Every finding on record at Cherrelyn Healthcare Center

Based on record review and interviews, the facility failed to obtain a signature from a resident's legal representative for one (#1) of seven residents reviewed out of 20 sample residents for beneficiary notices and appeal rights of changes in their services covered by Medicare.Specifically, the facility failed to ensure Resident #1's representative was provided a written notification of a Medicare Non-Coverage (NOMNC) due to Resident #1's cognitive impairments.Findings include:I. Professional reference According to the Center for Medicare and Medicaid Services (CMS) website: Medicare Claims Processing Manual Chapter 30 Financial Liability Protections, issued 10/31/24, retrieved on 8/11/26, https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c30.pdf revealed in pertinent part: The NOMNC may be delivered to a beneficiary's appointed or authorized representative. Appointed representatives are individuals designated by beneficiaries to act on their behalf during the appeal process. CMS usually requires that notification to a beneficiary who has been deemed legally incompetent be made to an authorized representative of the beneficiary. Generally, an authorized representative is an individual who, under State or other applicable law, may make health care decisions on a beneficiary's behalf (e.g., the beneficiary's legal guardian, or someone appointed in accordance with a properly executed durable medical power of attorney). The date that someone at the representative's address signs (or refuses to sign) the receipt is considered the date received. Place a copy of the annotated NOMNC in the beneficiary's medical file.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE], and discharged on 3/27/26. According to the March 2026 computerized physician orders (CPO), diagnoses included fracture of the left femur, cognitive communication deficit (communication trouble caused by disorganized thinking skills, attention, memory, and problem solving), dementia unspecified severity with other behavioral disturbances, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder, and pain. The 1/30/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment. The resident had short and long term memory problems. The resident's cognitive skills for daily decision making was moderately impaired with poor decisions, with staff required to cue/supervise the resident. The resident required substantial to maximal assistance from staff for toileting, bathing, lower body dressing, and taking on and off footwear. The resident was frequently incontinent of bowel and bladder. B. Record reviewThe comprehensive care plan, dated 1/27/26, revealed Resident #1 had impaired dementia or thought processes, with other behavioral disturbances. Resident #1 had alcohol dependence with alcohol induced persisting dementia and was unable to complete a BIMS assessment due to cognitive impairments. Pertinent interventions included for the staff to communicate with Resident #1's family regarding her capabilities and needs. The NOMNOC was provided by the nursing home administrator (NHA) #2 on 8/6/26 at 1:00 p.m. The documented revealed that on 3/20/26 Resident #1 was provided notice that Medicare coverage of their current skilled nursing services would end on 3/25/26. The notice was signed by Resident #1 on 3/20/26. The notice documented Please sign below to show you received and understand this notice. I've been notified that coverage of my service will end on the date on this notice and that I can appeal this decision by contacting my QIO (quality improvement organization). The social service director (SSD) signed as the witness to the resident's signage of the NOMNC.Resident #1 signed the notice which contained the following; Your provider and/or health plan determined that Medicare probably won't pay for your Skilled Nursing services after the above date. You may have to pay for any services you get after this date. Your right to appeal this decision. You have the right to appeal the decision to end Medicare coverage of your services. This means you'll get an independent medical review right away. Your services will continue during the appeal. If you choose to appeal, the independent reviewer will ask for your opinion. You don't have to prepare anything in writing, but you have the right to do so. The reviewer also will look at your medical records and/or other relevant information. Once you ask for an appeal, you'll get a notice with a detailed explanation about why your service coverage should end. If the Independent reviewer agrees Medicare coverage for your services should end, neither Medicare nor your plan will pay for these services after the above date. If you stop services by the above date, you will avoid financial liability. How to ask for an Immediate appeal. Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the above date. Make your request to your Quality Improvement Organization (QIO). A QIO is the independent reviewer authorized by Medicare. If you miss the deadline to ask for an immediate appeal, you may still have appeal rights. Call your QIO (Name and phone numbers to reach the insurance company) to appeal, or if you have questions. The QIO will let you know its decision as soon as possible, generally no later than two days after the effective date above. If you're in a Medicare health plan, the QIO generally will let you know its decision by the effective date above. Please sign below to show you received and understood this notice. I've been notified that coverage of my services will end on the date on this notice and that I can appeal this decision by contacting my QIO.-Review of Resident #1's electronic medical record (EMR) did not reveal Resident #1's representative was notified of the NOMNC, despite the resident's cognitive impairments.C. Resident representativeThe resident's representative was interviewed on 8/6/26 at 9:52 a.m. via the telephone. The resident's representative said she never signed, nor gave a verbal consent to the NOMNC. The resident's representative said Resident #1 signed the NOMNC and was cognitively unable to sign the paperwork. The resident's representative said she was provided with the NOMNC by the director of rehabilitation in person several days after Resident #1 signed the NOMNC. (see director of rehabilitation interview below). The resident's representative said Resident #1's signature was on the paperwork, and not the representative as it should have been. The resident's representative said Resident #1 would not have understood what she was signing, nor understand how to appeal the NOMNC decision. The resident's representative said it would be up to the representative to contact the QIO. The resident's representative said she was very upset that the facility had their family member sign paperwork who could not have called insurance companies and made appeals to stay longer in the facility. The representative said even though she discussed with the social service person about her family member returning to the former place of residence, a NOMNC was never presented to her to sign. The representative said she would be the one to take the initiative to contact the necessary entities to get a legal extension of days for her family member, not Resident #1. The resident's representative said on 3/24/25 the director of rehabilitation escorted her to a staff member to help with the appeals process because Resident #1 signed the paperwork on 3/20/26 and did not know how to make an appeal. D. Staff interviewsThe social services assistant was interviewed on 8/5/26 at 3:00 p.m. The social services assistant said the social service director quit and she was in social services now but was not a director. The social services assistant said she was the one who had Resident #1 sign her NOMNC on 3/20/26. The social services assistant said the family representative did not respond to any of the calls or emails about the NOMNC. The social services assistant said the family representative did speak with her about Resident #1's discharge over the phone. The social services assistant documented on 3/25/26 in the electronic medical records (EMRs); that the resident's representative was very upset that Resident #1 had signed legal documents related to her care. The social services assistant said the legal representative said they were provided with the legal document by the director of rehabilitation (see interview below). The social services assistant said Resident #1 was provided with the NOMNC on 3/20/26 with the end of paid services date of 3/25/26. The social services assistant said she did not have Resident #1's representative signature on the NOMNC document, nor did the family representative provide verbal consent over the phone to the NOMNC. The director of rehabilitation was interviewed on 8/6/26 at 3:30 p.m. The director of rehabilitation said on 3/24/26 during a care conference, he was the one who gave Resident #1's NOMNC to the resident's representative in person. The director of rehabilitation said the representative was upset that Resident #1 had signed the NOMNC. The director of rehabilitation said he told the representative that Resident #1 could sign the NOMNC. The director of rehabilitation said he took Resident #1's representative to a staff member who could help the representative with the NOMNC.NHA #1 was interviewed on 8/6/26 at 4:30 p.m. NHA #1 said Resident #1's representative did not sign the NOMNC.

Based on record review and interviews, the facility failed to provide medications as ordered for one (#2) of three out of 14 sample residents. Specifically, the facility failed to have physician ordered medications available at the facility to administer to Resident #2.Findings include: I. Professional reference According to Loss of brain function - Liver Disease, National Library of Medicine MedLine Plus, (8/7/23), retrieved on 1/7/26 from https://medlineplus.gov/ency/article/000302.htm. Loss of brain function occurs when the liver is unable to remove toxins from the blood. This is called hepatic encephalopathy (HE). This problem may occur suddenly, or it may develop slowly over time. An important function of the liver is to make toxic substances in the body harmless. These substances may be made by the body (ammonia), or substances that you take in (medicines). When the liver is damaged, these 'poisons' can build up in the bloodstream and affect the function of the nervous system. The result may be HE. HE can occur suddenly, and you may become ill very quickly. HE can get worse quickly and become an emergency condition. Medicines are given to help lower ammonia levels and improve brain function. Medicines given may include rifaximin (Xifaxan). These medications reduce the amount of ammonia made in the intestines. If the HE improves while taking rifaximin, it should be continued indefinitely. According to the full prescriber information of Xifaxan by the manufacturer (published October 2023), retrieved on 1/6/26 from https://shared.salix.com/globalassets/pi/xifaxan550-pi.pdf. Xifaxan is a rifamycin antibacterial (medication) indicated (used to treat) for: Reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults. Counsel patients that antibacterial drugs including Xifaxan should only be used to treat bacterial infections. They do not treat viral infections (the common cold). When Xifaxan is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may decrease the effectiveness of the immediate treatment and increase the likelihood that bacteria will develop resistance and will not be treatable by Xifaxan or other antibacterial drugs in the future. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. According to the December 2025 computerized physician's orders (CPO), diagnoses included hepatic encephalopathy, hepatitis C, hepatomegaly, and artificial right hip joint. The 11/12/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Resident and resident representative interview Resident #2 was interviewed on 12/29/25 at 3:00 p.m. Resident #2 said in the past, she had some difficulty getting her medications at the facility. She said she did not remember which medications. Resident #2's representative was interviewed on 12/30/25 at 12:22 p.m. Resident #2's representative said she helped unpack Resident #2's room on the first or second day after she was admitted on [DATE]. Resident #2's representative said she found a card of Xifaxan medication in her mom's belongings from the previous facility and she left the medication with the nurse on duty. C. Record review Review of Resident #2's November CPO revealed the following physician's orders: -Xifaxan oral tablet (used to treat bacterial infections or hepatic encephalopathy). Give twice a day for hepatic encephalopathy, ordered on 11/6/25. -Midodrine oral tablet (used to treat low blood pressure). Give three times a day for hypotension, ordered 11/5/25. - Lotilaner ophthalmic solution (used to treat parasitic eye infections). One drop in both eyes two times a day, ordered on 11/5/25 and discontinued on 12/1/25. Review of Resident #2's November 2025 medication administration record (MAR) revealed Resident #2 missed the evening dose of Xifaxan on 11/24/25 and 11/25/25. Review of the nursing progress notes on 11/24/25 and 11/25/25 documented the medication was not available in the facility and was on order from the pharmacy. Review of the order history from the pharmacy, provided by the facility pharmacy consultant, revealed the Xifaxan prescription was filled by the facility on 11/6/25 for a 14-day supply. This medication would have lasted through 11/20/25. The prescription was filled again by the pharmacy on 11/26/25 for another 14-day supply. -The facility did not have Xifaxan from the pharmacy between 11/20/25 to 11/25/25 when the prescription ran out and had not yet been filled. Review of the December 2025 (12/1/25 to 12/3/25 and 12/12/25 to 12/30/25) MAR revealed she did not receive two of two doses of Xifaxan on 12/12/25 and 12/14/25. The MAR revealed she was not given Xifaxan for one of two administrations on 12/13/25. The nursing progress notes written on 12/13/25 and 12/14/25 documented the facility was waiting for the pharmacy to deliver the medication to the facility. Review of Resident #2's nursing progress notes revealed additional missed medications because the medication was documented as not available at the facility. Review of the November 2025 MAR revealed Resident #2 was not administered lotilaner ophthalmic solution (an anti-parasitic eye drop medication) on 11/5/25, 11/6/25, 11/7/25, 11/15/25, 11/25/25, and 11/30/25, due to the medication not being delivered from the pharmacy. Review of the December 2025 MAR revealed Resident #2 was not administered midodrine (medication to prevent low blood pressure) on 12/12/25. D. Staff interviews The physician's assistant and registered nurse (RN) #1 were interviewed on 12/30/25 at 10:12 a.m. RN #1 said she remembered the resident's representative brought in a card of Xifaxan when Resident #2 was admitted and again on 11/5/25. RN #1 said there were 30 to 60 pills of the medication provided by the representative. RN #1 said the nursing staff would have administered the medication Resident #2's representative brought into the facility if the facility did not have the medication stocked. The physician's assistant said she also remembered Resident #2's representative brought in the medication. The physician's assistant said Xifaxan was a difficult medication to get insurance approval for because it was expensive. The physician's assistant said if the facility was out of a medication, the nursing staff was supposed to notify the provider on duty. The physician's assistant said there was no record of the provider group being notified when Resident #2 did not receive her Xifaxan on 11/24/25 and 11/25/25. The nursing home administrator (NHA) was interviewed on 12/30/25 at 1:25 p.m. The NHA said the facility had a 14-day supply of Xifaxan delivered on 11/6/25. The NHA said the prescription had been completed by 11/20/25, and the facility asked for a refill on 11/24/25. The NHA said the medication was then delivered on 11/26/25. The NHA said Resident #2's family brought in medication from home for the facility to use. The NHA said the nurses probably administered Resident #2's home medication during the time the facility did not have the medication from the pharmacy. The NHA said he did not know why the nursing staff had not provided the evening medication doses to the resident from the family provided medications on 11/24/25 and 11/25/26.

Based on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) for Resident #60, who was on enhanced barrier precautions (EBP); and, -Ensure residents were offered the opportunity for hand hygiene prior to meals. Findings include: I. Failed to ensure staff wore the appropriate PPE for Resident #60, who was on EBP A. Professional reference According to 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), retrieved on 1/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, 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. Observations On 1/27/25 at 10:43 a.m. there was a sign on Resident #60's door which indicated the resident was on EBP. The sign indicated gloves and gowns must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. Resident #60 had an indwelling urinary catheter in place. There was PPE, including gloves, gowns, eye protection and masks stocked on the back of Resident #60's bathroom door. On 1/27/25 at 11:12 a.m. Certified nurse aide (CNA) #4 and CNA #6 were transferring Resident #60 from bed to a wheelchair using a hoyer lift (mechanical lift). Both CNA #4 and CNA #6 had on gloves but they were not wearing gowns. On 1/30/25 at 9:16 a.m. CNA #7 and CNA #3 were transferring Resident #60 to a wheelchair with the mechanical hoyer lift. CNA #7 and CNA #3 were wearing gloves but they were not wearing a gown. C. Staff interviews CNA #6 was interviewed on 1/27/25 at 11:17 a.m. CNA #6 said staff only needed to wear gloves when providing care for Resident #60, unless they were emptying her foley catheter. CNA #6 said if staff were emptying the resident's foley catheter, then they needed to wear gloves and a gown. Assistant director of nursing (ADON) #1 was interviewed on 1/29/25 at 2:12 p.m. ADON #1 said he was in charge of the facility's infection control program and was certified as an infection preventionist (IP). Licensed practical nurse (LPN) #5 was interviewed on 1/30/25 at 9:14 a.m. LPN #5 said when staff were providing care for Resident # 60, staff were required to put on gloves, gown, mask and face shield. CNA #7 was interviewed on 1/30/25 at 9:18 a.m. CNA #7 said she only needed to put on gloves when providing care for Resident #60. CNA #3 was interviewed on 1/30/25 at 9:19 a.m. CNA #3 said she only needed to put on gloves when providing care for Resident #60 and maybe a mask sometimes. CNA #3 said staff did not get any education training regarding EBP protocols from the nurses. The director of nursing (DON) and ADON #1 were interviewed together on 1/30/25 at 12:35 p.m. ADON #1 said EBP were used for residents with any open wounds, feeding tubes, IV (intravenous) lines and foley catheters. He said staff should wear gowns, mask gloves, and eye wear depending on if they were going to drain foley catheters. -However, the sign on Resident #60's door indicated only gloves and gowns were required to be worn when providing resident care activities (see observations above). ADON #1 said PPE protected staff from spreading infections. The DON and ADON #1 both said in-service's based on individual infection concerns were given to staff along with a paper document for staff to sign that they had been provided with education related to infection control concerns, such as precautions. -Documentation of the facility's infection control in-service educations were requested, however the facility did not provide the documentation by the end of the survey on 1/30/25. 42838 II. Failed to ensure residents were offered the opportunity for hand hygiene prior to meals A. Professional reference According to the CDC's About Hand Hygiene for Patients in Healthcare Settings Clean Hands, updated 2/27/24, retrieved on 2/4/25 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, When patients and visitors should clean their hands: -Before preparing or eating food; -Before touching your eyes, nose, or mouth; -Before and after changing wound dressings or bandages; -After using the restroom; -After blowing your nose, coughing, or sneezing; and, -After touching surfaces such as bed rails, bedside tables, remote controls or the phone. Residents in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics and protects healthcare personnel and residents. B. Facility policy and procedure The Hand Hygiene policy, dated 2001, was provided by the director of nursing (DON) on 1/31/25 at 1:29 p.m. It read in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Residents, family members and/or visitors are encouraged to practice hand hygiene. -The facility policy did not identify when to offer residents hand hygiene. C. Observations On 1/27/25 at 11:30 a.m., during the lunch service in the facility's main dining room and the first floor dining room, staff did not offer any of the residents the opportunity to sanitize their hands prior to eating. There were hand sanitizer dispensers mounted on the walls in the dining room, but the mounted hand sanitizer dispensers were not accessible to residents with mobility limitations because they were blocked by dining room tables. On 1/28/25 at 4:11 p.m., during the dinner service in the main dining room, staff did not offer any of the residents the opportunity to sanitize their hands prior to eating. On 1/29/25 at 4:01 p.m., during the dinner service in the main dining room, staff did not offer any of the residents the opportunity to sanitize their hands prior to eating. On 1/30/25 at 9:31 a.m., the dietary manager (DM) was observed attempting to locate hand sanitizer wipes. The DM was unable to locate any hand sanitizer wipes and said the facility must be out of them. She said she would reorder some. On 1/30/25 at 11:07 a.m., during the lunch service in the first floor dining room, staff did not offer any of the residents the opportunity to sanitize their hands prior to eating. D. Resident interviews Resident #131 was interviewed on 1/30/25 at 9:32 a.m. Resident #131 said staff did not offer residents a way to wash or sanitize their hands prior to meals. He said he was one of the few residents who could wash his own hands and he remembered to do it himself. He said not all residents were able to wash their own hands, so they would go without washing their hands before meals. Resident #157 was interviewed on 1/30/25 at 10:50 a.m. Resident #157 said staff did not offer hand hygiene to residents at meals. E. Staff interviews The DM was interviewed on 1/30/25 at 9:31 a.m. The DM said she trained all dietary aides on infection control within the dining room. The DM said the residents were encouraged to use the hand sanitizer that was mounted on the walls but if they preferred the hand sanitizer wipes, the dietary aides could get them one. The DM said it was the residents' choice to clean their hands before meals and they do not force infection control. -However, the mounted hand sanitizer dispensers were not accessible to residents with mobility limitations because they were blocked by dining room tables. -Additionally, staff did not encourage the residents to use the hand sanitizer dispensers on the wall (see observations above). The dietary assistant (DA) was interviewed on 1/30/25 at 10:58 a.m. The DA said staff would ask residents if they wanted hand hygiene at meals and if they wanted it, staff would provide hand sanitizer wipes for residents to sanitize their hands. ADON #1 was interviewed on 1/30/25 at 12.35 p.m. ADON #1 said the facility offered hand sanitizer or sani-wipes at meal time for the residents. ADON #1 said hand sanitizer wipes should be on residents' room trays as well as in the dining room. ADON #1 said all residents should be offered the opportunity to sanitize their hands prior to meals. ADON #1 said the facility usually provided infection control education to staff twice a month verbally and all staff received written education upon hiring. He said the facility conducted random hand washing audits of staff twice a month.

Based on observations, record review and interviews, the facility failed to ensure one (#35) of three residents reviewed for activities out of 59 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being. Specifically, the facility failed to ensure Resident #35 was provided with one-to-one activities and invited to her preferred activities. Findings include: I. Facility policy and procedure The Activities Program policy and procedure, revised June 2018, was received from the director of nursing (DON) on 1/31/25 at 12:41 p.m. It revealed in pertinent part Activity programs are designed to meet the interests and support the physical. Mental and psychosocial well-being of each resident. Activities are offered based on the comprehensive resident-centered assessment and the preferences of each resident. Activities are considered any endeavor, other than routine activities of daily living (ADL), in which the resident participates. That intended to enhance his or her sense of well being and to promote or enhance physical, cognitive or emotional health. Our activities programs are designed to encourage maximum individual participation and are geared to the individual resident needs. All activities are documented in the resident's medical record. Residents are encouraged, but not required, to participate in scheduled activities. II. Resident #35 A. Resident status Resident #35, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, type two diabetes mellitus, peripheral vascular disease (decrease in peripheral circulation), hypertension (increase in Blood pressure) and chronic kidney disease (decrease in kidney function). The 11/26/24 minimum data set (MDS) assessment revealed the resident had short and long term memory issues per staff assessment. She was dependent on staff for eating, toileting, dressing and transfers. The assessment indicated the resident did not reject care from staff. It revealed per staff assessment the resident enjoyed listening to music, being around animals, doing things with groups of people, participating in favorite activities, spending time outdoors and participating in religious activities. B. Observations On 1/27/25 at 11:58 a.m. Resident #35 was observed laying in her bed staring at the ceiling. On 1/28/25 at 2:00 p.m. Resident #35 was observed in her bed with the television on. Bingo was going on in the main dining room. Resident #35 was staring at the ceiling. During a continuous observation n 1/29/25, from 9:50 a.m. to 1:50 p.m., the following was observed:. At 9:50 a.m. Resident #35 remained in her room in bed with the television on. At 11:00 a.m. a scheduled music activity began in the main dining room. -Resident #35 was not approached by staff to see if she would like to attend the activity. The resident liked listening to music (see record review below). On 1/29/25 at 1:13 p.m. an unidentified certified nurse aid (CNA) entered the resident room with a lunch meal tray. CNA sat down and assisted the resident with eating but she did not converse with the resident during this time. -The unidentified CNA failed to converse with Resident #35 per interventions in the care plan (see record review below). C. Record review The 3/4/19 comprehensive care plan documented Resident #35 enjoyed programs with music. Resident #35 required reminders and assistance with transportation. The care plan identified goals that included Resident #35 would engage in sensory stimulating activities two to three times a week, Interventions included Resident #35 would be part of one-to-one therapeutic programs one to three times a week to help with loneliness, boredom and isolation. The care plan also identified that Resident #35 enjoyed sensory music, talking and did not enjoy being touched and could become agitated -However the staff interviews indicated the resident liked physical contact (see staff interviews below). The Life Loop activities documentation (12/30/24 to 1/30/25) was provided by the activities director (AD) on 1/30/25 at 9:50 a.m. revealed the resident had received one session of one-to-one activities. -Resident #35 was missing a minimum of three other one-to-one activities sessions in the past month. D. Staff interviews The activities assistant (AA) was interviewed on 1/30/25 at 9:20 a.m. The AA said residents were evaluated on their likes and dislikes upon admission. She said it was determined if the resident would benefit from one-to-one interactions from the activities department. She said the evaluation also helped the staff determine which activities the resident may want to join. The AA said if a resident received one-to-one visits the visit would be scheduled for two to three visits a week. The AA said she had worked with Resident #35 for a while and Resident #35 enjoyed talking, physical contact, being with others and loved music. The AA said Resident #35 attended group activities all of the time. The AD was interviewed On 1/30/25 at 9:28 a.m. The AD said one-to-one programs were resident specific and would vary on one to three visits a week. The AD said all residents were invited to activities throughout the day. The AD said if there was an activity that a resident really enjoyed, the activities staff would invite them and talk with the CNA to ensure they were assisted to attend. The AD said sometimes the staff had to ask the residents who had dementia several times to participate in the activity due to their memory issues. The AD said one-to-one interactions with residents were documented in a paper spread sheet then were added to life loop electronic documentations. The AD said Resident #35 was non verbal and liked music, smells and physical contact. The AD was interviewed again on 1/30/25 at 10:00 a.m. The AD said per documentation Resident #35 had only received one out of four one-to-one sessions in the past 30 days. The AD said maybe the session had not been documented yet by the assistants.The AD said if it was not documented then it did not happen since documentation was proof something had occurred.

