility or discharge for the resident from the facility, except in limited circumstances. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be provided at the facility or the mandated transfer out of the facility or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Staff involved in the move in, transfer and move out process will ensure that the focus is the resident and their family and their needs and concerns. II. Resident #376 A. Resident status Resident #376, age 76, was admitted on [DATE]. According to November 2024 computerized physician orders (CPO), diagnoses included encounters for other orthopedic aftercare, difficulty in walking, muscle weakness and right and left foot drop. The 11/13/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status (BIMS) score of 12 out of 15. She required maximum assistance with all activities of daily living (ADL). B. Resident interview and observation Resident #376 was interviewed on 11/18/24 at 4:03 p.m. Resident #376 said she was visiting from another state when she ended up in the hospital for lumbar surgery. She said she had not received any communication regarding discharge planning. She said she felt she was forced to stay at the facility until the case manager deemed she was able to go home. She said she had not received any communication from the case manager since she was admitted to the facility. On 11/20/24 at 10:19 a.m., Resident #376 and certified occupational therapy assistant (COTA) #1 were in Resident #376's room. Resident #376 told COTA #1 that she was being discharged but she had not received any information. COTA #1 asked Resident #376 if she had received a Notice of Medicare Non-Coverage (NOMNC) and Resident #376 responded she had not received anything. COTA #1 told the resident she had not been told the resident was discharging and would go find out more information. Resident #376 refused therapy saying she was being discharged . C. Record review The discharge care plan, initiated 11/11/24, documented Resident #376 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #376's specific discharge goal or include any revisions or updates. The 11/18/24 physician's progress noted documented the resident's discharge date was to be determined. The 11/20/24 daily skilled nursing progress note documented Resident #376 had a projected discharge date of the following week. -However, a review of the resident's EMR did not reveal documentation of an active discharge planning process. Resident #376 was discharged on [DATE]. III. Resident #378 A. Resident status Resident #378, age 80, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included difficulty in walking, muscle weakness, infection and inflammatory reaction due to internal right knee prosthesis, sepsis due to methicillin resistant staphylococcus aureus (MRSA) and adjustment disorder with mixed anxiety and depressed mood. The 10/30/24 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status score of nine out of 15. She required substantial to maximum assistance with all (ADLs. B. Resident interview Resident #378 was interviewed on 11/18/24 at 3:48 p.m. Resident #378 said the facility had not discussed discharge plans with her. She said she had concerns about getting to out-patient physical therapy because she did not have any transportation. She said she had not been informed of any potential options for once she went home from the facility. She said she had not received any communication from the case manager since her initial care conference the first week she was admitted . C. Record review The discharge care plan, initiated 11/11/24, documented Resident #378 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #378's specific discharge goal or include any revisions or updates. -The daily nursing progress notes from 11/5/24 to 11/20/24 did not reveal documentation of any active discharge planning for Resident #378. -A review of the resident's EMR did not reveal documentation of an active discharge planning process. IV. Resident #380 A. Resident status Resident #380, age 76, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included aftercare following joint replacement surgery and presence of artificial knee joint, bilateral The 11/18/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance with ADLs. B. Resident interview Resident #380 was interviewed on 11/19/24 at 11:41 a.m. Resident #380 said she had not received any communication regarding her discharge plan or options for when she returned home. She said she felt like she was at the facility until they decided she could go home and she did not have any input. Resident #380 was interviewed again on 11/21/24 at 11:13 a.m. Resident #380 said a case manager came into her room and had her sign a document indicating she would be discharging on 11/22/24. She said prior to this meeting, she had not received any information or updates on her discharge status. C. Record review The discharge care plan, initiated 11/11/24, documented Resident #380 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #378's specific discharge goal or include any revisions or updates. The 11/18/24 physician progress note documented Resident #380's discharge date was to be determined. The 11/20/24 social services progress note documented a NOMNC was issued to the resident on 11/20/24 for a planned discharge of 11/23/24. -However, a review of the resident's EMR did not reveal documentation of an active discharge planning process since her admission. V. Resident #371 A. Resident status Resident #371, age 77, was admitted on [DATE]. According to the November 2024 CPO, diagnoses aftercare following joint replacement surgery, presence of left artificial knee, muscle weakness and post hemorrhagic anemia. The 11/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required moderate assistance with upper body activities and is dependent for walking/transfers that require lower body function. B. Resident and resident's representative interview Resident #371 and the resident's representative were interviewed together on 11/21/24 at 10:12 a.m. Resident #371 said her goal was to return home when she was ready. She said she had not received any communication since her admission regarding her discharge planning until two days prior, when the facility had her sign a document that indicated she was discharging. Resident #371's representative said they did not know if she was ready to return home, so he hired a private caregiver to assist with caring for the resident's ADLs. C. Record review The discharge care plan, initiated 11/3/24, documented Resident #371 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #371's specific discharge goal or include any revisions or updates. The 11/20/24 daily skilled nursing progress note documented there was no projected discharge date for Resident #371. However, the 11/20/24 social services progress note documented a NOMNC was issued to Resident #371 on 11/20/24 with the appeal rights explained. -Additionally, a review of the resident's EMR did not reveal documentation of an active discharge planning process. VI. Resident #388 A. Resident status Resident #388, age 80, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, morbid obesity, bilateral primary osteoarthritis and difficulty in walking. The 11/17/24 24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance with ADLs. B. Resident interview Resident #388 was interviewed on 11/19/24 at 9:12 a.m. Resident #388 said she had concerns regarding her discharge process. She said she was told when she was first admitted to the facility that she would be at the facility for two to three weeks. She said it had been two weeks since her admission and she had yet to receive any communication regarding her progress and discharge plan. Resident #388 said she was concerned about discharging home because she lived alone and her home was not set up for wheelchair access, as she was currently confined to a wheelchair. She said she did not have any assistance at home and had not been given any information or options for help when she did return home. C. Record review The discharge care plan, initiated 11/5/24, documented Resident #388 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #388's specific discharge goal or include any revisions or updates. -The nursing progress notes from 11/5/24 to 11/20/24 did not reveal documentation of discharge planning. -A review of the resident's EMR did not reveal documentation of an active discharge planning process. VII. Resident #382 A. Resident status Resident #382, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included fracture of left femur, history of falls, muscle weakness and gout. The 11/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required maximum assistance with all ADLs. B. Resident interview Resident #382 was interviewed on 11/18/24 at 4:52 p.m. Resident #382 said she had not received any communication about discharge planning since her admission to the facility. She said all she thought about was going home, but she did not know where she stood in that process. C. Record review The discharge care plan, initiated 11/3/24, documented Resident #382 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #388's specific discharge goal or include any revisions or updates. -A review of the resident's EMR did not reveal documentation of an active discharge planning process. VIII. Staff interviews COTA #1 was interviewed on 11/20/24 at 1:29 p.m. COTA #1 said the therapy team was not aware of the discharge for Resident #376. She said the therapy department felt she had not progressed enough and was not ready to discharge from the facility. She said the ankle foot orthosis (AFO - medical device that supports the foot and ankle) had not been delivered yet and was needed in order for Resident #376 to discharge safely. She said they were working on re-routing the AFO to the resident's home instead of the facility. Case manager (CM) #2 was interviewed on 11/21/24 at 3:46 p.m. CM#2 said she met with each resident she was assigned within three to five days of their admission to the facility. She said the meeting was required at the facility and was called the admission care conference. She said during the meeting, she explained her role, the discharge planning process and discussed any equipment needs of the resident. She said discharge planning should begin on the first day of each resident's admission to the facility and should be documented. She said she was responsible for issuing a NOMNC letter when the resident was ready for discharge, according to the interdisciplinary team (IDT). CM #2 said she did not document any active discharge planning in the resident's EMR. She said she kept it on a log in a binder on her desk. She said each resident had notes regarding their progress with therapy, but did not contain any documentation where the resident and/or family were spoken with or apprised of each resident's progress and movement toward discharge. She said her notes contained updates from the therapy department. She acknowledged updates from the therapy department did not show active discharge planning. CM #2 confirmed Resident #380 was issued a NOMNC. She said she could not recall if she had met with the resident or done any active discharge planning prior to the NOMNC being issued. CM#2 said she had not met with Residents #376, #388 and #382 to discuss any discharge planning. CM #1 and the director of nursing (DON) were interviewed together on 11/21/24 at 4:05 p.m. CM #1 said discharge planning was only documented on a log she kept in her office and not in the residents' EMRs. She said she was not required to document anything in the residents' EMRs other than the NOMNCs being issued and care conference notes. CM#1 said she was not responsible for developing the discharge care plan and making revisions throughout the resident's stay at the facility. She confirmed she was responsible for discharge planning for assigned residents at the facility. She said she was not responsible for identifying barriers for a resident's discharge. CM#1 said she had not met with or discussed resident progress or discharge planning with Resident #378 and #371 since their initial care conferences. 51163 IX. Resident #10 A. Resident status Resident #10, age 80, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included fracture of the T9-T10 (thoracic) vertebra, bipolar disorder and Parkinson's disease. The 11/1/24 MDS assessment revealed that the resident was cognitively intact with a BIMS score of 14 out of 15. She required partial assistance with most of her activities of daily living (ADL) and was dependent on staff for bathing and lower body dressing. The assessment indicated the resident's overall goal was to be discharged back into the community or to go back home. B. Resident interview Resident #10 was interviewed on 11/18/24 at 10:50 a.m. Resident #10 said she had asked the facility staff several times if she could go home. She said the facility staff seemed more interested in completing physical therapy, however, she was admitted because of clostridioides difficile (C-diff - a bacteria that causes diarrhea). She said the case manager told her she would not be able to go home until she could dress herself, shower herself and go to the bathroom by herself. She said she lived at home with her spouse and son who had been assisting her with all of her ADLs for a long time. Resident #10 said she told the case manager she would not be able to do all those things by herself because she had Parkinson's disease. She said the case manager seemed kind of cold and she felt the case manager thought she was lazy. Resident #10 was interviewed a second time on 11/20/24 at 9:53 a.m. Resident #10 said the facility staff had not updated her on her discharge plan or how she was progressing toward her discharge goals. She said no one would give her a straight answer and she felt like a prisoner at the facility. She said the case manager seemed angry when she told her that she wanted to go home. She said she did not think the case manager fully understood that she would never be fully independent because of her Parkinson's disease. Resident #10 was interviewed a third time on 11/20/24 at 3:13 p.m. with a family member present. Resident #10 said the facility held a care conference the first week she was at the facility, but she could not remember what was discussed. She said she was under the impression she would be discharged on ce the C-diff was no longer an issue. Resident #10's family member said he had not been apprised of the progress that had been made toward the resident's discharge. He said he was given a folder of papers upon her admission to the facility, but no one ever explained the discharge process. The family member said he went and spoke to the case manager and she said she would let him know what was going on but he said she had never followed up with him. Resident #10's family member said the facility had not done any discharge planning that he was aware of and he felt like the facility was keeping Resident #10 at the facility for the insurance money. He said Resident #10 had not been able to do any ADLs on her own for the last twenty years due to her diagnosis of Parkinson's disease. Resident #10 said she felt intimidated by the case manager because she was the one who controlled when she got to go home. C. Record review The discharge care plan, revised 11/19/24 (during the survey process), documented Resident #10 wanted to be involved in her discharge planning. The interventions included communicating with the resident as needed related to progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and encouraging the resident to make an effort toward achieving their goals. -Prior to the care plan being updated on 11/19/24, which was during the survey process, there were no new goals or interventions added to the care plan since 10/25/24, the date of the resident's admission. -The discharge care plan did not include Resident #10 lived at home with her spouse and son who provided assistance with her ADLs or any person-centered interventions or barriers to her discharge. The 10/28/24 discharge progress note documented Resident #10's plan for discharge was to increase her strength, mobility and ADL participation and return to her home with her spouse. The 10/29/24 discharge progress note documented the facility conducted a care conference. It documented the resident was welcomed to the facility and the discharge planning process was reviewed and a copy of her medications and care plan were given to the resident. It documented that case management would monitor for changes and needs and provide additional support throughout her stay. The review of the care plan summary revealed that the interdisciplinary team (IDT) met weekly to discuss and assess the progress of the resident's physical and medical status in determining the resident's date of discharge. -However, the resident's electronic medical record (EMR) did not reveal any documentation of the IDT meetings or the progress that the resident was making towards discharge. -The EMR failed to include any documentation that the resident and her family were involved in the discharge planning process or that a discharge planning process had occurred since Resident #10's admission to the facility. -The EMR did not reveal documentation that the resident's discharge goals had been identified and developed throughout her stay at the facility. D. Staff interviews CM #1, the DON and the chief operations officer (COO) were interviewed together on 11/21/24 at 3:05 p.m. CM #1 said she kept all the discharge documentation on the residents she was assigned to in a binder that was kept in her office. She said the documentation contained updates from therapy on each resident's progress. She said each time she documented in the binder did not mean she had met with the resident and/or their family to discuss their discharge progress, just that she had written down what the therapy department had communicated. CM #1 said Resident #10 had not had a formal care conference since her admission to the facility. She said she had not documented any of her interactions with the resident or her family. The COO said that he did not think anyone would tell a resident they could not go home if they were unable to complete certain ADLs. The COO said, based on the assistance level Resident #10 and her family described, he did not see any difference between her prior level of function and her current level of function. CM#1 said she had not met with Resident #10 or her family to discuss her discharge planning. She said she would be meeting with them tomorrow (11/22/24) because therapy had set a discharge date that day (11/21/24) to issue the notice of medicare non-coverage (NOMNC). CM #1 said discharge planning should occur prior to the NOMNC being issued. 47064 X. Resident # 185 A. Resident status Resident #185, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included right knee prostheses complication (artificial knee), vascular access device (device to access the blood vessel), dysphagia (difficulty swallowing) and hypertension (high blood pressure). The 11/11/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required partial staff assistance with toileting, dressing and transfers. She was independent with eating.The resident was on antibiotics intravenous (IV) medications. The assessment revealed the resident wanted to be discharged to the community B. Resident interview Resident #185 was interviewed on 11/18/24 at 11:36 a.m. Resident #185 said she was very concerned about her stay in the facility because she required at least six weeks of IV antibiotic treatment and no one had discussed with her what would happen if the insurance company did not allow her to stay in the facility that long. Resident #185 expressed financial concerns if her insurance did not cover her whole stay for the duration of her IV treatment. Resident #185 said her husband and son had been trying to communicate with the insurance company about her coverage and they had not been able to get any information on what could happen. Resident #185 said she was not able to care for IV lines and administer IV medication at home because it was a complicated system. Resident #185 said no one in the facility had discussed her discharge planning with her since her admission on 11/4/24 when they asked her what her plan was for discharge. She said her plan was to return home. C. Record review -Review of the 11/4/24 comprehensive care plan did not reveal a discharge planning care area focus for Resident #185. The care conference note dated 11/7/24 revealed the resident's discharge plan was to return home with her husband and son. The note indicated Resident #185 had 17 steps to go upstairs in her home. A social service note dated 11/7/24 revealed a care conference was held on 11/7/24. The note indicated the case manager discussed the resident and family discharge planning process, services and guidelines. -However, Resident #185 said she did not know what was occurring with her discharge plan (see resident interview above). D. Staff interview Case manager (CM) #1 was interviewed on 11/21/24 at 3:04 p.m. CM #1 said she did not document discharge planning in the residents' electronic medical records (EMR). CM #1 said she only documented the initial care conference with residents and when a Notice of Medicare Non-Coverage (NOMNC) was given. CM #1 said Resident #185's plan was to discharge home with her husband and son but she needed to work therapy to ensure she could manage the 17 stairs within her home. CM #1 said she had not discussed any discharge planning, such as home health services, with Resident #185. CM #1 said she had not given Resident #185 any information about her discharge. 50219 XI. Resident #225 A. Resident status Resident #225, age 71, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included surgical aftercare and local infection of the skin and subcutaneous tissue. The 11/5/24 brief interview for mental status (BIMS) assessment revealed the resident was cognitively intact with a score of 15 out of 15. B. Resident interview Resident #225 was interviewed on 11/20/24 at 2:37 p.m. Resident #225 said she had met the day prior (11/19/24) with her insurance representatives to discuss her discharge and she was going to discharge home from the facility on 11/24/24. Resident #225 said the facility staff had been coming in recently to talk to her about her upcoming discharge, and the occupational therapist had just been in to speak with her. -However, there was no documentation in Resident #225's EMR regarding updates to her discharge or changes in her discharge plan. C. Record review The discharge care plan, initiated 11/2/24 and revised 11/3/24, revealed Resident #225 established appropriate goals for herself and wanted to be involved in her discharge planning. Pertinent interventions included communicating with the resident as needed related to progress, goals and plans, contacting appropriate community agencies as needed when the resident was ready to discharge and encouraging the resident to make an effort toward achieving their goals. A progress note dated 11/7/24 at 2:42 p.m. revealed a care conference had been completed with Resident #225, her family, the therapy team and Resident #225's case manager. The care conference notes revealed the team discussed discharge planning, processes, services and guidelines. The progress note documented a copy of Resident #225's medications and her care plan were provided to the resident. A progress note dated 11/21/24 at 4:32 p.m. revealed on 11/19/24 the case manager discussed with Resident #225 and her family that a discharge date had been set by her insurance company. The case manager confirmed with Resident #225 that she would be discharging home with her family member and that the nursing staff would educate the resident and her family on how to administer intravenous (IV) medications and management of the indwelling IV line. The case manager told Resident #225 that home health services had been set up for her and a new wound vacuum had been ordered for her. -However, the progress note note was not added to Resident #225's EMR after the interview with the case manager on 11/21/24, two days after the discharge discussion with Resident #225. (see interview below). -Review of the care plan and Resident #225's EMR did not reveal any further documentation related to discharge planning or discussion of the discharge plan with the resident. D. Staff interviews The DON and CM #2 were interviewed together on 11/21/24 at 1:42 p.m. CM #2 said Resident #225 was going to discharge on 11/24/24. CM #2 said the facility conducted caregiver training with Resident #225's spouse and the nursing staff did IV training for the resident. CM #2 said Resident #225 was discharging home with a wound vacuum and an IV line and was to receive home health services. -However, there was no documentation in Resident #225's EMR regarding the caregiver training for the resident's spouse or the IV training conducted by the nursing staff (see record review above). CM #2 said the facility staff had a care conference with Resident #225 on 11/7/24. CM #2 said she had talked with Resident #225 on 11/19/24 and 11/21/24. CM #2 said she had discussed with Resident #225 the wound vacuum the facility had ordered, the home health services the facility had arranged and the training the resident's husband would receive. CM #2 said she had documented these conversations in a binder. XII. Facility follow up On 11/22/24 at 11:29 a.m., the NHA provided the logs for CM #1 and CM #2 for Resident #378, #376, #225, #388, #380, #10 and #382. -A review of the logs revealed therapy information on each resident's functional status but no discharge planning or coordination/communication with residents and or their representatives. -The information was not documented in the EMR.

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 diseases and infection on one of three units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) in COVID-19 positive resident rooms; -Ensure proper infection control practices were followed for wound care; -Identify an effective process to ensure staff were aware of which residents required enhanced barrier precautions (EBP); and, -Ensure staff wore the appropriate PPE for residents on EBP. Findings include: I. Failure to ensure staff wore the appropriate personal protective equipment (PPE) in COVID-19 positive resident rooms A. Professional reference According to the Center for Disease Prevention and Control (CDC) Infection control Guidance: SARS-CoV-2, (9/23/22) retrieved on 11/26/24 from https://www.cdc.gov/covid/hcp/infection-control/, Healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (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). 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 On 11/18/24 at 8:54 a.m. an unidentified housekeeper entered Resident #32's room. Resident #32 was on isolation precautions for COVID-19. The unidentified housekeeper was wearing a surgical mask. -The unidentified housekeeper did not put on a N95 mask, gown, gloves, or protective eyewear prior to entering Resident #32's room. On 11/20/24 at 2:52 p.m. a bin containing PPE was sitting outside the doorway to Resident #32's room. There were three signs on the resident's door. The first sign identified the room as requiring droplet precautions and instructed everyone entering the room to sanitize their hands and wear masks and face shields. The second sign said EBP and instructed everyone to sanitize their hands when entering the room and providers and staff must also wear a gown, gloves, mask and face shield when providing care. The third sign was a stop sign which instructed people to check with the nurse before entering the room. On 11/20/24 at 4:50 p.m. an unidentified certified nurse aide (CNA) put on a N95 mask, gown and gloves and delivered Resident #32's dinner tray. -The unidentified CNA did not perform hand hygiene or put on protective eyewear prior to entering the resident's room. On 11/20/24 at 5:57 p.m. a visitor was walking down the hallway and stopped at Resident #32's room. The visitor turned and spoke with registered nurse (RN) #4. RN #4 informed the visitor that Resident #32 was still on isolation precautions until the next day (11/21/24). The visitor proceeded to enter Resident #32's room without applying PPE. -RN #4 failed to educate the visitor on the appropriate PPE and precautions that should be taken when entering Resident #32's COVID-19 positive room. C. Staff interviews Housekeeper (HSK) #1 was interviewed on 11/19/24 at 11:18 a.m HSK #1 said housekeepers were to wear PPE, including gloves, gown, mask when cleaning a COVID-19 positive room or any room with isolation precautions. HSK #1 said it was important to wear PPE to protect the residents and to protect herself/staff. The infection preventionist (IP) was interviewed on 11/21/24 at 3:39 p.m The IP said COVID-19 was considered to be droplet transmission. The IP said droplet transmission meant the virus had to be inhaled to be transmitted to someone else and it could not be picked up off a surface. The IP said housekeepers were to wear PPE when cleaning rooms when residents were on droplet or contact isolation precautions in order to prevent the spread of an infection. 51163 II. Failure to ensure proper infection control procedures were following during wound care A. Observations On 11/21/24 at 8:40 a.m. the CWN and the DON were observed providing Resident #53's wound care and dressing change. The CWN cleared off the resident's bedside table, wiped it down with a disinfectant wipe, applied a barrier pad and placed her bag of resident wound care supplies on top. The DON placed a clean chucks pad (disposable absorbent pad) under the resident's abdominal fold but below the wounds. Three dressings were observed on the resident, one on the right, one in the middle and one on the left. All of the dressings had the date 11/20/24 with a nurse's signature. Both the DON and the CWN completed hand hygiene and put on clean gloves. The CWN removed all three dressings. The right and left wounds had moderate serosanguineous drainage (a thin watery fluid), the middle wound had a small amount of bloody drainage. The wound on the right was the largest of the three wounds. It was noted to have a ring of redness around it and the center had 20% eschar and 10% yellow slough (dead tissue). The remaining tissue was red and it had no odors. The middle wound was the size of a nickel and had red tissue throughout and did not have an odor. The wound on the left was noted to be about the size of a quarter and had 80% slough and 20% red tissue and did not have an odor. The CWN changed her gloves to set up her supplies for the wound care. She set up a stack of gauze, a spray can of saline solution and a lidocaine (used for pain control) spray. She started with the left wound by taking one gauze, sprayed it with saline and wiped the wound. She folded over the gauze and wiped the wound bed again three times with the same piece of gauze. The wound was observed with bloody drainage. The CWN threw the gauze away, and with her dirty glove, touched the saline bottle and then re-sprayed all three wounds with lidocaine per the resident's request due to pain. -The CWN did not change gauze pads after each wipe of the wound. -The CWN did not change her gloves or perform hand hygiene after cleaning the left wound, which had bloody drainage, and before picking up the saline and lidocaine spray bottles. Using the same dirty gloves, the CWN took another piece of gauze, sprayed it with the saline solution and moved to the middle wound. She wiped the wound bed twice with the same piece of gauze. The CWN moved to the wound on the right and wiped the wound bed three times with the same piece of gauze. She collected a second piece of gauze, moistened it with saline and wiped eight times over the wound. She disposed of that piece of gauze, took another piece of gauze, moistened it with saline solution and proceeded to wipe six more times over the wound bed. She disposed of the piece of gauze, grabbed another and dabbed the area three times due to bloody drainage. She threw away the gauze, changed her gloves and performed hand hygiene. The CWN used the same dirty gloves throughout the entire process. -The CWN did not change her gloves and perform hand hygiene after cleaning the left wound and before proceeding to clean the middle wound. -The CWN did not change gauze pads after each wipe of the wound. -The CWN did not change her gloves or perform hand hygiene after cleaning middle wound, which had bloody drainage, and before picking up the saline and lidocaine spray bottles. The CWN then conducted a wound culture to the right wound based on the wound physician's recommendation. She took only the culture tubing out of the sterilized package. She swabbed the right wound. She did not perform debridement of the wound prior to the wound culture. She inserted the sample into the test tube, closed it and used a resident label, placing it directly over the test tube so the sample could be identified. The CWN changed her gloves and performed hand hygiene. She started on the left wound, using gauze and saline to wipe the wound bed, applied skin prep to the peri-wound and cut calcium alginate (highly absorbent dressing) sheet to size and applied it. She applied medihoney (type of antimicrobial gel) and covered the wound with a border foam dressing. Using the same gloves, the CWN moved to the middle wound and used a saline-soaked gauze to wipe the wound four times. using the same gauze to apply the skin prep to the peri-wound. She cut another piece of calcium alginate and medihoney and applied both to the resident's wound and covered it with the foam dressing. Using the same gloves, the CWN moved to the right wound, using saline soaked gauze, she wiped the wound four times with noted serosanguinous drainage coming out of the wound as she applied skin prep. She measured the right wound which was 3.5 cm (centimeters) length by 9 cm width by 0.1 cm depth and said the wound was larger than last week. She took calcium alginate and medihoney and applied it to the wound and covered it with a foam dressing. -The CWN did not change her gloves or perform hand hygiene in between performing the treatment for each wound. All supplies were cleaned up, trash was removed, PPE was doffed and hand hygiene was performed by all parties prior to leaving the room. B. Staff interviews The CWN was interviewed on 11/21/24 at 9:11 a.m. The CWN said her cleaning technique with the gauze was to move from clean to dirty and then discard the gauze. She said she did not realize she had used the same gauze up to eight times to wipe the wound bed. She said the gauze should be changed in between each wipe to decrease the risk of infection. She said gloves should be changed in between each wound. She said she should have changed her gloves in between each wound site to decrease the risk of infection. NP #1 was interviewed on 11/21/24 at 12:21 p.m. NP #1 said the presence of slough in a wound could mean a wound had a potential infection. She said using the same gauze to wipe the wound multiple times could spread bacteria throughout the wound. She said not changing gloves in between cleaning each wound had the potential to spread a possible infection to the other wounds. The IP was interviewed on 11/21/24 at 3:39 p.m. The IP said each piece of gauze used to clean wounds should only be used for one wipe over the wound to prevent the spread of infection. The IP said the CWN should have changed her gloves between each wound site to prevent the spread of infection from one site to another. 50219 III. Failure to identify an effective process to ensure staff were aware of which residents required EBP and ensure staff wore appropriate PPE for residents on EBP A. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 11/25/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions policy and procedure, dated 3/27/24, was received from the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It read in pertinent part, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. Per the CDC, EBP are recommended (when contact precautions do not otherwise apply) during high-contact care activities with residents who are at higher risk of acquiring or spreading an MDRO. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Residents with MDROs, wounds, or indwelling medical devices will be placed on proper precautions when at the facility. Residents will be put on EBP when contact precautions do not otherwise apply. EBP involves staff utilizing gown and gloves during specified high-contact activities with the resident. Residents are not restricted to their room and can participate in group activities. EBP are intended to be in place for the duration of a resident's stay in the facility or until a resolution of wound or discontinuation of the indwelling medical device that placed them at higher risk. EBP are required for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO during high contact activities, including wounds that are chronic with drainage, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. High contact care activities: EBP include use of gown and gloves during the high contact patient care activities, including dressing, bathing/showering, transferring, when working with patients in the therapy gym that need mobility assistance and/or transfers that require a longer duration, providing hygiene, changing linens, changing briefs or assisting toileting and with device care or use of a central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care. C. Resident #225 1. Observations On 11/19/24 at 9:57 a.m. RN #2 entered Resident #225's room. Resident #225 was receiving antibiotics via a peripherally inserted central catheter (PICC) line. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). RN #2 donned gloves after entering the room, flushed Resident #225's PICC line with normal saline, disconnected the PICC line, wiped the connection points on the PICC line and removed her gloves. -RN #2 did not don a protective gown prior to performing care of Resident #225's PICC line -On 11/19/24 at 2:06 p.m. an EBP sign was observed on Resident #225's door and a bin containing PPE had been placed outside the resident's room. 2 Resident interview Resident #225 was interviewed on 11/19/24 at 9:55 a.m. Resident #225 said the nurses at the facility wore gloves to connect and disconnect her PICC line. Resident #225 said the nurses at the facility did not wear gowns when they handled her PICC line. D. Resident #231 1. Observations On 11/19/24 at 10:08 a.m. RN #2 entered Resident #231's room. Resident #231 had a PICC line and a wound vacuum (a treatment device that uses suction to help wounds heal). -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). RN #2 performed hand hygiene and donned gloves after entering the room, flushed Resident #231's PICC line with normal saline, disconnected the PICC line, wiped the connection points on the PICC line and removed her gloves. RN #2 offered to hold Resident #231's wound vacuum as the resident readjusted in bed. -RN #2 did not don a protective gown prior to performing care of Resident #231's PICC line or while holding the wound vacuum. -On 11/19/24 at 2:06 p.m. an EBP sign was observed on Resident #231's door and a bin containing PPE had been placed outside the resident's room. E. Resident #40 1. Resident observation and interview On 11/20/24 at 8:52 a.m. Resident #40 said he had a port (a small, disk-shaped device that's surgically implanted under the skin to provide access to a vein for medical treatments and blood draws) on his chest and a fistula (a surgically created connection between an artery and a vein that allows for hemodialysis treatments) in his left arm. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). On 11/21/24 at 1:26 p.m. an unidentified nurse said Resident #40 should have a sign on his door and a bin containing PPE outside his door so staff was aware PPE was required when working with the resident. The nurse went to obtain the items. 2. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 11/21/24 at 1:17 p.m. LPN #1 said EBP was used for any residents that had any indwelling device in their body and were used when doing any care related to that indwelling device. LPN #1 said residents were identified for EBP on admission or if a new indwelling device was implemented. LPN #1 said since Resident #40 had a dialysis port and should be on EBP. LPN #1 said if Resident #40 should have EBP put in place immediately. F. Resident #224 1. Resident observations and interview On 11/18/24 at 10:05 a.m. a PICC line was observed in Resident #224's arm. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). -At 12:04 p.m. an unidentified member of the activities staff went into Resident #224's room without performing hand hygiene. At 2:42 p.m. Resident #224 said the nursing staff administered medications through his PICC line in the evenings. Resident #224 said he could not recall whether the nursing staff wore gowns while caring for his PICC line. On 11/19/24 at 8:41 a.m. an EBP sign was observed on Resident #224's door and a bin containing PPE had been placed outside the resident's room. At 10:05 a.m. two unidentified members of the therapy staff were preparing to enter Resident #224's room. The therapy staff members were overheard discussing whether or not they needed to don gowns before entering the room.The therapy staff members said that since Resident #224 did not have COVID-19, they only needed to wear gloves while working with the resident. -The therapy staff members proceeded to enter the resident's room without putting on gowns. G. Resident #222 1. Observations On 11/19/24 at 3:00 p.m. there were no signs on the Resident #222's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). Resident #222's electronic medical record (EMR) identified the resident had bilateral extremity wounds. On 11/21/24 at 1:11 p.m. LPN #2 posted an EBP sign on Resident #222's door and a bin containing PPE inside or outside of the resident's room. 2. Staff interviews CNA #2 was interviewed on 11/21/24 at 9:50 a.m. CNA #2 said EBP were for residents with PICC lines or other indwelling devices. CNA #2 said the nursing staff needed to wear PPE for more high contact care, including a gown, gloves, and a mask. CNA #2 said the different signs on the residents' doors told the nursing staff what PPE they needed to wear for that specific resident. -However, EBP required a gown and gloves, but not a mask (see professional reference above). CNA #2 was interviewed again on 11/21/24 at 12:23 p.m. CNA #2 said he did not have to wear any gown, gloves, or other PPE when working with Resident #222 because the resident did not have any catheters or indwelling lines. -However, Resident #222 had bilateral lower extremity wounds which required the implementation of EBP (see professional reference above and facility follow up below). LPN #2 was interviewed on 11/21/24 at 12:47 p.m. LPN #2 said EBP were for residents with devices such as PICC lines, foley catheters and wound vacuums. LPN #2 said EBP was implemented so that when the nursing staff worked with the resident, it protected the nursing staff, the resident indicated and other residents from the spread of infection. LPN #2 said EBP meant staff needed to don a gown, gloves, and a mask. LPN #2 said EBP were identified when the resident arrived from the hospital when the nurses doing the admission identified the resident had an indwelling medical device. LPN #2 said EBP were only used for residents with wound vacuums and were not used for residents with more general open wounds. LPN #2 said staff did not need to use EBP for residents with open wounds. -However, EBP required a gown and gloves, but not a mask (see professional reference above). -Additionally, according to the CDC, EBP should be implemented for all residents with wounds or indwelling devices, regardless of their MDRO status (see professional reference above). LPN #2 there were were no signs or materials for EBP for Resident #222 because the resident did not have any indwelling lines or catheters, but she said the resident might be put on EBP by the wound nurse if he had some sort of infection in his wounds. LPN #2 said the nursing staff had not been using EBP during Resident #222's care because there were no signs or PPE outside his door to indicate EBP was required for the resident. LPN #2 said she thought he may have had an EBP sign up on his door at one time but she was not sure where it went. H. Resident #226 1. Observations On 11/18/24 at 10:13 a.m. there were no signs on Resident #226's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). Resident #226's EMR identified the resident had venous stasis wounds (open sores that develop on the lower legs or ankles due to poor blood circulation) on both lower extremities. 2. Staff interviews RN #2 was interviewed on 11/21/24 at 3:44 p.m. RN #2 said the IP had been putting residents on EBP if they had open and draining wounds, PICC lines or other indwelling lines. RN #2 said staff members only needed to wear PPE when working with the specific area that the resident needed EBP for. She said if staff was providing foley catheter care or working with a resident's PICC line, the staff should put on PPE. RN #2 said residents on EBP should have a sign on their door and a bin with PPE outside of their room. RN #2 said Resident #226 had wounds on both legs, however, she was not aware if the resident required EBP. RN #2 said she needed to clarify with the IP to see what constituted a wound that required EBP. -However, Resident #226 had venous stasis wounds on both legs which required the implementation of EBP (see professional reference above and facility follow up below). I. Resident #53 1. Observations On 11/21/24 at 8:40 a.m. the CWN and the DON were observed providing Resident #53's wound care and dressing change. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). On 11/21/24 at 11:40 a.m. an EBP sign was observed on Resident #53's door and a bin containing PPE had been placed outside the resident's room. 2. Staff interviews LPN #4 was interviewed on 11/21/24 at 11:48 a.m. LPN #4 said Resident #53 was on EBP because she had a dialysis port and an open wound. She said an EBP sign had been on the door and a PPE bin had been outside the resident's room previously, but she did not know who removed them or when. She said she replaced the EBP sign and put a bin outside the resident's room after the wound care was performed (on 11/21/24). J. Additional staff interviews CNA #3 was interviewed on 11/21/24 at 10:33 a.m. CNA #3 said the different signs on the residents' doors meant different things. CNA #3 said the EBP signs meant the resident had an intravenous (IV) line. CNA #3 said for EBP, the nursing staff needed to wear PPE, including a mask, gown, and gloves. -However, EBP required a gown and gloves, but not a mask (see professional reference above). The IP was interviewed on 11/21/24 at 3:39 p.m.The IP said the facility used signs on resident doors to indicate which residents were to be on EBP precautions and placed bins containing PPE outside the residents' doors. She said floor staff were not great at putting EBP in place. The IP said when she reviewed residents or became aware of an infection/illness, usually at morning meetings, which required isolation precautions ,she would complete an audit to ensure a bin with PPE supplies and a precaution sign on the resident's door was in place. The IP said she also ensured the residents met the criteria for EBP or any other infection precautions needed. The IP said it was the floor staff's responsibility to ensure the PPE carts outside of a residents room were stocked with all of the needed PPE. The IP said EBP were put into place when a resident had a MDRO infection and had devices such as ports, urinary catheters or chronic non-healing wounds and wounds showing signs of infection. The IP said when EBP were required, all caregivers/staff providing care needed to sanitize hands, apply gloves, gown and a mask. -However, according to the CDC, EBP should be implemented for all residents with wounds or indwelling devices, regardless of their MDRO status (see professional reference above). The director of nursing (DON) was interviewed on 11/21/24 at 5:56 p.m. The DON said that EBP was used for PICC lines, draining wounds, chronic wounds, foley catheters, and dialysis ports. The DON said EBP was used by the nursing staff when handling the resident and providing high-contact care. The DON said they used the PPE bins and EBP signs as indicators and thought the housekeeping staff may have been moving the PPE bins away from resident rooms. The DON said EBP was used to protect the residents and the nursing staff from infection. The DON said staff providing care to residents with those devices should be wearing PPE, including gloves, gown and a mask. -However, EBP required a gown and gloves, but not a mask (see professional reference above). The DON said a sign for EBP should have been placed on the doors and a PPE cart should have been placed outside the rooms for Residents #225, #231, #40, #224, #222, #226 and #53. K. Facility follow up The NHA provided CDC guidelines on EBP via email on 11/22/24 at 11:29 a.m. (after the survey). The guidelines revealed in pertinent part, In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of EBP is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds and not those with only shorter-lasting wounds. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers and chronic venous stasis ulcers. -However, observations and interviews revealed the facility had not implemented EBP for residents with wounds (see above).

Based on interviews and record review, the facility failed to develop an acute/baseline care plan for four (#380, #376, #382 and #225) of four residents reviewed for baseline care plans out of 60 sample residents. Specifically, the facility failed to ensure Resident #380, #376, #382 and #225 were provided a copy of their baseline care plan with 48 hours of admission to the facility. Findings include: I. Facility policy and procedure The Baseline Care Plan policy and procedure, revised March 2020, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It 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 identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the patient's strengths, limitations, and goals. The care plan will be specific and appropriate to the individual needs for each resident. The interdisciplinary care plan will be developed through collaborative efforts of the IDT and other health care professionals. 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. The care plan is to include measurable objectives and timeframes to meet a resident's medical, nursing, psycho-social, and functional needs identified with completion of the comprehensive assessment. To the extent that is practical, the resident and/or family will be involved in the development of their care plan. The care plans will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated and initiated. II. Resident #380 A. Resident status Resident #380, age 76, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included aftercare following joint replacement surgery and presence of bilateral artificial knee joint. The 11/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate assistance with activities of daily living (ADL). B. Resident interview Resident #380 was interviewed on 11/19/24 at 11:41 a.m. Resident #380 said she was not aware of her plan of care other than she had been receiving physical and occupational therapy. She said she had not been provided a written copy of her plan of care when she was admitted to the facility. She said she was frustrated that she did not know what was happening. C. Record review The 11/14/24 care conference progress note documented an initial care conference meeting was held with the case manager, therapy, the resident and the resident's family. It documented the resident was oriented to the role of the case manager, how to contact the case manager, discussed discharge planning processes, services and guidelines. The progress note indicated a copy of the resident's medication list and care plan were provided to the resident. -However, a review of Resident #380's electronic medical record (EMR) on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the director of nursing as the facility's process (see DON interview below). III. Resident #376 A. Resident status Resident #376, age 76, was admitted on [DATE]. According to November 2024 CPO, diagnoses included encounters for other orthopedic aftercare, difficulty in walking, muscle weakness and right and left foot drop. The 11/13/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required maximum assistance with all ADLs. B. Resident interview Resident #376 was interviewed on 11/18/24 at 4:03 p.m. Resident #376 said she was visiting from another state when she ended up in the hospital for lumbar surgery. She said she had not received her care plan in writing since she was admitted to the facility. She said she had not received any communication from the case manager since she was admitted . C. Record review The 11/14/24 care conference progress note documented an initial care conference meeting was held with the case manager, therapy, resident, and family. It documented the resident was oriented to the role of the case manager, how to contact the case manager, discussed discharge planning processes, services and guidelines. The progress note indicated a copy of the resident's medication list and care plan were provided to the resident. -However, a review of Resident #376's EMR on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the DON as the facility's process (see DON interview below). IV. Resident #382 A. Resident status Resident #382, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included fracture of left femur, history of falls, muscle weakness and gout. The 11/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required maximum assistance with all ADLs. B. Resident interview Resident #382 was interviewed on 11/18/24 at 4:52 p.m. Resident #382 said she had not been given a copy of her care plan since her admission to the facility. She said she had not received any communication regarding her discharge plan. C. Record review The 11/6/24 care conference progress note documented an initial care conference meeting was held with the case manager, therapy, resident, and family. It documented the resident was oriented to the role of the case manager, how to contact the case manager, discussed discharge planning processes, services and guidelines. The progress note indicated a copy of the resident's medication list and care plan were provided to the resident. -However, a review of Resident #382's EMR on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the DON as the facility's process (see DON interview below). V. Resident #225 A. Resident status Resident #225, age 71, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included surgical aftercare and local infection of the skin and subcutaneous tissue. The 11/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. B. Record review A progress note dated 11/5/24 at 1:47 p.m. revealed the activities department completed an activities assessment of Resident #225. The activity care plan had been updated to reflect Resident #225's interests. A progress note dated 11/7/24 at 2:42 p.m. revealed a care conference had been completed with Resident #225, her family, the therapy team and Resident #225's case manager. The care conference notes revealed the team discussed discharge planning, processes, services and guidelines. The note documented a copy of Resident #225's medications and her care plan were provided to the resident. -However, a review of Resident #225's EMR on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the DON as the facility's process (see DON interview below). VI. Staff interviews Case manager (CM) #2 and the DON were interviewed together on 11/21/24 at 3:46 p.m. CM #2 said she met with residents three to five days after their admission to the facility for an initial care conference. She said during the care conference, the resident's goals, preferences and initial discharge plan was determined with the resident and/or their family. CM #2 said she was not responsible for developing the discharge plan of care. She said the MDS nurse was responsible for developing the baseline care plan and providing each resident a copy within 48 hours of their admission to the facility. The DON was interviewed again on 11/21/24 at 3:57 p.m. The DON said all residents signed the Acknowledgement of Care Plan form upon receiving a copy of the baseline care plan. She said the form was then uploaded into the resident's EMR. The DON confirmed the facility did not have signed Acknowledgement of Care plan forms for Residents #380, #376, #382 and #225. 50219