Based on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#1) of two residents reviewed for vision problems out of 59 sample residents. Specifically, the facility failed to provide Resident #1 assistance in getting new glasses. Findings include: I. Resident #1 A. Resident status Resident #1, age 68, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, type two diabetes and chronic obstructive pulmonary disease (COPD). The 10/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required substantial/maximal assistance with toileting hygiene, showering/bathing, upper and lower body dressing and personal hygiene. The MDS assessment documented the resident had adequate vision with eye glasses. B. Resident interview Resident #1 was interviewed on 1/27/25 at 10:47 a.m. Resident #1 said he had his eye exam last year and was waiting for his glasses to come. He said that the facility had not assisted him with getting new glasses. He said he could not see out of his left eye and his right eye was blurry. He said he felt frustrated that he could not read his books. C. Record review The vision care plan, revised 9/11/24, documented Resident #1's wore glasses. It documented the resident preferred looking through his right eye. Pertinent interventions included for the staff to remain in line of sight, providing assistance to the resident if he needed help taking his glasses off, arranging vision care visits as needed and documenting any signs of eye problems. The 5/16/24 eye consult office visit revealed Resident #1 had an eye exam. The note included the resident's new prescription for eyeglasses. The note documented the resident was prescribed bifocal glasses. The note documented insurance would be billed accordingly. It indicated if there was no insurance coverage was available, the resident would be provided a separate invoice if they chose to purchase the eyeglasses. -Review of Resident #1's electronic medical record (EMR) did not reveal documentation indicating the resident had received his eye glasses. D. Staff interviews Social service (SS) #3 was interviewed on 1/30/25 at 11:26 a.m. SS #3 said she was responsible for arranging eye exams for the residents. SS #3 said the eye doctor was at the facility monthly. She said the residents should be seen by an eye doctor every three months. SS #3 said Resident #1 was seen by the eye doctor on 5/16/24 and he had Medicaid. SS #3 said Medicaid would pay for the glasses if the PETI (post-eligibility treatment of income) form was completed. She said she filled out the PETI form and was waiting for Medicaid to pay for them. She said she did not remember when she filled out the PETI form. She said it took a long time for Medicaid to pay for eyeglasses. SS #3 said Resident #1 had not received his eyeglasses because Medicaid had not paid for them. She said she gave the bill to the business office manager (BOM) after Resident #1 was seen by the eye doctor. The business office manager (BOM) was interviewed on 1/30/25 at 12:51 p.m. The BOM said Medicaid paid for all ancillary services. The BOM said Resident #1 should have received his glasses two weeks after his appointment on 5/16/24. She said if there was a delay in ordering glasses money would be taken out of residents personal needs funds. She said if residents did not have any money then the families would be notified. She said some families were willing to pay out of pocket for glasses. The BOM said the social services department was responsible for making sure residents received their glasses. She said it should not take eight months for residents to receive their eyeglasses. She said Resident #1 should have received his glasses within a month.

Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#578) of two residents reviewed out of 59 sample residents. Specifically, the facility failed to ensure Resident #578 received his tube feeding administrations as ordered by the physician. Findings include: I. Facility policy and procedure The Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 1/31/25 at 12:41 p.m. It read in pertinent part, Adequate nutritional support through enteral nutrition is provided to residents as ordered. The dietitian, with input from the provider and nurse: estimates calories, protein, nutrient and fluid needs; determines whether the resident's current intake is adequate to meet his or her nutritional needs; recommends special food formulations; and, calculates fluids to be provided (beyond free fluids in formula). Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary. The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. II. Resident status Resident #578, age 85, was initially admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician orders (CPO), the diagnoses included pneumonia and cerebral palsy (a congenital disorder of movement, muscle tone, or posture). The 11/11/24 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview status (BIMS) score of zero out of 15. He required substantial/maximal assistance with toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on and taking off footwear and personal hygiene. The MDS assessment documented the resident was receiving 51% or more of his calories through a feeding tube and 501 cubic centimeters (CC) a day of fluid through a feeding tube. III. Observation On 1/30/25 at 11:00 a.m. Resident #578 was not in his room and his machine was turned off (see interviews below). IV. Record review The enteral feeding care plan, revised 2/12/24, documented Resident #578 had cerebral palsy, history of impaired swallowing with aspiration pneumonia and nothing by mouth (NPO). Interventions included providing 200 milliliters (ml) water flush via peg-tube as per order, ensuring the insertion site was be free of signs or symptoms of infection, checking the placement of the tube and residual every shift, if residual greater than 500 cubic centimeter (cc) hold feeding and notify the medical doctor, elevating the head of the bed 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding was stopped, having the registered dietitian (RD) evaluate the resident monthly and as needed , monitoring caloric intake, estimating needs and making recommendations for changes to tube feeding as needed. The nutrition care plan, revised 8/15/24, documented Resident #578 was at risk for inability to maintain his nutrition related to diagnosis of dependence on enteral nutrition, gastroesophageal reflux disease (GERD), limited mobility, history of weight loss and underweight. Interventions included providing the enteral feed as ordered: Jevity 1.5 at 70 ml an hour for 22 hours via g-tube, providing 2310 kilocalories, 98 grams protein and 1170 ml water, 250 ml water flush every four hours, flush with 30 ml water before and after tube feeding administration, total water daily 2670 ml, monitoring and recording weight as ordered (weekly) and providing diet as ordered and as resident chooses NPO. The January 2025 CPO documented the following physician's orders for Resident #578: Jevity 1.5 calorie/fiber oral liquid (nutritional supplements) give 70 ml an hour via peg-tube one time a day for enteral nutrition Jevity 1.5 at 70 ml an hour for 22 hours via peg. On at 1:00 a.m. off at 11:00 a.m. Flush with 30 ml water before and after administration. Document total ml formula administered (1540ml). May use Nutren 1.5 if Jevity 1.5 was unavailable and remove per schedule, ordered on 10/1/24. Change bag and tubing every 24 hours at 1:00 a.m. for feeding tube in use, ordered on 12/6/24. 250 ml water flush via g-tube every four hours, ordered on 1/23/25. V. Staff interviews Registered nurse (RN) #2 was interviewed on 1/30/25 at 11:00 a.m. RN #2 said she disconnected Resident #578's feeding at 10:00 a.m. every day and restarted the feedings at 2:00 p.m. RN #2 said Resident #578 was off his tube feeding for four hours daily. -However, the physician's orders indicated to start the feedings at 1:00 p.m. and end the feedings at 11:00 a.m., indicating the resident did not receive feedings for two hours a day, from 11:00 a.m. until 1:00 p.m. RN #2 said the physician's order read Resident #578 was to receive feedings for 22 hours, starting at 1:00 p.m. and ending at 11:00 a.m. RN #2 said Resident #578 went to physical therapy everyday at 10:00 a.m. five days a week. RN #2 said she should have followed the physician's orders. She said she was responsible for taking Resident #578 off the feeding tube early on 1/30/25 (see observations above). She said Resident #578 was taken off at 10:00 a.m. for physical therapy. She said Resident #578 had physical therapy five days a week. She said she needed to follow the physician's orders. The registered dietitian (RD) was interviewed on 1/30/25 at 2:22 p.m. The RD said Resident #578 received enteral feedings for 22 hours a day. She said he did not receive feedings for two hours a day. The RD said she did not get a report on how much volume Resident #578 was receiving. She said she was in constant communication with the nurses about resident's weight and volume. She said Resident #578's weight had been going up and he was getting adequate nutrition The RD said Resident #578 went to therapy five days a week and was off for two hours and he sat at the nurses station. The RD said the tube feeding machine had kept track of information for 24 to 72 hours. She said Resident #578 should be getting the majority of the formula that was prescribed daily within 24 hours. She said Resident #578 should be getting 1540 ml of formula daily. She said the bag that held the formula needed to be changed every 24 to 48 hours. She said when the formula ran out the nurses changed the bag, which was not always at the same time each day. The RD said the physician's order for enteral feedings for Resident #578 read for the feedings to start at 1:00 a.m. and end at 11:00 a.m. The RD said Resident #578 was prescribed 70 ml of formula per hour for 22 hours a day. The RD said Resident #578 should not be off for four hours and the nurse was wrong. The RD said the nurses should have followed the physician's orders. The RD said the nurses could let her know if they needed to make changes to the physician's order. She said the nurses should be communicating with her about making any changes to the orders. She said it would be good to know that Resident #578 was off of his tube feeding for more than two hours so she could adjust the order.

Based on record review and interviews the facility failed to have a coordinated written plan of care that included both the most recent hospice plan of care and a description of the services furnished by the facility for two (#169 and #12) of three residents out of 59 sample residents. Specifically, the facility failed to ensure Resident #169 and Resident #12 had a written plan of care that included both the most recent hospice plan of care and a description of the services furnished by the facility Findings include: I. Facility policy and procedure A request for the hospice services policy was made on 1/30/25 at 4:15 p.m. to the nursing home administrator (NHA) and was not provided with the other policies requested. The Care Plans, Comprehensive Person-Centered policy, revised March 2022, was provided by the NHA on 1/31/25 at 12:41 p.m. It read in pertinent part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. I. Resident #169 A. Resident status Resident #169, age 69, was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included cirrhosis of the liver, a history of stroke and muscle wasting. The 9/27/24 minimum data set (MDS) assessment revealed the resident had short and long-term memory problems per staff assessment and did not participate in the brief interview for mental status (BIMS) assessment. The resident was able to recall the current season and knew she was in a nursing facility. The resident usually understood others and was usually understood in conversations. The assessment indicated the resident was receiving hospice services while a resident of the facility. B. Resident interview Resident #169 was interviewed on 1/27/25 at 12:46 p.m. Resident #169 said she recently was admitted to hospice but did not know what the plans were. She said the nurses were telling her one thing and the hospice staff were telling her something else. She asked the hospice nurse to talk to the hospice nurse to provide clarification on her medication orders to the facility nurse. She said the hospice nurse said she would. She said when the facility nurse came in later she said she was unaware of the medication question and said the hospice nurse had not talked to her. Resident #169 said she did not think the communication between the facility and the hospice provider was good and they were yet to hold a care conference to discuss her medical care plan. C. Record review Review of Resident #169's comprehensive care plan, last revised on 1/4/24, revealed documentation that the resident was on hospice services. -The care plan failed to include the explanation of care and services that hospice would provide and that the facility would provide in relation to hospice services and end of life care. The multidisciplinary care conference note, dated 11/13/24, documented a care conference held with the resident, the resident's family and the resident's physician assistant. -The note did not document a discussion with the resident about her declining health or a plan to seek hospice services at the time of the 11/13/24 care conference. The resident's progress notes revealed the resident's primary care physician's assistant (PA) documented an order for the resident to be evaluated for hospice services, dated 11/26/24. The resident was admitted to hospice on 12/13/24. The PA note, dated 12/11//24, documented the resident did have hospice evaluation and was admitted for end stage liver disease. The resident had further decompensation with rapid weight loss. The resident and family were understanding of the clinical situation and in agreement with hospice care. The note documented to coordinate comfort focused treatment plan. Hospice registered nurse services note, dated 1/14/25, read in pertinent part: Problem: Coordination of care needs: hospice. Intervention: Educate facility care providers regarding contacting hospice to ensure continuity of care and allow for continuing case management by the hospice care team. Goal: Continuity of care will be maintained as appropriate to the patient and primary caregiver's needs. D Staff interviews The hospice registered nurse (HRN) was interviewed on 1/30/25 at 2:30 p.m. The HRN said Resident #169 started receiving hospice services on 12/13/24. The HRN said the resident had been forgetful about the details of her hospice services and had been asking several questions about who would be in charge of making her medical decisions and who (hospice or facility staff) would provide her care The HRN said she checked in with the facility nurse on Resident #169's unit after each visit and has had lengthy conversations with Resident #169's family. HRN said she set up a care conference meeting with the resident, the facility and the resident's family on 2/5/25. Social services (SS) #1 was interviewed on 1/30/25 at 3:09 p.m. SS #1 said her responsibility was to make hospice referrals per the resident and resident representative preferences. SS #1 said the unit manager was responsible for coordinating care between the facility and the hospice provider. SS #1 said she was under the impression that the floor nurse would develop a resident care plan for hospice services and interventions. The director of nursing (DON) was interviewed on 1/30/25 at 5:10 p.m. The DON said that the hospice provider routinely checked in with the floor nurse to communicate changes in the resident's care. The DON said the floor nurses in return would notify the HRN of any changes in the resident condition and care needs. The NHA was interviewed on 1/30/25 at 5:10 p.m. The NHA said that they would not add hospice care services to the facility care plan because they could not be responsible for another provider's services and could not guarantee that the provider would provide services accordingly. 48114 II. Resident #12 A. Resident status Resident #12, age under 65, was initially admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician orders (CPO), the diagnoses included traumatic brain injury, quadriplegia (a condition characterized by the partial or complete loss of motor function, sensation, and autonomic function in all four limbs and the torso) and dementia. The 12/5/24 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview status (BIMS) score of zero out of 15. He required substantial/maximal assistance with all activities of daily living (ADLs). The MDS assessment indicated the resident was receiving hospice services. B. Record review The care plan for hospice, initiated 12/5/24 and revised 12/6/24, documented Resident #12 was admitted to hospice for cerebral infarction related to calorie and protein malnutrition. Interventions included offering/providing additional privacy for resident/family whenever possible during dying process, considering room options within community to best meet resident/family needs, working effectively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met and working with nursing staff to provide maximum comfort for the resident. -The care plan failed to include the explanation of care and services that hospice would provide and that the facility would provide in relation to hospice services and end of life care. The January 2025 CPO documented the following physician orders for Resident #12: Admission to hospice for cerebral infraction related to calorie and protein malnutrition, ordered on 11/27/24. Care conference note for 8/28/24 documented staff will encourage Resident #12 to participate with activities and his work outs with therapy. Staff will encourage resident to participate with his activities of daily living. -Review of the resident's electronic medical record (EMR) did not indicate why a care conference was not held in November 2024 or documentation indicating a care conference was held to discuss the resident admitting to hospice and how the resident's care would be delineated between the hospice staff and the facility staff. C. Staff interviews SS #2 was interviewed on 1/30/25 at 3:08 p.m. SS #2 said care conferences were completed quarterly. SS #2 said she was in charge of making arrangements for when care conferences were held. She said she made arrangements with family members when care conferences were scheduled. SS #2 said Resident #12's care conference should have been held in November 2024. SS #2 said she was not sure why it was not completed. She said a care conference should have been completed. She said the care conference got missed. SS #2 said during the holidays that the families were ok with not having care conference meetings. SS #2 said after the holidays she would resume the care conferences. SS #2 said she had Resident #12 on the calendar for the month of February to hold his care conference meeting. SS #2 said the nursing team would add what services they were providing for the resident. Licensed practical nurse (LPN) #4 was interviewed on 1/30/25 at 3:15 p.m. LPN #4 said SS, charge nurse or MDS coordinator would develop a care plan with goals and interventions. LPN #4 said during care conferences when they implemented or revised the goals and interventions. She said the MDS coordinators entered the goals and interventions for Resident #12. Minimum data set coordinator (MDSC) #1 was interviewed on 1/30/25 at 3:56 p.m. MDSC #1 said she coordinated with the unit managers, charge nurses, hospice company and the provider when implementing and revising goals and interventions. MDSC #1 said she created the goals and interventions for Resident #12. She said she could put in goals and interventions even though a care conference was not held. She said the interventions she entered were individualized. She said hospice sent over a chaplain to meet with Resident #12 and coordinated with the families. The NHA was interviewed on 1/30/25 at 4:00 p.m. The NHA said care conferences were held quarterly. He said he was unaware that the care conference was not held for Resident #12. He was surprised that a progress note was not written. D. Facility follow-up On 2/3/25 at 6:41 p.m. (after the end of the survey), the NHA provided documentation that a progress note was completed with an explanation as to why the care conference was not held. The progress note indicated due to the upcoming Thanksgiving holiday the family opted not to have the November care conference and resume the regular care conference schedule with the interdisciplinary treatment team next quarter. -However, review of the resident's EMR during the survey did not indicate documentation indicating why the care conference was not held.