Based on observations, record review and interviews, the facility failed to ensure one (#382) of one resident reviewed for pain out of 60 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to ensure Resident #382, who experienced an acute episode of pain, was provided pain relief and had an effective pain management program to address her continuous pain. Findings include: I. Facility policy and procedure The Analgesia policy and procedure, revised August 2022, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It read in pertinent part, Pain management procedure: based on the assessment, the facility, in collaboration with the attending physician, or medical director, and the resident initiated interventions to prevent or manage the resident's pain, beginning at admission. These interventions may be integrated into components of the comprehensive care plan, but at minimum will be evaluated at admission and every shift thereafter. 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. The facility will address/treat the underlying causes of the pain, to the extent possible. Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both. It is the responsibility of the staff member to address the complaint of pain and make sure some intervention (pharmacological or otherwise) is initiated. In the event the resident does not have an order for pain medications, contact the physician immediately to obtain an order for analgesia. In the interim, attempt non-pharmacological modalities for pain control such as repositioning, touch therapy, biofeedback, distraction (television, conversation). II. Resident #382 A. Resident status Resident #382, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), the diagnoses included left femur fracture status post closed reduction, muscle weakness, history of falls, heart disease and peripheral vascular disease (chronic condition that occurred when blood vessels outside of the brain and heart narrow or become blocked). The 11/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required moderate to maximum assistance with all activities of daily living (ADLs). The MDS assessment indicated the resident received scheduled pain medications and as needed opioids. The resident did not receive as needed pain medications or non-pharmacological interventions for pain on three days of the five days during the assessment period. Of these three days the resident reported a pain level of 5 or greater on a pain scale of 1 to 10, with an identified acceptable pain level of 5 out of 10 on the pain scale. B. Resident interview and observations Resident #382 was interviewed on 11/19/24 at 10:37 a.m. Resident #382 was sitting up in her bed, grimacing and appeared in distress. Resident #382 said she was in a lot of pain and needed pain medication. She said she had told a facility staff member she was in extreme pain, but had been waiting for two hours. She said no one ever returned to address her pain. Licensed practical nurse (LPN) #3 was immediately informed of the resident's verbal and non-verbal expressions of pain. LPN #3 entered Resident #382's room, however, did not administer the resident any pain medication (see record review and interviews below). Resident #382 was interviewed on 11/19/24 at 1:20 p.m. Resident #382 was sitting up in her bed, eating fast food and visiting with a family member. Resident #382 said her pain was okay for now but would like her pain medications to be given on time so her pain does not get out of control. She said the nurse took her catheter out the night before, it was very painful, and was not given pain medication prior to the procedure. Resident #382 was interviewed on 11/21/24 at 6:34 p.m. with the director of nursing (DON) and infection preventionist (IP) present. Resident #382 said she was very hesitant to talk as she did not want to get LPN #3 in trouble. The resident was reassured by all that this was not the case, but wanted to ensure that her needs were addressed. Resident #382 said she was always in pain and that some position changes made her feel better. She said her pain was not being managed effectively. She said she was only being given acetaminophen (Tylenol) prior to physical and occupational therapy. She said the Tylenol was not enough to address her pain and felt it did not work. She said it was difficult to participate in physical and occupational therapy to the best of her ability because she was in pain. She said her pain was throughout her right leg. She said the pain was throbbing all the time. Resident #382 said the tramadol was sometimes effective but not all the time. The DON said they would plan to meet with the physician in the morning to make adjustments to address her pain. C. Record review The opioid use care plan, initiated on 11/4/24, documented Resident #382 was on opioid pain medication therapy. The goal was to be free of any discomfort or adverse side effects from the pain medication. The interventions included administering analgesic medication as ordered by the physician and observing for side effects and effectiveness. The pain management care plan, initiated on 11/4/24, documented Resident #382 expressed pain related to pressure points, decreased mobility related to a fall, a left intertrochanteric hip fracture status post closed reduction and gout. It indicated the resident's pain was alleviated/relieved by rest, repositioning and medication. The interventions included anticipating the resident's need for pain relief by monitoring her pain level at every shift and as needed, notifying the physician of any changes in condition as needed, administering pain medication per physician orders and note the effectiveness, administering Biofreeze Gel 4% during therapy services observing, giving pain medications as needed for breakthrough pain per physician orders and note the effectiveness, acknowledging the resident's presence of pain and discomfort, listening to the patient's concerns as needed, and implementing non-pharmacological interventions when able such as: positioning/support, assistive devices/braces, exercise/stretching, ice packs/moist hot pack application, relaxation. etc. The November 2024 (11/4/24 to 11/21/24) medication administration record (MAR) revealed Resident #382 reported her pain greater than her acceptable level of pain rating of a 5 out of 10 on the pain scale, a total of 10 times since her admission on 11/3/24. A level 9 out of 10 pain on the pain scale was the highest pain level reported. Record review of the November 2024 (11/4/24 to 11/20/24) treatment administration record (TAR) and medication administration MAR confirmed that on 11/19/24, Resident #382 expressed pain and requested pain medication, however the facility failed to administer a dose of analgesic pain medication from the hours of 10:37 a.m. when it was verbally requested by Resident #382 until the scheduled acetaminophen dose was administered at 2:00 p.m. -A review of the narcotic log on 11/21/24 at 10:02 a.m. and MAR with registered nurse (RN) #3 confirmed the findings. The 11/7/24 pain assessment revealed that Resident #382 responded almost constantly when asked the question: Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain. Resident # 382 also rated her highest pain level at a 9 out of 10 over the previous five days. The 11/14/24 pain assessment revealed no change in response to the same question and rated her pain level an 8 out of 10 over the past five days. The November 2024 CPOs documented the following: -Oxycodone 5 milligrams (mg) four times per day as needed for pain, ordered on 11/12/24 and discontinued on 11/17/24. -Tramadol 50 mg three times per day as needed for pain, ordered on 11/3/24 and discontinued on 11/4/24. -Tramadol 50 mg three times per day (every 8 hours) as needed for pain, ordered on 11/5/24. -Lidocaine Patch 4% (percent) apply two patches to the affected area topically in the morning for discomfort/pain, remove at hour of sleep, ordered on 11/4/24. -Oxycodone 5 mg every four hours as needed for pain level 1-10 for 14 days, order to be held for dates of 11/4/24 to 11/12/24 and was discontinued on 11/15/24. -Voltaren External Gel 1% apply topically in the morning for discomfort/pain, ordered on 11/3/24. -Acetaminophen 1000 mg given three times per day for pain, not to exceed 3 grams daily, ordered on 11/3/24. The 11/19/24 daily skilled nursing progress note identified Resident #382 had a new area of pain to the left great toe and right ankle, with increased edema, and rated her pain level as a 4 out of 10 on the pain scale with her maximum acceptable rating of 5. LPN #3 documented she administered scheduled Tylenol and Gabapentin, as the resident had reported this was effective for pain. It indicated that Resident #382 declined repositioning or elevating her bilateral lower extremities as a form of non pharmacological intervention, and tubi grips were applied to bilateral lower extremities. -However, Gabapentin was not a physician's order documented in the CPO or MAR and according to a review of the narcotic log with RN #3 confirmed Gabapentin was not administered to Resident #382. -The progress note failed to identify any person centered non-pharmacological or medication interventions that were attempted or how Resident #382's pain was addressed when LPN #3 was informed the resident was in acute pain on 11/19/24 at 10:37 a.m. III. Staff interviews RN #3 was interviewed on 11/21/24 at 10:02 a.m. RN #3 said acetaminophen was administered as scheduled on 11/19/24 at 8:00 a.m., 2:00 p.m. and 10:00 p.m., and Tramadol was administered once at 9:00 a.m. RN #3 said that no other pain medications were administered to Resident #382 on 11/19/24 after 10:37 a.m., when LPN #3 was informed the resident was in acute pain. RN #3 confirmed the resident did not have an order to receive Gabapentin for pain. LPN #3 and the DON were interviewed together on 11/21/24 at 2:30 p.m. LPN #3 said the Gabapentin that was documented on the daily nursing note on 11/19/24 was an error. She said she did not administer Gabapentin to Resident #382. LPN #3 said she administered acetaminophen as ordered at 8:00 a.m. and 2:00 p.m. LPN #3 said she recalled the events from 11/19/24. She said she used non-pharmacological interventions with Resident #382 by repositioning, asked the resident if she needed to go to the restroom and that she folded and placed tubi grips in the drawer while she was in the resident's room. She said she remembered exactly what she did because the resident was eating fast food brought in by the resident's daughter. -However, according to observations made during the survey process, the resident's family member did not bring Resident #382 fast food until later that afternoon, three hours after LPN #3 was informed of the resident's acute pain. -Additionally, record review showed LPN #3 had documented in the daily nursing note on 11/19/24 at 4:00 p.m. that the resident had a 4 out of 10 pain level, the resident declined repositioning or elevating to her bilateral lower extremities and that she had applied the tubi grips to the resident's bilateral lower extremities. The DON was interviewed on 11/21/24 at 3:56 p.m. The DON said if a resident's pain regimen was not effective, the facility should review the medications and call the physician. She said it was the facility's goal to always keep residents comfortable and free of pain. She said acute pain should be addressed immediately either by providing non-pharamacological interventions or medication to alleviate the resident's pain. She said any acute pain should be documented in the resident's medical record at the time the resident expressed pain and interventions provided. She said all documentation should be accurate and should pertain to the resident.

Based on observations, record review and interviews, the facility failed to ensure one (#174) of one resident reviewed for pressure ulcers out of 60 sample residents received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure Resident #174's physician ordered heel protection boots were consistently implemented as an intervention to prevent potential pressure wounds. Findings include: I. Professional reference According to the International Wound Journal's Summary of Best Evidence For Prevention and Control Of Pressure Ulcers on Support Surfaces (3/9/23), retrieved on 12/2/24 from https://pmc.ncbi.nlm.nih.gov/articles/PMC10332999/#:~:text=Therefore%2C%20this%20study%20included%20heel,in%20a%20%E2%80%9Cfloating%E2%80%9D%20position.&text=This%20means%20keeping%20the%20heel,risk%20assessment%20in%20the%20future, A pressure ulcer is a localized injury caused by continuous pressure on the skin and/or subcutaneous soft tissues, usually located at a bony prominence, or involving a medical device or other instrument. Pressure redistribution is important in pressure ulcer prevention and control strategies. The ideal way to prevent heel pressure ulcers is to ensure that the heel does not touch the bed to avoid all pressure, that is, to keep the heel in a 'floating' position. For patients with established pressure ulcers and those who are bedridden, heel support devices are recommended, but there are many different types, such as heel suspension boots. II. Facility policy and procedure The Pressure Ulcer policy and procedure, reviewed on 3/14/24, was received from the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part The facility will provide the necessary requirements to ensure that a resident 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 with identifying factors contributing to or predisposing residents to skin breakdown. III. Resident #174 A. Resident status Resident #174, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included cerebral hemorrhage (brain bleed) affecting the right side, dysphagia (difficulty swallowing), aphasia (difficulty speaking), hypertension (high blood pressure) and pre-diabetes (abnormal glucose). The 11/20/24 minimum data set (MDS) assessment revealed the resident had short and long term memory issues. She required maximal assistance from staff for transfers, toileting, personal hygiene and dressing. The resident required minimal staff assistance with bed mobility and eating. B. Observations On 11/18/24 at 10:50 a.m. Resident #174 was sleeping in bed. A right foot heel protection boot was hanging off the bed and not on the resident's foot in order to protect the heel. Resident #174's right heel was resting directly on the mattress. On 11/20/24 at 10:42 a.m. Resident #174 was in her wheelchair visiting with her family. She was not wearing her heel protection boots while in the wheelchair. Resident #174's feet were resting directly on the foot pedals of the wheelchair. On 11/20/24 at 11:34 a.m. Resident #174 was transferred back into bed. Her heel protection boots were not put on when she was transferred back into bed. On 11/20/24 at 11:48 Resident #174's was laying in bed with her feet resting directly on the mattress. The resident's heel protection boots were lying on the desk in the room. On 11/20/24 at 3:02 p.m. Resident #174 was laying in bed with three visitors in her room. Resident #174 did not have her heel protection boots on and the boots were still lying on the desk in the room. On 11/20/24 at 3:26 p.m. Resident #174 was sleeping in her bed with her feet resting directly on the bed. The resident's heel protection boots were lying on the desk in her room. On 11/20/24 at 4:04 p.m. registered nurse (RN) #1 entered Resident #174's room and observed that the resident's heel protection boots were not on the resident's feet but were instead lying on the desk approximately five feet from the resident. RN #1 completed a skin check of Resident #174's bilateral feet and applied the heel protection boots to both feet. RN #1 said one of the boots was broken because it was missing a strap which would help ensure the boot remained on the resident's foot. On 11/21/24 at 10:22 a.m. Resident #174 was laying in bed. The resident's heel protection boots were on her bed but were not on the resident's feet. Resident #174's feet were resting directly on the mattress. C. Resident family member interview Resident #174's family member was interviewed on 11/19/24 at 10:08 a.m. The family member said Resident #174 could not move her right hand or her right leg due to her medical condition. The family member said the resident had been wearing heel protection boots to both feet since her hospital stay but the family member was not sure why the resident needed them. The family member said no one in the facility had informed the family when the resident should or should not be wearing the heel protection boots. D. Record review The 11/13/24 admission Braden Scale assessment (a tool used to calculate the risk of pressure injuries) revealed Resident #174 was at high risk for skin breakdown. The resident's high risk factors contributing to skin breakdown included limited sensory response, bedfast (confined to bed), completely immobile and required maximum assistance in moving. Review of Resident #174's November 2024 CPO revealed the following physician's order: Turn and reposition throughout shift, as tolerated. Offload bilateral heels while in bed, as tolerated. Foam boots to be worn at all times as tolerated. May remove during ambulation, ordered 11/14/24. The 11/13/24 comprehensive care plan revealed Resident #174 had potential for skin breakdown related to pressure points, immobility and incontinence. Resident #174 was admitted with redness under bilateral breasts and bruises on her abdomen from medication injections. Her heels and coccyx were intact. Resident #174 had heel protection boots on bilateral feet. The goal was for Resident #174's skin to remain intact. Interventions included conducting a Braden Scale assessment every week per protocol, encouraging the resident to turn and reposition throughout the shift, offloading bilateral heels while in bed every shift for skin integrity, providing pressure reduction devices as needed for mattress and wheelchair, prophylactic skin treatments as ordered and skin assessments as needed. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/20/24 at 3:15 p.m.CNA #1 said, on admission, a resident's care plan would document any special care the resident may need so staff was aware of their needs. CNA #1 said if a resident required heel protection boots, the therapy department would assess the resident and order the correct size or style of heel protection boots needed. CNA #1 said Resident #174 did not wear any heel protection boots and her heels could be floated off the bed with pillows. -However, Resident #174 had a physician's order for heel protection boots to be worn on her bilateral feet at all times, except when she was ambulating (see record review above). CNA #1 said Resident #174 required assistance with transfers and bed mobility because she was weak on the right side of her body due to her medical condition. RN #1 was interviewed on 11/20/24 at 4:04 p.m. RN #1 said the nursing staff was to conduct an assessment on residents to determine their risk of skin breakdown and interventions would be implemented based on the outcome of the assessment. RN #1 said pressure areas were considered to be any bony areas that had direct contact with a surface, such as a mattress. RN #1 said Resident #174 had a physician's order for heel protection boots to her bilateral feet. RN #1 said Resident #174 had right-sided weakness and limited mobility to her right side, which increased her risk of skin breakdown. RN #1 said heel protection boots were important to prevent skin breakdown for Resident #174. RN #1 said Resident #174 should have been wearing her heel protection boots per the physician's order. The director of nursing (DON) was interviewed on 11/21/24 at 5:37 p.m.The DON said heel protection boots were implemented to prevent skin breakdown on a resident who was at an increased risk of skin breakdown. The DON said the admitting nurse was to complete a Braden Scale assessment to determine the risk a resident had for the development of pressure injuries. The DON said it was up to the nurses to check to ensure that Resident #174's heel protection boots were on every shift if there was a physician's order for them. The DON said if a resident had a physician's order for heel protection boots, it was important for the intervention to be used to help prevent skin breakdown. The DON said the nurses would be educated on the importance of ensuring heel protection boots were in place when ordered to help prevent skin breakdown.

Based on record review and interviews, the facility failed to honor resident choices for one (#53) of one resident out of 60 sample residents. Specifically, the facility failed to ensure Resident #53's preference to have her bed bath completed during the day shift was honored. Findings include: I. Resident #53 A. Resident status Resident #53, age less than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, bathing, and lower body dressing and was partially dependent on staff for all other activities of daily living (ADL). The assessment indicated that it was very important that she was able to choose between a tub bath, shower, bed bath or sponge bath. B. Resident interview Resident #53 was interviewed on 11/18/24 at 11:27 a.m. Resident #53 said bathing was scheduled based on the room the resident resided in. She said the certified nurse aide (CNA) would come to give her a bed bath at night. She said she had asked to be put on the day shift bathing schedule since she was admitted and the facility still had not accommodated her request. She said her hair had only been washed once since being admitted to the facility. Resident #53 was interviewed again on 11/20/24 at 8:56 a.m. Resident #53 said she was unable to sit in the shower chair comfortably, which was why she received bed baths. She said she had refused her bed bath because the CNA would come to give her a bed bath between 7:00 p.m. to 8:00 p.m. She said it was too late to receive a bed bath as she was starting to wind down for the evening. She said she requested to be moved to the day shift for her baths, but it still had not been done. Cross reference F684: The facility failed to prevent the development and worsening of Resident #53's abdominal wounds. C. Record review The ADL care plan, revised 10/5/24, documented Resident #53 required assistance with ADLs due to her recent injury. It documented Resident #53 preferred to get up around 6:00 a.m. and preferred bed baths on her scheduled bath days. -The care plan did not address Resident #53's preference to receive bed baths during the day. The Kardex (a nursing tool that summarizes resident information regarding daily schedules and interventions) documented Resident #53 was scheduled to receive a bed bath on Wednesday and Saturday nights. Resident #53's preference sheet documented Resident #53 should receive a bed bath on Tuesdays, Thursday and Saturdays. -It did not document the resident preference of day or night. The shower documentation from 10/4/24 to 11/17/24 documented Resident #53 refused all of her bed baths except for one, on 11/3/24. It documented Resident #53 had requested to be changed from the night schedule to the day schedule and on days in which she did not receive dialysis on 10/12/24 and 11/16/24 II. Staff interviews CNA #6 was interviewed on 11/21/24 at 9:59 a.m. CNA #6 said she never assumed a resident wanted a certain type of bath or shower and would ask them each time. She said she asked each resident when each resident preferred to have their bath or shower. She said if a resident refused, the resident had to sign a sheet of paper, but they would try and reschedule their bath or shower for another day and time. The director of nursing (DON) was interviewed on 11/21/24 at 5:38 p.m. The DON said the preferences sheet was completed upon admission and should identify when the resident preferred a shower or bath. She said showers were split between the day shift and the evening shift. She said if a resident communicated they wished to have their bathing day or time moved, then the residents preference should be honored. The DON said she was not made aware by the floor staff that Resident #53 had been refusing her bed baths because of the time of day they were being offered. She said she would change Resident #53 to the day shift immediately. The DON confirmed Resident #53's preference had been documented on 10/12/24 and 11/16/24.

Based on observations, record review and interviews the facility failed to ensure activities were designed to support residents physical, mental and psychosocial well-being were provided for two (#373 and #36) of two residents out of 60 sample residents. Specifically, the facility failed to identify and meet the socialization needs for Resident #373 and #36. Findings include: I. Facility policy and procedure The Activities policy and procedure, revised February 2024, was received by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part, The resident has the right to choose activities and participate in activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility. The facility will ensure and implement an ongoing resident-centered activity program that incorporates the resident's hobbies and culture preferences, which is integral to maintaining and or improving a resident's physical, mental and psychosocial well-being and independence. The facility will support and create meaningful life by supporting his/her domain of wellness. Activities Procedures: The resident will make choices about the activities they would like to participate in. The facility will promote one to one visits in the resident's room as needed. Activities will be provided seven days a week on days and evenings. The activity room will have self-directed activities 24 hours a day available to the resident. II. Resident #373 A. Resident status Resident #373, age 75, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included spinal stenosis to the cervical region (when the spinal canal narrows putting pressure on the spinal cord and nerves) and muscle weakness. The 10/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. She required maximum assistance with activities of daily living (ADL) B. Resident and resident's representative interviews and observations Resident #373 was interviewed on 11/19/24 at 9:39 a.m. Resident #373 said she was lonely and just wanted someone to sit with her and watch The Price is Right (television show). She said she wanted someone to talk with and share her stories about her children and grandchildren. Resident #373 said she had asked facility staff to take her outside for a walk, but she was always told they were too busy. She said she wanted to get some fresh air. On 11/19/24 at 2:00 p.m. the facility had a scheduled group activity of painting. -Resident #373 was not invited to attend the group activity. During a continuous observation on 11/20/24, beginning at 8:50 a.m. and ending at 11:30 a.m., Resident #373 activated her call light five times for non-care related reasons from 8:50 a.m. to 9:56 a.m. At 11:00 a.m. the facility held a group activity of Monopoly. -Resident #373 was not invited to attend the group activity. At 1:30 p.m. Resident #373's representative was observed wheeling the resident out of her room and down the hallway. Resident #373's representative was interviewed on 11/20/24 at 1:57 p.m. The representative said he had just taken Resident #373 for a walk outside. He said Resident #373 was happy to go outside and have someone to talk to and tell her stories to. On 11/20/24 from 1:30 p.m. to 3:00 p.m. the facility had a group activity of pet visits. -Resident #373 was not invited to participate. C. Record review The activities care plan, initiated 10/24/24, documented Resident #373 expressed interest in participating in group activities and enjoyed watching television. It indicated the resident required one-to-one activities to be coordinated by the activities director (AD). The interventions included activity calendar to be available for resident's review, encourage participation in expressed individual and/or group activities of interest, AD will remind, encourage/assist and/or transport resident to activities of interest as needed, AD will encourage maximum participation according to functional capacity, and provide supplies as needed such as books, newspapers, magazines, batteries, craft supplies, word games, etc . A review of the November 2024 treatment administration record (TAR) revealed Resident #373 should have activities available as requested for both day and night shifts. The TAR documented Resident #373 was only offered activities on 11/4/24 at 4:09 p.m. and 11/13/24 at 3:48 p.m. III. Resident #36 A. Resident status Resident #36, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of the left femur (broken bone of the upper leg), kidney failure, major depressive disorder (disorder affecting how someone feels) and hypertension (high blood pressure). The 10/21/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She was dependent on staff for toileting, dressing and transfers. She required moderate assistance for eating and personal hygiene. B. Observations On 11/18/24 at 4:22 p.m. Resident #36 was observed to be calling out to anyone who walked by her room. -Staff did not enter the resident's room to see what she needed or offer to provide her with any activities of interest. On 11/19/24 at 10:00 a.m. Resident #36 was observed to be calling out from her room saying help me. -Staff did not enter the resident's room to see what she needed or offer to provide her with any activities of interest. On 11/19/24 at 3:34 p.m. Resident #36 said good morning to an unidentified certified nurse aide (CNA) who was sitting at the nurses station. Resident #36 called out three times before the CNA went to her room. The unidentified CNA remained in the resident's room for 30 seconds then returned to the nurses station. -The CNA did not offer to provide the resident with any activities of interest. On 11/20/24 at 11:40 a.m. Resident #36 was awake in her bed looking out the door towards the nurses station. The television was not on and no books were observed in her room. C. Record review The activity care plan, initiated 10/14/24, revealed Resident #36 enjoyed watching television, reading (historical fiction) and spending time with her family. An activities progress notes dated 10/16/24 revealed an initial activities assessment was completed for Resident #36. The progress note documented Resident #36 would be involved in leisure activities as desired and the activity care plan had been developed to reflect these interests. Staff would monitor for any problems or concerns that might inhibit Resident #36's participation in leisure activities. Furthermore, staff would support the leisure needs of Resident #36 by offering reminders, encouragement, assistance and supplies as needed. A late entry activities progress note dated 11/1/24 revealed Resident #36 was offered a monthly activities calendar. The calendar identified times and locations of future activities. Resident #36 was told to contact activities at the activities extension number for any additional supplies or if she had an interest in any group activities. -However, according to Resident #36's 10/21/24 MDS assessment (see resident status above), the resident was severely cognitively impaired and therefore would not have been able to call the activities extension number for activities supplies. An activities progress note dated 11/4/24 documented Resident #36 refused the daily chronicle which had an educational short read and an engaging puzzle. -However the comprehensive care plan identified Resident #36 liked to read but the daily chronicle was not a topic she enjoyed (see record review above). There was no other documentation to indicate Resident #36 had been provided with individual activities of interest or been invited to group activities. The activities log identified several days where one-to-one visits occurred for Resident #336. -However, the one-to-one visits were with the resident's family members and not members of the facility's activities staff (see interviews below). IV. Staff interviews CNA #5 was interviewed on 11/20/24 at 3:16 p.m CNA #5 said Resident #373 was lonely and wanted someone to sit and talk with her. She said most of the time, Resident #373 wanted the CNAs to sit on her bed and watch television with her. The AD and the NHA were interviewed together on 11/21/24 at 5:03 p.m. The AD said she did not actually conduct the one-to-one activities for each resident, but instead relied on each residents' family and friends. She said she did not take residents outside during this time of the year because of the cold weather. The AD said she provided a monthly calendar of activities to all residents on admission and monthly. The AD said she relied on floor staff to encourage residents to attend activities the day before the activity and to help her identify any residents who may need help to attend activities. The AD said, because the facility had a large census, it was difficult for her to meet with all residents prior to the activity but she had her CNA license which helped her transport residents to the activities. The AD said each resident's participation in group activities was based on their physical and cognitive abilities. She said the nursing staff should notify her of any residents asked to attend activities. She said the activities staff did not personally invite residents to group activities. She said there was not usually a high turnout for regular group activities. The AD said each resident's activity preferences were established upon admission and she did not re-evaluate those preferences throughout their stay at the facility. She said she was the only one that provided activities to all residents in the facility and it was a lot for one person to handle. The AD said she had not been informed that Resident #373 was lonely or wanted to attend activities. She confirmed she had documented the resident wanted to attend group activities and required one-to-one visits during Resident #373's admission activity assessment. She said she had not personally provided Resident #373 with any one-to-one activities but relied on the resident's family for that. The AD said Resident #36 had a cognitive impairment and made communication difficult for the resident. The AD said Resident #36 had a strong family involvement and the one-to-one visits documented on the resident's activities log were when the resident's family visited with her. The AD said she did not conduct one-to-one activities visits with Resident #36. The AD said she had not checked in with Resident #36 about needing any books or other leisure activities supplies. The AD said she did not think she needed to make any changes to the activity program at the facility. The NHA said Resident #36 enjoyed visits from family members. He said Resident #36 seemed to like familiar faces over strangers. The NHA said the housekeeping staff would remove books from residents' rooms when they were cleaning and return them to the library. He said that might be the reason no books were observed in Resident #36's room (see observations above). The NHA said the activities department needed to change their approach with residents in order to build rapport with residents to ensure their needs were being met. The NHA said, going forward, the activity staff would check in with the residents more often and determine if their preferences had changed throughout their stay at the facility. He said he would put a system in place to ensure residents were being invited to group activities every day. The director of nursing (DON) was interviewed on 11/21/24 at 5:47 p.m. The DON said she did not have any involvement in activities other than directing residents to seek out the activities staff for something to do or to review the calendar with a resident. The DON said the AD, along with all other staff, were responsible for inviting residents to group activities 30 minutes prior to the start of the activity. The DON said the AD should be completing one-to-one visits with residents and should be inviting residents to all planned/scheduled activities. 47064

Based on record review and interviews, the facility failed to prevent misappropriation of property for three (#228, #46 and #229) of three residents reviewed for personal property out of 60 sample residents. Specifically, the facility failed to prevent the loss of property for Resident #228, Resident #46 and Resident #229 during their time in the facility. Findings include: I. Facility policy and procedure The Dignity policy and procedure, revised 8/15/22, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, Residents' private space and property shall be respected at all times. Staff will not handle or move a resident's personal belongings (including radios and televisions) without the resident's permission. II. Resident #228 A. Resident status Resident #228, age less than 65, was admitted on [DATE] and discharged home on 7/29/24. According to the November 2024 computerized physician orders (CPO), diagnoses included muscle weakness and hypotension (low blood pressure). The 7/23/24 brief interview for mental status (BIMS) assessment revealed the resident was cognitively intact with a score of 14 out of 15. B. Resident interview Resident #228 was interviewed on 11/21/24 at 6:29 p.m. via telephone. Resident #228 said her daughter had brought her some money to get her hair done while she was at the facility but she had not been able to get her hair done the day her daughter brought the money. Resident #228 said her sister visited her the next day and took her outside, but before they went outside, Resident #228 put her money into her bag inside her closet. Resident #228 said when she came back inside, the money was no longer in her bag. Resident #228 said an unidentified facility staff member was standing across the hallway from her room and when she told the staff member what happened, the staff member said she had not seen anything. Resident #228 said she spoke with the police but had not heard any updates about the investigation. Resident #228 said the facility never offered her a lockbox or a safe, and if they had, she would have given them all her belongings to secure. C. Record review The facility's misappropriation investigation, dated 7/29/24, was provided by the NHA on 11/20/24 at 12:50 p.m. It documented Resident #228 stated she was missing $200. She said she had the money because she was scheduled to have her hair done yesterday (7/28/24) but the beautician was not able to get it done. She said her daughter came today (7/29/24) to pick up the $200 but when she went to get her money from her bag, she noticed her $200 was missing. The resident thought that the money went missing when she went outside with her sister at approximately 3:00 p.m. The police were notified and the resident was re-educated to lock her valuables in the business office manager's (BOM) safe or the director of nursing's (DON) office. The staff was educated about the incident. Based upon the interviews and review of documentation, the facility determined that Resident #228 did have the money and that the money was misplaced while the patient was staying at the facility. The facility would reimburse Resident #228 the full amount of $200. The staff were educated about the incident that occurred and the policy on locking items away for safety. A review of Resident #228's progress notes and electronic medical record (EMR) did not reveal any other information regarding the incident. A grievance for Resident #228, dated 7/25/24, was provided by the DON on 11/21/24 at 3:53 p.m. It revealed Resident #228 was crying because she wanted to have her hair done but the beautician at the facility told her it would be almost $200. Resident #228 was crying because she did not have enough money to pay for that. The resolution listed in the grievance was that the DON spoke with the beautician and determined she charged based on time and that it would take the beautician a long time to brush out Resident #228's hair. -However, both the interview with Resident #228 and the facility's investigation revealed the resident's family member brought her the money to have her hair done (see above). III. Resident #46 A. Resident status Resident #46, age 83, was admitted on [DATE] and discharged home on 11/2/24. According to the November 2024 CPO, diagnoses included muscle weakness and right femoral fracture. The 10/24/24 BIMS assessment revealed the resident was cognitively intact with a score of 15 out of 15. B. Record review The facility's misappropriation investigation, dated 10/31/24, was provided by the NHA on 11/20/24 at 12:50 p.m. It documented Resident #46 had a smart watch on the charger in her room on Friday 10/25/24. The resident noticed the next morning (10/26/24) that the watch was missing. Resident #46's daughter called the DON on 10/26/24 and reported the watch may have been missing but she wanted to verify before officially reporting. Resident #46's daughter called the DON again on Friday 11/1/24 and officially reported the watch missing. The watch was tracked electronically to a residential address. The police were notified. The facility staff and residents were interviewed immediately, without resolution. Education was completed for residents and staff to secure valuables in the BOM's safe or DON's office. The facility additionally educated the residents and staff to report any suspicious occurrences immediately. Based on interviews and review of documentation, the facility determined the watch could have been taken from the facility. The facility would reimburse the family the cost of the same make and model of the missing watch. A review of Resident #46's progress notes and EMR did not reveal any other information regarding the incident. IV. Resident #229 A. Resident status Resident #229, age 71, was admitted on [DATE] and discharged home on 9/11/24. According to the November 2024 CPO, diagnoses included infection following a surgical procedure and disruption of an external surgical wound. The 8/28/24 BIMS assessment revealed the resident was cognitively intact with a score of 15 out of 15. B. Record review The facility's misappropriation investigation, dated 9/9/24, was provided by the NHA on 11/20/24 at 12:50 p.m. It documented the alleged assailant was identified as certified nurse aide (CNA) #4. Resident #229 stated that she was missing $40. Resident #229 looked in her wallet and noticed the money was missing. Resident #229 thought the money went missing on 9/9/24 but was unsure. The DON and the NHA interviewed all of the residents residing on the same hallway that Resident #229 was residing on. The DON and the NHA interviewed the staff member identified by Resident #229. The police were notified and Resident #229 was re-educated on locking her valuables in the BOM's safe or the DON's office. The identified staff member was immediately suspended pending an investigation. The staff were educated about the incident. Resident #229 reported she last saw the money on 9/7/24. Resident #229 said she had the money in her wallet, had wrapped the wallet in a towel and placed the towel in a drawer in her bathroom. She said she noticed that the wallet had been unwrapped and that the money was missing on 9/9/24 and reported it to management on 9/10/24. Resident #229 was interviewed by the facility staff and reported that CNA #4 had asked her questions about the wallet. Resident #229 hid the wallet out of caution by wrapping it in a towel and placing it in a drawer in her bathroom. Resident #229 said she was 90% sure that CNA #4 had taken the money but was not 100% certain. CNA #4 was interviewed privately by the facility's administration staff. CNA #4 reported he was not aware that Resident #229 had money in her room. Based upon the interviews and review of documentation, the facility determined that Resident #229 did have the money and that the money was misplaced while she was staying at the facility. The facility would reimburse Resident #229 the full amount of $40. Re-education was provided to Resident #229 on how and where to keep valuable or personal items locked in the DON's office or the BOM's safe. Resident #229 was resistant to locking up her wallet. An interview with CNA #4, dated 9/10/24, was included with the investigation. It revealed CNA #4 was asked about the missing money from Resident #229's room. CNA #4 said he knew nothing about the money. CNA #4 then said he was upset and did not want to talk with the interviewer anymore. A review of Resident #228's progress notes and EMR did not reveal any other information regarding the incident. V. Staff interviews The NHA was interviewed on 11/20/24 at 1:37 p.m. The NHA said the facility did not have the police reports for the incidents but that he requested the reports from the local police department. CNA #2 was interviewed on 11/21/24 at 9:50 a.m. CNA #2 said he had not heard anything about any residents having their property misplaced. CNA #2 said he had not received any training about what to do when residents' property went missing, but that he would go tell the DON if he heard anything about missing property. CNA #3 was interviewed on 11/21/24 at 10:33 a.m. CNA #3 said she had heard about residents having property go missing on other hallways but did not know much about the situations. CNA #3 said she had received training on what to do about residents reporting missing property and that the facility staff had meetings about it once a month. Licensed practical nurse (LPN) #2 was interviewed on 11/21/24 at 12:47 p.m. LPN #2 said she had not personally received any training or education about what to do when residents reported missing property. The DON, the NHA, and the chief operating officer (COO) were interviewed together on 11/21/24 at 2:16 p.m. The DON said if a resident reported something missing, the facility staff filed a grievance, reviewed the grievance with the NHA and the DON and then filed a police report. The DON said the facility was trying to investigate CNA #4's role in the incidents, since CNA #4 had been involved in caring for both Resident #228 and Resident #229. The DON said they had suspended CNA #4 but he later quit. The DON said Resident #46's smart watch had been tracked to a residential address. The DON said the facility administrators had cross-referenced the residential address with their employees' home addresses but did not identify any potential suspects among the staff. The DON said the police also investigated the incident, including looking at the employees' families' home addresses and could not identify any connection to the facility staff. The NHA said the police department denied his request for Resident #229's police report as it was an ongoing investigation. The NHA said he had not heard back from the police department yet regarding the other two residents' investigations. The DON said the police had reached out with updates in the past regarding any ongoing investigations. The COO said the facility staff received training on missing property upon hire, annually, and if an incident occurred. The DON said an all-staff meeting on misappropriation of resident property was conducted on 11/4/24. The NHA said they had educated the staff on misappropriation and that the residents could secure their items in the BOM safe or the DON offices. The NHA said the CNAs and nurses should have been informing residents where they could secure their valuables and that the information on that subject was also in the residents' admissions agreement. The COO said the facility would be keeping in contact with the police department more regularly going forward. The NHA said if a resident declined to secure their valuables in the BOM safe or the DON office, the facility would encourage the resident's family to take their valuables home with them. The DON said she had discussed Resident #228's hair appointment with the resident and Resident #228 said she did not have enough money for the hair appointment and complained about how expensive it was. The DON said they filed a grievance with Resident #228 related to this prior to the incident in which Resident #228 reported having money go missing. The COO said Resident #228's daughter had visited the resident and that he thought the resident's daughter may have taken the money home. The COO said from a customer service standpoint, the facility generally just reimbursed any money residents report missing. -However, resident reports of missing property continued to occur at the facility and the facility had not implemented a process to effectively prevent misappropriation of resident property.

Based on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#226) of five residents reviewed for unnecessary medications out of 60 sample residents. Specifically, the facility failed to ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained for Resident #226 prior to the administration of a psychotropic medication. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy and procedure, revised 2/8/21, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, Psychotropic consent will be obtained from the resident and or family on admission or within 72 hours of admission. II. Resident #226 A. Resident status Resident #226, age 74, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included adjustment disorder with mixed anxiety and depressed mood and depression. The 11/17/24 brief interview for mental status (BIMS) assessment revealed the resident was moderately cognitively impaired with a score of 10 out of 15. B. Record review The antidepressant medication care plan, initiated 11/15/24, revealed Resident #226 received an antidepressant medication due to her depression and adjustment disorder diagnoses. Pertinent interventions included administering the medication as ordered and observing for side effects and effectiveness of the medication each shift. Review of Resident #226's November 2024 CPO revealed the following physician's order related to psychotropic medications: Venlafaxine (antidepressant) oral capsule extended release. Give 225 milligrams (mg) by mouth in the morning for depression, ordered 11/15/24. Review of Resident #226's electronic medical record (EMR) revealed a psychoactive medication therapy consent form for Venlafaxine dated 11/14/24. -However, the form was not signed by the resident and the staff member that obtained the consent until 11/18/24, four days after the resident's admission to the facility. Resident #226's November 2024 medication administration report (MAR) revealed the following Venlafaxine was marked as administered once a day from 11/15/24 through 11/20/24 and antidepressant monitoring was marked as completed each shift from 11/14/24 through 11/20/24. -However, the psychoactive medication therapy consent form was not signed by the resident until 11/18/24 (see above). III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 11/21/24 at 12:47 p.m. LPN #2 said the nurses at the facility were the ones who went over the medication consents with the residents along with the rest of their admission paperwork. LPN #2 said there had been times where agency staff had missed the consent forms and not had the resident sign them, or missed the medication orders and did not realize the resident needed a consent form. LPN #2 said the unit manager went through and checked to make sure the admissions packets were signed appropriately. LPN #1 was interviewed on 11/21/24 at 1:17 p.m. LPN #1 said the nurse that admitted the resident was responsible for ensuring all of the medication consents were signed. LPN #1 said there was sometimes a delay in getting the consents signed if the resident wanted a family member to read through it. LPN #1 said the nursing staff could not administer an antidepressant or other psychoactive medication until the resident had signed the respective consent form. LPN #1 said the unit manager followed up the next day after a resident was admitted to ensure all of the consent forms were signed appropriately on admission, and if they were not signed, the unit manager would follow up with the resident and try to answer any questions the resident might have. Registered nurse (RN) #2 was interviewed on 11/21/24 at 3:44 p.m. RN #2 said Resident #226 admitted to the facility with a physician's order for an antidepressant medication on 11/14/24. RN #2 said the facility had a consent form that the resident was supposed to sign prior to receiving the medication. RN #2 said sometimes the nurses missed the medication consent forms or the residents refused to sign them. RN #2 said she was not sure what happened in Resident #226's case, but thought that the agency nurse that admitted the resident may have missed the consent form for that medication. RN #2 said she, or one of the other unit managers, usually reviewed the admission paperwork to ensure all the paperwork was filled out correctly. The director of nursing (DON) was interviewed on 11/21/24 at 5:56 p.m. The DON said antidepressant medications had a consent form that the resident needed to sign immediately when they went through the admission packet with the admitting nurse, or have a family member come in to sign it. The DON said the resident was not supposed to receive psychotropic medication prior to signing the consent form. The DON said the hospital sent the facility a list of medications which the resident's practitioner then had to approve before it was ordered from the pharmacy. The DON said usually by the time the facility received the medication from the pharmacy, the consent form had been signed. The DON said RN #2 was the one that wrote the consent form so she guessed the form was dated incorrectly. The DON said she had not heard anything about Resident #226 not wanting to sign the medication consent form. The DON said consent forms were needed for any high risk medications to ensure the resident knew what they were taking, why they were taking it and what the side effects could be. D. Facility follow up A signed statement from Resident #226 was provided by the NHA on 11/22/24 at 11:29 a.m. (after the survey exit) The statement revealed Resident #226 signed all of her consent forms upon admission on 11/14/24, including her psychoactive medication therapy consent form for Venlafaxine. The statement was undated and also signed by a member of the staff. -However, the medication consent form in Resident #226's EMR during the survey was signed by Resident #226 and a staff member on 11/18/24, not 11/14/24 (see record review above).

Based on record review and interviews, the facility failed to provide pharmaceutical services to meet the needs of one (#1) of three residents out of three sample residents. Specifically, the facility failed to ensure two inhaler medications for Resident #1 were ordered and delivered to the facility as ordered by the physician. Findings include: I. Facility policy and procedures The Medication Ordering From Pharmacy policy, reviewed 4/2/24, was provided via email on 10/9/24 at 1:21 p.m. by the director of nursing (DON). It revealed in pertinent part, The purpose of this policy is to assure that patients receive their medication delivery when admitted to the facility in a timely manner. Standard Process: All medications will be faxed to the pharmacy once the medications have been verified with the provider when a patient admits to the facility or when a new RX (prescription) is received and patient(s) need a medication refill. If medications are on the delivery manifest but were not delivered the provider pharmacy should be contacted for a correction and nurse management should be notified. II. Resident #1 A. Resident status Resident #1, age 85, was admitted on [DATE] and discharged on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnosis included COVID-19, sepsis, acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), anemia, unspecified atrial fibrillation (AFIB), hypertension (high blood pressure) and depression. The minimum data set (MDS) admission assessment was not completed because the resident discharged before it could be completed. The 7/9/24 admissions functional ability assessment revealed the resident required maximum assistance with oral hygiene. The resident was dependent on staff for toileting, sitting to lying down, sitting to stand, and chair to bed transfers. The resident required staff supervision or touch assistance with eating. B. Record review Resident #1 was admitted to the hospital on 6/27/24 with a diagnosis of COVID-19 pneumonia and was admitted to the facility 11 days later, on 7/7/24. The comprehensive care plan, initiated 7/8/24, revealed Resident #1 was at respiratory risk related to respiratory conditions and/or deficiencies/abnormalities in pulmonary function, acute respiratory failure with hypoxia, deconditioning with hospital stay/acute medical condition, metabolic encephalopathy, COVID-19, sepsis, pleural effusion and elevated white blood count. The goal was that respiratory risks related to pulmonary conditions/function would be minimized with interventions over the next 90 days. Interventions included administering medications per physician orders. Review of Resident #1's July 2024 CPO revealed the following physician's orders: Fluticasone-Salmeterol Inhalation Aerosol PowderBreath (steroid medication inhaler) Activated 113-14 MCG (micrograms)/ACT (activation) (one) puff inhale(d) orally two times a day, ordered 7/7/24. Spiriva HandiHaler Inhalation (medication used to treat shortness of breath) Capsule 18 MCG (micrograms) (Tiotropium Bromide Monohydrate) one puff inhale(d) orally at bedtime, ordered 7/7/24. Review of the July 2024 medication administration treatment record (MAR) revealed the following: The Fluticasone-Salmeterol Inhalation Aerosol PowderBreath was not administered on the evening of 7/7/24, the morning of 7/8/24 or the evening of 7/8/24 (for a total of three doses). The Spiriva HandiHaler Inhalation Capsule 18 MCG was not administered on the evening of 7/7/24 or 7/8/24 (for a total of two doses). The nursing progress note on 7/7/24 at 8:48 p.m. documented the Fluticasone-Salmeterol inhalation aerosol powder and the Spiriva Handihaler inhaler were not available. The pharmacist progress note on 7/8/24 at 10:27 a.m. documented an admission review of medications was completed and there were no clinically significant medication issues identified. The nursing progress note on 7/8/24 documented the Fluticasone-Salmeterol inhalation aerosol powder and the Spiriva Handihaler inhaler were not available. III. Staff interviews The DON was interviewed on 10/8/24 at 2:00 p.m. The DON said the pharmacy decided, on 7/7/24 at 2:30 p.m., that the medication list in the medical record system was Resident #1's medication current list, however, she said that was incorrect. The DON said the facility always ensured the physician, as well as two nurses, read and signed off on a medication order before the order went to the pharmacy to be filled. The DON said the facility sent the correct medication list to the pharmacy on 7/7/24 at 3:40 p.m. The DON said she spoke with the pharmacy today (10/8/24) and the pharmacy representative told her the medication list which had been sent to the pharmacy on 7/7/24 at 3:40 p.m. was deleted and put into the computer trash bin with the assumption that what was read by the pharmacy on 7/7/24 at 2:30 p.m. was the correct medication list for Resident #1. The DON said the pharmacy never did get the order correctly done for Resident #1's stay in the facility from 7/7/24 through 7/9/24. She said today (10/8/24) the pharmacy representative told her the pharmacy would do a plan of correction with the pharmacy employees so this type of situation would never occur again. The DON said the pharmacy threw away the facility's correct medication list for Resident #1. She said the particular medications in this situation were not carried in their emergency medication kit to be retrieved. She said with all Resident #1 had been through with her health, the inhalers would have benefited the resident. The DON said she was not informed of the medication situation for Resident #1 by the nursing staff. Registered nurse (RN) #1 was interviewed on 10/8/24 at 3:17 p.m. RN #1 said she called the pharmacy on 7/8/24 to request them to send over the missing medications. RN #1 said she assumed the pharmacy would comply with her request. RN #1 said she did not document the conversation with the pharmacy and she did not report the situation to the DON. The DON was interviewed again on 10/8/24 at 3:35 p.m. The DON said the facility had started a training (during the survey) for all of the facility nursing staff about how to ensure pharmacy orders were to be followed through on if a medication was not delivered. The DON said the training contained information to let the DON know when the pharmacy did not comply with the physician's medication orders. The DON said the training reminded the nursing staff to document in the residents' medical records when a call to the pharmacy took place to correct a pharmacy order. IV. Facility follow-up On 10/9/24 at 9:04 a.m. (after the survey) the DON provided an email written by the pharmacy representative on 10/8/24 at 4:27 p.m. The email read in pertinent part, Admission orders faxed on 7/7/2024 for Resident #1 for Spiriva and Fluticasone were misinterpreted by pharmacy staff as duplicate orders. Facility did not report missing these or any medications. The incident has been reviewed and pharmacy staff has been counseled. We have updated our process to include a review of duplicate orders to prevent further incident(s).