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, in two of two dining rooms and with resident room trays. Specifically, the facility failed to: -Ensure cold food holding equipment and ready to eat perishable food were kept at the appropriate holding temperature in two of two walk-in refrigerators; -Ensure proper unit refrigerator temperatures were maintained in one one of three resident snack refrigerators that contained ready to eat perishable food; -Ensure the high temp dish washing machine functioned at the proper temperatures; -Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in the first floor dining room; and, -Ensure residents were offered hand hygiene before eating their meals in two of two dining rooms and in resident rooms with meal trays. Findings include: I. Cold food holding of ready to eat food and unit refrigerators A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 8/23/23 from https://cdphe.colorado.gov/environment/food-regulations read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified. The FDA (Food and Drug Administration) food code reviewed 3/27/23 and retrieved 8/23/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. B. Facility policy The Food Receiving and Storage policy, revised November 2022, was provided by the nursing home administrator (NHA) on 8/14/23 at approximately 10:00 a.m. It read in pertinent part, Danger zone means temperatures above 41 degrees F and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially hazardous foods (PHF) or time and temperature control for safety (TCS) foods held in the danger zone for more than four hours (if being prepared from ingredients at ambient temperature) may cause a foodborne illness outbreak if consumed. Food services, or other designated staff, maintain clean and temperature/humidity appropriate food storage areas at all times. PHF/TCS foods are stored at or below 41 degrees F, unless otherwise specified by law. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. Food and snacks kept on nursing units: All food items to be kept at or below 41 degrees F are placed in the refrigerator located at the nurses' station and labeled with a 'use by' date. Refrigerators must have working thermometers and are monitored for temperature according to state- specific guidelines. C. Kitchen observations, record review and interviews The following observations were made on 8/9/23: At 9:13 a.m. during the initial kitchen walk through, walk-in refrigerator #1's digital thermometer revealed the refrigerator's internal temperature was 46 degrees F; five degrees above acceptable temperatures to ensure food safety (see professional reference above). Walk-in refrigerator #2's digital thermometer revealed the refrigerator's internal temperature was 43 degrees F; two degrees above acceptable temperature to ensure food safety. Walk-in refrigerator #1's temperature log was posted on a clipboard outside the walk-in door, staff documented the walk-in refrigerator temperature as 46 degrees F on 8/8/23; five degrees above acceptable temperature to ensure food safety . Staff documented the temperature of walk-in refrigerator #2's as 41 degrees F on 8/9/23 as 43 degrees F; two degrees over acceptable food temperatures to ensure food safety. -Neither temperature logs had reference temperature ranges to alert staff to acceptable temperature ranges. Walk in refrigerator #1 contained several perishable food items including six cases of four ounce yogurt containers, three containers of sour cream, two containers of soy milk, three-five pound logs of sliced american cheese, one six to eight pound ham, approximately eight ounces of sliced deli ham, approximately three pounds of tuna salad, and a case of two six to eight pound turkey breasts. At 9:15 a.m. the dietary manager (DM) was alerted to the observed walk-in refrigerators temperatures being out of range (see above). The DM was interviewed at 9:16 a.m. The DM said the dietary staff called her on 8/8/23 in the evening and informed her walk-in refrigerator #1 was running at a higher temperature than appropriate. The DM said she instructed staff to take temperatures of the individual food inside walk-in refrigerator #1; the food items tempt within correct temperature ranges (41 degrees F and under), so the food was not discarded. The DM said there was no adjustments made to walk-in refrigerator #1 and no additional monitoring of the food temperatures to see how long the temperature of walk-in refrigerator #1 remained above acceptable temperature of range or to ensure the food in the refrigerator remained within safe range. The DM said she was not aware that the second walk-in refrigerator's temperature was also temping higher than acceptable range. The DM said both walk-in refrigerators were new and just installed on 8/6/23 and both were cooled to appropriate refrigerated temperatures (40 degrees F or below) before staff placed food into each of the walk-in refrigerators. The dietary staff then checked the walk-in temperatures at 5:00 a.m. the following day (8/7/23) and again first thing the next morning after the door had been closed and left unopened all night; staff responded that the refrigerator had maintained appropriate temperatures until the evening of 8/8/23 when staff reported high temperatures. At 9:22 a.m. walk-in refrigerator #1's digital thermometer documented the internal refrigerated temperature was 42 degrees F and walk-in refrigerator #2's digital thermometer documented the internal refrigerator temperature was 45 degrees F. At 9:30 a.m. temperatures of perishable food items in walk-in refrigerator #1 were taken and observed to be greater than 41 degrees F. -Sour cream (unopened and unused) was 45 degrees F. -Sliced deli ham was 45 degrees F. -Silk soy milk was 45 degrees F. -Tuna salad was 43 degrees F. At 11:13 a.m. walk-in refrigerator #1 was 37 degrees F and walk-in refrigerator #2 was was 43 degrees F. The tuna salad in walk-in refrigerator #1 was not discarded and observed to have some product scooped out. The other food items that had temped above acceptable temperatures had been discarded. -Because the time of day temperature logs only documented two temperatures per day it could not be determined how long the temperature for walk-in refrigerator #1 was out of range. The DM was interviewed at 11:15 a.m. The DM said she had not yet taken temperatures of any of the additional perishable items that were observed to be in the walk-in refrigerators when the refrigerators were observed to be above safe food holding temperatures (see above). The perishable items observed still in walk-in refrigerator #1 included six cases of four ounce yogurt containers, three containers of sour cream, one container of soy milk, three-five pound logs of sliced american cheese, one six to eight pound ham and a case of two six to eight pound turkey breasts. -The safety of the food items (see above), that had not been tested immediately when it was discovered they had been in the walk-in refrigerator for an undetermined amount of time when the refrigerator's internal temperature was above acceptable range, could not be verified to be safe for resident consumption because it was unknown if the food items maintained safe food temperatures and it could not be verified how long the food might have temped at unsafe temperature ranges. D. Unit refrigerator observations On 8/10/23 at 12:59 p.m., the 300 and 400 units shared resident snack refrigerator temperatures were observed. The thermometer inside the shared unit snack refrigerator had a high out of range temperature reading of 42 degrees F. The refrigerator temperature log contained a.m. and p.m. columns for recording refrigerator temperatures; the refrigerator temperatures were not consistently recorded. The recorded temperatures for August 2023 were as follows: -On 8/2/23, the morning temperature was 50 degrees F; -On 8/3/23, the morning temperature was48 degrees F; -On 8/4/23, there were no recorded temperatures; -On 8/5/23, the morning temperature was 48 degrees F; -On 8/6/23, the morning temperature was 48 degrees F; -On 87/23, there were no recorded temperatures; -On 8/8/23, the morning temperature was 46 degrees F; -On 8/9/23, the morning temperature was 42 degrees F; and, -On 8/10/23 there was no temperature. -The refrigerator temperature log did not contain a reference range for appropriate refrigerator temperatures, nor was there documentation of a corrective action for temperatures recorded out of range over the temperature of 40 degrees F. Each of the unit refrigerators contained 10 four ounce yogurt containers. D. Staff interviews Registered nurse (RN) #1 was interviewed on 8/10/23 at 12:59 p.m. RN #1 said she was unsure who was responsible for checking and recording the temperatures of the snack refrigerators. Assistant director of nursing (ADON) #2 was interviewed on 8/9/23 at 1:04 p.m. a ADON #2 said the overnight staff were responsible for checking the temperatures of the unit snack refrigerators. ADON #2 was interviewed on 8/9/23 at 2:00 p.m. ADON #2 said the recorded temperatures in the 300 and 400 unit refrigerator were unacceptable and too high to ensure food safety. The director of nursing (DON) was interviewed on 8/17/23 at 11:00 a.m. The DON said the overnight staff checked the unit refrigerator temperatures. She said a new log was put in place that included a temperature range for reference and staff were instructed to check temperatures in the morning and evening. E. Facility follow-up The DM was interviewed on 8/15/23 at 2:30 p.m. The DM said a plan was created and staff were trained that if walk-in refrigerator or freezer temperatures were higher than the acceptable temperature range, staff were to record the temperatures and alert the dietary manager. This included a refrigerator temperature over 41 degrees F. The DM said if the temperature of the walk-in refrigerator was higher than the acceptable range for more than 15 minutes without the refrigerator door opened then the internal food temperature of the food inside the walk-in refrigerator needed to be taken and monitored. If the food temperature was over 41 degrees F the food needed to be discarded. IV. Proper high temperatures dish machine temperatures A. Professional reference The Colorado Retail Food Regulations, effective 1/1/2019 were retrieved 8/21/23 from https://cdphe.colorado.gov/environment/food-regulations. It read in pertinent part, for Mechanical warewashing equipment and hot water sanitization temperatures in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold (dish compartment space) may not be less than 180 degrees F. B. Facility policy and procedure The Sanitization policy, revised November 2022, was provided by the dietary manager (DM) on 8/14/23 at 3:35 p.m. It read in pertinent part, General recommendations for heat sanitization is High temperature dishwasher (heat sanitization) wash temperature 150-165 degrees F and rinse temperature 180 degrees F; and 160 degrees F at the rack level/dish surface reflects 180 degrees F at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured. C. Observations On 8/14/23 at 10:50 a.m. the high temperature dish machine was observed during a wash and rinse cycle. The wash temperature was observed at 152 degrees F and the rinse temperature was observed at 181 degrees F. The dish machine log was observed on a clipboard in the dish room, and dish machine temperatures were not recorded for 8/13/23 dinner and 8/14/23 breakfast. The DM asked the dietary staff member why there was no dish machine temperature recorded for breakfast. The dietary staff member said she forgot and asked if she could write in the dish machine temperatures she observed earlier that morning. The DM was interviewed at 10:51 a.m. The DM said a new associate who was observed working in the dish room was being trained on 8/14/23 by another dietary staff member observed working in the dish room. The DM said the rinse temperature of the dish machine needed to be 180 degrees F to sanitize the dishes properly. D. Record review The high temperature dish machine temperature logs were provided by the DM on 8/14/23 at approximately 3:00 p.m. The temperature logs documented that the minimum wash temperature reference was 150 degrees F and the minimum rinse temperature was 180 degrees F. -A review of the August 2023 dish machine logs revealed that 14 of the 39 recorded rinse temperatures were below 180 degrees F with no documentation of corrective action. A review of the July 2023 dish machine logs revealed that 57 of the 93 recorded rinse temperatures were below 180 degrees F with no documentation of corrective action. E. Staff interviews The DM and NHA were interviewed on 8/15/23 at 2:30 p.m. The DM said the dietary supervisor (DS) was to take a nightly kitchen walk through checking for irregularities including checking the dishwasher temperature log. If the DS found any concerns the DM would hold a briefing to educate staff on proper procedure with staff the next morning. The DM said if the dishwashing machine was not working correctly she would contact the vendor/company who provided their dish machine for a technician to service the machine. The NHA said the company who provided the dishwashing machine service the unit monthly to ensure the machine was working correctly. The NHA said the dietary staff needed to tighten up on their temperature monitoring. The DM and NHA were interviewed on 8/17/23 at 9:30 a.m The DM said the dietary associates were trained on to properly check the dishwashers wash and rinse cycle temperatures and how to respond properly if the temperature were not adequate to ensure proper dish ware sanitation. The DS's were trained to check the dishwasher temperature log and how to respond to irregularities. IV. Hand washing A. Professional reference The Colorado Retail Food Regulations, effective 1/1/2019 were retrieved 8/21/23 from https://cdphe.colorado.gov/environment/food-regulations. It read in pertinent part, Food employees shall keep their hands and exposed portions of their arms clean. Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. Food employees shall clean their hands and exposed portions of their arms as specified under immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning gloves to initiate a task that involves working with food; after engaging in other activities that contaminate the hands. B. Facility policy The Handwashing/Hand Hygiene policy, revised August 2019, was provided by the Dietary Manager (DM) on 8/14/23 at 3:35 p.m. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled. Use an alcohol based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty, before and after direct contact with residents, before donning (putting on) sterile gloves; after contact with a resident's intact skin; after removing gloves, before and after eating or handling food; before and after assisting a resident with meals; and after personal use of the toilet or conducting your personal hygiene. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. When applying and removing gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. Apply/ remove one glove from the dispensing box touching only the top of the cuff. C. Observations On 8/9/23 at 11:55 a.m., lunch service was observed in the first floor dining room. The meal was brought to the dining room from the main kitchen, placing the hot foods in the preheated stem table, and placed the cold food on ice on a table beside the steam table. The main server, cook (CK) #1, started the meal service by washing his hands with soap and water and applying disposable plastic gloves, but failed to perform proper hand hygiene while serving residents their meals. Meal tickets were delivered to CK #1 and left on the counter at the steam table. CK #1 plated a hamburger and side dish options, as ordered, and walked the plate to the resident's table. While at the table CK #1 Touched several surfaces including the back of a resident's chair and the dining table then returned to the steam table to palate another hamburger. CK #1 did not change gloves or perform hand hygiene before reaching into the bread bag and grabbing a roll for the next resident's meal. This method of serving continued through the meal service. While plating on resident meal CK #1 scooped up a serving of ground hamburger to serve a resident and packed it onto a roll with the same gloved unwashed hands that previously touched unsanitary surfaces such as counters, cupboards, the refrigerator doors, the microwave meal tickets handled by residents and other staff. CK #1 only change gloves and performed hand hygiene once during the entirety of serving resident meals. However, after performing hand hygiene and changing gloves CK #1 cleared a used place setting from a resident's table, handled the plate and used napkin, scraped the plate into the trash. CK#1 removed the dirty gloves while touching the dirty surface of the gloves but did not perform hand hygiene prior to putting on new gloves then continued to serve other resident meals handling the rolls and meat with contaminated gloves and unwashed hands. D. Staff interviews Dietary aide (DA) #1 was interviewed on 8/17/32 at 4:32 p.m. DA #1 said staff should wash their hands after each task and remove their gloves, changing the gloves in between each task. DA #1 said staff should wash their hands after performing a service for a resident and also before putting on new gloves, after using a broom, after taking a break, after using the restroom, after taking out the trash and after working with a resident. DA #1 said staff could not touch a ready to eat food like a sandwich with their bare hands or touch a utensil and then a ready to eat food with the same gloves. Staff should wash their hands for 20 seconds and sing happy birthday twice while washing your hands before moving from one resident task to another The DM was interviewed on 8/17/23 at 4:45 p.m. The DM said she educated CK #1 on proper food handling; CK #1 was able to correctly demonstrate proper food handling and handwashing procedure. The DM planned to educate the entire dietary team. 47150 IV. Failed to ensure residents were provided with an opportunity to participate in hand hygiene before and after meals. A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 8/21/23 from:https://www.cdc.gov/handwashing/when-how-handwashing.html revealed in part, Handwashing is one of the best ways to protect yourself and your family from getting sick. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surface to person when you prepare or eat food and drinks with unwashed hands. Stay healthy by washing your hands often. Washing hands with soap and water is the best way to get rid of germs in most situations. If soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. You can tell if the sanitizer contains at least 60% alcohol by looking at the product label. B. Facility policy The Hand Hygiene policy, revised in August 2019, was provided by the dietary manager (DM) on 8/14/23 at 3:25 p.m. It read in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation included, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the hand washing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 3. Residents, family members, and visitors will be encouraged to practice hand hygiene. C. Observations On 8/9/23 at 11:25 a.m., lunch service was observed in the main dining room on the second floor. The staff passed lunch trays without offering any of the residents in the dining room the opportunity to perform hand hygiene before and after eating their lunch. The residents were served hotdogs and hamburgers and most ate the sandwiches with their hands. On 8/9/23 at 11:55 a.m., lunch service was observed in the first floor dining room. Resident hand hygiene opportunities were not offered or encouraged to any resident in the dining room. Residents entered the dining room with staff assistance and on their own propelling their wheelchairs by handling the large wheels and rolling forward. None of the residents entering for the meal were offered an opportunity for hand hygiene prior to eating the meal. Lunch that day consisted of hamburgers and hotdogs which residents ate with their hands. On 8/10/23 at 12:30 p.m., the delivery of a room tray for lunch service was observed on hall 300. Staff delivered the resident meal and helped the resident set up their food. Staff entered eight shared resident rooms serving approximately 10 residents on hall 300 their lunch and did not offer any of the residents an opportunity to perform hand hygiene with hand sanitizers or sanitizing wipes for the residents occupying those rooms. Most of the residents had ordered grilled cheese sandwiches and other finger foods which they ate with their hands. On 8/15/23 at 5:15 p.m., dinner service was observed on hall 300. Staff started passing room trays to resident rooms without offering or encouraging any of the residents the opportunity to perform hand hygiene. The residents in rooms #306B and #307A used their fingers to pick up and ate the food items from their plates and were not offered an opportunity to perform hand hygiene. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 8/15/23 at 6:25 p.m. The CNA said there were no sanitizing wipes on the resident's room trays, but they had paper towels on the resident trays. She said if a resident requested hand sanitizer she would deliver it to the resident. The CNA said hand hygiene was important to prevent the transmission of infectious diseases. The director of nursing (DON) and assistant director of nursing (ADON) #1 were interviewed on 8/16/23 at 1:30 p.m. The DON said staff members should provide hand hygiene opportunities to residents before and after meals. ADON #1 said hand hygiene was important to prevent infections and the spread of diseases. The DON said she would provide education for staff and residents about the importance of hand hygiene. 41032

Based on observations and staff interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to: -Ensure residents were provided independence and dignity while dining by avoiding the use of disposable cutlery and dishware; and, -Ensure ensure meals were delivered to residents in a timely manner. Findings include: I. Disposable cutlery A. Facility policy The Residents Rights policy, revised February 2021, was provided by the nursing home administrator (NHA) on 8/17/23 at approximately 3:30 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness and dignity; privacy and confidentiality. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our resident's rights. B. Resident interviews and observations Resident #7 was interviewed on 8/10/23 at 9:00 a.m. Resident #7 said he continued to get plastic utensils at meal time, he did not like plastic utensils and wanted regular silverware. He said because of his multiple sclerosis his hands were increasingly numb and tingly and he was unable to properly grip the flimsy plastic spoon with his hands so the food would fall off the spoon and onto his meal tray, lap or bed. Resident #7 was interviewed on 8/14/23 at 8:45 a.m. Resident #7 said he received a plastic knife with his breakfast meal and it was hard to cut and eat the meal with plastic utensils. Plastic utensils were observed on the resident's meal tray. Resident #7 said he was sent a plastic spoon for a meal on either 8/12/23 or 8/13/23 but remembered it was hard to eat the meal with the plastic utensil. During a meal observation on 8/14/23 at 11:54 a.m. a plastic four compartment cutlery bin in the kitchen that held silverware contained plastic forks. At 1:10 p.m. dietary aide (DA) #1 said she was out of silverware to put on meal trays for unit 400. She asked the cook to stop assembly of resident meal trays for unit 400 because she did not have enough silverware. The dietary manager (DM) held meal services and asked staff to wash more silverware. The clean silverware that was just washed was brought to DA #1 at 1:12 p.m. This caused a delay in getting lunch served to residents on time. A sample meal tray for a regular diet was evaluated by five surveyors on 8/14/23 at 1:30 p.m. after the last resident had been served lunch. The test tray contained an apple curry chicken entree served as a whole chicken breast. The apple curry chicken recipe provided by the nursing home administrator (NHA) at 8:00 a.m. 8/14/23 documented cut up boneless, skinless chicken thighs were to be used instead of chicken breasts. The chicken breast was difficult to cut with plastic utensils as the plastic utensils bended under the pressure needed to cut through the chicken breast and did not cut through or [NAME] the chicken easily. During a group interview on 8/15/23 at 3:00 p.m. with nine residents (#114, #27, #29, #153, #359, #2, #93, #94 and #111) said they received plastic silverware with their meals on numerous occasions. Resident #29 said if there was not a regular spoon available it was replaced with a plastic spoon and plastic utensils did not cut anything; plastic utensils were useless. Resident #111 said we were not at a picnic, we needed regular silverware. Resident #93 said she had her family bring in regular silverware for her to use at meals and keeps that set in her room for occasions when the facility provided plastic silverware in place of regular stainless steel silverware. C. Staff interviews The DM and NHA were interviewed on 8/17/23 at 9:25 a.m. The DM said she had residents that liked to keep the facility's metal silverware in their rooms after a meal and that caused a shortage of silverware. The DM said the facility had run out of clean silverware during lunch on 8/14/23. While she tried to keep as much silverware as possible in house, she did not stock a specific inventory amount of silverware. The DM said she was coordinating with the housekeeping department to check for silverware in the residents' rooms to restore the facility's silverware stock for resident meal service. The NHA said the housekeeping and nursing department would assist with checking residents' rooms for silverware that could be returned to the kitchen. The NHA said residents had not expressed their unhappiness with the plastic utensils. D. Facility follow-up On 8/17/23 at 9:30 a.m. the DM said she ordered 120 forks, spoons and knives for resident meals to increase the silverware inventory. II. Meals delivered timely A. Resident interviews Resident #11 was interviewed on 8/9/23 at 12:05 p.m. He said some days he and his wife's (who was his roommate) meals come 30 minutes apart. He said he asked to have their meals sent at the same time so he and his wife could eat at the same time but it did not always happen. Resident #7 was interviewed on 8/10/23 at 10:28 a.m. He said his lunch meals were delivered late and he never knew what time the meals would be delivered and delivery times were 12:30 p.m, 1:30 p.m. or 1:45 p.m. During a group interview on 8/15/23 at 3:00 p.m. Resident #2 said the dining room meal was very late on 8/14/23 and room tray meals were late a lot, depending on how many cooks worked that day. B. Record review Two separate grievances completed on 5/5/23 documented room tray service took a long time and when the residents received their food the food was cold. Lunch service times were listed as 11:00 a.m. to 1:00 p.m located in a binder provided during the survey. C. Observations Meal service was observed on 8/14/23 from 11:00 a.m. to 1:24 p.m. At 11:21 a.m. cook (CK) #1 said she was waiting for the chicken entree for lunch to cook to the correct temperature before removing it from the oven. At 11:31 a.m. resident meal assembly began for residents seated in the dining room. -However, this was 31 minutes after the post meal time. At 12:11 p.m. resident meal tray assembly for the first of four room tray carts began. At 12:17 p.m. resident meal tray assembly was stopped when the DM asked an unidentified dietary staff member to remove a pan of the one-half inch diced chicken from the steam table and grind it smaller. The dietary staff member ground the chicken and placed the pan in the steam table which caused a delay in meal service. At 12:24 p.m. the DM asked the dietary staff to stop assembling meal trays and asked dietary staff to modify the apple crisp to size listed in the recipe which caused a delay in meal service. At 1:07 p.m. resident meal tray assembly for the last of four room tray carts began. At 1:24 p.m. room trays were delivered to the 400 hall. Staff began passing out room trays to residents and room tray delivery was completed at 1:30 p.m. -However, this was 24 minutes past the posted meal times that ranged from 11:00 to 1:00 p.m. D. Staff interviews Dietary aide (DA) #1 was interviewed on 8/14/23 at 1:11 p.m. She said she did not know how often meals were delivered late due to delays with the dietary staff. The DM was interviewed on 8/14/23 at 1:13 p.m. She said meals tray assembly was usually completed by 12:30 p.m. but two dietary staff members called in that day. The nursing home administrator (NHA) was interviewed on 8/15/23 at 2:30 p.m. He said two dietary staff members called in and did not report to work that day which caused the dietary staff to serve breakfast late. He because breakfast was served late that morning and the dietary staff were unable to catch up and serve lunch on time. 46851