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 diseases and infection for six out of six rooms. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles, phone and hand rails); -Ensure surface disinfectant times were followed; and, -Ensure staff followed personal protective equipment (PPE) precautions for a resident diagnosed with COVID-19 when providing care and when cleaning the resident room. Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 6/6/23 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 6/9/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping Services policy and procedure, issued on 11/1/17, was provided by the director of maintenance (DOM) on 6/5/23 at 4:07 p.m. It read in pertinent part, We prevent our patients, visitors and staff from infections everyday. Our team can control the spread of infection by daily disinfection and following all hand hygiene protocols. Disinfecting kills germs. Allowing adequate time for a disinfectant to sit on a surface assures 100% disinfection. This is known as the 'kill time'. We currently use a 1:10 bleach solution that has a 3 minute kill time and 730 hydrogen peroxide disinfectant cleaner that has a kill time of 10 minutes. Only use approved cleaners as they are kept track of with up to date MSDS (material safe data sheets) sheets and safety binders. Daily routine needs to include high touch areas which can include: door, knobs, light switch, sharps table and tray, call light, and phone, call box and pull cord, commode seat, rim and flusher. All patient rooms to include the bathroom and shower should be cleaned daily and some may need to be cleaned more often. C. Manufacturer recommendations The disinfectants in the facility were identified as: 730 HP Disinfectant Cleaner The product label was reviewed which read in pertinent part, For Use as a Daily One-Step Cleaner/Disinfectant: Pre-clean heavily soiled surfaces. Apply Use Solution by coarse trigger sprayer to hard, non-porous surfaces. Spray 6-8 inches from the surface, making sure to wet surfaces thoroughly. All surfaces must remain wet for ten minutes. Wipe surfaces and let air dry. D. Observations On 6/5/23 housekeeper (HSKP) #1 was continuously observed cleaning in room [ROOM NUMBER] from 10:42 a.m. to 11:04 a.m. HSKP #1 wiped the surfaces in the room with a soaked 730 HP disinfectant cloth for nine seconds per surface. The surface was no longer wet within 45 seconds from when the disinfectant was applied and she did not apply the disinfectant correctly by spraying it on the surface. The resident's towel fell on the ground twice prior to the floor being mopped and was not replaced. HSKP #1 folded the towel and hung it back on the bathroom rail for the resident to use. The shower was not cleaned or disinfected. No high frequency touch areas were disinfected (see above policy and procedure). HSKP #2 was continuously observed cleaning in room [ROOM NUMBER] from 11:21 a.m. to 11:41 a.m. HSKP #2 wiped the surfaces in the room with the soaked 730 HP disinfectant cloth for a few seconds per surface. She did not apply the disinfectant correctly by spraying it on the surface and did not clean the entire surface of the bedside table and desk. The surface was no longer wet within 45 seconds from when the disinfectant was applied. High frequency touch areas were wiped but not disinfected (hand rail, room call light, light switches, closet handles, bed controller and television remote). For the areas HSKP #2 did use the disinfectant to clean, the surface disinfectant time was not followed per manufacturer recommendations. E. Staff interviews HSKP #1 was interviewed on 6/5/23 at 11:07 a.m. HSKP #1 said she did not know the surface disinfectant time of the housekeeping disinfectant products and she did not clean all high frequency touch areas in the residents' room. HSKP #1 said she ran out of chemicals monthly and therefore she would dilute chemicals with water and clean the residents' rooms if the facility ran out of disinfectant. HSKP #2 was interviewed on 6/5/23 at 11:46 a.m. HSKP #2 said she did not know the surface disinfectant time of the housekeeping disinfectant products. The director of maintenance (DOM) was interviewed on 6/5/23 at 3:53 p.m. The DOM said chemicals should never be diluted because they would no longer be effective. The DOM said if the surface disinfectant time(how long the surface must remain wet) was not adhered to; the disinfectant then would not be effective. The DOM said the facility should use Virex and ready to use bleach (not to be diluted) and not use 730 HP. The DOM said she needed to provide training to all housekeeping staff and she needed to revise the current training and onboarding program to cover surface disinfectant times, cleaning supply access and locations, room cleaning procedures and high frequency touch areas. The infection preventionist (IP) was interviewed on 6/6/23 at 3:07 p.m. The IP said she was involved with the housekeeping department, it was her job to make sure housekeeping adhered to infection control guidelines. Surface disinfectant times should be adhered to, adherence to the surface disinfectant time would ensure surfaces were properly disinfected and all pathogens were destroyed. High frequency touch areas should be disinfected and chemicals should never be diluted. Diluted chemicals would be ineffective. D. Additional information The facility provided two different versions of the housekeeping policy. The version provided by the DOM was issued on 11/1/17. No revision and or review dates have been listed since 2017(6 years ago). The chemicals used in the policy were in contrast with the DOM's chemical list (see above). The DOM said she trained housekeeping staff according to the policy provided dated 11/1/17. The nursing home administrator (NHA) was interviewed on 6/6/23 at 1:43 p.m. The NHA said the policies and procedures of the facility needed to be revised as some were outdated; once the policies were revised all staff would receive education on the revised policies and procedures. Policies and procedures should be reviewed and updated as needed and or at least annually. The NHA acknowledged there were discrepancies between the housekeeping policy provided by the DOM and the current last revised policy that he provided. The NHA said the facility should be following the current last revised policy. The NHA said the facility's housekeeping practice should align with the policy established. The NHA provided an updated housekeeping policy last revised on 8/17/22. 46851 II. COVID-19 PPE precautions A. Observations and record review Certified nurse aide (CNA)# 5 was observed on 6/31/23 at 3:47 p.m., entering and exiting room [ROOM NUMBER] (a room under COVID-19 isolation precautions) while wearing a surgical mask and no other PPE. CNA #5 did not use hand sanitizer after leaving the room and walked down the hallway wearing the same mask that was worn in the isolation room. The COVID-19 positive resident was moved to room [ROOM NUMBER]. On 6/1/23 at 2:07 p.m. an unknown female staff member was observed with a medication cart delivering supplies. The unknown staff member walked into the COVID-19 positive room and was about two feet inside the room talking to the resident. They remained inside of the room for a couple of minutes. The unknown staff member came out of the room without sanitizing her hands. She looked through the cart and continued the task. There was a PPE cart and folder with diagnosis and PPE instructions. The instructions said all staff including housekeeping staff need to wear full PPE which include the following: N95 mask, goggles, gown and gloves. Staff should put PPE on before entering the room and take it off before leaving the room. At 2:12 p.m., room [ROOM NUMBER] had been occupied by a resident that had COVID-19. room [ROOM NUMBER] was empty and had previously worn PPE in a trash bag located on the ground. At 2:23 p.m. HSKP #3 was observed while cleaning room [ROOM NUMBER]. HSKP #3 did not wear any PPE except gloves, while cleaning a room previously occupied by a resident that was diagnosed with COVID-19. B. Staff nterviews The DON was interviewed on 6/1/23 at 3:20 p.m. She said when a resident contracted COVID-19, administration puts the resident on isolation and all staff who entered the resident's room should adhere to full precautions; which include N95 mask, goggles or face shield, a gown and gloves. The staff should perform hand hygiene after exiting the room. She said staff should dispose of all PPE before exiting the isolation room and dispose of the mask they wore in the isolation room and get a new mask. She said she did not know the expectation of PPE for housekeeping when cleaning a room after a resident diagnosed with COVID-19 left but they should deep clean the room. She said staff should not wear surgical masks in a COVID-19 resident rooms and should not continue to wear masks after exiting the room. She said staff should not be in the isolation room without proper PPE and when they exit they should perform hand hygiene. She said she would follow up with education for all staff on proper protocol when working with a resident that is diagnosed with COVID-19. The DON was interviewed again on 6/5/23 at 2:01 p.m. She said she talked CNA #5 said she wore a N95 mask over her surgical mask and wore PPE in the isolation room. She said the unidentified staff was on the threshold and not inside the room. She educated the staff on proper PPE while working with COVID-19 positive residents. The housekeeping supervisor (HSKS) was interviewed on 6/5/23 at 4:00 p.m. She said housekeepers should wear full PPE when cleaning a room that had occupied a positive COVID-19 resident. She said the housekeeper did not know room [ROOM NUMBER] had been occupied with a COVID-19 positive resident. She said nursing staff notified housekeeping staff when there was a COVID-19 positive resident. She said HSKP #3 was not aware the room had been occupied by a resident that had COVID-19. The DON was interviewed again 6/5/23 at 4:45 p.m. She said staff knew residents have COVID-19 because they have carts in front of their rooms with a folder telling staff directions on how to proceed. She said housekeeping staff would know the COVID-19 positive residents by the carts in front of the door. She said if a resident moved rooms housekeeping staff should know since the cart and folder was previously there.

Based on observations, record review, and staff interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of one kitchens. Specifically, the facility failed to: -Ensure a clean and sanitary kitchen within the dry storage room; around the grill and fryer; within smaller refrigerator units; and surfaces of the kitchen; and, -Ensure open food items were properly labeled with open dates and sealed for storage to prevent contamination. Findings include: I. Professional standards According to The Colorado Department of Public Health and Environment (CDPHE), Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 6/12/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view Persons who are more likely than other people in the general population to experience foodborne disease because they are older adults; and they obtain food at a facility that provides services such as nursing homes. Food Storage. Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; Preventing Food and Ingredient Contamination: food shall be protected from cross contamination by: storing the food in packages, covered containers, or wrappings; Food packaged in a food establishment, shall be labeled as specified in law, including Labeling, marking devices, and containers. Label information shall include:The common name of the food , or absent a common name, an adequately descriptive identity statement; The name of the food source for each major food allergen contained in the food unless the food source is already part of the common or usual name of the respective ingredient. Cleaning, Frequency and Restrictions. Physical facilities shall be cleaned as often as necessary to keep them clean. Soiled receptacles and waste handling units for refuse, recyclables, and returnable shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. II. Facility policy and procedure The Food Storage policy, last reviewed 2/8/21, was provided by the director of nursing (DON) on 6/6/23 at 5:15 p.m. It read in pertinent part: Food items within the building are to be stored to ensure they are optimal for safe consumption by patients and staff. Storing foods properly helps to prevent foodborne illness and maintains the food's peak qualities such as flavor, texture, color and aroma. An untitled, undated document with the facility's logo was provided by the DON on 6/6/23 at 5:15 p.m., it read in pertinent part: Keep all kitchen equipment and utensils used to produce food products clean and in a good condition. Protect food from dirt, vermin, unnecessary handling, droplet contamination, overhead leakage, or other environmental sources of contamination. III. Observations On 5/31/23 at 9:08 a.m., the main kitchen was observed, the following conditions were present: -Two large trash cans did not have lids on them; -The floor in the dry storage room was heavily soiled at the side walls where the floor met the wall to include a heavy layer of blackened debris and dust all along the long wall where food was stored. -The was behind the food storage shelves were solid with dried drips of red, brown, tan and blackened substances; -Condiment containers were soiled with blackened smudges and dried drips of tan, debris; -There were four dented cans stored on food shelves with un-dented cans with no indication to not use the dented cans; -There was a large open bag of bread crumbs that was fully open to air and not resealed or dated after opening; -Two packages of pasta that had been opened were not sealed for storage; -The walk-in refrigerator shelved several unlabeled, undated and some uncovered prepared leftover food items. Some foods appeared to be easily identifiable (corn, cauliflower and broccoli) and other items were not so easily identifiable (two containers of differing type of a thick brown gelatinous substance, red sauce with of unidentified brown chuck mixed in); -There were four open packages of sliced cheese not dated or resealed after opening; -In the main kitchen, the ice machine outer vent was heavily soiled with gray dust and the door and top surface was soiled with a film of fine dust; -The stand alone refrigerator was soiled with dust and the inner door had dried brown drips on it; -The trashcan placed in between two meal prep tables and the steam table prep area had a layer of dust and debris on the push lid and around the edges were it met the prep tables met the tables; -Exposed pipes behind the grill were soiled with dust and blackened debris; -The top of the back wall of the grill was heavily soiled with a thick layer of a dark black substance; and, -The metal splatter guard surfaces on either side of the deep fat fryer were heavily soiled with a thick layer of dark amber grease. During observations of the walk-in refrigerator, the dietary manager (DM) said the unlabeled food items should have been tossed out. During the observation of the main kitchen, the DM said the kitchen trash cans had lids and needed to be placed on the trash cans for sanitation. On 6/5/23 at 10:50 a.m. the main kitchen was observed the conditions in the main kitchen and dry storage room continued as observed on 5/31/23 (see above). IV. Staff interviews The DM was interviewed on 6/6/23 at 11:22 a.m., during a tour of the kitchen. The DM said since returning to work in the facility, she had done a lot of work to get the kitchen cleaned particularly with the floor; it had to be bleached to get rid of the past buildup of soiling and restore it. The DM said some areas like in the dry storage were missed due to having to move the food storage shelving and really be able to remove the surface dirt. The DM said there was still some work to complete. The DM said the kitchen was cleaned routinely after each meal service and at the end of the day; then given a deeper clean once a week. The DM said the splattered oil on the metal splash guard walls on each side of the fryer were very hard to keep clean. During the interview, the DM assigned specific kitchen staff to clean on specific areas identified during the kitchen tour. The DM said any opened unused food item should be thoroughly sealed for storage and removed the bread crumbs due to the product being exposed for an extended period of time. The DM said she would in-service kitchen staff and address all identified areas to ensure proper food storage and kitchen sanitation.

Based on observations and interviews the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards on two of two units reviewed of four units. Specifically the facility failed to: -Ensure prescribed medications were labeled correctly; -Remove expired medications from the cart; and, -Ensure topical medications were not stored with oral medications. I. Professional standards According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. [NAME] Missouri, pp. 608, Medication error often occurs because a patient gets a medication intended for another patient. Therefore, an important step in safe medication administration is being sure that you give the right medication to the right patient. II. Facility policy The Storage of Medications policy and procedure, revised on 2/8/21, received from the director of nursing (DON) on 6/5/23 at 11:29 a.m. revealed in pertinent part, the medication and biological were stored properly, following manufactures or provider pharmacy recommendations, to maintain integrity and to support safe effective drug administration. Provider pharmacy dispensed medications in containers that meet state and federal labeling requirements. Internally administered medications were stored separately from medications used externally such as lotions, creams, and ointments. III. Observations and staff interviews Review of the second floor D wing cart on 6/1/23 at 3:39 p.m. revealed three cefazolin two grams in 100 milliliters solution intravenous (IV) bags that expired on 5/29/23. Registered nurse (RN) #3 removed the three IV bags from the cart and took them to the medication storage room and placed them into the return to pharmacy bin. RN #3 said the medications should have been removed from the cart by the 30th to ensure expired medications were not given to the resident. RN #3 said she thought the night shift went through the medication carts to remove expired medications and keep the carts clean but unsure how often this occurred. Review of the third floor D wing cart on 6/1/23 at 3:49 p.m. revealed a tube of miconazole nitrate 1% antifungal cream stored next to oral medications. Licensed practical nurse (LPN) #1 said the antifungal cream should not have been stored next to oral medications. He said topical creams could leak and contaminate medications. A bottle of latanoprost ophthalmic solution 0.005% (eye drop used for glaucoma) with an open date of 4/30/23 was in the medication cart. The prescription label identified the medication belonged to a resident however the name was blacked out with a permanent marker. The blacked out name was still visible. Another resident name was handwritten in permanent marker on the prescription label over the other resident's name. LPN #1 said the medication had been relabeled with another resident name. He said medication should not be relabeled for another resident. LPN #1 placed the miconazole nitrate %1 cream into another section of the cart that stored topicals only. LPN #1 then took the latanoprost eye drops to the DON. The DON was interviewed on 6/1/23 at 3:59 p.m. The DON said the prescription label had been relabeled when LPN #1 showed her the latanoprost. She said prescriptions were resident specific and should not be relabeled to be administered to another resident. The DON said topical medications were to be stored in separate sections in the medication cart from oral medications. Topical medications have the potential to leak and contaminate other medications or cause a chemical reaction. The DON said expired medications should be removed immediately by the nurse who finds them or by a night shift nurse who reviews the medication cart nightly. Expired medications or discontinued medications were to be disposed of in the medication room for pharmacy to destroy.

Based on record review observations and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents. Specifically, the facility failed to: -Follow up and document Resident #33's grievance reported to a staff member; and, -Ensure residents were aware how to file a grievance and place grievance forms in prominent locations throughout the facility. Findings include: I. Facility policy The Grievance policy, last revised on 2/8/21, was provided by the director of nursing (DON) on 6/6/23 at 5:30 p.m. it read in pertinent, Grievances can be communicated to a staff member either verbally or in writing. All patients will be informed of the location of the facility's grievance forms should they wish to write a formal complaint. Any patient who wishes to do so may express his/her grievances in writing or verbally to any staff member; however, they are strongly encouraged to express the complaint (s) directly to Social Services, Executive Director, or the Manager on Duty. If the complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. The completed form must be provided to the Executive Director or Designee immediately. It is the responsibility of the Department Managers in coordination with the Executive Director, when appropriate, to develop a process/plan for resolution of the grievance and notify the complainant about the plan for resolution. If the complainant or aggrieved party is dissatisfied with the finding and/or remedies, the Executive Director will make reasonable attempts to resolve the grievance. The Ombudsman will be notified if the grievance is not resolved per patient/family representative request. II. Resident #33 A. Resident status Resident #33, [AGE] years old, admitted on [DATE], according to the June 2023 computerized physician orders (CPO) diagnosis included abdominal surgical infection, benign prostatic hyperplasia (BPH a blockage of urine flow), type two diabetes (insulin insufficiency) and dementia (impaired memory). The 5/25/23 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status score of 10 out of 15. He required one person physical assistance with transfers, bed mobility, dressing, toileting and personal hygiene. B. Resident interview Resident #33 was interviewed on 5/31/23 at 11:55 a.m. he said he had a nurse or certified nurse aide (CNA) come in one night and tell me what are you doing? Who told you you could do this.'' Resident #33 said he was in the bathroom and had to go and could not wait for staff. He said he felt reprimanded and he soiled himself and staff did not offer assistance. He was unable to recall the specific night it occurred but believed it was around 5/24/23 around 1:00 to 2:00 a.m. in the morning. Resident #33 said the staff member's tone of voice was harsh and made him mad. He said he asked the staff member why are you doing this to me? He said he did not need an attitude, what he needed was assistance to use the restroom inorder to pass stool related to my surgery and here the staff are yelling at me when using the restroom. Resident #33 was interviewed a second time on 5/31/23 at 4:37 p.m. He said the staff member said what were you doing without staff here to escort you to the restroom. He identified the staff member but was unsure if it was a nurse or CNA. Resident #33 said he had not seen the staff member since that night. He said he was startled with the situation and felt the staff member was bold to talk to him the way she did. Resident #33 said his call light had to have been on,why else would the staff member come into the room and find him in the bathroom. Resident #33 said he was left soiled and had to clean himself up, which was not easy due to his current medical condition. Resident #33 said he reported to the occupational therapist (OT) the next morning that the CNA was rude to him. Resident #33 said no staff had followed up with him since reporting to the OT. C. Record review The 5/22/23 care plan revealed Resident #33 required assistance with activities of daily living (ADLs) due to self care deficits and decreased functional mobility secondary to recent hospitalization for surgical interventions. Interventions were: call light within reach, encouraged to do as much for self as able and praise for effects with self care. Resident #33 needs assistance with transferring, toileting related to weakness from colostomy closure with infection at surgical site. Interventions check patient frequently and offer toileting as needed. D. Grievance form A grievance form was requested on 5/31/23, per the NHA interview (see below) there was not a grievance form for Resident #33. The NHA was interviewed on 5/31/23 at 5:11 p.m. He said he had not heard about Resident #33 having complaints about staff. He said he would start an investigation. The NHA completed a grievance form on 5/31/23 for Resident #33 (after being identified during the survey). The grievance form identified Resident #33 was self ambulating in room late at night, he had used his call light but could not wait much longer. While he was urinating a CNA came behind him and startled him saying who said you could do that? She was intent on conveying to him going to the bathroom independently was wrong. The resident was told staff would be educated and he was satisfied with the outcome. E. Staff interviews The OT was interviewed on 6/1/23 at 12:21 p.m. She said during a morning visit with resident #33 he advised her of a situation he had that night. She said Resident #33 said I'm ok, I had a problem last night. Someone was rude to me and my feelings got hurt. She said she offered to lodge a formal complaint for the resident and the resident said no it will be ok. She said the resident appeared to be his baseline other than staff who were curt with him. The OT was unable to recall a specific date the resident reported this to her. The OT acknowledged that she did not document the situation nor report it to administration. She said in the future she would report a resident grievance to her supervisor even if she was unsure about the situation. The DON was interviewed on 6/6/23 at 4:28 p.m. She said Resident #33 was not independent with ambulation and required assistance to restroom. The DON said all staff were to treat residents with respect and dignity. The grievance follow up was completed on 5/31/23 by the NHA and DON after extensive discussion with Resident #33. He did not indicate fear or harm during the 30 minute interview. III. Grievance process and forms A. Observations On 6/5/23 at 1:10 p.m. the second floor had no grievance forms located anywhere on the unit or on the counter of the nurses' station. At 1:20 p.m. the third floor one of the nurses' station had grievance forms located on the counter and the other nurses station there were no grievance forms found. At 2:43 p.m. CNA #4 had an admission packet on the counter. The admission packet did not have a grievance form in it. B. Resident group interviews The resident group interview was conducted on 6/5/23 at 11:00 a.m. with three residents (#62, #330 and #335) identifed by the facility and assessment as interviewable. All the residents said they did not know how to file a complaint or where the grievance forms were kept. C. Staff interviews CNA #3 was interviewed on 6/5/23 at 2:38 p.m. CNA #3 said she did not know where the grievance forms were and said to speak with the registered nurse (RN). Licensed practical nurse (LPN #3) was interviewed on 6/5/23 at 2:40 p.m. LPN #3 said the grievance forms were kept behind the nurses' station in a black bin hung on the wall. LPN #3 then pointed to the black bin on the wall. She said residents did not have access to the grievance forms and the forms were not convenient for residents to get at any time. CNA #4 was interviewed on 6/5/23 at 2:43 p.m. CNA #4 said the grievance forms are kept behind the nurses' station. She said that if someone was upset about something she offered them a grievance form and assured them it was ok to file a grievance. RN #4 was interviewed on 6/5/23 at 2:53 p.m. RN #4 said the grievance forms were located on the counter at the nurses' station counter. RN #4 could not find any grievance forms on the counter, so she went behind the desk and started looking through a drawer and could not find a grievance form. The physical therapist (PT) was interviewed on 6/5/23 at 2:56 p.m. She said the grievance forms were located on the counter at the nurses' station. The PT could not find the grievance form, so she went to the other nurses' station on the other side and took a form from their counter and brought it back, made copies and placed them on the nurses' station counter. The case manager (CM) was interviewed on 6/6/23 at 2:20 p.m. He said the grievance process was a group effort and everyone had a hand in resolving the grievances at the facility. He said he would send an email to the DON and the nursing home administrator (NHA) to let them know they have grievances since they handled the resident grievances. The CM said he did not know how long the grievance process took to resolve the complaint. He said he was not sure if residents knew how to fill out a grievance and had to talk with the NHA about the process. The CM spoke with the NHA and he was informed during the resident's admission process the nurses verbally went over the grievance process with each resident. The CM said the grievance forms were not part of the admission packet and said it would be beneficial to include them in the packet. The CM said residents should have a hard copy of the grievance form instead of being informed by nursing staff verbally. 47064

Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for three residents (#226, #232 and #236). Specifically, the facility had a medication error rate of 7.89 percent, which was three errors out of 38 opportunities for error. Findings include I. Professional reference and manufacturer recommendations According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. [NAME] Missouri, pp. 606-607, retrieved on 6/12/23, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. According to the Humalog (Lispro) package insert, retrieved 6/12/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf Instructions for use: priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin. According to the Humalin N kwikpen (NPH) instructions for use, retrieved on 6/12/23 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf priming your pen; prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If not primed before each injection, you may get too much or too little insulin. To prime the pen, turn the dose knob to two units, hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. You should see insulin at the tip of the needle. II. Facility policy The Medications Administration policy and procedure, revised on 2/8/21, received from the director of nursing (DON) on 6/5/23 at 11:29 a.m. revealed in pertinent part, medications are to be administered as prescribed by the attending physician. The Insulin Pen Injection policy and procedures, revised on 6/14/22, received from the DON on 6/5/23 at 12:24 p.m. revealed in pertinent part, the insulin pen is an injection device that delivers insulin. Prime the insulin pen. Priming means removing air bubbles from the needle and ensures the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. III. Observations On 6/5/23 at 8:20 a.m. registered nurse (RN) #1 was observed administering medication to Resident #236. The medication ordered was Insulin NPH (neutral protamine [NAME] type of intermediate use insulin)100 units/milliliter (used to manage diabetes) give10 units subcutaneously two times a day for diabetes mellitus. The nurse collected an insulin NPH pen, she rolled the pen between her hands to mix insulin within the pen and dialed the pen to 10 units. RN #1 administered the insulin to the resident. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 8:37 a.m. RN #1 was observed administering insulin to Resident #232. The medication ordered was insulin lispro (humalog) 100 units/milliliter per sliding scale 71-149= 0 (no intervention);150-200=2 units give Subcutaneous; 201-250=4 units give subcutaneous;251-300=6 units give subcutaneous;301-350=8 units give subcutaneous; 351-400=10 units give subcutaneous. If greater than 400, call a physician. RN #1 collected Lispro insulin from the medication cart, reviewed the resident's blood sugar reading 155 and reviewed lispro insulin order. RN #1 said Resident #232 required two units based on order. RN #1 dialed the pen to two units and administered insulin into the resident's right arm. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 9:26 a.m. RN #2 was observed passing medication to Resident #226. The medication order was Insulin NPH subcutaneous Suspension 100 UNIT/ML; give five units two times a day. RN #1 reviewed Resident #226 blood sugar reading 196 and indicated the resident would receive five units of NPH insulin. RN #2 entered the residents room and administered the insulin. -RN #2 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). IV. Staff interviews RN #1 was interviewed on 6/5/23 at 9:16 a.m. She said in order to administer insulin via a pen the nurse must first verify the order, if an insulin was cloudy in nature it must be rolled between their hands to ensure insulin was mixed well. Then the nurse dialed the pen to the physician's order and administered the insulin. RN #1 said she only primed an insulin pen on initial access to remove air if any air was seen in the pen. RN #1 said she would not prime a pen for each injection. RN #2 was interviewed on 6/5/23 at 9:52 a.m. She said the process of administering insulin via a pen was to dial the pen to the ordered dose and administer medication. RN #2 said insulin pens would not prime as they were pressurized and it made it hard. RN #2 then demonstrated by dialing the insulin pen to two units, pressed the injection button and nothing was observed coming out of the pen. There was no needle attached to the pen during RN #2 demonstrations. RN #2 said she was unaware of the need to prime an insulin pen for each administration. The director of nursing (DON) was interviewed on 6/5/23 at 10:26 a.m. She said nursing staff were to administer insulin by reviewing the order, collecting the medication, alcohol swabs and needle. The insulin pen then could be dialed to the ordered units of insulin and then administer the insulin. The DON said after observations of the insulin pen not being primed (see above), the insulin pen needed to be primed with two units of insulin prior to each injection to remove the air in the needle. The DON said if a needle was not primed it could deliver too much or too little insulin to the resident, which could cause issues with regulating the resident's blood glucose levels.

Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for three residents (#226 #232 and #236) of four reviewed for medication administration out of 44 sample residents. Specifically, the facility failed to ensure insulin pens were primed prior to medication administration for Residents #226, #232 and #236. Cross-reference F759 failure to ensure the medication error rate was less than five percent. Findings include: I. Professional reference According to the Humalog (Lispro) package insert, retrieved 6/12/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf Instructions for use: priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin. According to the Humalin N kwikpen (NPH) instructions for use, retrieved on 6/12/23 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf priming your pen; prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If not primed before each injection, you may get too much or too little insulin. To prime the pen, turn the dose knob to two units, hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. You should see insulin at the tip of the needle. II. Facility policy The Medications Administration policy and procedure, revised on 2/8/21, received from the director of nursing (DON) on 6/5/23 at 11:29 a.m. revealed in pertinent part, medications are to be administered as prescribed by the attending physician. The insulin pen injection policy and procedures, revised on 6/14/22, received from the DON on 6/5/23 at 12:24 p.m. revealed in pertinent part, the insulin pen is an injection device that delivers insulin. Prime the insulin pen: priming means removing air bubbles from the needle and ensures the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. III. Observations On 6/5/23 at 8:20 a.m. registered nurse (RN) #1 was observed administering medication to Resident #236. The medication ordered was Insulin NPH (neutral protamine [NAME] type of intermediate use insulin)100 units/milliliter (used to manage diabetes) give10 units subcutaneously two times a day for diabetes mellitus. The nurse collected an insulin NPH pen, she rolled the pen between her hands to mix insulin within the pen and dialed the pen to 10 units. RN #1 administered the insulin to the resident. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 8:37 a.m. RN #1 was observed administering insulin to Resident #232. The medication ordered was insulin lispro (humalog) 100 units/milliliter per sliding scale 71-149= 0 (no intervention);150-200=2 units give Subcutaneous; 201-250=4 units give subcutaneous;251-300=6 units give subcutaneous;301-350=8 units give subcutaneous; 351-400=10 units give subcutaneous. If greater than 400, call a physician. RN #1 collected Lispro insulin from the medication cart, reviewed the resident's blood sugar reading 155 and reviewed lispro insulin order. RN #1 said Resident #232 required two units based on order. RN #1 dialed the pen to two units and administered insulin into the resident's right arm. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 9:26 a.m. RN #2 was observed passing medication to Resident #226. The medication order was Insulin NPH subcutaneous Suspension 100 UNIT/ML; give five units two times a day. RN #1 reviewed Resident #226 blood sugar reading 196 and indicated the resident would receive five units of NPH insulin. RN #2 entered the residents room and administered the insulin. -RN #2 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). IV. Staff interviews RN #1 was interviewed on 6/5/23 at 9:16 a.m. She said in order to administer insulin via a pen the nurse must first verify the order, if an insulin was cloudy in nature it must be rolled between their hands to ensure insulin was mixed well. Then the nurse dialed the pen to the physician's order and administered the insulin. RN #1 said she only primed an insulin pen on initial access to remove air if any air was seen in the pen. RN #1 said she would not prime a pen for each injection. RN #1 said it was important residents got the correct dose of insulin to help regulate their glucose levels. RN #2 was interviewed on 6/5/23 at 9:52 a.m. She said the process of administering insulin via a pen was to dial the pen to the ordered dose and administer medication. RN #2 said insulin pens would not prime as they were pressurized and it made it hard. RN #2 then demonstrated by dialing the insulin pen to two units, pressed the injection button and nothing was observed coming out of the pen. There was no needle attached to the pen during RN #2's demonstrations. RN #2 said she was unaware of the need to prime an insulin pen for each administration. She said insulin was used to regulate blood glucose levels and residents need to get the correct dose ordered in order to maintain healthy blood glucose levels. The DON was interviewed on 6/5/23 at 10:26 a.m. She said nursing staff were to administer insulin by reviewing the order, collecting the medication, alcohol swabs and needle. The insulin pen then could be dialed to the ordered units of insulin and then administer the insulin. The DON said after observations of the insulin pen not being primed (see above), the insulin pen needed to be primed with two units of insulin prior to each injection to remove the air in the needle. The DON said if a needle was not primed it could deliver too much or too little insulin to the resident, which could cause issues with regulating the resident's blood glucose levels. The DON acknowledged not priming a pen prior to administration was a medication error due to incorrect dose of insulin being administered.