Based on observations record review and interviews the facility failed to ensure that the resident environments remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for for one resident (#151) of one reviewed for medications left unsecured in a common area, two residents (#86 and #23) reviewed for medications at bedside and one (#151) of four residents reviewed for falls out of 56 sampled residents. Specifically, the facility failed to: -Ensure medications were not left unattended for Resident #151's access, who had severely impaired cognition related to dementia and a tendency to wander and pick up items along the way; -Ensure Resident #86 and Resident #23 did not have medications at bedside when not assessed; -Ensure Resident #151 was provide sufficient monitoring, non-slip footwear and other fall interventions the resident was assessed to need in order to prevent multiple falls; and, -Ensure that Resident #151 was assessed by a registered nurse after an unwitnessed fall. I. Unsecured medicion A. Facility policy and procedure The Medication Labeling and Storage policy, revised last February 2023, received from the nursing home administrator (NHA) on 8/12/23 at 2:50 p.m. It revealed in pertinent part nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Items were not left unattended if open or otherwise potentially available to others. B. Resident #151 1. Resident status Resident #151, age 70 was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance. According to the 5/29/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for a mental status score of three out of 15. She required extensive assistance of one person with toileting, bed mobility, dressing, transferring and personal hygiene. The behavior assessment failed to assess the residents' wandering behavior. 2. Record review The 5/23/23 comprehensive care plan documented that Resident #151 had behaviors of wandering and eating and drinking anything she finds. Interventions documented were to anticipate and meet the residents needs, provide positive reinforcement/praise any indication of the resident's progress/improvement/control in behavior. -The care planned interventions failed to have an intervention to for staff monitor the resident when wandering to ensure the resident did not get ahold of potentially dangerous and hazardous items. 3. Observation On 8/10/23 at 9:58 a.m. licensed practical nurse (LPN) #1 was observed leaving her medication cart unattended with loose pills in a medication cup on top of the cart. Resident #151 walked up to the medication cart and was grabbing items off the medication cart. As Resident #151 reached for the loose pills in the medication cup a hand was placed over the medication cup containing the loose pills to prevent Resident #151 from picking up the medication cup until nursing staff returned to the area and could be alerted to the situation. At 10:01 a.m. LPN #1 and the director of nursing (DON) were observed walking down the hallway towards the medication cart. The DON redirected Resident #151 towards the nursing station and removed an open pudding cup from Resident #151's hands that the resident had picked up off the medication cart. LPN #1 disposed of the loose medication. 3. Staff interview LPN #1 was interviewed on 8/10/23 at 10:03 a.m. LPN #1 said she left medications unattended and identified the unattended medication as claritin (allergy medication). She stated medications were not to be left unattended because residents who wandered may pick them up. LPN #1 said residents who take medication not ordered for them could cause them to have an allergic reaction or affect them adversely. The DON was interviewed on 8/16/23 at 11:00 a.m. The DON said medications were not to be left unattended because the medication could be given to the wrong person or found and taken by a resident for whom the pill was not prescribed. A resident can have a reaction to a medication if it was not ordered for them. 4. Facility follow up On 8/16/23 at 11:00 a.m. the DON said the LPN involved with leaving the medication unattended was provided education for medication safety and suspended pending further review. II. Medications at bedside A. Facility policy The Administering Medications policy and procedure, revised April 2019, received from the Nursing home administrator (NHA) on 8/11/23 at 4:34 p.m. revealed in pertinent part, Medications were administered in a safe and timely manner and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. B. Resident #86 1. Resident status Resident #86, under 65, admitted on [DATE]. According to the August 2023 CPO diagnosis include malignant neoplasm of the colon (colon cancer), type two diabetes (abnormal insulin levels), chronic kidney disease (decreased kidney function) and hypertension (high blood pressure). The 5/25/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required one person assistance for bed mobility, transfers, dressing, toileting and personal hygiene. 2. Resident observations and interview On 8/9/23 at 12:16 p.m. a tube of diclofenac cream (topical pain cream), a Flonase (allergy nasal spray) and Peridex (prescription antiseptic mouthwash) were observed on the resident's bed side table. Resident #86 was interviewed on 8/10/23 at 11:53 a.m. Resident #86 said she used these medications regularly and kept them on her bedside table to keep them within reach. Resident #86 was unable to recall if the facility had assessed her for self administration and she said she did not have a lock box in her room to safely store the medications. Diclofenac, flonase and peridex were on her bedside table during the interview. 3. Staff interview Licensed practical nurse (LPN) #2 was interviewed on 8/1/23 at 4:16 p.m. LPN #2 reviewed Resident #86's room and found the following medications on the bedside table and night stand; triamcinolone acetonide 0.5% cream (cream for skin irritation), Peridex 0.12 % liquid, Flonase 50 micrograms (mcg)/actuation (act), lidocaine 5% prilocaine 2.5% cream (topical pain relief, diclofenac sodium 1%, and nystatin 100000 units per milliliter (ml) suspension (antifungal). All medications were removed from the resident's bedside pending further assessment. LPN #2 said if a resident was able to self administer medications they would have a locked box in their room to keep medications safe from other residents who should not have access the medicions LPN #2 said the facility nursing needed to complete an evaluation to determine if the resident was able to administer medication independently. LPN #2 said there were not any residents in the 200 hall that were able to self administer medications and no residents should have medications in their rooms to self administer without a physician order. LPN #2 reviewed Resident #86's medication list on 8/10/23 at 4:20 p.m. LPN #2 said that Resident #86 only had orders for three of the six medications (see record review below) removed from Resident #86's room. LPN#2 did not say the physician would be notified about self administration of medications of medications nor if the physician would be informed of the medications Resident #86 was taken without physician orders. 4. Record review Review of Resident #86 electronic medical records revealed there was no physician order for self administration of medications. Review of Resident #86's medical record failed to reveal if the resident had been assessed for self administration of medications. The August 2023 CPO documented the following orders: Triamcinolone acetonide 1 percent cream; Flonase nasal suspension 50 mcg/act; and, Peridex solution 0.12 percent. -There were no orders for lidocaine 5 percent prilocaine 2.5 percent cream, diclofenac sodium 1 percent cream, and the Nystatin 100000 units/ml suspension. 5. Other staff interview The director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said in order for a resident to self administer medications they would need to be assessed to ensure that they were cognitively able to safely administer the medications, have physician approval/orders, and a lock box would be provided for the residents room to safely store the medications away form the reach of other residents not approved ot have access to the medications. The DON said even if the resident was assessed to have the ability to self administer a medication the nurses would still need to monitor medication to ensure they were taken properly. The DON said there was a risk a resident would take too much or too little and residents who wander to encounter medication if not secured appropriately. 6. Facility follow up A health status note dated 8/10/23 at 5:34 p.m. documented the resident willingly turned over her medications to the nurse as she could not self administer her medications due to the lack of a safe place to store them. 47151 C. Resident #23 1. Resident status Resident #23, age 75, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included dementia, anxiety, chronic respiratory failure, and mild intermittent asthma. The 7/19/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required extensive assistance from one person for bed mobility, locomotion on and off the unit, dressing, toilet use, personal hygiene, bathing, and needed supervision and one person assistance for eating. 2. Observations and resident interview Resident #23 was interviewed on 8/9/23 at 12:05 p.m. A bottle of vitamin B12 gummies that was one-third full was observed unsecured on a bedside table next to Resident #23's bed. Resident #23 said the B12 vitamins were hers. She said other residents wandered into her room and items were picked up from her bedside table. Resident #23 said she kept candy bars on her table and thought it was possible some candy bars were missing and taken by a resident who frequently wandered into her room and picked things up without permission. Resident #23 was interviewed on 8/17/23 at 10:00 a.m. The B12 vitamins were observed unsecured on Resident #23's bedside table. Resident #23 said her daughter brought the vitamin B12 gummies in and she might not take them anymore after she finished the vitamins in the bottle. 3. Record review A review of the August 2023 CPO on 8/17/23 at 10:30 a.m. revealed Resident #23 did not have a physician's order for vitamin B12 and there was no record of the resident being assessed to be competent to self-administer any medications including the vitamin B12. 4. Facility follow-up The director of nursing was interviewed on 8/17/23 at 11:30 a.m. She said the vitamin B12 gummies were removed from Resident #23's bedside table. 46851 III. Resident fall A. Facility policy The Fall policy, revised March 2018, was provided by the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, Based on previous evaluation's and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming, external force. An episode, where a resident lost his/her balance, and would have fallen if not for another person, or if he, or she had not caught him/herself is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, the fall is considered to have occurred. If falling reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of nature, or category of falling until falling is reduced or stopped, or until the reason for the continuation of the is identified or unavoidable. The staff will monitor and document each resident response to interventions intended to reduce falling or the risk of falling. If the resident continues to fall, staff will reevaluate the situation, and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. -The policy failed to document steps for a registered nurse to assess a resident for injuries following a fall. B. Resident #151 1. Observations On 8/10/23 at 9:44 a.m. Resident #151 was observed on the floor. The resident was alone in the room barefoot on her hands and knees crawling across the floor in front of the privacy curtain dividing side A from side B. There were no fall mats on the floor. At 9:47 a.m. CNA #1 entered the resident's room and lifted the resident from the floor, by reaching under the resident's arms and lifting her off the floor and assisted the resident to sit on the bed. The CNA assisted the resident to put on non-slip socks with rubber grippers. After doing so the CNA left the resident alone in the room. -None of the nurses on duty provided the resident a post fall exam to assess for injury to include an assessment of mobility or neurological assessment in case the resident hit her head or attempted to determine the cause of the resident coming to be on the floor. At 9:54 a.m. the resident left her room to walk the hallway grabbing items in the common area. The resident was off balance and was unsteady on her feet. Staff did not intervene or provide interventions as care planned. On 8/10/23 at 1:00 p.m. Resident #151 was observed walking down the hall, barefoot without non-slip footwear. A CNA approached and assisted the resident to use the bathroom, but did not assist the resident to put on any non-slip footwear. At 2:45 p.m. the resident continued to walk through the halls without barefoot non-slip footwear on her feet. On 8/14/23 at 8:47 a.m. Resident #151 was observed sitting on her bed. Staff assisted her from her bed to a chair the resident did not have shoes or socks on and staff did not assist her to put on any footwear. At 9:49 a.m. the resident continued to sit in a chair without socks or shoes on. Staff did not go into the residents room or encourage the resident to put footwear on. At 10:18 a.m. the housekeeper mopped the resident room and placed a wet floor sign outside the resident's room. The floor was visibly wet and the resident was in the room sitting in a chair and she was completely bent over falling asleep with her head touching the floor. The resident continued to not have footwear on. At 10:56 a.m. the resident was still sitting on the chair slumped over sleeping in her chair without non-slip footwear. The medication nurse brought the resident her medications. The nurse did not offer to assist the resident to lay down or put on non-slip footwear. At 10:54 a.m. the resident was observed barefoot standing on one foot and scraping the other foot on the door jam; then she started to wander the hallways. The resident gait was off balanced. Two staff members passed the resident but did not offer to help the resident with footwear. At 10:57 a.m. a CNA walked up to the resident while she was wandering the hall and said no socks for you? The CNA kept walking and did not help the resident put on any non-slip socks. The resident did not respond and continued to walk down the hallway. At 11:12 a.m. a CNA walked her into the common area and the resident remained barefoot. At 11:45 a.m. the resident was sitting in the common area near the nurse station without non-slip socks or shoes on. Two unknown staff walked by the resident and did not offer footwear. On 8/14/23 at 3:06 p.m. the resident was observed in the hallway walking with one non-slip sock on and one sock off. An unknown staff member walked by the resident and did not assist the resident to put on appropriate non-slip footwear. 2. Record review According to the 5/29/23 MDS assessment, the residents' balance was not steady, but able to stabilize with human assistance. The assessment documented the resident had not fallen in the prior three months. The resident's comprehensive care plan had a care focus for fall prevention, revised on 5/31/23. The care focus documented the resident was at risk for falling, due to memory loss, and a need for frequent redirection and cueing. Additionally, it documented the resident had impaired balance and safety awareness. Care plan interventions included: Encourage the resident to lay down in her bed when tired. Provide frequent rounding, anticipate resident's needs. Follow fall protocol. Keep the resident bed in the lowest position. Ensure the resident was wearing appropriately fitting footwear and clothing. Provide an environment free of clutter and remind the resident to use the call device light for assistance. A post fall investigation dated 6/24/23 documented the resident had witnessed fall. The resident was sleeping in a chair and slipped out of the chair onto the floor. The investigation documented that the resident had balance problems, and a history of prior falls having had more than three falls in the last 90 days. A post fall investigation dated 7/28/23 documented the resident had an unwitnessed fall and was found on the floor in her room just outside of the bathroom. The investigation documented that the resident had an unsteady gait and had balance problems. -The facility was not able to produce a post all investigation report investigating the unwitnessed fall on 8/10/23 when CNA #1 was observed picking Resident #151 up off the floor in her room (see the DON interview below). 3. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said staff should assume the resident fell if they find them on the floor. LPN #1 said residents who were found on the floor need to be assessed by a registered nurse and put on neurological checks to assess for a potential head injury. LPN#1 said Resident #151 was a fall risk. LPN#1 said interventions were in place and should be followed. LPN #4 said if staff saw the resident sleeping in a chair they should suggest she be laid down in her bed to prevent a fall. CNA #4 was interviewed on 8/16/23 at 10:00 a.m. CNA #4 said when a resident was found on the ground the CNAs should immediately get the nurse so they could assess the resident before moving the resident. CNA #4 said Resident #151 was at risk for falling and she should always have gripped socks or non-slip shoes on. CNA #4 said Resident #151 had a history of slipping out of her chair. The DON was interviewed on 8/16/23 at 11:05 a.m. The DON said staff should assume a resident fell if the staff found the resident on the floor. The DON said if a resident was found on the floor an RN assessment and neurological checks should happen before picking up a resident off of the floor. The DON said staff should follow the interventions put into place to prevent individuals from falling. The DON said the staff did not report that Resident #151 had a fall on 8/10/23. The DON said Resident #151 did slip out of her chair when she was tired and if that happened the staff should have helped the resident to her bed before she fell . If staff found Resident #151 sleeping in a chair staff should offer to assist her to lay down for a nap. The resident's bed should always be in the low position with a fall mattress on the floor next to her bed. The DON said the facility did not have a post fall investigation for the resident falling on 8/10/23.

Based on observations and interviews the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for two of three medications carts reviewed for storage and labeling. Specifically the facility failed to: -Ensure Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; and, -Ensure medication carts were maintained clean and free of loose pills. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, revised February 2023, received from the nursing home administrator (NHA) on 8/11/23 at 4:34 p.m. It revealed in pertinent part Nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Multi-dose vials that have been opened or accessed needle puncture were dated and discarded within 28 days. Medications were stored in an orderly manner in cabinets, drawers, and carts to prevent the possibility of mixing medications of several residents. -Insulin which is used for diabetes is considered a multi-dose vial. II. Observations On 8/10/23 at 1:43 p.m. the 300 hall medication cart was reviewed. One glargine insulin (used to treat abnormal glucose levels) injection pen 100 units/milli litter (ml) with no open date. One open Insulin glargine vial with no open date. Once alerted that the vial was not labeled registered nurse (RN) #1 discarded the insulin vial and injection pen into the sharps container on the medication cart. On 8/10/23 at 1:57 p.m. the 600 hall medication cart was reviewed. One Degludec injection flex touch insulin pen 100 units per ml had no open date. The cart had six whole tablets and five half tables loose in the cart. III. Staff interviews RN #1 was interviewed on 8/10/23 at 1:43 p.m. RN #1 said the vial and insulin pen had no open dates and they need to be dated when they were opened to ensure they were not used past the one month window as they could not be as efficient in the residents management of diabetes. RN #1 said she put the medications into the sharps container to dispose of them in order to make sure it was not used. RN #2 was interviewed on 8/10/23 at 1:57 p.m. RN #2 said the insulin pen did not have an open date and needed to have one since it needs to be used within 30 days of being opened. RN #2 said she was unsure by who or when the medication carts were cleaned and medications should not be loose in the medication cart. RN #2 did not know how to dispose of the insulin pen and left it in the cart to call the assistant director of nursing (ADON) for further directions. The ADON was interviewed on 8/10/23 at 2:27 p.m. The ADON said the insulin pen did not have an open date and pens were only good for 30 days once opened/accessed. The ADON said medications that were discontinued or no longer can be used were placed in the medication room in containers for the night shift supervisor to dispose of them in the appropriate containers per pharmacy directions. The director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said insulin pens or vials should be dated with the date of opening to ensure they were not used past the 28 day period of use. The DON said expired medications including insulin were to be placed into the medications room for destruction and never be put into the sharps container due to state regulations. The DON said medications carts were cleaned every night during night shift but they did not have a sign off sheet to ensure the task was completed. The DON said it was important to keep the carts clean and free from debris to prevent contamination and infection control purposes.

Based on record review and observations, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the resident's care plan. Specifically, the facility failed to: -Ensure meals were provided to Resident #103 according to the prescribed diet order; and, -Ensure three residents had food prepared according to their diet orders of mechanical soft-ground texture as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Food and Nutrition Services Staff policy, revised October 2017, was provided by the nursing home administrator (NHA) on 8/17/23 at approximately 3:00 p.m. It read in pertinent part, The food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competencies to carry out functions of the department. The food and nutrition services staff under the supervision of the dietitian and/or food and nutrition services manager will safely and effectively carry out the functions of the food and nutrition services department. The department will maintain staffing levels to meet resident nutrition needs and preferences taking into consideration the acuity and diagnoses of the residents as well as individual assessments and plans of care. Food will be palatable, attractive and served in a timely manager at proper temperatures. Meals and nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident ' s medication requirements. The Therapeutic Diets policy, revised October 2017, was provided by the nursing home administrator (NHA) on 8/17/23 at 2:00 p.m. It read in pertinent part, Therapeutic diets are prescribed by the attending physician to support the resident ' s treatment and plan of care and in accordance with his or her goals and preferences. The diet order should match the terminology used by the food and nutrition services department. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. The dietitian and nursing staff will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. The attending physician may liberalize the diet at the request of the IDT (interdisciplinary team) if the resident is not eating well, or the resident. If the resident or the resident ' s representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives. II, Resident #103 A. Resident status Resident #103, age 84, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, bipolar disorder, dysphagia (difficulty swallowing) and falls. The 8/9/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required extensive assistance from one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and hygiene. She needed supervision and set-up assistance for eating. The MDS assessment documented Resident #103 had coughing or choking during meals or when swallowing medications and she was on a mechanically altered diet. B. Resident interview and observation Resident #103 ' s representative was interviewed on 8/9/23 at 1:58 p.m. The representative said Resident #103 had difficulty swallowing and food that was too dry caused Resident #103 to choke and not eat. The representative said Resident #103 ' s diet texture was not served correctly in the past and her meal was not cut up as small as usual. The representative said she reported her concern to staff who removed Resident #103 ' s meal tray and returned with her food cut smaller. The representative said Resident #103 loved tomato soup and grilled cheese sandwiches. On 8/14/23 at 12:41 p.m., Resident #103 ' s meal tray was observed with a grilled cheese sandwich that was only cut in half with the crusts cut off. Resident #103 ' s meal ticket was observed on her meal tray and documented the texture as mechanical soft-ground. -The grilled cheese recipe for a mechanical soft diet modification was provided by the dietary manager (DM) on 8/14/23 at 8:00 a.m. The recipe documented the mechanical soft-ground modification for a grilled cheese sandwich as, If SLP (speech language pathologist) allows bread, shred the cheese and moisten with condiments. Moisten the bread and cut into pieces no larger than one eighth of an inch. C. Record review A review of Resident #103 ' s August 2023 CPO documented a diet order for a mechanical soft texture diet, ordered on 10/24/22. Resident #103 ' s annual dietary profile dated 8/9/23 documented Resident #103 ' s diet required mechanical soft texture and that Resident #103 enjoyed grilled cheese sandwiches. -Neither the physician ' s diet order or annual dietary profile documented if the ordered mechanical soft texture diet was supposed to be mechanical soft-ground or mechanical soft-chopped. II. Mechanical soft food preparation A. Meal service observation, record review and staff interview Meal service was observed on 8/14/23 from 11:00 a.m. to 1:24 p.m. The posted menu documented the lunch meal as apple curry chicken, parmesan potatoes, green beans, apple crisp and dinner roll. Two pans of one-half inch size diced chicken pieces were observed in the hot food holding/steam table. Cook (CK) #2 said the two pans of one-half inch diced chicken were prepared for the residents who were prescribed mechanical soft textures diets. -According to the dietary manual (see below) the mechanic chopped and mechanical soft ground were two different consistencies but the facility had one consistency of diced chicken to serve residents on both textured diets. There was no differentiation consideration given to the resident on chopped versus a ground textured consistency. -The recipes for the 8/14/23 lunch meal were provided by the dietary manager (DM) on 8/14/23 at 8:00 a.m., The recipes documented mechanical soft-ground and mechanical soft-chopped textures were offered; the recipe modification for apple curry chicken for mechanical soft-chopped was specified as one-half in size diced chicken as observed in the steam table; the recipe modification for mechanical soft-ground texture was specified as diced to one-eight of an inch and was not observed in the steam table prior to meal service starting. -At 12:16 p.m., a resident ' s lunch plate was assembled by CK#2 with one half inch diced chicken. The meal ticket on the tray documented a mechanical soft-ground texture. The meat was not chopped to the one-eight inch size as was the instruction on the recipe modification for a mechanical soft-ground texture. The DM said the mechanically altered chicken on the plate was the incorrect size for a mechanical soft-ground texture, which the resident for whom the meal was prepared for was prescribed. Once alerted to the concern the DM asked CK#2 to stop plate assembly and then asked an unidentified dietary staff member to remove a pan of the one-half inch diced chicken from the steam table and grind it smaller for a mechanically soft-ground textured diet. The dietary staff member ground the chicken to the appropriate size of one-eighth inch and placed the pan in the steam table. The DM was interviewed on 8/14/23 at 12:17 p.m. The DM said the mechanical soft-ground chicken should have been diced smaller than the one-half inch size chicken pieces that were observed in the steam table CK #2 was interviewed on 8/14/23 at 12:19 p.m. CK #2 said she thought the one-half inch diced chicken was fine to be served as bite size and told the DM she was sorry for the error. -At 12:23 p.m. a clear plastic dessert dish of apple crisp contained apples sliced one inch in length and was placed on a resident ' s meal tray. The meal ticket on the tray documented that the resident was on a mechanical soft-ground texture. The meal tray was placed in the serving window. DA #1 and the DM were alerted that the size of the apples in the apple crisp was incorrect for the residents on a mechanical soft-ground texture. -At 12:24 p.m. the DM asked staff to stop assembling meal trays and she removed the apple crisp from the meal tray in the serving window. -At 12:26 p.m. CK #2 said she grabbed the wrong apple crisp and placed it on the trays of the residents on a mechanical soft ground diet by mistake. The recipes provided by the DM documented both mechanical soft-chopped and mechanical soft-ground apple crisp were offered; the recipe modification for mechanical soft-chopped apple crisp was apples diced to one-half of an inch; the recipe modification for mechanical soft-ground apple crisp was apples diced to one-eight of an inch The DM was interviewed at 12:27 p.m. The DM said the mechanical soft dessert modifications for ground or chopped diet textures had not been prepared for the lunch meal; only the puree and regular texture desserts were prepared. The DM told the cook the apples should have been chopped for the dessert. The DM stopped meal assembly and asked dietary staff to modify the apple crisp to the size listed in the recipe. B Other record review The facility ' s diet manual dated 2022 was provided by the nursing home administrator (NHA) on 8/14/23 at 8:00 a.m. The diet manual documented the mechanical soft-chopped consistency as meats and other foods diced to one-half of an inch and the mechanical soft-ground consistency as meats and other foods diced to one-eighth of an inch. III. Other staff interviews The speech language pathologist (SLP) was interviewed on 8/16/23 at 8:30 a.m. The SLP said that she performed a comprehensive assessment of a resident including their plan of care before she upgraded food items listed as restricted on a modified texture diet. The SLP said she had not assessed Resident #103; however Resident #103 was scheduled for a nutrition evaluation per the therapy schedule. The SLP said there was a risk assessment and education provided to a resident regarding the risks of choking associated with consuming food items not part of the resident ' s prescribed diet order. The DM and NHA were interviewed on 8/15/23 at 2:30 p.m. The DM said the mechanical soft textures offered were ground and chopped and staff should have followed the recipes to modify textures correctly. The DM said the facility started a new menu program in May 2023 and the texture modifications were on individual recipes whereas a spreadsheet of modifications was used in the previous menu program. The DM said the dietary department tried to adjust to the new menu program quickly and use new menu program recipes for staff education, but did not use the diet manual. The DM said due to time constraints sliced bread was used at lunch on 8/14/23 instead of dinner rolls, and was supposed to be moistened for mechanical soft texture modification. Resident #23 was able to have a grilled cheese sandwich because the crust was cut off the sandwich; however, the DM could not verify the bread was moistened. The DM said the dietary staff did remove the one-half inch size diced chicken from the steam table and ground the chicken to a smaller size. She said the one-half inch sized chicken in the steam table was a product she ordered that was pre-cooked and pre-cut to one-half inch in size. The NHA said the facility should have done more staff education on the new menu program when it was implemented and the education that was done was not enough. The NHA said if a resident requested a menu item that was restricted on their diet, the facility staff would educate the resident the first time the request was made and then provide the menu item to the resident as it was the resident ' s right. -Education for Resident #103 regarding consumption of menu items listed as not allowed on her modified texture diet was requested and not provided. The DM was interviewed on 8/17/23 at 9:17 a.m. The DM said a paper diet communication form was provided for each resident with a diet change and upon admission. The facility kept the paper diet order for 30 days and then the document was destroyed. The DM said she clarified a diet order if she received written diet communication that said mechanical soft and did not include ground or chopped. F. Facility follow up On 8/16/23 at 10: 30 a.m. the regional clinical support (RCS) provided a Liberalized Diets for Older Adults policy. She said she contacted the facility ' s corporate dining support team and they said the facility followed the liberalized diet orders listed on the policy. The policy read in pertinent part, Soft, dental soft, dysphagia (difficulty swallowing) mechanical soft may not be liberalized unless any improvement in chewing or swallowing was approved by the speech therapist.

Based on observations and staff interviews, the facility failed to ensure that residents were provided privacy during personal care for one (#151) resident out of 56 sample residents. Specifically, the facility failed to provide Resident #151's personal privacy while using the toilet. Findings include: I. Facility policy The Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, Residents are treated with dignity and respect at all times. Staff promote, maintain and protect resident ' s, privacy, including bodily privacy during assistance with personal care, and during treatment procedures. demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. II. Resident status Resident #151, age 70, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance. According to the 5/29/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for a mental status score of three out of 15. The resident required extensive assistance of one person with toileting, bed mobility, dressing, transferring and personal hygiene. III. Observations On 8/10/23 at 1:56 p.m. certified nurse aide (CNA) #1 assisted Resident #151 to her room in order to change her soiled brief and pants leaving the main door open. CNA #1 brought the resident into the bathroom. The CNA did not tell the resident what he was about to do or speak to the resident while providing care during the entire care procedure. CNA #1 helped Resident #151 pulled down her pants and sat the resident on the toilet. When the resident was done going to the bathroom the staff cleaned her peri area. The resident was naked from the waist down and exposed to anyone walking by her room. Two unknown staff members walked by and did not offer to close the door. CNA#1 left the bathroom door and the door to the hall open so anyone walking by had a clear view into the resident ' s bathroom; the resident sitting on the toilet and the peri care that was being provided could be viewed. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said when staff assisted residents with toileting or incontinent care the staff should always shut the door or pull a curtain to maintain privacy for a resident. LPN #1 said they should do this regardless of cognitive functioning. The director of nursing (DON) was interviewed on 8/16/23 at 11:03 a.m. The DON said staff should always close the door or use curtains when helping a resident toilet, changing them or while performing incontinent care. The DON said it did not matter the cognitive functioning of the resident, the staff should still provide privacy for the resident. The DON said when staff did not provide the resident with privacy, staff were not treating the resident with dignity of respect. V. Facility follow-up The DON provided additional documentation that facility staff had been provided an inservice on 8/16/23 at 3:09 p.m. to provide all residents privacy while using the toilet.

Based on observations, interviews and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#101 and #111) of two residents reviewed for catheter care of 56 sample residents. Specifically, the facility failed to: -Ensure Resident #101's catheter bag was positioned below the bladder; and. -Ensure Resident #111's physician orders were followed. Findings include: I. Facility policy and procedure The Catheter policy, revised in August 2022, was provided by the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, The purpose of this procedure is to prevent urinary catheter - associated complications, including urinary tract infections. Review the residents care plan to assess for any special needs of the resident. Catheter evaluation: review and document the clinical indications for catheter use prior to inserting. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use. Remove the catheter as soon as it is no longer needed. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. If the catheter material contributes to obstruction, notify the physician and change the catheter, if instructed to do so. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstructions. Change catheter and drainage bags based on clinical indication, such as infection, obstruction, or when the closed system is compromised. Residents who form encrustations that can quickly lead to an obstruction need more frequent catheter changes at intervals specific to the individual resident. The catheter should be changed before blockage is likely to occur. II. Resident #101 A. Resident status Resident #101, age 68, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included Parkinson's, neuromuscular dysfunction of the bladder and anxiety disorder. According to the 6/30/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. She required extensive assistance of one person with toileting, bed mobility, dressing, transferring, locomotion eating and personal hygiene. The resident had an indwelling catheter. B. Observations On 8/9/23 at 12:20 p.m. the resident was in the bathroom emptying her own catheter. An unidentified certified nurse aide (CNA) went into the bathroom to help the resident with her catheter. After assisting the resident with emptying the catheter, the CNA took the bag and stuffed it behind the resident's back so the catheter bag was resting on the resident's seat and was between the wheelchair and the resident's back which was above her bladder Observations 8/14/23 -At 10:30 a.m. the resident's catheter was placed on the resident's seat behind her back between the resident and the back of the chair. CNA #5 interacted with the resident, however, did not move the catheter below her bladder. -At 12:36 p.m. the resident went to the bathroom. CNA #5 said she put the catheter on the resident's seat behind her due to her messing with the catheter bag. CNA #5 put the catheter bag on the wheelchair behind her so the resident was leaning against the catheter. -At 3:16 p.m. the resident's catheter remained in the same position placed on the resident's seat between her and the back of the seat. The resident was in a common area and several staff walked by her and no staff attempted to lower the catheter bag to below her bladder. C. Record review According to the August 2023 CPO the resident had a Foley catheter since 1/66/22 with the associated diagnosis of neuromuscular dysfunction of the bladder. According to the catheter care plan revised 6/7/23 documented the resident had a catheter. The resident perseverates over the Foley bag. Staff should implement the following interventions: Staff should reassure the resident the Foley bag was emptied. The resident needed to be reminded to not pull on the Foley tubing. Staff should check tubing for kinks. Nurse should provide catheter care as ordered. D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said catheter bags should be covered and placed under the wheelchair. LPN #1 said the catheter needed to be placed below the bladder to prevent blockage which could cause a urinary tract infection (UTI). LPN #1 said that Resident #101 would put the catheter bag on her seat behind her so the bag was between the resident and the back of the wheelchair. LPN #1 said staff should redirect the resident and encourage the resident to place the catheter under her chair. CNA #4 was interviewed on 8/16/23 at 10:00 a.m. CNA #4 said catheter bags should be covered and placed under the wheelchair. CNA #4 said the catheter needs to be placed below the bladder to prevent blockage which could cause a UTI. CNA #4 said the resident liked to empty the catheter without help. CNA #4 said staff should place the catheter bag under the resident's wheelchair. The director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said the Foley catheter bag needed to be placed below the bladder. The DON said if the bag was placed above the bladder it could cause the urine to go back into the bladder and could cause a urinary tract infection. The DON said because of behavioral issues Resident #101 was concerned about her Foley bag. The DON said staff should redirect and attempt to put Resident #101's Foley bag below her bladder. The DON said the refusal to keep the catheter bag below the bladder should be careplanned due to the risks. III. Resident #111 A. Resident status Resident #111, age 74, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included obstructive and reflux uropathy (obstructed urinary flow), benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms and chronic respiratory failure. According to the 6/30/23 MDS assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. He required extensive assistance of one person with toileting, bed mobility, dressing, locomotion eating and personal hygiene. He required extensive assistance of two people with transfers. The resident has an indwelling catheter. B. Resident interview and observations Resident #111 was interviewed on 8/9/23 at 3:37 p.m. the resident was in bed and had a green chux (a protective pad) bunched up around his waist. The resident said his catheter had been leaking on and off for months. The resident said the chux was there to catch the urine and he was wearing a brief because it leaked so bad. The resident said the leaking stopped after the catheter was flushed but the catheter had started to leak continuously again for three or four days. Resident #111 was interviewed on 8/16/23 at 3:38 p.m. The resident had a brief on and said his catheter continued to leak. He said he did not get daily flushes. He said the nurses might flush his catheter once a month. He said when they flush the catheter it no longer leaked. He said he had to ask nurse staff to flush his catheter otherwise the staff would not do it. He said he did not understand why he had a catheter if he had to continue to wear a brief. He said he worried about developing wounds because of urinating and sitting in a wet brief. C. Record review The catheter care plan revised 4/13/23 identified the resident had a catheter. Pertinent interventions included: observe and report signs of infection provide catheter care twice per shit and as needed, position catheter bag below level of bladder and encourage fluids. The August 2023 CPO documented catheter care according to protocol should be done daily. Staff should document output daily. Change Foley bag and tubing every Sunday. The June 2023 medication administration record (MAR) and treatment administration record (TAR) had no documentation of changing the Foley bag and tubing every Sunday. The July 2023 MAR and TAR there was no documentation of changing the Foley bag and tubing every Sunday. The August 2023 MAR and TAR there was no documentation of changing the Foley bag and tubing every Sunday. According to the progress notes: The 6/17/23 progress note documented the nurse changed Foley catheter. The 7/1/23 progress note documented the nurse flushed the catheter with normal saline so urine can drain from the bladder. The 7/19/23 progress note documented the nurse changed Foley as needed for leaking per order. The 5/4/23 urology physician visit documented the resident had urine retention. The order for treatment was the following: -Encourage increased fluid intake; -Daily catheter flushes with normal saline or sterilized water; -Catheter exchanged every two to three weeks; and, -Do not treat UTIs unless the resident was symptomatic. According to 5/5/23 healthcare practitioner notes documented the resident went to a urology appointment recommendations are encouraging increased fluid intake. Daily catheter flushes with normal saline or sterilized water. Catheter exchanged every two to three weeks. Do not treat UTIs unless the patient was symptomatic. -The order for daily catheter flushes were not indicated in the physician's orders. According to the 8/2/23 physician progress note documented the facility needs to follow up with 5/3/23 urology orders. -The medical record failed to show the facility followed up with the urologist. D. Staff interviews LPN#1 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said when a catheter was leaking the nurses notified the physician. LPN #1 said it could be a sign of blockage. LPN# 1 said blockage could cause UTIs. LPN #1 said any orders for the catheter would be in the resident's MAR or TAR. LPN #1 confirmed there was no orders to flush or change Resident #111's catheter as ordered by the urologist. The director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said when a catheter leaked they would likely change the bag. The DON said catheter care orders did not include flushing or changing the catheter. The DON said Resident #111 had an urology appointment because his catheter was leaking. The DON acknowledged the urologist ordered daily flushes and catheter changes every two to three weeks. The DON said the nurse practitioner (NP) got the recommendations from the urologist. The DON said if the NP wanted to follow the orders from the urologist he would have put them in. The DON said the NP sometimes gave verbal orders to the nurses. The DON said it was the NP's responsibility and the NP would let a nurse at the facility know if the NP wanted orders to be put in. -However, according to the practitioner note on 5/5/23 it was documented for the orders to be followed from the urologist (see above).

Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#92 and #411) of four residents reviewed for supplemental oxygen use out of 56 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Residents #92 and #411. Findings include: I. Facility policy The Oxygen Administration policy, revised October 2010, was provided on 8/16/23 at 5:00 p.m. by the director of nursing (DON). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure and review the physician orders or the facility protocol for oxygen administration. II. Resident #92 A. Resident status Resident #92, over age 65, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included chronic diastolic congestive heart failure, generalized anxiety, and depressive disorder. According to the 5/9/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistance for bed mobility, grooming, toileting, and two-person total assistance with transfers. The resident received oxygen therapy. B. Record review The care plan initiated on 2/2/22 and revised on 4/12/23 identified that the resident had an increased risk for a potentially ineffective respiratory pattern. Interventions included oxygen as ordered by the physician. Monitor for signs and symptoms of respiratory distress. The August 2023 CPO included an order dated 2/2/22 for oxygen therapy at four (4) liters per minute (LPM) continuously via nasal cannula every shift. C. Observation On 8/10/23 at 9:27 a.m. Resident #92 was lying down in bed with her oxygen nasal cannula in her nostril. The resident's oxygen concentrator was set to 2 LPM. On 8/14/23 at 2:44 p.m., Resident #92 was sleeping in her bed with her cannula on. The concentrator was set at 2 LPM. On 8/15/23 at 2:15 p.m., Resident #92 was awake in bed with her oxygen cannula in her nostril. The concentrator was set at 2 LPM. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 8/15/23 at 3:15 p.m. LPN #3 said oxygen was considered a medication and needed to be administered according to the physician's orders. The LPN said the resident was receiving oxygen at 2 LPM and then adjusted Resident #92's oxygen to 4 LPM to be given per the physician's order. The LPN said a possible negative outcome of the resident not receiving oxygen therapy at the rate of LPM as per the physician's could be the resident's organs and tissues would not be receiving sufficient oxygenation to keep functioning properly which could be fatal. The director of nursing (DON) was interviewed on 8/16/23 at 1:13 p.m. The DON said oxygen therapy required a physician's order in order to be administered. The DON said Resident #92's oxygen should have been administered as the provider ordered it. The DON said a negative outcome from not following the physician's order could have resulted in respiratory distress for resident #92. III. Resident #411 A. Resident status Resident #411, age 78, was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 CPO, diagnoses included idiopathic epilepsy, seizures, systolic and diastolic congestive heart failure, dementia and Parkinson's disease. According to the 6/6/23 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and total staff assistance with toilet use. The resident received oxygen therapy. B. Record review The care plan initiated on 8/13/17 and revised on 4/14/21 identified that the resident had the potential and/or actual altered respiratory pattern due to the inability to maintain an effective airway clearance with a history of asthma and Parkinson's with chronic oxygen use. Interventions included monitoring for increased anxiety and restlessness. Monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. Administer oxygen via nasal prongs as per the physician's order. The August 2023 CPO included an order dated 3/18/18 for oxygen therapy at 3 LPM to be delivered continuously via nasal cannula every shift, for shortness of breath. C. Observation and interview On 8/9/23 at 10:30 a.m., the resident was observed lying in bed with his oxygen concentrator set to 2 LPM. The oxygen cannula was in his nostril. On 8/10/23 at 12:15 p.m., the resident was observed in the dining room sitting in his wheelchair waiting for his lunch. He was wearing his portable oxygen concentrator which was set at 2 LPM. On 8/14/23 at 3:15 p.m., Resident #411 was sleeping in his bed without his oxygen. The oxygen cannula was wrapped together inside a plastic bag hanging beside the oxygen concentrator. The concentrator was turned off. D. Staff interview Certified nurse aide (CNA) #3 was interviewed on 8/15/23 at 1:09 p.m. CNA #3 said Resident #411 used oxygen continuously. The CNA said the resident received oxygen at a rate of 2 LPM. LPN #3 was interviewed on 8/15/23 at 3:20 p.m. LPN #3 said Resident #411 was not receiving oxygen as the concentrator was turned off, but should have been. The LPN said Resident #411 required continuous oxygen at 2 LPM. The LPN said the resident could suffer medical emergencies due to low oxygenation. -However, LPN #3 was incorrect in saying the resident was supposed to be on 2 LPM of oxygen when the physician's orders were for the resident to receive oxygen therapy at 3 LPM (see physician's orders above) The DON and ADON #1 were interviewed on 8/16/23 at 1:13 p.m. The DON said Resident #411 should have his oxygen on at all times. The DON said the nursing staff should have ensured oxygen orders were followed accordingly for all residents with oxygen orders. The DON said not following the physician's order could result in medical complications for Resident #411. ADON #1 said facility staff were not permitted to titrate a resident's oxygen without consulting with the resident's physician and getting an order to change the oxygen liter flow. If the resident was having respiratory distress or improved oxygenation the nurse could make an immediate and temporary adjustment in the resident's oxygen liter flow based on nursing assessment and nursing judgment; however, the nurse had to make immediate notification to the resident's physician to report the change in the resident's condition and obtain an order to make any long term changes in the resident's oxygen liter flow. Any changes in condition and changes in medication administration for oxygen therapy were to be documented in the resident's record. The DON said she would initiate education for nursing staff on the proper way to administer oxygen therapy and the importance of following the physician's orders for all residents.

Based on record review and resident and staff interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#20) of two residents reviewed for psychosocial well-being out of 56 sample residents. Specifically, the facility failed to coordinate timely mental health services for Resident #20. Findings include: I. Facility policy The Behavioral Health Services policy revised February 2019, was provided by the Nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, The facility will provide residents behavioral health services as needed to attain or maintain the highest, practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person centered approach to care. Residents who exhibit signs of emotional and psychosocial distress receive services and support that address their individual needs and goals for care. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial, adjustment, substance abuse or post-traumatic stress disorder will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavailable. Staff must promote dignity, autonomy, privacy, socialization, and safety, as appropriate for each resident and are trained in ways to support residents in distress. II. Resident #20 A. Resident status Resident #20, age 70, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included Parkinson's disease and dementia and depressive episodes. According to the 7/7/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. He required extensive assistance of one person with toileting, bed mobility, dressing, locomotion, eating, transfers and personal hygiene. Psychology therapy was administered zero days and psychological therapy was administered for at least fifteen minutes in the last seven days. B. Resident interview Resident #20 was interviewed on 8/10/23 at 2:13 p.m. The resident said he wanted to see a therapist/counselor and the facility did not provide him with one. He said he feels paranoid and thinks staff were tricking him, tracking him and keeping him in the facility against his wishes. He said that he needed to talk to someone to help him work through these feelings. C. Record review According to the care plan initiated on 4/11/23 documented the resident meets criteria for a preadmission screening and resident review (PASSAR) II due to schizoaffective disorder and bipolar. Interventions included: The resident will receive appropriate specialized services to attain or maintain their highest practicable psychological, physical, functional, and psychosocial well-being. The resident will be educated on the benefits of counseling. Resident #20 was to be scheduled to receive counseling services. According to the trauma informed care plan revised on 4/10/23 the resident has a history of trauma. Interventions included the following; Behavioral health consults. Explain and collaborate care with the resident. Encourage the resident to express their feelings. According to the PASSAR II evaluation Resident #20 had a diagnosis of major depressive disorder. The treatment included psychiatric case consultation, psychosocial rehabilitation services and individual therapy. According to the 6/12/23 diagnostic assessment the resident's PHQ-9 (depression assessment) score revealed the resident had severe depression with a score of 16 out of 19. Recommendations were individual therapy four times a month with a review on 10/12/23. -A request was made to the facility for therapy notes from 6/12/23 to 8/16/23; the facility was only able to present verification of one subsequent psychiatric visit for consultation on a gradual dose reduction (GDR) assessment related to psychotropic medication taken by the resident, but no actual documented therapy session. According to the 7/28/23 psychiatric GDR assessment the resident was seen for a pharmacy request for gradual drug reduction and not therapy counseling services. -There was no other documentation of individual psychological therapy for Resident #20. Additional documentation was presented by the director of nursing (DON) on 8/17/23 at 12:42 p.m. revealed that the facility called the therapy provider to see why there was a delay in providing Resident #20 with the recommended psychiatric services The community provider told the facility that there was a change in psychologists causing a shortage of available psychologists to provide community services. The newly assigned psychologist had not seen Resident #20 yet. The new assigned psychologist was in the facility on 8/9/23 and was in the building seeing other residents. The psychologist did not go see Resident #20. D. Staff interview The social service assistant (SSA) was interviewed on 8/16/23 at 9:00 a.m. The SSA said when a resident had a PASSAR II recommendations the facility would follow those recommendations. The SSA said the resident had a PASSAR II and was recommended individual therapy four times a month. The SSA said Resident #20 did receive behavioral health services including individual therapy. The SSA said Resident #20 had confusion but he was receiving individual therapy. -The SSA was not able to provide documentation of individual therapy notes. Licensed practical nurse (LPN)#1 was interviewed on 8/16/23 at 9:45 a.m. LPN #4 said Resident #20 was paranoid and thought the nurses were tracking him. LPN #4 said the resident saw a behavioral therapist but did not know how often or where the documentation was. The DON was interviewed on 8/16/23 at 11:00 a.m. The DON said the facility followed all PASSAR II recommendations. The DON said Resident #20 was getting individual therapy four times a month, but the resident refused services. The DON said the documents provided for psychiatric services dated for 6/12/23 and 7/28/23 were the only documents the facility had to show dates of services related to provision of behavioral therapy for Resident #20.

Based on observations, interviews and record review the facility failed to ensure the residents had access to the results of the facility's most recent survey conducted by Federal or State surveyors over the past three years of survey, to include survey findings and any plan of correction, in a place readily accessible to residents, family members and legal representatives of residents. Specifically, the facility failed to make accessible survey results of the previous recertification survey of 6/15/22, and the complaint survey findings for the past three years. Findings include: I. Resident group interview On 8/15/23 at 3:30 p.m., a group interview was conducted with nine (#2, #27, #29, #93, #94, #111, #114, #153 and #359) alert and oriented residents. None of the residents knew the location of the results from previous annual and complaint survey findings. Resident #93 said she did not know she could see the results of past surveys. II. Observations On 8/16/23 at 10:44 a.m. the survey findings book was located at the reception desk on a bookcase. The findings book was missing the previous annual survey findings completed 6/15/22 and all complaint surveys for the past three years 2023, 2022 and 2021. III. Interviews The nursing home administrator (NHA) was interviewed on 8/16/23 at 11:59 a.m. The NHA said he was responsible for updating the survey findings binder. The NHA said that he pulled out the annual survey for 2022 in June or July for his quality assurance performance improvement (QAPI) meeting. The NHA said he only puts the annual survey results into the binder not the complaint survey results. The NHA said he reviewed the survey results with the residents during a resident council meeting.