Based on observations, record review and interviews, the facility failed to provide an environment as free from accident hazards and risks as possible for two (#1 and #13) out of five residents reviewed for accidents out of 16 sample residents. Specifically, the facility failed to recognize Resident #1 was at high risk for falls and did not identify and initiate initial fall interventions. The resident was admitted to the facility for rehabilitation on 1/1/21 from the hospital after a previous fall that resulted in a head injury and a broken neck. The resident fell 45 minutes after being admitted to the facility as she attempted to self-transfer to the restroom. During interviews, the admitting staff said they were not aware of the resident's high fall risk and did not place the resident on high fall risk precautions; even though the resident's hospital records, available for review, identified the risk. Additionally, injuries sustained in a recent fall were included in the resident's admitting diagnoses. Interviews revealed the two nurses were responsible for the complete admission of three residents admitted near or at the same time. A certified nurse aide (CNA) was not available for assistance and the admitting nurses were responsible to complete the CNA and the nurse duties. The resident was not taken to the restroom on admission. The hospital records identified the resident was confused and impulsively stood up, including when she needed to use the restroom. The facility record and staff interviews revealed the resident was not stabilized after the fall and was assisted to the restroom, then the resident was placed in an observation room. The resident then walked to the door of the observation room. Resident #1 was then placed at the nursing station for additional monitoring. The resident was not immediately sent to the hospital after the fall and remained at the facility for an additional two hours. Due to the facility failures, the resident sustained [REDACTED]. In addition, the facility failed to consistently update the comprehensive fall care plan and failed to implement new interventions after falls for Resident #13. Findings include: I. Facility policy and procedure The Fall Prevention Policy and Procedure, dated 10/13/17, was provided by the executive director/nursing home administrator (ED) via email on 1/20/21. The policy read, in pertinent part: Falls in the skilled nursing setting represent one of the most potentially devastating occurrences that can negatively impact a patient's recovery. In facility, falls directly causes tens of thousands of bone fractures, [MEDICAL CONDITION], re-hospitalization s and deaths every year in the United States. It is because of these unfortunate events that the Centers are implementing it's comprehensive program to prevent falls and injury Any patient deemed to be high risk by nursing and/or therapy staff will have the following interventions implemented or at least considered .Low bed, bedside floor pads on both sides of the bed, day sitter, increased time in common area in line of sight of nursing staff as needed Move patient to a room closer to nurse's station .If a patient admits with dementia, Alzheimer's, or altered mental status, initiate the following on admission and for a minimum of 72 hours: Routine toileting schedule throughout the shift . According to the post fall procedure included in the facility's fall policy and procedure: RN (registered nurse) to assess the patient immediately for injuries. Once the RN has assessed the patient, she will then determine the most appropriate course of action Leave the patient on the floor while awaiting paramedics if indicated, calling 911 if indicated, perform first side prior to transfer if indicated, assessing for pain and injuries. If the patient is stable, able to be transfered, the transfer may be performed . II. Resident #1 A. Resident status Resident #1, age 76, was admitted on [DATE]. According to the nursing comprehensive admission data collection assessment, [DIAGNOSES REDACTED]. The facility did not complete an initial needs assessment before transferring the resident back to the hospital. B. Family interview A family member was interviewed on 1/12/21 at 5:09 p.m. The family member reported Resident #1 fell within an hour of being admitted to the facility. The family member said a nurse told her the facility was not aware the resident was at high risk for falling or that she would impulsively pop up out of bed. The family said the resident suffered a brain bleed from the fall at the facility. C. Record review 1. 1/1/21 fall resulting in hospitalization and facility response An admission note completed by licensed practical nurse (LPN) #1 on 1/1/21 at 4:30 p.m. revealed Resident #1 was admitted to the facility on [DATE] at 4:00 p.m. The LPN documented the resident arriving from the hospital with admitting [DIAGNOSES REDACTED]. According to the note, the resident was alert and orientated at two to three. She was pleasant but anxious. The 1/1/21 daily nurse note read a loud bang and crash followed by Help me, was heard from Resident #1's room at 4:45 p.m. The nurse entered the room and found the resident on the floor. The LPN summoned a registered nurse (RN) who assessed the resident for neurological symptoms and orthostatic vital signs were obtained. According to the note, the resident was assisted to a wheelchair and moved to an observation room. The family and the physician were notified. The 1/1/21 daily nurse note completed at 7:28 p.m. read the nurse spoke to the on call physician. The note indicated the physician requested the resident to be sent to the hospital for a CT scan (computed tomography) due to the nature of the fall and the fact that she hit her head. A 1/1/21 nurse's note completed at 7:38 p.m. by an RN, read the resident was found supine on the floor. A pillow was under her head and her c-collar was in place. The call light was not alarming. According to the note, the resident said she was trying to go to the bathroom, and hit her head. The resident expressed pain to the back of her head. The resident had slight redness and bruising to the back of her head. She knew her name, part of the date and the president. She did not know the place or situation. The RN continued to assess the resident, noting the resident's slightly weak hand grasps and her left pupil of her eye was brisk at a six and her right pupil was sluggish at a four. According to the note, the three nurses (LPN #1, LPN #2 and registered nurse (RN) #2 then moved the resident off the floor and into a wheelchair. A daily nurse note completed on 1/1/21 at 9:30 p.m., read the resident was sent out approximately an hour prior. The note read the resident's son wanted more information on the resident's status after learning of her fall three hours ago. He said he was told the resident was sent out as non-emergent but was concerned because he expected to have more communication from the facility. The 1/1/21 post-fall evaluation read the resident was moved to a wheelchair and then the bathroom because she would not remain on the floor. According to the note, the resident was moved to an observation room in front of the nursing station. The resident rose from her chair, walked to the room door and requested to go home. She was assisted back to her wheelchair and placed at the nursing station. The 1/1/21 neurological flowsheet was initiated following the resident's fall. The flow sheet documented the resident's vital signs were observed every 15 to 30 minutes between 4:45 p.m. and 6:45 p.m. The flow sheet revealed the resident remained at the facility for at least two hours after she had an unwitnessed fall with resulting head injury. At 7:15 p.m., the flow sheet read the resident was at the hospital. A fall checklist was provided by the ED via email on 1/20/21. The checklist identified the steps taken following a fall. According to the checklist, the patient could be moved if it was determined he or she was stable. If the RN determines paramedics needed to be called, the patient should not be moved and the neck should be stabilized. The patient should be sent to the hospital if major injury was suspected. The Fall with Possible Head Injury Staff Education, dated 1/14/21, signed on 1/15/21, was provided by the ED. The education read, in pertinent part: If a patient has had a fall, hits their head or if the fall is unwitnessed, neuro (logical) checks should be started and the provider needs to be contacted for further orders per facility policy. If a patient falls, as above, and has signs and symptoms of a head injury, example: bleeding, abnormal pupils, AMS (altered mental status), new or decreased loss of movement/grasps, complaints of back or neck pain, nurse to call 911. Staff to encourage the patient to remain on the floor. Staff to attempt to keep the patient from changing positions. The 1/7/21 employee education for LPN #1, LPN #2 and RN #2 was provided by the ED via email on 1/26/21 at 10:23 a.m. The education was completed in response to the resident's fall on 1/1/21. The documentation revealed staff assisted the resident off the floor from an unwitnessed fall after she presented pupils of different sizes and complained of pain to the back of her head. The staff moved her to an observation room. Resident #1 was treated at a hospital from 1/1/21 to 1/6/21 following the fall at the facility. She was discharged to a nursing facility on 1/6/21. Hospital records following the 1/1/21 fall were provided by the 1/6/21 admitting facility via email on 1/29/21 at 9:26 a.m. Review of the records revealed the following: The 1/1/21 attending trauma/critical care unit physician evaluation revealed Resident #1 was admitted to the trauma intensive care unit after her fall at the facility on 1/1/21. The physician identified a new [MEDICAL CONDITION] was present (bleeding in the brain). The physician evaluated the injuries caused by a previous fall, resulting in her first hospital admission. The physician determined the status of prior injuries and conditions of the subacute infarct (stroke) in the right PICA (post inferior cerebellar artery) territory, a left frontal [DIAGNOSES REDACTED] (tumor), the C1 and C2 vertebrae fracture remained unchanged after the second fall and the right vertebral artery dissection were all improving. The 1/2/21 physician note documented a CT scan identified the resident was stable with exception of a new small traumatic subarachnoid hemorrhage (tSAH). 2. Identification of high fall risk Resident #1 was hospitalized for [REDACTED]. The resident was transferred from the hospital to the facility on [DATE]. The 12/26/2020 facility report sheet documented in the [DIAGNOSES REDACTED]. The following documents were uploaded on 12/31/2020 to the resident's facility medical record and were available for review prior to her 1/1/21 admission to the facility. The available documents identified Resident #1 was at high risk for falling and impulsive: a. Hospital discharge summary The 12/19/2020 hospital discharge summary signed 12/31/2020 by the DO (osteopathic physician), identified the resident had a history of [REDACTED]. She was required to wear a cervical collar for three months. According to the DO, Resident #1 was stable enough for discharge. b. Hospital occupational therapy The 12/19/2020 hospital occupational therapy (OT) data flow sheet read Resident #1 demonstrated confusion, difficulty following directions and exhibited impulsivity. The 12/21/2020 hospital OT data flow sheet read Resident #1 reported needing to use the restroom and impulsively attempted to get out of bed. According to the OT, the resident had intermittent confusion and required redirection. The 12/23/2020 OT note read Resident #1 was impulsive and a fall risk related to decreased insight and reported double vision. The 12/24/2020 OT note read Resident #1 was making steady progress but continued to have deficits in strength, coordination and balance. The deficits put Resident #1 at high risk for falls and decreased activities of daily living (ADL) independence. The 12/26/2020 OT note read Resident #1 was confused with dementia, believing the therapist was a family member. According to the note, Resident #1 wanted to use the bathroom five minutes after declining therapy twice. The 12/29/2020 OT note identified the resident had decreased safety and judgement due to balance, strength, range of motion. The OT noted the resident was at risk for falls and required supervision and set up for toileting. Review of the occupational therapy notes revealed bed rails and an activated alarm were put in place during her stay at the hospital as safety precautions. c. Hospital speech therapy The 12/21/2020 speech evaluation identified the resident was confused and preservative. The 12/29/2020 speech therapy note identified the resident had short term memory deficits and would benefit from staff reminders. d. Hospital physical therapy The 12/18/2020 physical therapy (PT) evaluation identified the resident had dementia, impaired balance requiring physical assistance to prevent falls and required cueing to not attempt to stand on her own. The evaluation identified her chair alarm was activated. The 12/16/2020, 12/21/2020, and 12/24/2020 PT notes identified the resident was impulsive. The 12/27/2020 PT note identified bed and chair alarms were put in place and Resident #1 was impulsive with decreased cognition. The 12/28/2020 PT assessment identified Resident #1 required skilled interventions due to decreased mobility, falls, decreased mental status, decreased safety,and post-surgical precautions. The 12/29/2020 PT note documented the resident was impulsive and needed physical assistance to use the restroom. D. Staff interviews LPN #1 was interviewed on 1/14/21 at 10:19 a.m. The LPN reviewed fall interventions available for residents with recent falls or at increased risk of falling. The LPN said residents at high risk for falls required extensive monitoring and usually placed in an observation room across the nursing station. She said the admission department or nursing staff determine who was appropriate for the observation room on admission, based on their level of fall risk. She said residents who were impulsive or had multiple falls would be appropriate to be placed in an observation room for additional supervision. The LPN said the observation room was available at time of Resident #1's admission but the resident was not identified as having a high risk for falling. LPN #1 said the hospital reports were not as accurate as they once were prior to the COVID-19 pandemic. She said she found the resident laying on the floor after hearing a thud down the hall and a yell for help. The resident said she was attempting to use the restroom. The resident complained of head pain after the fall but insisted she still needed to use the restroom. LPN#1 said at the time of the resident's admission, both she and LPN #2 believed the resident was alert and oriented. She said they did not know the resident had a cognitive deficit, was impulsive, had a fall history and was at high risk for falling again. Because they lacked this understanding, Resident #1 was admitted to a regular room down the hall. The LPN said three residents were admitted on [DATE] at the same time. She said a certified nurse aide (CNA) was not available to assist in the admissions so LPN #1 and LPN #2 had to do the admissions together, performing duties normally done by a nurse and a CNA. The LPN said this was usually not a problem but having three admissions at the same time made getting everything in place very difficult. The LPN said the admitting nursing staff was responsible for assisting the resident to bed on admission, review and complete the nurse admission paperwork, complete the preference sheet with the resident and explain call light use. She said no additional procedures were needed immediately upon resident arrival. CNA #3 was interviewed on 1/14/21 at 10:50 p.m. The CNA explained the procedure a CNA completed for a new admission. She said CNAs helped set up the room prior to the new resident's arrival. Once a resident arrived at the facility, CNAs were supposed to make sure the resident was comfortable. She said CNAs would determine the new resident's restroom needs and help them to the restroom. She said the CNAs would make sure the new admission had fresh water within their reach and ask them if they were hungry and complete the preference sheet with them as another way to ensure comfort. The CNA said it was important to have time to focus on new admission and get as much information as possible about the needs of the resident before the resident arrived. LPN #2 was interviewed on 1/14/21 at 2:20 p.m. LPN #2 said the nurse admitting a resident would receive a verbal report from the discharging hospital and or review downloaded hospital documentation under the miscellaneous tab in the medical record to determine the needs of an admitting resident. She said it was common that the hospital report to be incomplete or different from the records or the needs of the resident. LPN #2 said she received a report from the hospital liaison on the status of Resident #1. She said during the report, the liaison did not mention the resident had dementia or was impulsive to get up. The LPN said they did not know the Resident #1 was a high fall risk. She said she knew the resident had a fracture from a fall but did not know the fall was recent. The LPN said she did not review the available hospital records because she felt at the time she received a complete report from the hospital liaison. LPN #2 said she was the admitting nurse for Resident #1. She placed the resident into bed when she arrived. The LPN completed admission paperwork with the resident and ensured the call light was in reach. She said no additional fall prevention interventions were put in place because the resident was not known to be at high risk for falling. The resident did not show signs of confusion or impulsivity. LPN #2 said she did not offer the restroom at the time of the admission and the resident did not express a need. LPN #2 said LPN #1 took the resident to the restroom after the fall. LPN #2 said she believed the three admissions on 1/1/21 were spaced out well enough to process but, at the same time Resident #1 was admitted , she was still attending to another new resident who needed to be medically triaged. The LPN said Resident #1's fall happened very fast and was not expected. LPN #2 said she was in the unit manager's office discussing the needs of the other new resident at the time of Resident 1's fall. RN #2 and LPN #2 received a call from LPN #1 informing them of the fall and requesting assistance. RN #2 was interviewed on 1/14/21 at 3:18 p.m. The RN identified herself as the unit manager. She said an admitting nurse was informed of a new admission from communication with the admissions department and information found on the home page. The home page contains information such as the resident's name, date of birth, diagnosis, brief medical history, the discharge plan, the physician and the height, weight and diet of the resident. RN #2 said nurses determined the needs of a new admission from gathering information from the hospital report and review of the home page. She said most of the hospital records were available for review prior to a resident's admission. She said it was not required that a nurse read the record but would be beneficial when preparing to admit new residents. RN #2 said she was responsible for retrieving and inputting information into the medical record and gathering physician orders. She said the hospital records were available for review at time of Resident #1 admission but she only reviewed the primary information needed to admit the resident. She said the second day following a new admission is when she usually reviewed the resident's medical record. RN #2 said she did not recall anything in the Resident #1's discharge information or in communication that would have led her to believe that the resident was a high fall risk and the admitting nurse told her she received a report that Resident #1 was alert and orientated. RN #2 said she assessed the resident after the fall and the resident continued to express the need to use the restroom. She said the admitting nurse told her the resident kept trying to get up to use the restroom. The RN said the resident fell because she had to use the restroom and attempted to take herself. She said CNAs were usually available to help with admission but not when the census was low. She said a CNA was not available on 1/1/21 at the time of the admission but the nurses could usually handle the admissions without having a CNA. She said it was not routine for a nurse to toilet a resident when they arrived at the facility unless the resident expressed the need. RN #2 confirmed the resident was taken to the restroom after the fall. To prevent future new admission falls, RN #2 said she felt the facility needed to improve communication to better understand the needs of the resident. Initial interventions could be put in place such as a sitter to stay with the resident or increased supervision in an observation room. The director of nursing (DON) was interviewed on 1/19/21 at 4:26 p.m. She explained the CNA role during the admission process included vitals, orientating the resident to their room, and completing the preference sheet. She said CNAs offer a welcome bag, snacks, water and would usually assist the resident to the restroom. The nurses complete a head to toe assessment and review consents. She said CNAs usually complete their part of the admission process but all nurses were trained on the CNA responsibilities for a new admission and could complete both roles. The DON said the admitting floor nurse was supposed to review the report from the hospital and any pertinent information on the homepage to prepare for the new admission. She said the unit manager would review the discharge orders from the hospital, and review any communication from admissions. The unit manager would be responsible for reviewing the hospital therapy and wound care notes. The DON said it was important to review the hospital notes prior to admission of the resident. The DON said if the resident was determined to have safety concerns such as having falls and confusion, precautions would be put in place. The resident would be placed in an observation room across from the nursing station, if one was available, at time of admission. The resident's door would be left open and the facility would determine a need for a sitter. Staff would be informed of the concerns and high fall risk interventions would be included on the care plan as a staff directive. The DON said RN #2, LPN #1 and LPN #2 were re-educated on fall protocols on either 1/7/21 or 1/8/21 as a result of Resident #1's fall. She said Resident #1 SDH (subdural hematoma), and her pupils dilated at different sizes. The DON said the nurses should have called 911 instead of having the resident be sent to the hospital non-emergent. She said all nursing staff were reminded of the fall protocols on 1/15/21. The DON confirmed the resident's hospital computed tomography (CT) scan after the 1/1/21 fall indicated a subdural hemorrhage (SDH) and read her documented findings on the IDT risk management assessment on 1/5/21, identifying the resident acquired a SDH from the fall as reported by the hospital. She said LPN #1 and LPN #2 were re-educated on fall protocols on either 1/7/21 or 1/8/21. She said all nursing staff was reminded of the fall protocols on 1/15/21. According to the DON, if the facility knew Resident #1 was at high risk for falls, or was placed on precautions at the hospital such as bed alarms or received a report or if it was documented that she was impulsive, they would have put additional interventions in place. The DON said the facility was not aware of Resident #1's high risk for falling. The facility physician assigned to Resident #1 was interviewed on 1/20/21 at 10:06 a.m. The physician said if a resident hit their head on a fall and had pupils were different sizes after the fall, it could indicate a head injury. The staff should not move the resident and keep their neck in a neutral position, began neurological checks and contact the physician. The resident would be sent out to the hospital. According to the physician, he did not assess the resident due to her rapid return to the hospital shortly after admission. The facility contacted the on-call physician and received orders to send the resident out for a CT scan. III. Resident #13 A. Resident status Resident #13, age 76, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. The 1/17/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required limited assistance from one person for bed mobility, transfers and toileting. B. Resident interview and observation Resident #13 was interviewed on 1/14/21 at 4:10 p.m. The resident said he often got up on own because waiting 10 to 20 minutes for the call light to be answered felt like hours because of his kidney disease. He said he got out of bed without staff assistance multiple times since his 12/26/2020 admission. He said he continued to get out of bed without staff assistance even after falling on 1/3/21 and 1/7/21. The resident said he was focused and preparing to go home but needed to be able to perform his own care. Observations between 2:30 p.m. and 4:10 p.m. revealed the door to the resident's room was closed. During the 1/14/21 interview, Resident #13 said he did not request for the door to be closed nor had stated as a preference. He said he was comfortable if the door remained partially open. C. Record review 1. Fall on 1/3/21 The 1/3/21 incident note read a bang, with a loud scream was heard by the nurse at the nursing station. Resident #13 was found on the floor of the bathroom. The resident had his non-skid socks on when he was found, and call light was within his reach. He said was walking from the toilet to the sink to look for his shaving kit. According to the incident note, the resident was very impulsive all day on 1/3/21, and had been refusing help when provided, stating that he was [AGE] years old, and old enough to do his own care. The 1/3/21 post-fall evaluation identified interventions to be implemented including: -A toilet schedule after meals which the resident agreed; and, -Provide safety education such as call light use and urial education and use. The review of the fall risk care plan, initiated 12/26/21, did not include the identified interventions from the 1/3/21 fall of a toilet schedule or education of the call light and urial, until 1/9/21, two days after the resident had his second fall on 1/7/21. A fall program for the resident was added to the care plan on 1/4/21. The care plan did not identify his impulsivity as documented in the 1/3/21 incident note. The care plan did not identify his refusal for assistance and how to attempt to remedy his refusal. 2. Fall on 1/7/21 The 1/7/21 fall progress note read Resident #13 was found on the floor between his bed and window. The resident stated he got dizziness and lost his balance. The nurse identified his call light was not sounding and he had non-skid socks in place. She noted there was low light in the room at time of the fall. The 1/7/21 post fall evaluation read the resident door would remain open for closer monitoring and the nursing staff would offer assistance to bed during hours of sleep (HS) rounding. The fall risk care plan, initiated 12/26/20 and revised on 1/9/21, was reviewed on 1/13/21. The care plan included an intervention to ensure the environment was lit, provide toilet schedule after meals and provide education such as call light use and urinal use. The care plan was not revised to include the interventions identified in the 1/7/21 post fall evaluation of having the resident door remain open for closer monitoring and the nursing staff would offer assistance to bed during HS rounding. Revisions to the fall care plan were reviewed again on 1/18/21 and revealed the resident's fall program was resolved on 1/12/21 even though the resident continued to get out of bed without assistance. D. Staff interviews RN #1 was interviewed on 1/14/21 at 2:50 p.m The RN said residents who have fallen in the last three months would be considered a high fall risk. She said interventions for a resident with a high fall risk would be to have the residents in rooms near the nursing station, would be educated on call light use and have their door left open for additional supervision. She said a fall risk resident would only have their door shut if they insisted on it. RN #1 identified the high fall residents. She did not identify Resident #13 as a high risk resident. CNA #3 was interviewed on 1/14/20 at 3:11 p.m. The CNA said was not aware if Resident #13 was on a toileting plan but he would often request to use the bathroom after he ate. She said she did not if his door should remain open but it was common to be closed. The director of rehabilitation (DOR) was interviewed on 1/14/21 at 2:06 p.m. The DOR said Resident #13 was eager to go home but the resident's safety and his poor judgment were an issue. She said he was a caretaker to his wife and would be more appropriate in an assisted living facility related to his current safety deficits. She said the resident's falls were reviewed the following day in a morning meeting. She said dizziness contributed to his falls. The DOR said Resident #13 did not have specific therapy fall interventions after the two unwitnessed falls in his room. She said her staff always provided safety reminders to residents and made sure they knew to use call lights. The DON was interviewed on 1/19/21 at 5:39 p.m. The DON identified the care plan served as a staff directive. She said new interventions identified after a fall would be placed on the care plan the following day, or at least the following business day to help prevent future falls.

Based on record review and interviews, the facility failed to ensure one (#2) of three out of four sampled residents who required respiratory care was provided such care consistent with professional standards of practice. Specifically, the facility failed to ensure the oxygen was connected to the [MEDICAL CONDITION] machine for Resident #2 throughout the night, which resulted in severe decreased oxygen saturation level, change of condition and ultimate transfer to the hospital. Findings include: I. Facility policy and procedure The Respiratory Care policy and procedure, developed (MONTH) (YEAR), was provided by the director of nursing (DON) on 6/24/19 at 1:00 p.m. It revealed, in pertinent part, The Centers will provide its patients with necessary respiratory care and services in accordance with professional standards of practice, the patient's care plan, and the patient's choice. II. Resident #2 status Resident #2, age 87, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/11/19 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. She required extensive assistance of two people with bed mobility, transfers and toileting. She required limited assistance of one person with dressing and personal hygiene. It indicated the resident used oxygen and a non-invasive mechanical ventilator such as a [MEDICAL CONDITION] machine. III. The facility's knowledge the resident had acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues) A. Record review The 6/4/19 nursing comprehensive admission data collection assessment revealed the resident had labored respirations with a dry, persistent cough with frothy white sputum. It indicated the resident's breath sounds had rales, rhonchi and were diminished to both the right and left sides. It indicated the resident utilized oxygen and a [MEDICAL CONDITION] machine. The respiratory risk care plan, initiated on 6/5/19, revealed the resident was a respiratory risk due to [DIAGNOSES REDACTED]. The interventions included: administer medications as ordered by the physician, check for placement of the [MEDICAL CONDITION] machine frequently throughout the night shift, initiate the [MEDICAL CONDITION] at bedtime with 4L of oxygen to maintain oxygen saturation of above 88%, and notify the physician of any change of condition. The 6/12/19 physician progress notes [REDACTED]. It indicated the resident had acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. IV. The facility failed to execute a physician's orders [REDACTED]. The failure to execute the physician's orders [REDACTED]. A. Record review The (MONTH) 2019 CPOs revealed the following physician orders: - Initiate [MEDICAL CONDITION] at bedtime with 4L (liters) of oxygen - document the liter flow, maintain oxygen saturation greater than 88% every night shift for [MEDICAL CONDITION] use. Ordered 6/5/19. The 6/13/19 investigation of the above incident revealed: -The resident used a [MEDICAL CONDITION] machine at night with 4L of oxygen through the machine. It indicated registered nurse (RN) #1 entered the resident's room to turn on the [MEDICAL CONDITION] machine at 9:15 p.m. on 6/12/19; however, the resident said she did not want to go to bed yet. The nurse signed off on the MAR indicated [REDACTED]. -The certified nurse aide (CNA) #1 turned on the [MEDICAL CONDITION] machine at 10:00 p.m. CNA #1 did not ensure the oxygen was connected to the [MEDICAL CONDITION] machine. -On 6/13/19 at 7:30 a.m., the CNA for the day shift entered the resident's room.The resident's call light was on the floor and the [MEDICAL CONDITION] machine was on and in place. The resident stated to the CNA, feeling like I am not getting enough oxygen. The CNA took the resident's vital signs with an oxygen saturation result between 44-45%. The CNA observed the oxygen was not connected to the [MEDICAL CONDITION] machine. The CNA took off the [MEDICAL CONDITION] machine mask off the resident, replaced it with an oxygen nasal cannula at 4L of oxygen and notified the nurse. -The resident's oxygen saturation level rose to 50-60% while on the oxygen at 4L per minute. The nurse placed a non-rebreather on the resident and her oxygen saturation level rose to 94%. The nurse then placed the resident back on the nasal cannula at 5L per minute with the resident's oxygen saturation to 92%. -At 8:05 a.m., the resident's oxygen saturation decreased to 88% and she was placed on a non-rebreather again. The physician was notified and the resident was sent to the acute care hospital for further evaluation and intervention. At the time of the arrival of emergency personnel, the resident's oxygen saturation was 80%. -The investigation revealed RN #1 was provided education and a written medication error for signing off on a physician's orders [REDACTED]. It indicated RN #1 did not tell the oncoming nurse the resident's [MEDICAL CONDITION] machine had not been placed. -Licensed Practical Nurse (LPN) #1 was provided education and a written medication error for failing to monitor, check the placement and function of the resident's [MEDICAL CONDITION] machine and ensure the oxygen was connected to the [MEDICAL CONDITION] machine. -CNA #1 was provided written action for failing to know the resident required an oxygen connection to the [MEDICAL CONDITION] machine and education on how to connect the oxygen to the [MEDICAL CONDITION] machine. The (MONTH) 2019 Medication Administration Record [REDACTED]. However, according to the investigation, the oxygen had not been connected to the [MEDICAL CONDITION] machine as the documentation indicated. This physician's orders [REDACTED]. to an acute care hospital on [DATE]. V. Staff interviews CNA #2 was interviewed on 6/24/19 at 12:30 p.m. She said she was unsure of the purpose of a [MEDICAL CONDITION] machine. She said she had recently received training on how to properly use a [MEDICAL CONDITION] machine. She said a CNA was able to assist the resident in putting on the [MEDICAL CONDITION] machine. She said she would place the mask on the resident, turn on the machine and ensure the clamps and tubes were hooked up properly. She said she would check to ensure if the resident required oxygen through the machine, that it was properly connected. She said it was both the responsibility of the CNA and the nurse to ensure the resident was hooked up to the [MEDICAL CONDITION] machine and it was functioning properly. LPN #2 was interviewed on 6/24/19 at 12:35 p.m. She said the purpose of a [MEDICAL CONDITION] machine was to increase the resident's respiratory intake. She said the CNAs may assist the resident in putting on the mask and turning on the machine, but it was ultimately the nurses responsibility to ensure proper function because it was a physician's orders [REDACTED].>She said it was the nurses responsibility to ensure the resident was hooked up to the machine, ensure machine was functioning properly, and if needed, ensure the oxygen was hooked into the machine. She said the nurse should ensure the settings on the machine matched the physician's orders [REDACTED].>She said the nurse should check on the resident multiple times throughout the night to ensure the proper functionality of the machine and status of the resident. She said the CNAs were not aware of the machine settings and would not know if the machine was set to the correct flow rate. She said the facility had recently provided training on the use of [MEDICAL CONDITION] machines. The director of nursing (DON) was interviewed on 6/24/19 at 1:10 p.m. She said each [MEDICAL CONDITION] machine came with a physician's orders [REDACTED]. She said after the incident with Resident #2, the facility completed an audit of all residents using [MEDICAL CONDITION] on 6/17/19 and put a prompt in (an alert check in the resident's electronic record) for all [MEDICAL CONDITION] machines to initiate the oxygen, check the oxygen flow rate, check the resident's oxygen saturation and check the oxygen connection if applicable. Another prompt would initiate at 1:00 a.m. to check the connections and the resident's oxygen saturation. She said RN #1 did not apply the [MEDICAL CONDITION] machine on the resident, however she still signed off on the MAR indicated [REDACTED]. She said if RN #1 had not signed off on the MAR, then the oncoming shift would have received an alert to check the function of the [MEDICAL CONDITION] machine. She said LPN #1 did not check on the resident after coming on shift. She said LPN #1 should have checked on the resident throughout the night to ensure the connections to the [MEDICAL CONDITION] machine, the resident's oxygen saturation levels and the functionality of the [MEDICAL CONDITION] machine. She said all nurses and CNAs were provided education regarding the use of [MEDICAL CONDITION] machines and how to ensure the machines were connected properly.