Based on observations, record review, and interviews, the facility failed to provide a comfortable and homelike environment for residents on three of six halls in the facility. Specifically, the facility failed to ensure that staff provided clean washcloths and hand towels to residents in their rooms on two of six halls. Findings include: I. Facility policy and procedure The facility was unable to provide a policy regarding the provision of clean washcloths and towels for the residents. II. Resident interviews Resident #60 was interviewed on 2/2/23 at 11:03 a.m. Resident #60 said he frequently did not have washcloths or hand towels in his room. He said he often had to ask the staff to bring him some. Resident #72 was interviewed on 2/2/23 at 11:31 a.m. Resident #72 said he did not have hand towels and washcloths in his bathroom very often. III. Observations On 2/2/23, the following double occupancy room observations were made: -At 11:31 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; -At 11:45 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; -At 11:59 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; -At 12:03 p.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; -At 12:07 p.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; and, -At 12:10 p.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom. On 2/7/23, the following double occupancy room observations were made: -At 9:49 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; -At 9:53 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; -At 10:02 a.m., room [ROOM NUMBER] had one hand towel and no washcloths in the bathroom; -At 10:07 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; and, -At 10:10 a.m.; room [ROOM NUMBER] had one washcloth and no hand towels in the bathroom. On 2/9/23, the following double occupancy room observations were made: -At 10:44 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; -At 10:47 a.m., room [ROOM NUMBER] had one washcloth and no hand towels in the bathroom; -At 10:51 a.m., room [ROOM NUMBER] had one hand towel and no washcloths in the bathroom; and, -At 10:55 a.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom. On 2/9/23 at 3:09 p.m., the linen carts on the 300/400 halls were observed to contain a stock of hand towels and washcloths. On 2/9/23 at 3:12 p.m., the linen closet on the 100/200 halls was observed to contain a stock of hand towels and washcloths. On 2/13/23, the following double occupancy room observations were made: -At 12:15 p.m., room [ROOM NUMBER] had one washcloth and no hand towels in the bathroom; -At 12:18 p.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom; and, -At 12:24 p.m., room [ROOM NUMBER] had no hand towels or washcloths in the bathroom. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/9/23 at 3:04 p.m. CNA #1 said the residents were provided with one washcloth and one hand towel which were stocked in the bathrooms by the night shift CNAs. She said the day shift CNAs used the linens when providing morning personal care with the residents. She said the hand towels and washcloths were put in the soiled utility cart when the CNAs were finished providing care. CNA #1 said if the rooms did not have washcloths or hand towels that meant the linens had already been used for the morning care of residents. She said the linens would be stocked again on the night shift, however, she said if a resident needed another towel or washcloth during the day, the resident could ask a CNA to get them. CNA #2 was interviewed on 2/9/23 at 3:11 p.m. CNA #2 said the night shift CNAs were responsible for providing each resident with a hand towel and washcloth. She said if the linens were used for morning care and put in the laundry, the CNAs should go to the linen cart or linen closet and obtain a fresh hand towel and washcloth for the residents to use throughout the day. CNA #3 was interviewed on 2/13/23 at 12:26 p.m. CNA #3 said the CNAs were responsible for stocking hand towels and washcloths in resident bathrooms. She said that was part of the night shift duties, however, she said CNAs on the day shift should replace the linens when they had used them with a resident. CNA #4 was interviewed on 2/13/23 at 12:30 p.m. CNA #4 said the night shift CNAs were responsible for stocking each resident's bathroom with fresh hand towels and washcloths every night. She said the linens should be restocked when needed. The director of nursing (DON) was interviewed on 2/13/23 at 12:35 p.m. The DON said CNAs were responsible for putting washcloths and hand towels in the resident rooms. She said stocking the linens was part of the night shift CNAs routine duties. The DON said every resident in each room should be supplied with one hand towel and one washcloth. She said once the day shift CNAs had used the linens for morning care with the residents, the CNAs put the hand towels and washcloths in the dirty laundry. She said if a resident needed another hand towel or washcloth during the day, CNAs could go and get the supplies out of the linen closet or the linen carts located at the end of each hall. The DON said residents also had paper towel dispensers in their bathrooms if they did not have a hand towel to use.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility failed to provide services and treatment to prevent multiple areas of concern including that resulted in actual harm; abuse prevention, accident prevention, identifying residents who had changes in health conditions so they could receive proper treatment, ensure wound care was provided, and daily provided care such as dressing, toileting, and identify residents who had pain. Cross-reference citations related to resident care that were cited at actual harm: -F600 failure to prevent verbal abuse; -F677 failure to provide dependent residents assistance with activities of daily living (ADLs);. -F684 failure to identify and treat a resident experiencing a change of condition in a resident; -F686 failure to assess and treat a resident's wound; -F689 failure to prevent accident/hazards; and, -F697 failure to manage a resident's pain. Additional cross-reference citations related to resident care for a potential for more than minimal harm: -F695 failure to provide respiratory services; and, -F744 failure to provide residents with dementia the appropriate care and treatment. I. Resident census and conditions According to the 6/9/22 Resident Census and Conditions of Residents report, the resident census was 168. The following care needs were as identified: -140 residents needed assistance of one or two staff with bathing and 28 residents were dependent on staff to complete all bathing tasks. -152 residents needed assistance from one or two staff members for toilet use and six residents were dependent on staff to use the toilet. -158 residents needed assistance from one or two staff members for dressing and six residents were dependent on staff to get dressed. -127 residents needed assistance from one or two staff members for transfers and 32 were dependent on staff to move from surface to surface. -47 residents needed assistance from one or two staff members with eating and five residents were dependent on staff to eat their meals. -168 residents received preventative skin care. -61 residents required special respiratory treatments. -34 residents had behavioral health care needs. II. Resident interviews On 6/8/22 at 2:43 p.m. six interviewable (#36, #133, #89, #127, #85 and #22) residents were interviewed during the resident council meeting. All six residents said the facility failed to provide sufficient nursing staff, which resulted in delayed and/or inadequate care. -The resident group said the facility had increased resident census over the past few months but provided no increase in staffing to keep up with the addition of new residents and their needs. The residents said with more people moving in there needed to be more staff to work to prevent residents from going without care. -The resident group said they were speaking for themselves and other members of the resident council because of short staffing they were not able to get showers when the wanted and needed showering assistance, some did not receive proper assistance getting their teeth brushed, and some missed getting help getting dressed and changed because the facility did not have enough staff to do the work. -The residents group said typically there were two certified nurse aides (CNAs) on a wing, sometimes just one, and with the increased number of residents admitted to the facility there needed to be three CNAs on each wing. -The resident group said over the last five months they had voiced their concerns that the facility needed more nursing staff numerous times with management as well as the corporate office and had got no response. III. Nursing schedule The staffing schedule for 6/6/22 through 6/13/22 was provided by the nursing home administrator (NHA) on 6/13/22 at 12:30 p.m. The staffing schedule revealed the facility had six units each were staffed similarly. The provided schedule showed shortages in the staffing patterns based on the NHA explanation of how staff were to be scheduled per resident census (see NHA interview below). Staffing patterns did not match with the staffing ratio staff per number of residents as the NHA explained (see NHA interview above). The schedule revealed the following staffing ratios: -Each day of the provided schedule was calculated per the NHAs formula for staffing needs. The calculation each day indicated the number of residents (census) multiplied by 3.2 direct care hours for nursing staff. The answer to the equation was then compared to the actual number of hours of direct care staff per day. The results were: -On 5/6/22: resident census 165 multiplied by 3.2 equaled 528 hours needed for direct care staff. The total hours of staffing were 446 hours. The facility was short 82 hours for staffing. -On 5/7/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 418 hours. The facility was short 116.40 hours for staffing. -On 5/8/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 372. The facility was short 162.40 hours for staffing. -On 5/9/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 324. The facility was short 210.40 hours for staffing. -On 5/10/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 316. The facility was short 218.40 hours for staffing. -On 5/11/22: resident census 161 multiplied by 3.2 equaled 515.20 hours needed for direct care staff. The total hours of staffing were 251 hours. The facility was short 264.20 hours for staffing. -On 5/12/22: resident census 163 multiplied by 3.2 equals 521.60 hours needed for direct care staff. The total hours of staffing were 243 hours. The facility was short 278.60 hours for staffing. -On 5/13/22: resident census 170 multiplied by 3.2 equals 544 hours needed for direct care staff. The total hours of staffing were 468 hours. The facility was short 76 hours for staffing. IV. Staff interviews Certified nursing aide (CNA) #6 was interviewed on 6/9/22 at 2:40 p.m. She said she worked the evening shift. She said she had worked several times when there were only two CNAs working on the hallway with 36 residents to care for. She said two CNAs were not enough to meet the activities of daily living (ADL) for the residents. She said the residents did not get the care required because they did not have extra help to meet the ADL needs for all of the residents. She said she only had time to refill the residents' water cups on her floor one time even if the residents needed more. CNA #8 was interviewed on 6/13/22 at 10:59 a.m. She said since there were usually just two CNAs caring for 36 residents. She said the staff had to prioritize ADL care by not doing certain care for the residents. She stated her priority for care was changing and feeding the residents. She said with only two CNAs on a wing some care did not happen like taking out the residents trash and giving showers to the residents. She said a CNA could not do everything for the residents that were needed or wanted on a shift because there were not enough staff to do everything. The director of nursing (DON) was interviewed on 6/7/22 at 11:35 a.m. She said she had been the DON for only five days.The DON said currently the facility had 168 residents. She said she did not have an answer as to how to increase staff with 47 residents being admitted in the last two months. She said she would need to speak with the nursing home administrator (NHA) to get an answer as to how the facility would adjust to increase staff with the increase of residents they were accepting. Licensed practical nurse (LPN) #3 was interviewed on 6/7/22 at 3:56 p.m. She said it was always a challenge with there being enough nursing staff on the floor to help the residents, and nursing staff were usually short staffed on the weekends. LPN #3 said that only one CNA worked on each wing for the weekends. She said residents needed to wait for things and to be cared for by the staff because there was not enough staff to help. She said on the weekends residents were not getting out of bed. She said she felt there was not enough staff to meet the needs of all the residents. She said she would then help a CNA to provide resident care. She said she could not always answer the resident's call lights in a timely manner, or get the residents out of bed. She said residents often did not get showers. She said the unit did not get what was called a float CNA, meaning they went wherever they were needed. She said she had never had a float CNA to help her. She said the nursing staff was told the facility was no longer allowed by the corporation to use agency nursing and CNAs because it cost too much money. She said only recently had the facility tried to schedule a second CNA on wings to help but two CNAs were not always available on each wing. The nursing home administrator (NHA) was interviewed on 6/7/22 at 4:50 p.m. He said according to the company that owned the facility he was to staff the facility according to a mathematical formula. He said the formula used was to take the total number of residents admitted in the facility (census) and multiply that number by 3.2 hours. He said 3.2 hours was what was projected that each resident in the facility needed for direct care by nursing. He said the census multiplied by 3.2 hours provided the number of hours required to staff the facility each day. He said according to the 4/2/22 facility assessment the census on average were 110-121 residents in the facility. He said the facility had increased in new admissions over the last five months. He said not all residents required 3.2 hours per day. He said the rehabilitation unit required more staffing for those residents.He said he looked at what residents needed mechanical lifts for their nursing care and he looked at the residents' acuity needs. He said he also calculated the staffing ratio based upon the MDS (resident's minimum data set assessment). He said he also calculated staffing hours based upon the facility numbers in the [NAME] Reports (Certification and Survey Provider Enhanced Reports). He said he used both of the reports to evaluate triggers to indicate specific needs of residents. He said the formula his company used to calculate resident to staffing hours needed daily were: He said he scheduled the staffing needs of the facility with that formula because it made scheduling easier. He said family members always want more with staffing than the facility could provide the residents. He said he knew when the facility was short staffed because falls had increased and the residents who had skin breakdown. He said he discussed staffing needs during his quality assurance meetings. -However, according to the resident census and condition the facility had 168 residents with high acuity needs: 158 residents required staff assistance with toileting, 164 residents required assistance with dressing, 168 residents required staff assistance with bathing and 159 residents required staff assistance for transfers. The staffing coordinator (SC) was interviewed via the phone on 6/15/22 at 11:00 a.m. She said she planned the schedule the month prior so that the day and evening shift would have one nurse and three CNAs on each of the six wings. She said the night shift had one nurse and two CNAs on each wing. She said if there were further staffing needs she communicated with the NHA and the DON to get approval for additional staffing based on resident care needs. She said agency staff had been difficult to utilize because they often did not show up to work. She said she would then send out a text to the facility staff or call the facility staff to help fill any missed positions.

Based on record review and interviews, the facility failed to protect one (#70) of four residents out of 64 sample residents from abuse by Resident #120. On 6/2/22, Resident #120 verbally abused and threatened his roommate, Resident #70, with physical harm, stating he was going to kill someone. Record review and interview revealed the facility failed to protect Resident #70 from further abuse. Specifically, aware of the abuse, the facility failed to immediately separate the residents even though, per staff, Resident #120 was throwing items, calling names, and slamming doors. Further, there was no documentation Resident #120's behaviors and Resident #70's safety were monitored prior to Resident #120's transfer to the hospital later that evening. Resident #70 reported that until Resident #120 was transferred, he feared for his safety, afraid to close his eyes and go to bed. Cross-reference F609 failure to identify and report abuse. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation Prevention Program policy, revised September 2019, was provided by the director of nursing (DON) on 6/15/22 at 11:30 a.m. It revealed in pertinent part: The purpose of this program is to provide a mechanism for the prompt identification, investigation, and reporting of any allegation or complaint of abuse, neglect, or exploitation, and to educate staff about state and federal regulation regarding reporting suspected abuse, neglect, and /or exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, resulting in physical harm, pain, or mental anguish. This includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Verbal abuse is oral, written, or gestures language towards residents to include threats of harm or saying things to frighten a resident. Mental abuse is humiliation, harassment, threats, deprivation, or other actions that result in mental anguish experienced by a resident. The policy guidelines read in pertinent part: Every resident has the right to be free from verbal, sexual, physical, and mental abuse. Each community takes reasonable, appropriate steps to ensure that each resident is free from abuse, neglect, and exploitation by anyone including but not limited to staff and other residents. Prompt, thorough investigations are conducted in response to complaints or allegations of abuse, neglect, and/or exploitation, and all proper notifications are made to the proper individuals and authorities according to state and federal regulations. The administrator is responsible for the oversight and implementation of the abuse, neglect, and exploitation prohibition and prevention program. II. Resident #70 A. Resident status Resident #70, age 68, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/19/22 significant change minimum data set (MDS) assessment revealed the resident had intact cognitive function with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required one person assistance with activities of daily living and used a wheelchair for mobility. The resident did not have any care areas related to behaviors or mood disorders. Review of the resident's clinical record revealed there was no documentation related to a resident to resident altercation on 6/2/22. B. Resident interview Resident #70 was interviewed on 6/6/22 at 11:18 a.m. He said he had a new roommate a week ago that did not work out and the roommate had been sent to the hospital for psychiatric concerns. He said his roommate (Resident #120) moved in and wanted the window bed. He said Resident #120 asked him to switch beds and said he would pay him $50.00 for the window bed. Resident #70 said he felt pressured to say yes, and then changed his mind when the floor nurse told him he did not need to agree to move from the window bed. He said when he told Resident #120 that he did not want to move, Resident #120 became very upset and told him he was going to kill someone, but then Resident #120 said he was just kidding. Resident #70 said he did not feel safe and did not think Resident #120 was kidding so he did not want to close his eyes and go to bed that night until Resident #120 was removed from the room and sent to the hospital. He said he was afraid. He said he told the social services director (SSD) that he did not want Resident #120 back as a roommate and told the SSD he would move out if they put the resident back in his room. III. Resident #120 A. Resident status Resident #120, age 68, was admitted on [DATE]. According to the June 2022 CPO, the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/12/22 admission MDS assessment revealed the resident had intact cognitive function with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required one person assistance with activities of daily living and used a walker for mobility. His care areas identified were for mood, psychosocial well being, psychotropics and pain management. B. Record review The 5/15/22 care plan revealed Resident #120 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He verbalized feelings of distress with a history of paranoia and delusions. His goal was to improve his sleep patterns and lessen the daily thoughts of delusions and distress. The interventions in place included redirection for inappropriate social behaviors, observing signs and symptoms for [CONDITION(S)] and mood changes and educating the staff regarding treatment and maintenance regarding medications and behaviors. Review of Resident #120's nurses progress note dated 6/2/22 at 5:04 p.m. revealed the resident was rude and disrespectful towards his roommate (Resident #70), throwing stuff, calling names, and slamming doors. Nurse notified social services and social services was involved. Resident continued showing aggressive behaviors towards his roommate and the nurse on duty offered to send him to the emergency room for further evaluation, however, the resident refused. Physician assistant (PA) was contacted for further evaluation. Review of Resident #120's record revealed there was no documentation Resident #120 behaviors were monitored after he refused a transfer to the hospital and until he agreed to the transfer later that evening. IV. Staff interviews Interviews revealed staff failed to recognize and protect Resident #70 from further abuse by Resident #120. A. The SSD was interviewed on 6/8/22 at 11:19 a.m. He said he was aware of the resident to resident incident that occurred on 6/2/22. He said he met with both residents on that day; however, he did not document his communication in either resident's clinical record. He said he had a soft copy of notes in his office related to the incident and would enter a late entry for both residents regarding the incident. He said he understood Resident #120 became verbally aggressive towards his roommate (Resident #70) and said Resident #120 declined to go to the emergency room during the afternoon. He said the residents were not separated and continued to be in the room together until later that evening when Resident #120 eventually agreed to go to the emergency room to be evaluated for his hallucinations and aggressive behaviors. He said Resident #70 felt threatened and was relieved when Resident #120 left the room. He said Resident #70 requested not to have him back as his roommate. The SSD said he did not report the incident as abuse to the State Agency (cross-reference F609). However, he agreed, based on the verbal aggression and the fear reported by Resident #70, it should have been reported as abuse. B. The registered nurse unit manager (RN #4) was interviewed on 6/15/22 at 10:00 a.m. He said he was working on 6/2/22 and wrote a progress note in Resident #120 ' s clinical record. He said Resident #120 became very upset and verbally aggressive towards his roommate and was throwing things in his room. He said Resident #120 moved in with Resident #70 that day and thought he would have the window bed. He said Resident #120 became very upset and verbally aggressive towards his roommate because Resident #70 did not want to move from the window to the door bed. He said he asked the SSD to meet with Resident #120 to calm him down, but he did not separate the two residents or have Resident #120 move out of the room. He said he suggested Resident #120 should go to the emergency room , however, the resident declined to leave. He said he had his PA assess him and she made a change in his medications to assist him with his hallucinations and aggression. He said he did not write a progress note in Resident #70's clinical record because he was not the aggressor. He said he notified the SSD and Resident #120's PA but he did not report it to the nursing home administrator (NHA) because there was no physical abuse. When asked further about not reporting the incident to the NHA, RN #4 said he did not take into consideration the verbal abuse that occurred until now. C. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 6/14/22 at 3:09 p.m. They said RN #4 wrote a note on 6/2/22 in Resident #120's record regarding the resident to resident incident. They acknowledged Resident #120 was verbally abusive towards Resident #70 based on the nurse's documentation. They said that residents had the right to be free from abuse and, based on the nurse's progress note and Resident #70's interview, the incident should have been investigated and reported to the state as an occurrence. The DON said she was notified by RN #4 that Resident #120 was upset and verbally aggressive and had social services meet with him. She said if she had known Resident #70 felt threatened and unsafe, she would have removed Resident #120 immediately and reported the incident as abuse. She said because there was no physical harm to Resident #70, she did not think it was abuse. She agreed now, however, that verbal abuse was abuse.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for six (#266, #56, #61, #147, #6 and #119) of eleven residents reviewed for ADL care assistance out of 64 sample residents. Resident #266 was newly admitted to the facility after a medical setback, on 6/1/22, for skilled nursing services including occupational and physical therapy services. The resident goal was to restore as much independence and physical function as possible. The resident required extensive assistance from staff with most of her ADLs. The resident expressed not getting out of bed, not having a wheelchair for mobility and not bathing since her admission on 6/1/22. The resident felt uncomfortable, itchy and dirty due to not being bathed and felt lonely and isolated with not getting out of bed. Due to the lack of getting out of her room to move her muscles and not being provided bathing, she felt more depressed and she would lose her independence. Resident #56, who required extensive assistance from staff for toileting, expressed anger and anxiety for the feeling she developed when staff were not able to provide timely ADL care assistance. On 6/6/22 the resident had to wait over an hour for the staff to assist her with incontinence care and expressed she did not like sitting in a soiled brief for long periods of time.When able to use the bathroom, she relied on a bed pan, due to the long waits for staff assistance it would cause her pain from sitting on the bed pan for long periods of time. In addition, the facility failed to: -Ensure dependent Residents #61, #147, #6 and #119 received regular bathing in accordance with their assessed care needs; -Ensure dependent Residents #61, #147 and #6 received timely toileting assistance in accordance with their assessed care needs; -Ensure dependent Residents #61, #147 and #6 received positioning assistance in accordance with their assessed care needs; -Ensure Residents #147 and #6 was assisted to get dressed and out of bed; and, -Ensure Resident #61 was assisted with drinking water needs in accordance with their need for hydration. Cross-reference F725 for insufficient staffing. Findings include: I. Professional reference Potter, P.A., Perry, A.G., et.al. (2017) Fundamental of Nursing (9th ed.), pp. 179, 823, 264, and 841, read in pertinent part, Functional status in older adults include the day to day ADLs involving activities within physical, psychological, cognitive, and social domains. A decline in function was often linked to illness or disease and is its degree of chronicity. However, ultimately it is the complex relationship among all of these areas that influences older adults ' functional abilities and overall well-being. Keep in mind that it may be difficult for older adults to accept the changes that occur in all areas of their lives, which in turn have a profound effect on their functional status. -The fear of becoming dependent is overwhelming for older adults who are experiencing functional decline as a result of aging. When you identify a decline in a patient's function, focus your nursing interventions on maintaining, restoring and maximizing an older adult's functional status to maintain independence while preserving (the resident ' s) dignity. Personal hygiene affects patients ' comfort, safety and wellbeing. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower promotes comfort and relaxation, foster a positive self-image, promote healthy skin and help prevent infection and disease. A person's appearance and feeling of well-being often depends on the way the hair looks and feels. When patients are immobilized their hair soon becomes tangled. -Basic hair and scalp and care includes brushing, calming and shampooing. II. Facility policy and procedure A policy and procedure for providing activities of daily living (ADLs) for dependent residents was requested from the nursing home administrator (NHA) on 6/10/22. The facility provided a policy titled Lifestyles 360 Program Overview, effective date 8/1/18, in response to the request. -The policy was directed towards activities/recreational programming and did not document expectations for providing ADL care (bathing, toileting, dressing, grooming, transfer assistance, bed mobility, and feeding/hydration assistance) type activities for dependent residents. The Care Plans, Comprehensive Person-Centered policy, undated, was provided by the NHA on 6/13/22 at 8:20 a.m. The policy read in pertinent part: A comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. III. Resident #266 A. Resident status Resident #266, age 76, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/8/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident interview for daily preferences indicated it was important to the resident to choose between a tub bath, shower, bed bath or sponge bath; choose bedtime; and be able to go outside to get fresh air when the weather was good. The resident required extensive assistance involving staff providing weight bearing assistance from staff for bed mobility, transfers, toileting, dressing with limited assistance from staff to complete personal hygiene. Bathing services did not occur during the assessment period but it was documented that the resident would need assistance from staff to complete the task. The resident was not steady with standing and balancing and was not able to walk. The resident was always incontinent of both bowel and bladder and was at risk for developing pressure injuries. The resident's mood interview revealed the resident scored a five on the depression scale indicating the resident was experiencing mild depression. The interview revealed the resident was feeling down, depressed or hopeless; was having trouble falling asleep, staying asleep or sleeping too much; was feeling tired or having little energy; and was feeling bad about herself. The resident did not reject care assistance or present with any behavioral symptoms. B. Resident interview and observation Resident #266 was interviewed on 6/8/22 at 3:55 p.m. Resident #266 said she had not been assisted out of bed since admission (6/1/22) and had not been given a shower or even a bed bath. All they do is wipe my private areas when they assist me with brief changes, it's not enough and I need a shower. The resident said she felt uncomfortable, itchy and dirty. Towards the end of the interview, Resident #266 said because she had been stuck in bed and in her room since her admission five days ago, she was lonely and felt isolated. Resident #266 said staff only come in infrequently to provide minimal care and were in and out of the room quickly. Additionally, she said her roommate (Resident #262) who was also dependent on staff to complete ADLs and had cognitive deficits was constantly asking her for help with care and getting in and out of bed. When Resident #266 tried to explain to her roomate, Resident #262 was not able to understand and got mad and distressed. Resident #266 said she called for staff assistance to help Resident #262 but it took time for staff to respond to help Resident #262 because they were short staffed. Resident #266 said she did not have a wheelchair at the facility or clothing and no staff had approached her to discuss plans for being able to get her out of bed and get her into the shower, which was preferred. Resident #266 was observed from 6/6/22 to 6/9/22 and 6/13/22 to 6/14/22 to be lying in bed with matted hair. Resident #266 was interviewed again on 6/13/22 at 3:22 p.m. Resident #266 said she still had not been assisted out of bed and had still had not been provided showering or bathing assistance other than staff cleaning her private area with brief changes. Resident #266 still wanted a shower and was feeling unclean. Resident #266 said she was starting to feel depressed and worried that she would lose more independence if staff did not start getting her out of bed so she could move her muscles, leave the room and get into the shower. C. Record review The 6/1/22 Admission Data Collection with Care Plan documented the resident preferred to get up at 7:00 a.m., take showers twice a week and go to bed at 9:00 p.m. The interim care pan portion of the document read in part: Does the resident have an ADL self-care deficit? Yes. The goal: staff will assist me to maintain my functional status and decrease my risk for functional decline to perform and /or assist with completing my ADLs. Interventions: Discuss with resident care any concerns related to loss of independence, decline in function. The resident's comprehensive care plan initiated 6/2/22 revealed Resident #266 had impaired ability or care for herself and needed staff assistance with ADLs. Interventions included need for limited to extensive assistance with bed mobility, dressing needs, personal hygiene, oral care, toileting and transfers. -There was no detail on how much assistance the resident needed with each task and no mention of personal preferences. -The resident's tasks record for showers, dated 6/14/22, revealed the resident had no record of showers being offered, refused or provided. The director of nursing (DON) was interviewed on 6/14/22 at 12:30 p.m. The DON confirmed the resident record did not have any record of the resident receiving a shower since admission on 6/1/22. The DON said she would talk to the resident and staff and get the resident on a regular showering schedule. IV. Resident #56 A. Resident status Resident #56, age 76, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/7/22 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 12 out of 15. The resident interview for daily preferences indicated it was somewhat important to the resident to choose between a tub bath, shower, bed bath or sponge bath; choose bedtime. The resident required extensive assistance involving staff providing weight bearing assistance from staff for bed mobility, transfers, toileting, dressing with limited assistance from staff to complete personal hygiene. The resident was totally dependent on staff for bathing services. The resident was not able to stand or balance alone and was not able to walk. The resident was always incontinent of bladder, frequently incontinent of bowel and was at risk for developing pressure injuries. The resident's mood interview revealed the resident was feeling bad about herself. The resident did not reject care assistance or present with any behavioral symptoms. B. Resident interview and observation Resident #56 was observed on 6/6/22 from 2:30 p.m. to 4:15 p.m. Resident #56 was in bed she used the call light for staff assistance to get her up and incontinence care at 2:40 p.m. Certified nurse aide (CNA) #15 entered Resident #56's room, talked with Resident #56, turned off the call light and exited the room and went down the hall to help other residents. CNA #15 returned to the nurses desk at 3:38 p.m. CNA #15 was then alerted that a dependent resident across the hall from Resident #56 had a bowel accident and was trying to get up unassisted while using the bedside table as a walking device. CNA #15 responded to that resident. Once CNA #15 finished assisting the resident across the hall from Resident #262, CNA #15 had to respond to Resident #262, who was engaging in unsafe wandering off the unit. The CNA did not return to Resident #56's room during the time of the observation. Resident #56 was interviewed on 6/6/22 at 3:47 p.m. Resident #56 said she had put her call light on to request that staff change her and get her washed up, but that was over an hour ago, because she had gone to the bathroom in her brief and needed assistance getting cleaned up. Resident #56 said CNA #15 responded to the call light but said she would be back to assist with the request to get washed up. Resident #56 expressed anger and said she had been waiting for over an hour for staff to return to check her brief and give her a bed bath, and that CNA #15 had not returned. Resident #56 was interviewed on again on 6/9/22 at 2:21 p.m. Resident #56 said the staff did finally return the other day to get her changed and cleaned up but it was a long wait. Long waits for staff assistance was why she got anxious when she got the urge to go to the bathroom. Resident #56 said she did not like the feeling of having a wet or soiled brief; and she did not like to sit on the bed pan for longer periods of time. The resident said she was sometimes able to know when she had to use the bathroom but it made her very anxious about calling staff for the bedpan because she knew that she would have to sit on the bed pan for long periods of time, which caused her pain. I almost hate to ask staff for the bed pan; just the thought makes me anxious, to think about how long I will have to sit on the bedpan waiting for staff to return to get me off and clean me up. Resident #56 said waiting for staff was a frequent occurrence when the building was short on staff. C. Record review The 3/31/22 Admission Data Collection with Care Plan documented the resident preferences were to take bath twice a week. The resident's comprehensive care plan initiated 4/4/22 revealed Resident #56 had impaired ability or care for herself and needed staff assistance with ADLs. The resident was able to make some needs known and some needs were anticipated and met by staff. Resident #56 preferred to take a shower or a bath Sunday and Wednesday during the night shift. Interventions included need for limited to extensive assistance with bed mobility, dressing needs, personal hygiene, oral care, toileting and transfers. -There was no detail on how much assistance the resident needed with each task; there was no care plan intervention to document how to assist the resident with continent episodes and use of the bedpan. -The resident's shower sheet record documented no showers offered, refused or provided. The resident's shower sheet record, for May 2022 and June 2022, was provided by the DON on 6/14/22. The record for the dates from 5/8/22 to 6/14/22 were reviewed. The shower record documented the resident was not offered consistent bathing assistance on Sunday and Monday night shift. Out of two possible showers a week for the reviewed period, the resident should have had 12 total showers/bathing assistance; the resident was not offered or assisted to bathe on five of those occasions. -The resident showers were missed on 5/8/22, 5/11/22, 5/15/22 5/18/22, 5/22/22 and 6/1/22 when offered a shower on the next day 5/9/22, 5/12/22, 5/16/22, 5/19/22 and 6/2/22 the resident refused three of the five make up shower dates. The record did not document if the facility staff explored the reason for the refusals. -From 5/25/22 through 5/29/22 the resident received no bathing assistance or documented offers for showering assistance and missed two-scheduled shower dates that week with no documented explanation. -From 6/5/22 through 6/12/22 the resident received no bathing assistance or documented offers for showering assistance and missed three-scheduled shower dates that week with no documented explanation. V. Resident #61 A. Resident status Resident #61, age 84, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/15/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance with two people for bed mobility, and total dependence for transfers, locomotion on/off the unit in a wheelchair, bathing, and toilet use. Extensive assistance with one person for dressing, eating, and personal hygiene. She was incontinent of bowel and bladder and at risk for developing pressure injuries. No behaviors or rejection of care. The resident interview for daily preferences, 7/17/21 admission MDS, indicated it was somewhat important to the resident to choose between a tub bath, shower, bed bath or sponge bath; and very important to have family or a close friend involved in discussions about her care. B. Resident observations On 6/13/22 a continuous observation was performed from 9:57 a.m. to 1:09 p.m. -At 9:57 a.m. the resident was in her room in bed. The resident was positioned on her right side, facing the wall. An unidentified certified nurse aide (CNA) went around the unit picking up the breakfast trays. The resident was wearing a hospital gown. There was a plastic cup with water on the resident's dresser, but it was not within reach of the resident. -At 10:13 a.m. the resident was still in bed, in the same position. -At 10:56 a.m. the resident was still in bed, in a gown, in the same position on the right side. -At 11:09 a.m. the resident was still in bed, in the same position, on the right side. -At 11:14 a.m. lunch service started in the dining room on the second floor. -At 11:29 a.m. the resident was still in bed, in the same position on her right side. -At 11:45 a.m. CNA #3 went into the resident's room briefly (less than 10 seconds) and came back out of the room. The resident was still in bed, in the same position on her right side. -At 12:01 p.m. Resident #61's roommate returned to the room in her wheelchair and put on the call light. The roommate requested to be transferred to a bedside chair after her lunch at the dining room. Resident #61 was still in bed, in the same position on her right side facing the wall. Licensed practical nurse (LPN) #5 helped the roommate into a bedside chair and left the room. -At 12:14 p.m. unit manager (UM) #1 brought the wound care cart to Resident #61's door, she said she was providing wound care treatments and Resident #61 was the last resident. She prepared the wound care treatment on a cart. UM #1 went into the room and shut the door. UM #1 was in the room for five minutes. Observed that Resident #61 was still in the same position on her right side following the wound care treatment to her sacrum. -At 12:16 p.m. an unnamed dietary aide brought a drink cart to the end of the hall. -At 12:28 p.m. an unnamed CNA entered Resident #61's room and placed a fall mat on the floor in front of the resident's bed and left. Resident #61 was still in the same position on her right side. -At 12:50 p.m. an unnamed CNA dropped Resident #61's lunch tray off in her room and placed it on the dresser, not within reach of the resident. There was no offer of hydration to the resident. There was one cup of juice on the residents lunch tray. Resident #61 was still in the same position on her right side. -At 1:09 p.m. CNA #17 assisted Resident #61 with eating her lunch, the resident was now sitting up in bed. CNA #17 said that Resident #61 was up in the morning for breakfast and her daughter helped assist her with eating, but the resident vomited, so they put her back to bed. The glass of juice on the tray was not given yet. -During the continuous observation the resident was not encouraged or offered anything to drink for over three hours. In addition, she continued to lay on her right side during the observation and she was identified as being at risk for pressure ulcers/injuries, she was not offered incontinence care during the observation. C. Record review Documentation of activities of daily living (ADL) care for May and June 2022 was provided by the DON on 6/14/22 at 12:45 p.m. it revealed the following: Preferred bath days Wednesday and Saturday. The resident's May 2022 shower sheet record documented two showers on 5/7/22 and 5/18/22 and two bed baths 5/21/22 and 5/25/22. There were no refusals documented. Out of two possible showers a week for May 2022, the resident should have had eight total showers/bathing assistance but only four were offered and completed. The resident's June 2022 (6/1-6/14/22) shower sheet record documented one shower on 6/11/22 and two bed baths on 6/1/22, and 6/8/22. There were no refusals documented. Out of the two possible showers a week from 6/1-6/14/22, the resident should have had four total showers/bathing assistance but only three were offered and completed. The resident's ADL comprehensive care plan, initiated 7/10/21 and revised 4/18/22, revealed impaired mobility and ability to care for herself and dependent assistance with ADLs. The resident's risk for dehydration comprehensive care plan, initiated 7/12/21, and revised 1/17/22, revealed most needs are anticipated and met by staff due to Alzheimer's dementia and memory loss. Interventions included to encourage fluid intake and to offer fluids frequently. The resident's bowel and bladder incontinence comprehensive care plan, initiated 7/10/21, and revised 10/18/21, revealed she has functional incontinence. Interventions include to check on rounds and as required for incontinence. The resident's risk for skin breakdown comprehensive care plan, initiated 7/12/21, revised 10/18/21, revealed she was at risk for skin breakdown and was incontinent. Interventions included pressure relieving bed mattress and wheel chair cushion. -However there was no intervention for re-positioning, changing positions, rotating positions, or pressure relief (other than to offload heels), fluids being offered between meals or frequently, and lack of incontinence rounds. Cross reference F686 pressure ulcers, for the resident acquiring a facility-acquired stage three sacral pressure injury.\ VI. Resident #147 A. Resident status Resident #147, age 86, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/25/22 minimum data set (MDS) assessment revealed the resident with moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required total dependence with two people for physical assistance for transfers. Extensive assistance with one person for bed mobility, locomotion on/off unit in a wheelchair, dressing, toilet use, bathing, and personal hygiene. No behaviors or rejection of care. The resident interview for daily preferences indicated it was not very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath; and very important to keep up with the news. B. Resident observations and interviews On 6/6/22 at 1:35 p.m. the resident was supine in bed, her hair was greasy and not combed. The resident was wearing pajamas. Resident #147 said she has had no shower since her admission (5/18/22) to the facility. She said her preference was a shower at least one time per week. On 6/13/22 at 11:00 a.m. The resident's fingernails were about one fourth of an inch and had brown/yellow matter under her nails and around her fingertips. Resident #147 said she preferred a shower instead of a bed bath. She said a bed bath was ok for in-between showers but that she felt good when she had an actual shower. Resident #147 said she would like to have her hair washed. She said the nursing staff had not taken her to the shower room since she was admitted to the facility. C. Record review Documentation of activities of daily living (ADL) care for May and June 2022 was provided by the DON on 6/14/22 at 12:45 p.m. it revealed the following: Preferred bath days Monday and Friday. The resident's May 2022 shower sheet record documented zero showers in the month of May and three bed baths on 5/19/22, 5/23/22, and 5/30/22. There were no refusals documented. Out of two possible showers a week for May 2022, the resident should have had four total showers/bathing assistance but only three were offered and completed. The resident's June 2022 (6/1-6/14/22) shower sheet record documented zero showers and three bed baths on 6/3/22, 6/10/22, and 6/13/22. There were no refusals documented. Out of two possible showers a week for June 6/1-6/14/22, the resident should have had four total showers/bathing assistance but only three were offered and completed. -However, according to the resident interview she preferred showers two times a week. She was provided with bed baths since her admission on 5/18/22 and not showered as she preferred. The resident's ADL comprehensive care plan, initiated 5/23/22, revealed a need for moderate to extensive assistance with ADLs. Interventions for bathing and showering included, Use short, simple instructions such as hold your washcloth in your hand; put soap on your washcloth; wash your face; to promote independence. VII. Resident #6 A. Resident status Resident #6, age 87, was admitted [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/3/22 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. He required extensive assistance with one person for bed mobility, locomotion on/off the unit in a wheelchair, dressing, toilet use, personal hygiene, and bathing. No behaviors or rejection of care. The resident interview for daily preferences indicated it was somewhat important to the resident to choose between a tub bath, shower, bed bath, or sponge bath; and very important to have family or a close friend involved in discussions about his care. B. Observations and interview Resident #6 was interviewed on 6/6/22 at 10:43 a.m. He said he rarely gets showers. His hair was combed but greasy with large (size of fingernails) white patches and flakes. Resident #6 said he cannot reach his hair to comb it because of his limited shoulder range of motion (ROM) and he was unable to wash his own hair. On 6/7/22 at 11:24 a.m. Resident #6's hair continued to be greasy with large white patches and flakes. On 6/8/22 at 10:25 a.m. Resident #6 said he had received a shower yesterday and the CNA had tried to wash his hair but he did not have any shampoo. He said the facility did have soap for his body but not shampoo. His hair remained greasy with large white patches and flakes. On 6/8/22 at 10:28 a.m. the shower room was toured on unit four and observed that there was a soap dispenser but no shampoo. CNA #18 said most residents have their own shampoo. She said if they did not have their own shampoo they tried to use the soap in the dispenser on the wall. Resident was interviewed again on 6/8/22 at 2:16 p.m. He said his hair did not feel clean since his shower yesterday since they were not able to wash it due to lack of shampoo. On 6/8/22 at 2:19 p.m. the shower room on unit four was toured with UM #1 and UM#1 was unable to locate any facility shampoo. UM #1 said she would find out why shampoo was not provided in the shower. UM #1 said she would notify the unnamed physician assistant who was in the building, to check with Resident #6 to see if he would benefit from a specially medicated shampoo for his dandruff symptoms. C. Record review Documentation of activities of daily living (ADL) care for May and June 2022 was provided by the DON on 6/14/22 at 12:45 p.m. it revealed the following: Preferred bath days Tuesday and Saturday. The resident's May 2022 shower sheet record documented one shower on 5/17/22 and three bed baths on 5/7/22, 5/21/22, and 5/28/22. There were no refusals documented. Out of two possible showers a week for May 2022, the resident should have had eight total showers/bathing assistance but only four were offered and completed. The resident's June 2022 (6/1-6/14/22) shower sheet record documented two showers on 6/7/22 and 6/11/22 and one bed bath on 6/4/22. There were no refusals documented. Out of the two possible showers a week for 6/1-6/14/22, the resident should have had four total showers/bathing assistance but only three were offered and completed. -However, the admission data collection preference plan, dated 1/19/22, revealed the resident had a preference for showers two times a week, not a bed bath. The resident was inconsistently provided showers as he prefered in May and June 2022. The resident's ADL comprehensive care plan, initiated 6/1/21 and revised 1/20/22, revealed impaired mobility and ability to care for himself. Interventions for bathing and showering included, Use short, simple instructions such as hold your washcloth in your hand; put soap on your washcloth; wash your face; to promote independence. A progress note dated 6/8/22 at 3:08 p.m. documented, Resident showered last night but refused head wash due to shampoo was not available; found it in his dresser today. -However there was no documentation why shampoo was not provided by the facility during his shower. D. Staff interview UM #1 was interviewed on 6/8/22 at 2:19 p.m. She said the staff did wash the residents' hair as part of a shower unless the resident declined. UM #1 said the facility provided shampoo and soap, although there were a few residents who provided their own shampoo. UM #1 said if a resident's hair was greasy the doctor could order a special kind of shampoo and if there were white flakes in a resident's hair, it may require a special medicated shampoo. UM #1 acknowledged Resident #6 white flakes and greasy hair, saying I saw his hair today. -However, the progress note on 6/8/22 identified the resident did have shampoo located in his dresser. VIII. Resident #119 A. Resident status Resident #119, age 74, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required one-person physical help for bathing. B. Resident interview Resident #119 was interviewed on 6/9/22 at 1:22 p.m. The resident stated a month or two ago, he went three weeks without a shower because the facility did not have hot water. He said he finally received a shower last week. He stated he would like to have had two showers per week but was lucky to get one. He said of the three facilities he had been in, he felt as if he had not received the best care. He said he deserved better care than he received. C. Record review The 2/2/22 Admission Data Collection Preferences section was reviewed. The resident's documented preference for bathing was to have a shower every two days. The shower documentation report showed the [TRUNCATED]

Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two (#26 and #256) of six residents out of 64 sample residents. Resident #26, an insulin dependent diabetic, was experiencing problems with low blood glucose (BG) levels on 3/19/22. The resident was prescribed to have a BG check three times a day prior to each insulin administration. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When the nurse assessed the resident's 4:30 p.m. BG level by finger stick, the resident's BG had lowered to 79, under the prescribed parameter of 80. The resident's insulin was held in line with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse on duty called 911 for emergency medical services (EMS). There was no documentation of the nurse reassessing the resident's vital signs including BG level, after noticing the resident decline. EMS arrived at the facility and assessed the resident at approximately 6:03 a.m., and found the resident BG level had dropped to 31, a dangerously low result. EMS treated the resident for low blood glucose and took the resident to the hospital for further assessment and medical treatment. The facility's failure to fully assess the resident's condition, put the resident in a critical state and in need of hospital level care for [CONDITION(S)]. Additionally, the facility nurse failed to document any details of the resident's change in condition, emergency state and reason for EMS and hospital care. In addition, the facility failed to ensure Resident #256's change in condition was identified, assessed, monitored and treated appropriately and timely. The resident was found by his representative on 5/23/22 with rapid breathing and declining condition. Subsequently, the resident was sent to the hospital for emergent treatment and diagnosed with aspiration pneumonia and newly prescribed antibiotic treatment. Findings include: I. Facility policy The Resident Condition Changes that Require Physician Notification Guidelines policy, effective 5/1/18, was provided by the nursing home administrator (NHA) on 6/13/22 at 8:20 a.m. It read in pertinent part: Clinical policies and procedures serve as clinical guidelines to assist in clinical staff decision-making, staff education/training, and evaluation of employee performance. -In the event of any doubt, the physician is notified. Provision and procedure -Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. -The nurse completes an assessment of the condition, including level of urgency. The nurse implements appropriate interventions and has accurate information available when contacting the physician. -Documentation of the resident condition change and proper notification is the responsibility of the nurse who observes and assesses the change. -Changes in resident condition must be documented in the following locations: Resident chart - notation made by all shifts for 72 hours . -The licensed nurse also notifies the unit/nurse manager or nursing supervisor -The unit/nurse manager or nursing supervisor is responsible for: Assessing any resident with a condition change. Verifying proper notification and documentation of the condition change. The Charting and Documentation, revised July 2017, was provided by the NHA on 6/13/22 at 8:20 a.m. It read in pertinent part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. II. Other facility documents The Facility Assessment, updated 4/1/22, was provided by the nursing home administrator (NHA) on 6/7/22, it reads in pertinent part: Services provided based on resident need. Specific care of practice: Management of Medical conditions-Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, [CONDITION(S)] [CONDITION(S)]), gastroenteritis, infections such as [CONDITION(S)] (urinary tract infections) and gastroenteritis, pneumonia, [CONDITION(S)]. III. Resident #26 A. Resident Status Resident #26, age 73, was admitted on [DATE] and discharged on [DATE] to the hospital. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/22/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident had no aggressive behaviors, [CONDITION(S)] and did not reject care. The resident was on daily insulin injections. B. Interview The resident was no longer residing in the facility so observation and interview were not possible. Emergency medical service (EMS) personal #3 was interviewed on 6/10/22 at 10:31 a.m. EMS #3 said they responded to an emergency call on 3/19/22 at 6:03 p.m. During this call, it was determined there was one nurse that was taking care of a large number of patients. The nurse walked the EMS responder to the resident's room. Resident #26 was found to be unresponsive, exhibited stroke-like facial paralysis and only responded to painful stimuli. The EMS responders questioned the nurse about the resident's change in condition and were told the resident had been in that condition for approximately 45 minutes, but all vital signs were stable. EMS gathered diagnostic information and began an assessment of the resident's condition. Upon discovering that the resident's blood glucose (BG) level was 31, the EMS responders asked the nurse if she had recently checked the resident's BG levels. The nurse said yes, the resident's BG level was 79 at last check. The EMS provider asked to see the resident's record for more detail. EMS #3 said the team was concerned because the resident's record failed to document a recent BG assessment or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review The resident's March 2022 CPO revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 26 units subcutaneously before meals. Hold if not eating or BG is less than 80. Start date 2/10/22, discontinued 3/19/22. The resident's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident's 7:18 a.m. BG level was 201 and insulin was administered; -The resident's 11:47 a.m. BG level was 179 and insulin was administered; and -The resident's 4:16 p.m. BG level was 79 and insulin was held. 3/19/22-Hospital emergency room note read in part: Nursing staff called EMS because the patient was not acting right. EMS found blood sugar was 31 and brought up to 164 after treatment. -Progress notes for 3/19/22 were reviewed; there was no documentation of the resident change in condition or nursing assessment leading up to 911 being called for emergency services; what nursing interventions were conducted prior to the nurse calling 911; or why the resident was sent to the hospital for assessment. The first documented note was: 3/19/22 at 6:46 p.m., nursing progress note: (Hospital name) called and given report to charge emergency department nurse. -There were no other notes about the emergency event. IV. Resident #256 A. Resident status Resident #256, age 71, was admitted on [DATE] and discharged on [DATE] to the hospital. According to the May 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/23/22 minimum data set (MDS) assessment revealed the resident had severely impaired cognition and was not able to participate in a brief interview for mental status (BIMS) exam. Staff assessment of the resident revealed the resident had short and long-term memory deficits and severely impaired cognitive skills for daily decision making. The resident required extensive assistance from staff to complete all activities of daily living including bed mobility, transfers and eating. The resident did not reject care. The assessment documented the resident was on antibiotic treatment B. Interview The resident was unavailable for interview and observations. The resident's representative was interviewed on 6/2/22 at 4:57 p.m. The resident's representative said the Resident #256 had a change in condition. Upon arrival to the facility for a visit on 5/23/22, they found the resident in a declining state. The resident appeared visibly sick and was breathing rapidly. The resident representative approached nursing staff about concerns over the resident condition and staff were not aware the resident was experiencing a change in condition. After speaking with nursing staff, the resident representative requested they send Resident #256 to the emergency room for assessment. 2. Record review Review of the resident progress notes revealed no nursing notes to document the resident status or condition from 5/20/22 through discharge 5/23/22, to the hospital. There was one note on 5/20/22 indicating the resident's regular tube feeding supplement was out of stock so a substitute supplement was ordered and prescribed to be administered at a higher rate than the recommended feeding supplement. -There were no notes to document if the resident was tolerating the new feeding rate or if he was having any other complications with swallowing or breathing. -The resident's record failed to document the resident's change of condition or how long the resident had been experiencing the abnormal rapid breathing or other symptoms. There was no indication of what type or if the nursing staff were providing regular monitoring of the resident change in condition. Per the hospital notes (see below), the resident was recently diagnosed with aspiration pneumonia and prescribed antibiotic treatment. The resident record did not document this new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Relevant Progress notes read in pertinent part: -5/20/22 at 2:11 p.m. Nutrition note: Resident's ordered enteral formula is out of stock. Ordered to receive [MEDICATION(S)] 1.2 (formula) until Nepro (formula) is available. Recommend increasing rate to 80 ml/hr (milliliters per hour) when [MEDICATION(S)] 1.2 is being used to better meet needs. [MEDICATION(S)] 1.2 at 80 ml/hr for 24 hours to provide 2304 kcal (calories), 106 g (gram) protein and 1549 ml of water. Once Nepro is available, recommend decreasing rate back to 60 ml/hr. Informed nursing of enteral feed change. Will continue to monitor. The next note read: - 5/24/22 at 6:50 a.m. Health Status Note: Transported to (hospital name) via ambulance. -This discharge note was a late entry and did not document the resident's change in condition or why the resident was sent to the hospital. The resident was sent to the hospital the afternoon of 5/23/22 and admitted at 1:31 p.m. Hospital progress note: Emergency department to hospital admission (admission 5/23/22, discharged [DATE]); dated 6/9/22, read in pertinent part: Admission Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Health and physical from admission Patient with a history of recent [CONDITION(S)] and [CONDITION(S)] [CONDITION(S)] (a process that begins with the cessation of cerebral blood flow to brain tissue) who currently resides in a skilled facility admitted to the ICU (intensive care unit) with possible [CONDITION(S)], respiratory failure and aspiration pneumonia. He presides in a skilled nursing facility and is alert and oriented times zero at baseline. Per records from the skilled nursing facility he was recently diagnosed with aspiration pneumonia and started on [MEDICATION(S)] today. He then developed tonic-clonic (rapid jerky) movements concerning [CONDITION(S)] today and EMS (emergency medical services) was called. He was given 2 mg (milligrams) of IV (intravenous) [MEDICATION(S)] (antiseizure/sedative medication) in route. Improvement in the tonic-clonic movements. While in the emergency department he was noted to have worsening respiratory distress and he was intubated after the case was discussed with the patient's family. He was given IV fluids and started on empiric antibiotics. Current Outpatient Medications (included): -[MEDICATION(S)]-potassium clavulanate ([MEDICATION(S)]) 250-62.5 mg/5 mL suspension by peg tube, every 8 (eight) hours scheduled, History of present illness: -Presented with myoclonic (quick movements) jerking and [CONDITION(S)]-like activity. He was hypoxic and intubated (providing an airway by placing a tube down the patient's windpipe) in the emergency room with copious white secretions noted upon intubation. He was tachypneic (abnormally rapid breathing) and gurgling prior to intubation. Final Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . V. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 6/8/22 at 3:19 p.m. LPN #3 said the nurse should notify the resident physician to discuss any changes in health condition. The nurse should document the physician's response and provide treatments and medication as ordered as well as resident response to treatment. The nurses should also notify the unit manager and or DON of the resident change in condition. LPN #11 was interviewed on 6/8/22 at 3:52 p.m. LPN #11 said the nurse was responsible to monitor the resident for changes in condition if a mild change was suspected or if the nurse was unfamiliar with the resident the nurse should speak with the charge nurse or DON to confirm the resident status. If there was a major change in condition the nurse should assess the resident and take a full set of vital signs and report to the resident physician for further orders. If the resident was experiencing a life-threatening emergency the nurse should respond to the emergency and treat the resident according to nurse practice. If the resident could not be treated in the facility, the nurse should call 911 for emergency assistance. All assessment and treatment should be documented in the resident's chart and reported to the oncoming nurse at the end of shift. If the resident was diabetic and experiencing a change in condition the nurse should assess the resident's BG level if the BG levels were low the nurse could give the resident juice if the resident was unable to drink or eat the nurse could use the [MEDICATION(S)] to inject the resident with a glucose elevating solution. [CONDITION(S)] should be assessed and treated quickly to avoid further complications. LPN #10 was interviewed on 6/9/22 at 11:35 p.m. LPN #10 said if a resident presented with a significant change of condition, such as, having a change in baseline that cannot be explained such as being less alert; confusion; presenting with new pain; weakness; respiratory symptom; etc. the nurse should immediately assess. The assessment should include a full set of vital signs and other assessments as applicable to the condition. Once the resident was fully assessed, the nurse should call the resident physician to present the resident assessment and ask for treatment recommendations/orders. The nurse should document and provide the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #10 said the resident BG level should be included in the full set of vital signs if the resident was diabetic. This should be done immediately upon discovery of a change in condition. The DON and assistant director of nursing (ADON) were both interviewed on 6/15/22 at 11:31 a.m. The DON said the nurse should respond immediately when a resident experiences a change in condition to assess and provide treatment as soon as possible. As soon as the floor nurse notices a change of condition they should assess the resident and notify the house manager. The house manager would respond to the unit and assist the nurse to provide treatment and assess the resident's condition. The DON was not sure where the failures in treating Resident #26 and #256 and would have to review the records to be able to respond accurately. The DON acknowledged the nurse should have retested the Resident #26's BG level as part of assessing the resident for a change of condition where she was found to be unresponsive since she was diabetic. The DON said the staff should have responded to Resident #256's call light. If the staff had responded to Resident #256's complaints of being short of breath and checking the oxygen typing they could have offered the resident reassurance and helped the resident's breathing.