Based on observations, record review, and interviews, the facility failed to ensure one (#722) of three residents identified with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and the development of new pressure injuries. Specifically: The resident, who entered the facility with blanchable redness on his right buttock, developed pressure injuries compromising his right and left heel and right and left buttock within two weeks of admission. The resident was identified to be very limited in bed mobility, making it difficult to turn and position and interventions to relieve pressure points were not implemented. His wound evaluations and treatments were delayed. There was no evidence of an interdisciplinary approach or at-risk review to discuss the needs of the resident from therapy, dietary, and nursing related to the development of the resident's declining skin condition. The findings included: Professional Reference According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. - Scheduled repositioning should be done to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. - Heels should be placed in a position that eliminates pressure, referred to as floating the heels, by placing a cushion under the full back of the resident's calf. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: - Positioning that places pressure on the pressure injury should be avoided. - For heel ulcers, the heel should be floated. - The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. - The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. - Signs of deterioration in the wound should be addressed immediately. - The assessment should include: --Location --Category/stage --Size --Tissue types --Color --Periwound (the skin around the wound) condition --Wound edges --Any undermining or tunneling --Exudate --Odor --Source: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (2/17/2017). 1. Resident Status Resident #722, age 80, was admitted on [DATE]. The 3/17 computerized physician orders [REDACTED]. According to the 3/8/17 minimum data set (MDS) assessment, the resident's cognition was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required extensive assistance with bed mobility, transfers, walking, dressing, toileting, and locomotion on/off unit. He had an unstageable pressure ulcer (injury) due to suspected deep tissue injury. There was [MEDICATION NAME] tissue. Interventions included pressure-reducing device for chair, bed, and turning/repositioning program. 2. Record Review Record review revealed that within two weeks of admission, the resident developed additional pressure injuries to his right and left buttock and right and left heels. Record review further revealed delay in initiating wound evaluation and treatments and a failure to investigate the cause of the resident's development of additional pressure injuries. a. Care plans A review of the 3/3/17 skin care plan revealed the resident had potential for skin breakdown related to spinal surgery. -The goal was the resident's skin would remain intact. -Interventions included: Air mattress and/or air mattress overlay as indicated; Braden scale weekly; encourage proper nutrition and hydration; pressure-reducing devices as needed; skin assessments, wound nurse evaluation and treatment, therapy. A review of the 3/5/17 skin care plan revised 3/12/17 (during survey) revealed ulceration or interference with structural integrity of layers of skin caused by prolonged pressure related to decreased activity, friction and shear problem, impaired mobility. On 3/1/17, right buttock and 3/12/17 right heel, left heel. -The goal was the resident's skin integrity would remain intact. -Interventions included: Apply pressure reduction cushion to chair or wheelchair as needed; apply pressure reduction mattress to bed as needed; diet and supplement as ordered; frequent repositioning in bed as needed; frequent repositioning in chair as needed; monitor lab values, pressure ulcer treatment as ordered, referral to registered dietician, wound nurse to evaluate and treat. Neither skin integrity care plan provided a detailed a repositioning plan for the resident, known to have impaired mobility, decreased activity, and friction and shear problem (see risk assessments below). Neither care plan addressed interventions to minimize pressure to the resident's heels. A review of the 3/3/17 pain care plan revealed pain related to back surgery, pressure points, immobility, and sacral fracture. A review of the 3/3/17 nutritional care plan revealed unplanned/unexpected weight gain related to [MEDICAL CONDITION]. There was no mention of concerns with skin breakdown. b. Risk Assessments A review of the 3/1/17 initial skin integrity assessment revealed the resident was slightly limited in his ability to respond to pressure-related discomfort. He was not always able to communicate discomfort or his need to be turned. The resident was bedfast and confined to bed. He was very limited with the ability to change and control his body position. The resident had a potential problem with friction and shearing. A review of the 3/11/17 Braden scale for predicting a pressure sore revealed the resident was not always able to communicate discomfort or the need to be turned. His activity was bedfast and confined to bed. He was very limited in his ability to change and control his body position. There was a potential problem with friction and shearing. c. Skin Assessments A review of the 3/1/17 initial skin integrity assessment revealed the resident skin color and turgor were normal, temperature warm, equal and dry. The right buttock had blanchable redness. There were no additional descriptions or measurements of the resident's right buttock. A review of the 3/3/17 wound care evaluation, signed on 3/5/17, four days after resident's admission, revealed description of the right buttock was a suspected deep tissue pressure injury (SDTI) with length - 2.5 centimeters (cm), width - 3.5 cm, and depth unknown. The description of a SDTI on the evaluation form was a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that was painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. A review of the 3/11/17 skin evaluation revealed the resident had blanchable redness to both buttocks. There were no measurements or further description available, although skin condition had changed from SDTI right buttock to both buttocks with blanchable redness. A review of the 3/12/17 wound care evaluation revealed: -The right buttock was staged SDTI with length - 2.5 cm, width 3.5 cm, depth unknown. The wound care evaluation also included left heel staged as a SDTI length - 1 cm, width - 1 cm, depth unknown. The right heel staged, SDTI length - 5 cm, width - 8 cm, depth unknown. -The physician and responsible party were informed 3/1/17 although the resident arrived with blanchable redness to right buttock only. The form read dietary was contacted on 3/3/17. The form was not marked to alert the dietician when the resident's skin was further compromised. -The wound progress was documented as deteriorated. The right buttock had a total surface area (TSA) of 8.75 cm squared (cm2). The area was a well-defined intact deep tissue injury (DTI). The treatment was to have frequent turning throughout shifts and barrier cream placed for patient. -The right heel had TSA, 40 cm2. The wound was a large intact DTI, purple in color. The resident stated no pain when touched. The resident was to have medication, [MEDICATION NAME], twice daily and elevation. -The left heel had TSA, 1cm2. There was 100% [MEDICATION NAME] covered DTI. The treatment was to have skin prep and elevation. -The wound care evaluation failed to address the left buttock redness identified on 3/11/17. d. Interdisciplinary Progress Notes (IPN) A review of IPN from 3/1/17 through 3/13/17 revealed the following: -On 3/2/17, right buttock with blanchable redness. -On 3/3/17 at 7:08 a.m., right buttock, 2.5 cm x 3.5 cm (TSA 8.75 cm2). Area noted as a well-defined intact DTI. Periwound was without induration, maceration or [DIAGNOSES REDACTED]. The treatment was for frequent turning throughout shifts and barrier cream. -On 3/3/17 at 6:58 p.m., 3/4/17, 3/5/17, and 3/6/17 at 4:12 p.m., right buttock described as blanchable redness although on 3/3/17 at 7:08 a.m., the wound was described as a well-defined intact DTI. -On 3/7/16 at 8:48 p.m., sores to bilateral heels, skin prepped and elevated. Sores to bilateral buttocks, barrier cream applied and every two-hour turning program. There was no mention of communication to the physician, director of nursing (DON), wound nurse, dietician, therapy department, or resident representative regarding the development of additional sores to bilateral heels and left buttock. There were no measurements or further descriptions of the identified wounds. -On 3/8/17 at 9:43 p.m., sores to bilateral heels, skin prepped and elevated. Sores to bilateral buttocks, barrier cream, and every two-hour turning program. There were no measurements or further descriptions of the new wounds identified on 3/7/17. -On 3/9/17 at 9:09 p.m., sores to bilateral heels, skin prepped and elevated. Sores to bilateral buttocks, barrier cream applied, and every two-hour turning program. -On 3/11/17 at 10:37 p.m., sores to bilateral heels, skin prepped and elevated. Sores to bilateral buttocks, barrier cream applied, and every two-hour turning program. -On 3/12/17 at 11:41 a.m., right buttock with well-defined intact DTI. The periwound was without induration, maceration, or [DIAGNOSES REDACTED]. The treatment was for frequent turning throughout shifts and barrier cream. There was a new wound to the right heel. The right heel had no exudate, foul odor or signs of infection. The treatment was for medication, [MEDICATION NAME], twice daily and elevation. There was a new wound to the left heel. The left heel had 100% [MEDICATION NAME] covered DTI. The treatment was for skin prep and elevation. There was no monitoring or evaluation of the left buttock. -On 3/12/17 at 6:17 p.m., the resident had sore to right heel with [MEDICATION NAME] applied. Sore to left heel skin prepped and heels elevated. There were sores to bilateral buttocks with barrier cream applied and every two-hour turning program. -On 3/13/17 at 1:40 p.m., a nurse went to elevate resident. The resident's spouse stated she thought the resident's heel wound was leaking. The nurse stated she applied [MEDICATION NAME] to heel earlier in the day and now noticed serous/sanguine drainage coming from the DTI. The wound nurse was notified and gave verbal order to apply dressing, [MEDICATION NAME] and float heels while in bed. It was unknown if physician was notified or consulted. -On 3/13/17 at 10:06 p.m., sore to right heel with [MEDICATION NAME] applied. Sore to left heel skin prepped and heels elevated. There were sores to bilateral buttocks barrier cream applied and every two-hour turning program. There was no evidence to show the facility performed an at-risk review to address the development of additional pressure injuries and discuss appropriate interventions with feedback from all departments. e. Physician Notes A review of the physician notes revealed the following: -On 3/3/17 and 3/6/17, no mention of right buttock treatment or observation conducted by the physician. -On 3/7/17, there were was no mention of the right buttock pressure injury. The resident reported pain ranged from three to seven on a pain scale of ten. -On 3/10/17, NP identified SDTI of unknown depth of heel. An order to continue to float heels and monitor right heel daily. The wound care nurse to assess and skin prep, twice daily. There was no mention of the right buttock, left buttock, or left heel. The resident said pain ranged from two to seven on a pain scale of ten. He reported pain level depended on the activity. The right heel was described as DTI with skin intact, black boggy area. -On 3/13/17, NP made no changes to the condition of the right heel. There was no mention of the right buttock, left buttock, or left heel. f. Physical Therapy Notes A review of the 3/2/17 physical therapy (PT) evaluation and plan of treatment revealed the resident's skin integrity was intact. His gross motor coordination was impaired. He required maximum assistance with bed mobility and transfers. The resident demonstrated impaired functionality with mobility, transfers, gait, bed mobility, activity tolerance, and safety awareness. Risk factors included immobility. A review of the treatment encounters revealed: On 3/13/17, PT noticed the resident had a pressure ulcer on his right heel. There was no evidence of communication with therapy regarding the pressure ulcer or any DTI to screen or assess for therapeutic interventions to promote healing. g. Occupational Therapy Notes A review of the 3/2/17 occupational therapy (OT) evaluation and plan of treatment revealed the resident's skin integrity was intact. His gross and fine motor coordination was impaired. Risk factors included further decline in function. On 3/6/17, the resident required maximum assistance of one person with transfer and standing. The resident was unable to move legs in bed for mobility. Low pain issues, medication administered prior to treatment. On 3/7/17, the resident was described as not having walked since 1/17 and displayed a form of paralysis in lower extremities. He was maximum assistance with bed mobility. Low pain issues, medication administered prior to treatment. On 3/8/17, the resident remained maximum assistance with bed mobility. He had wounds on his buttocks with nursing aware. There were no screens or assessments performed by OT to promote healing of the resident's pressure injuries. Low pain issues, medication administered prior to treatment. On 3/11/17, the resident's functionality described as no lower extremity function or extremely limited. On 3/13/17, heel wound identified and nursing asked to get airbed and moon boots. On 3/14/17, the resident had heel wound on left foot. A float bar was used while supine. h. Nutrition/Dietary A review of the 3/3/17 nutritional assessment revealed a stage one or two pressure area. There was no additional reference to the resident's nutritional needs related to his skin integrity. A review of the resident's record revealed there were no dietary progress notes from 3/1/17 to 3/13/17 to show the dietary department was involved to promote healing of the resident's pressure injuries. i. Medication Administration Record [REDACTED] A review of the 3/17 MAR indicated [REDACTED]. The MAR indicated [REDACTED] j. Treatment Administration Record (TAR) A review of the 3/17 TAR revealed orders for barrier cream to buttocks/coccyx, twice daily for wound care began 3/5/17, four days after resident admitted when blanchable redness to right buttock identified by admitting nurse and the CPO listed a [DIAGNOSES REDACTED]. An order to turn and reposition resident every 2-3 hours and as needed began 3/5/17 although blanchable redness of right buttock on admission changed to well-defined intact SDTI on 3/3/17. Bilateral heels elevated using off support surface when in bed for sores ordered on [DATE] began 3/9/17 although identification of bilateral heel sores was 3/7/17. Skin prep to bilateral heels for sores every shift was ordered on [DATE], began 3/9/17 although identification of bilateral heel sores was 3/7/17. Additionally, the treatment on day shift, 3/12/17 was not signed off as completed. k. Investigations Despite the resident's development of additional pressure injuries after his admission to the facility, there was no evidence the interdisciplinary team investigated the development of the injuries. There was no root analysis provided by the facility to show an attempt was made to review any potential systemic failures related to the development of pressure injuries while the resident resided at the facility. 2. Observations Observations revealed a failure to relieve pressure to areas identified as compromised due to pressure. Observations further revealed six areas of skin injury. On 3/10/17 at 2:06 p.m., the resident sat in his manual wheelchair inside his room. His heels were not off-loaded while seated in his chair. His feet were on the ground with pressure applied to his heels. His heels were not elevated. There was no air mattress, gel surface, or overlay in the resident's bed. On 3/14/17 at 2:50 p.m., the resident was lying in bed. He was not off-loaded on his back, his heels were not floated or elevated. The resident's spouse removed the sock from the right heel, revealing a bandage saturated with round red substance. The resident grimaced as his wife moved his foot. The spouse placed his right heel back on the bed. The yellow sock was left partially applied. The mattress was standard foam; there was no overlay or air mattress in use. The resident did not have any pressure relieving boots in his room. -At 2:54 p.m., a registered nurse (RN) #11 confirmed the resident's heels and backside were not floated or off-loaded. However, she did not reposition the resident or off-load his heels. She said the resident required maximum assistance with bed mobility and transfers. She said the resident had probably been back from lunch since 1:00 p.m. She confirmed the resident's right heel was draining fluid. -At 3:16 p.m., RN #11 returned to the room. The RN again did not reposition the resident or off-load his heels. -At 3:36 p.m., 46 minutes after the resident was observed on 3/14/17, RN #11 entered the room and floated the resident's heels with a large blue wedge. She placed a pillow on the right side of his back. She said she applied the wedge and pillow to off-load the resident because it had not been performed by the certified nurse aide (CNA). -At 3:40 p.m., the wound nurse (WN) entered the room. He gathered supplies and setup treatment. At 3:45 p.m., he said he had initially assessed the resident's pressure injuries on 3/12/17. The WN said at the time, the right heel had no odor or drainage. He said the right heel was a semi-fluid filled blister. He said there was no induration or maceration. -At 3:50 p.m., the WN removed the foam dressing on the right heel. The dressing had a large amount of yellow serous fluid with red rim substance. The skin was stained orange around the pressure injury. The right heel wound in circumference was the size of a billiard pool ball. The wound extended from his Achilles tendon down towards the bottom of his foot. The wound had a thick cover of white skin. The WN used skin prep spray on the wound then dabbed the wound with a thick gauze pad. The WN then opened the medication, [MEDICATION NAME], and swabbed the wound, leaving it open to air. There was no bandage applied. He said the order was for [MEDICATION NAME], open to air and he said he did not know why a foam dressing had been applied. He said [MEDICATION NAME] was used to dry out a wound and the foam was to keep a wound moist. The WN confirmed there was drainage from the right heel. -At 3:54 p.m., the WN and unit manager (UM) prepped the resident's left heel. There was an excessive amount of dry skin on the resident's left foot. The pressure injury on the left heel was black in color and located at the upper left corner of the heel. The left heel pressure injury in circumference was the size of a penny coin. Skin prep used on the pressure injury then dabbed with gauze. The skin was non-blanchable. -At 3:54 p.m., the WN stated the resident had a non-blanchable DTI on the left heel. -At 3:57 p.m., the WN, UM, and RN #11 turned the resident to his left side to treat the pressure injuries on his buttocks. The right buttock had one injury, non-blanchable, dark red in color. The injury in circumference was the size of a penny coin. The left buttock had three injuries, non-blanchable. The injury north was dark red in color and the size of a pencil eraser. The second injury was perpendicular to the gluteal fold, dark purple, and in length of a sewing needle. The third injury, south of the other two left buttock injuries, was round, dark red in color, and the size of a dime coin. Barrier cream was applied to the pressure injuries. There were six pressure injuries observed. 3. Interviews Interviews revealed planned and recommended interventions to promote healing and prevent further skin breakdown (see care plans above) and nutritional support were not implemented. Interventions further revealed the resident's right heel ulcer was painful and caused discomfort. RN #13 was interviewed on 3/10/17 at 3:34 p.m. She said the resident had a pressure ulcer on his right heel. She said she did not think the wound was staged. The RN did not mention additional pressure injuries to the resident's right and left buttock, or left heel. The resident's spouse was interviewed on 3/14/17 at 2:50 p.m. She said the resident's sore (pressure injury) was bleeding. The spouse stated when she asked about the sores, she was informed the sores developed from him being in bed. The resident was interviewed on 3/14/17 at 3:08 p.m. and again at 3:44 p.m. -He said the sore on his right heel hurt and was painful when moved or touched suddenly. He said the sores on his heels were there for more than a couple days. He said he had not had an air mattress since his arrival. The resident and his spouse said his heels have never been compromised; they said this was the first time he had pressure injuries to heels. -He said the only contact with the registered dietician (RD) was when he first arrived at the facility. He said there had been no dietician follow-up since. RN #11 was interviewed on 3/14/17 at 3:16 p.m. and again at 3:46 p.m. -The RN said another nurse put in an order yesterday to treat the resident's heels. She was not sure what the correct treatment was because there were now two conflicting orders. The RN said she contacted the WN to come and treat the resident's pressure injuries. -The RN said she spoke with the resident's CNA about the resident not off-loaded on his back or floated heels. The CNA told her she was not aware the resident required repositioning or his heels floated. The RN said pressure injuries on the heels needed to be off-loaded and off the bed to prevent the wounds from developing or worsening. She said she did not know why pressure-relieving boots were not ordered because they were beneficial. -The RN said when she spoke with the Unit Manager (UM) about the lack of an air mattress for the resident (see care plan intervention above), the UM said an air mattress was only used when an open pressure injury was present on the bottom, not for redness. -The RN looked at the resident's orders and confirmed there was no order or information that showed communication with the registered dietician about the decline in the resident's skin condition. She said the only evaluation she could find performed by the RD was when the resident first arrived. She said she could not find any order of supplement or monitoring to promote healing for the pressure injuries. The WN was interviewed on 3/14/17 at 5:37 p.m. He said the facility had identified a problem with the development of pressure injuries throughout the facility on 3/9/17. He said the facility provided an in-service with staff on wound care and the expectation to send an email to the WN and director of nursing (DON) when a new wound was identified. -The WN said residents unable to turn or position themselves needed to be turned and repositioned. He said resident #722 needed to be turned and repositioned to ensure all pressure points were off-loaded to prevent development and worsening of the resident's pressure injuries. -The WN stated the mattress the resident used was acceptable for pressure injuries up to stage two. -The WN stated there were no investigations into the pressure injuries resident #722 had acquired since admission. The WN said the risk assessment revealed the resident was a moderate risk for the development of a pressure injury but the facility still had to implement the necessary interventions. He said a standard mattress and no heel elevation or positioning or turning could have contributed to the resident's development of additional pressure injuries which could impact the effectiveness of rehab. The certified occupational therapist assistant (COTA), occupational therapist (OT), and director of rehab (DOR) were interviewed on 3/15/17 at 10:09 a.m. The OT stated she had not evaluated the resident but supervised and signed off on documents completed by the COTA. She said she would evaluate the resident after the interview. The COTA said the resident was very limited (in mobility) and was not able to move his extremities without assistance. The COTA stated on 3/13/17, he informed the licensed practical nurse (LPN) #4 he was aware of heel and buttock injuries. He said he recommended the use of an air mattress and pressure-relieving boots. He said with his experience and the resident's inability to turn and position without assistance, the recommendations were made to nursing. The DOR said the resident required one to two maximum assistance with all aspects of mobility, transfers, bed mobility and his ability was very limited. The RD was interviewed on 3/15/16 at 11:46 a.m. He said he met the resident when he admitted . He said the resident had a good appetite and was on medication for a medical condition with adverse effects to certain protein. The RD said since the resident stated he had a good appetite, he felt monitoring the resident was appropriate treatment for [REDACTED]. He said with new admissions over the weekend to assess on Mondays, he did not get to confer with the resident until 3/14/17. The RD stated he obtained lab work and due to results, he ordered a supplement on 3/15/17. He said the dietary department had the opportunity and responsibility to help the resident heal from the inside out and if not notified, the dietary department was unable to put appropriate interventions in place timely. The UM and LPN #4 were interviewed on 3/15/17 at 12:01 p.m. The UM stated she was able to find out the facility became aware of the pressure injuries to the bilateral buttocks and heels on 3/7/17. -The UM stated she tried to locate an email informing the WN of the pressure injuries but was unsuccessful. She said she knew the WN observed the resident on 3/12/17. She confirmed this was five days after the injuries were identified. -The LPN said on 3/13/17, she observed the resident's heels were not elevated and the spot on bed linens of the right heel showed draining. She said she contacted the WN and was told to apply the dressing and the WN would evaluate in the morning. -The LPN said the COTA spoke to her about an air mattress and pressure-relieving boots on 3/13/17 but she said she took his statements as recommendations and not something to obtain orders for treatment. She said she told the WN of the recommendations made by the COTA; however, there was no documentation of this exchange. -The UM said the wounds could have been avoided if, when the resident came in with a blanchable redness on his buttock, turning and positioning was implemented immediately when it became known he was very limited with mobility and bedfast. She said communication and involvement with all departments could have improved his treatment and the development of pressure injuries. The UM said she spoke with the CNA assigned to the resident on 3/14/17 and she stated she was not told the resident required his heels to be elevated or that he was on a turn and reposition program. -The LPN said the pressure injuries could have been avoided by providing staff with more education on the heels up program. She agreed issues with communication could have added to the development of the pressure injuries compromising the resident. The DON was interviewed on 3/15/17 at 1:57 p.m. -The DON said she was not notified of the facility acquired pressure injuries upon identification and development of the pressure injuries to the buttocks and heels. The DON said the mattress was rated for pressure redistribution up to a stage two-pressure injuries. She said it was not an air mattress. She said the mattresses have been in the building for 4.5 years and the facility was considering replacing the mattresses. -The DON said the facility started skin prep on 3/8/17 to the heels but it wasn't until 3/12/17 when the WN assessed the wounds and changed the treatment to the right heel. The DON acknowledged confusion around the appropriate treatment for [REDACTED]. -The DON stated the CNA misunderstood the treatment and interventions to float heels and off-load the back. The DON said the communication for the treatment and care of pressure injuries should have been much better to promote healing and avoid development of the injuries. 4. Facility Follow-up A review of the 3/15/17 dietary notes revealed pre-[MEDICATION NAME] labs showed results of 10.5 mg/DL. A normal pre-[MEDICATION NAME] reference range was 17.6 to 36.0 mg/DL. The resident's value of 10.5 showed malnutrition. The RD stated a value of less than ten indicated significant malnutrition. The 3/15/17 nursing note and OT note showed pressure-relieving boots would be used to ensure continuous off-loading. OT spoke with nursing on the appropriate order for the wearing of the boot. The facility was offered an opportunity to provide material of the mattress manufacturer information during survey and did not present any information. There were no investigations provided on the development of the pressure injuries compromising the resident's skin condition.