Based on record review and interviews, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for two (#61 and #143) of five residents reviewed for wounds, out of 64 sample residents. Resident #61 was at risk for developing pressure injuries due to being admitted to the facility on [DATE] with a deep tissue injury to her left side of foot/heel, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She required extensive assistance with two people for bed mobility, and total dependence for transfers. There was a delay in assessment by an appropriate staff member, registered nurse (RN) or wound care physician when a new open sacral/coccyx pressure ulcer was discovered 1/27/22 for Resident #61. The sacral wound was not assessed by the wound care physician until 3/1/22 which was approximately five weeks later and at that time was a stage 3 pressure injury. The facility failed to stage the new pressure ulcer, according to professional standards, so that the appropriate treatment options could be selected to prevent the wound from worsening and minimize the resident's risk. There was no repositioning program in the care plan to prevent or cause further progression of the pressure ulcer. An air mattress was implemented on 2/28/22, which was over one month since the development of the sacral open area. Due to facility failure's, the resident developed an avoidable facility acquired stage 3 pressure injury to her sacrum. Additionally, the facility failed to accurately assess Resident #143's wounds on admission 5/13/22. Resident #143's wounds were not assessed until observed by the wound physician on 5/24/22 which was eleven days later (Resident #143 was found to have two pressure ulcers one unstageable and one a stage 3 see below); Resident #143 did not have wound treatment orders initiated until 5/19/22 which was six days after admission, and failed to complete wound care treatment on 6/8/22. Findings include: I. Professional References The National Pressure Ulcer Advisory Panel (2017) NPUAP Pressure Injury Stages, retrieved on 6/15/22 from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ revealed the following pertinent information: Pressure injuries can be numerically staged (i.e. Stage 1, 2, 3, or 4), if the type of tissue injured can be visualized or directly palpated (e.g., in case of Stage 4 when exposed bone is visible or directly palpated). The NPUAP also recognizes the very real clinical limitations of being able to visualize the types of tissue exposed by injury. Based on these limitations, the NPUAP staging system provides two additional options: (1) unstageable pressure injuries to address situations where the wound base is obscured by slough and/or eschar and (2) Deep Tissue Pressure Injury (DTPI) where the skin may still be intact, but is purple or maroon indicating deeper tissue damage has occurred. After DTPIs evolve, or unstageable pressure injuries are debrided, these injuries can be numerically staged. Due to the unique anatomy in mucosal membranes, pressure injuries in these tissues should be noted, but can never be staged. -In many situations, the level of tissue injury can be accurately assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .g., pain), temperature (e.g., warmer from inflammation, colder as tissues die), firmness (firmer or boggy with tissue destruction and [CONDITION(S)]), color (signs of inflammation consistent with skin tone) and drainage expressed from surrounding tissues as they are palpated. This more thorough assessment of surrounding tissue may alert the clinician to more extensive damage than is readily visible. These additional findings should be described and documented. II. Facility policy and procedure The Skin and Wound Management Program Overview policy, revised on 11/26/18, was provided by the director of nursing (DON) on 6/9/22 at 2:20 p.m. It read, in pertinent part, The goal of the Program is to prevent the development of pressure injury unless clinically unavoidable and delineate the provision of care and services to: -Promote the prevention of pressure injury development; -Promote the healing process of pressure injuries that are present; -Prevent the development of additional pressure injury; and, -Ensure the resident's plan is monitored during treatment. Clinical policies and procedures serve as clinical guidelines to assist in clinical staff decision-making, staff education/training, and evaluation of employee performance. (Name of corporation) is committed to providing optimal care and services to attain and/or maintain the highest practicable physical well-being regarding skin and wound management. This is achieved through an interdisciplinary approach, which includes screenings, comprehensive evaluations, reviews and monitoring, and plans of care. The Program is the responsibility of everyone who provides care to the residents, each with their own set of responsibilities. Initial and ongoing education is provided to staff; competency is established and accountability for compliance is determined. Oversight of the program is a shared responsibility at both the corporate and community levels, with reporting to their appropriate level Quality Assurance/Improvement Committees. Data/outcomes are collected, analyzed, and evaluated to determine the efficacy of the Program and allow for program/practice changes as necessary. Unless otherwise indicated, the Program uses definitions provided by the Centers for Medicare & Medicaid Services (CMS) and/or National Pressure Injury Advisory Panel (NPUAP) and NPUAP guidelines and standards. A licensed nurse performs a visual head-to-toe skin review within 8 (eight) hours of admission or readmission to determine general skin condition and identify any pre-existing skin concerns and/or wounds. Findings are documented on the Admission/Readmission Skin Review Form. Whenever a new wound is identified, a licensed nurse conducts a comprehensive evaluation and documents the findings on the Initial Wound Review Form. Pressure injuries are numerically staged, by a Registered Nurse or licensed nurse with a current certification as a wound care nurse (unless otherwise indicated by state regulation or standards of nursing practice), according to the classification System specific to pressure injuries. III. Resident #61 A. Resident status Resident #61, age 84, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/15/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She did not exhibit behaviors or reject care. She required extensive assistance with two people for bed mobility, and total dependence for transfers, locomotion on/off the unit in a wheelchair, bathing, and toilet use. She required extensive assistance with one person for dressing, eating, and personal hygiene. She was always incontinent of bowel and bladder and at risk for developing pressure injuries. The MDS documented Resident #61 had one stage 3 pressure ulcer which was not present upon admission. The MDS assessment documented Resident #61 was on a turning/repositioning program. -However, there was no such program documented on the care plan (see record review below). B. Resident observations On 6/8/22 at 12:58 p.m. wound care was observed being performed by unit manager (UM) #1 and certified nursing aide (CNA) #3, who assisted with positioning the resident. UM #1 said the resident had a stage 3 wound to her coccyx which was healing. The resident was observed lying in bed. UM #1 and CNA #3 washed their hands and donned gloves. UM #1 gathered supplies and placed them on the overbed table with a clean surface. CNA #3 positioned the resident on her right side, UM #1 removed the resident's dressing, and there was scant serous (thin watery) drainage. UM #1 doffed her gloves, performed hand hygiene, donned clean gloves, and cleansed the resident's wound. There were no signs of infection to the wound. The wound bed was red with 100% granulation; the surrounding skin was intact. UM #1 applied [MEDICATION(S)] (antibacterial/anti-[CONDITION(S)] gel) and foam dressing to the wound bed. They doffed their gloves and washed their hands. UM #1 said the wound assessment with measurements would be completed by the wound physician on Friday 6/10/22. On 6/13/22 at 9:57 a.m. a continuous observation was performed from 9:57 a.m. to 1:09 p.m. -At 9:57 a.m. the resident was in her room in bed wearing a hospital gown. The resident was positioned on her right side, facing the wall. An unidentified CNA went around the unit picking up the breakfast trays. -At 10:13 a.m. the resident was still in bed, in the same position. -At 10:56 a.m. the resident was still in bed, in the same position on the right side. -At 11:09 a.m. the resident was still in bed, in the same position, on the right side. -At 11:29 a.m. the resident was still in bed, in the same position on her right side. -At 11:45 a.m. CNA #3 went into the resident's room briefly (less than 10 seconds) and came back out of the room. The resident was still in bed, in the same position on her right side. -At 12:01 p.m. Resident #61's roommate returned to the room in her wheelchair and put on the call light. The roommate requested to be transferred to a bedside chair Resident #61 was still in bed, in the same position on her right side facing the wall. Licensed practical nurse (LPN) #5 helped the roommate into a bedside chair and left the room. -At 12:14 p.m. unit manager (UM) #1 brought the wound care cart to Resident #61's door, she said she was providing wound care treatments and Resident #61 was the last resident. She prepared the wound care treatment on a cart. UM #1 went into the room and shut the door. UM #1 was in the room for five minutes. Observed that Resident #61 was still in the same position on her right side following the wound care treatment to her sacrum. -At 12:28 p.m. an unnamed CNA entered Resident #61's room and placed a fall mat on the floor in front of the resident's bed and left. Resident #61 was still in the same position on her right side. -At 12:50 p.m. an unnamed CNA dropped Resident #61's lunch tray off in her room. Resident #61 was still in the same position on her right side. -At 1:09 p.m. CNA #17 assisted Resident #61 with eating her lunch, the resident was now sitting up in bed. CNA #17 said that Resident #61 was up in the morning for breakfast and her daughter helped assist her with eating, but the resident vomited, so they put her back to bed. -During the continuous observation the resident continued to lay on her right side during the observation and she was identified as being at risk for pressure ulcers/injuries, she was not offered incontinence care during the observation or offered repositioning. -Cross-reference F677 for lack of ADL care for dependent residents. C. Record review The quarterly Braden scale for predicting pressure injuries was conducted 10/15/21 with a score of 15 (indicating mild risk). However, the Braden scale checklist question asked if the total score was 16 or less-and the facility answered no (incorrectly since the score was 15). If it had been marked correctly, yes, there would have been a completion of a checklist by the facility to select appropriate care plan options. 1. Care plan The resident's ADL comprehensive care plan, initiated 7/10/21 and revised 4/18/22, revealed impaired mobility and ability to care for herself and dependent assistance with ADLs. The resident's bowel and bladder incontinence comprehensive care plan, initiated 7/10/21, and revised 10/18/21, revealed she has functional incontinence. Interventions include to check on rounds and as required for incontinence. The resident's pressure injury comprehensive care plan initiated 7/13/21 for the stage 3 pressure injury to her left heel, and revised 6/7/22 (during the survey) adding the stage 3 pressure ulcer to her coccyx. -However the coccyx pressure ulcer was discovered 1/27/22 and there was no coccyx care plan until 6/6/22 (during the survey). There were no new interventions added to the care plan for care of the coccyx pressure ulcer, stage 3, on 6/6/22. -The air mattress was not added until 2/28/22, the coccyx pressure ulcer was discovered 1/27/22 (see orders below). The resident's risk for skin breakdown comprehensive care plan, initiated 7/12/21, revised 10/18/21, revealed she was at risk for skin breakdown and was incontinent. Interventions included pressure relieving bed mattress and wheel chair cushion. -However, there was no intervention for re-positioning, changing positions, rotating positions, or pressure relief (other than to offload heels). 2. Progress notes/assessments Review of the admission progress note, dated 7/11/21 at 7:22 p.m late entry, revealed on admission, a head to toe assessment completed. The resident did not have any open areas. The daughter reported deep tissue injury (DTI) on the left side of foot that was assessed by a nurse, no discoloration or [CONDITION(S)] noted on the side. Review of the progress note, dated 7/13/22 at 1:37 p.m. revealed Resident #61 had DTI to her left heel and her right heel was boggy. Review of the total body skin assessment, dated 1/24/22, identified no new wounds. Review of the total body skin assessment, dated 1/27/22, identified one new wound, however there was no documentation of wound measurements or staging or location. Review of the total body skin assessments for February and March 2022, identified no new wounds. Review of the first progress note to mention an open area to the coccyx, dated 1/27/22 at 1:54 p.m. It revealed the resident with a small open area on the coccyx 0.5 centimeters (cm) by (x) 0.5 cm. The area was cleaned with normal saline, applied [MEDICATION(S)] and covered with bordered foam dressing. Resident #61 was incontinent of bowel and bladder, and got up out of bed every day. The plan was to put the resident in bed after lunch and continue to reposition while in bed. The medical doctor (MD) and family were notified. Review of progress notes/assessments related to the coccyx wound revealed: -1/27/22 at 5:46 p.m. The resident remained on charting for a new open area to coccyx. She was alert and oriented to person, staff to assist with the resident's needs. Continued to encourage fluids, reposition resident in bed, and offer supplements. The resident remained at baseline, and did not complain of pain at that time. -1/28/22 at 3:32 a.m. The resident was being monitored related to open area to coccyx. She was repositioned frequently. No signs or symptoms of infection noted. Will continue to monitor. -1/28/22 at 8:09 a.m. Order changed to barrier cream per MD. -1/28/22 at 10:47 a.m. The resident was being monitored for a small open area on the coccyx. Barrier cream was being applied. Resident was sitting up in a wheelchair and had just had breakfast. She had no complaints of pain or signs/symptoms of infection. -1/29/22 at 6:42 a.m. The resident was on alert charting related to open area on coccyx. Barrier cream applied as indicated. She was repositioned frequently. No signs/symptoms of infection noted. -1/29/22 at 11:11 a.m. The resident was being monitored for an open area to coccyx and just applying cream and leaving it open to air. No signs/symptoms of infection. -1/29/22 at 10:36 p.m. The resident was being monitored for a small open area to the coccyx, cream applied and open to air, no signs/symptoms of infection. The resident went to bed after lunch. -1/30/22 at 1:18 a.m. The resident was on alert charting related to a small open area to coccyx. Barrier cream applied as indicated and was repositioned frequently. No signs/symptoms of infection. -2/4/22 at 12:00 p.m. The skin/wound progress note discussed the progress of the right medial foot wound, and left heel wound, but made no mention of the coccyx wound. -2/14/22 at 12:22 p.m. interdisciplinary team (IDT) note read, IDT met on 2/10/22 to discuss residents' wound quality and status, reviewed current treatment modalities. -However, the IDT note did not discuss which wounds and their specific treatments. -2/25/22 at 1:59 p.m. Resident noted with open area to coccyx that measures approximately 3 cm x 3.5 cm and 0.2 cm depth. Resident also noted with open area to right posterior thigh that measures about 3 cm x 2.5 cm with 0.2 cm depth. Resident is incontinent of bowel/bladder, gets up every day in a wheelchair. Area cleansed with normal saline, medi honey applied and covered with bordered foam dressing. Will continue to reposition resident while in bed. MD and family notified. Will continue to monitor. -However, the coccyx wound had increased in size since initial discovery on 1/27/22 (see above) despite documentation of repositioning. -2/25/22 at 11:14 p.m. The resident on a change of condition related to the open areas to coccyx and right posterior thigh. The resident repositioned every two hours. No signs/symptoms of distress noted. -2/26/22 at 1:58 a.m. The resident was being monitored related to having open areas to the coccyx and right posterior thigh. Dressing intact and no signs/symptoms of infection noted. -2/26/22 at 11:43 a.m. The resident was being monitored related to having open areas to the coccyx and right posterior thigh. Resident was repositioned every two hours. No signs/symptoms of distress noted. -2/27/22 at 1:17 a.m. The resident was on alert charting related to having open areas to the coccyx and right posterior thigh. Dressing intact. No indication of infection or pain was noted. -2/27/22 at 10:15 a.m. Resident was being monitored for the wound on her coccyx. Today she was in bed and being turned from side to side every two hours. She had a treatment done and wound was red and there was some drainage. -2/27/22 at 7:57 p.m. The resident monitored for coccyx and right posterior thigh pressure wounds, repositioned every two hours. Resident had no signs/symptoms of pain. -2/28/22 at 2:12 a.m. The resident was being monitored related to having open areas to the coccyx and right posterior thigh. She had been repositioned to the side frequently. Dressing intact and no signs/symptoms of infection noted. -2/28/22 at 4:08 p.m. The resident received an air mattress to her bed. Dressing intact to coccyx and right posterior upper thigh. Review of the initial consultation note by the wound care physician (PHY) #2, dated 3/1/22 revealed the following. Wound #1 coccyx was a stage 3 pressure ulcer injury and had received a status of not healed. Initial wound encounter measurements are 3 cm length, 2.5 cm width, 0.2 cm depth. The patient reported a pain level 0/10. Wound bed had 20% slough, and 80% granulation. The periwound skin was normal. -However, the coccyx wound was discovered 1/27/22 and the first physician wound evaluation was 3/1/22, nearly five weeks later. -3/3/22 at 1:01 p.m. IDT reviewed skin and wounds, some improvement noted to areas, interventions were in place. Staff continued with wound care per MD order, and the wound team continued to round and follow closely. -However, there was no indication which wounds were reviewed and which areas were improving. The nurse's daily wound evaluation notes for the coccyx did not begin until 3/11/22, which was more than one week after the wound physician saw the resident on 3/1/22. -4/11/22 at 2:42 p.m. The nutrition progress note revealed the first mention in the progress notes of the staging of the coccyx wound, Skin: Left heel-deep tissue injury; Coccyx-stage 3 pressure ulcer. -Review of progress notes 4/11/22-6/8/22 revealed no further mention of the coccyx pressure ulcer stage 3 wound and if the resident was provided repositioning. D. Staff interview The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 6/14/22 at 2:49 p.m. The DON said Resident #61's coccyx wound was discovered 1/27/22 from a skin assessment. The DON said when Resident #61 developed her coccyx wound the facility did not have a wound care physician, just a wound care nurse that performed weekly wound assessments; however that wound care nurse did not assess Resident #61's coccyx, she only assessed Resident #61's heel wound. The DON said the wound care physician began rounding at the end of March 2022. Between 1/18/22 and March 2022, the nursing staff followed the resident's wounds until referral to a new wound care doctor began in March 2022. The DON said that registered nurses were able to assess wounds, complete wound care and staging of the wounds, however a licensed practical nurse/unit manager (UM) #1 found the sacral wound and did not ask an RN to completely assess the wound. The DON said staging should have been done right away when the wound was first identified on the coccyx (1/27/22). The DON said the primary care physician (PCP) did not come in to stage or assess the coccyx wound. The DON said the first documented assessment of Resident #61's wound was with the wound care physician on 3/29/22. The DON and ADON said they could not locate any wound staging notes for Resident #61 prior to the wound care doctors' visit. The DON and ADON said Resident #61's pressure ulcer was acquired in-house as a stage 3 wound. The DON said the protocols the facility had to prevent resident pressure injuries was an air mattress, especially if the resident was dependent on staff for care. The DON said the facility used the Braden scale to identify if a resident was at risk for pressure injuries and a score of 15-18 would alert the staff that a resident was at risk. The DON said every resident in a wheelchair would have a cushion and their protein intake was monitored. The DON said a change of condition form should be completed right away when a new pressure injury or new skin concern was discovered. The DON said there had been a gap with wound care documentation, treatment and the facility did a quality assurance and performance improvement (QAPI) meeting and did an in-house audit. The DON said she was not the DON during that time period of January-March 2022 and acknowledged that there were some problems with the wound care process at that time. IV. Resident #143 A. Resident status Resident #143, age 86, was admitted on [DATE]. According to the June 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/20/22 MDS assessment revealed Resident #143 was moderately impaired with a BIMS score of 12 out of 15. He required extensive two-person assistance with bed mobility, transfers and toilet use; and extensive one-person assistance with dressing and personal hygiene. He was always incontinent of bowel and bladder. Resident #24 had one stage 3 pressure ulcer and one unstageable pressure ulcer. He had a pressure reducing device for her bed/chair, was on a turning/repositioning program, had nutrition or hydration intervention and received pressure ulcer/injury care including application of ointments/medications and nonsurgical dressings. The resident was at risk for pressure ulcer/injury development. B. Resident interview Resident #143 was interviewed on 6/7/22 at 10:27 a.m. He said that since his admission, staff have not gotten him out of bed. He said staff would come in once a day to reposition him. Resident #143 was interviewed a second time on 6/8/22 at 3:20 p.m. He said the staff had not been in to change his dressing. C. Record review 1. Care plan The skin care plan, initiated 5/16/22 and revised on 5/25/22 revealed Resident #143 admitted to the facility with a pressure injury to his buttock stage 3 and unstageable pressure ulcers. Interventions included to assess, record, and monitor wound healing. Administer treatments as ordered and monitor for effectiveness. Monitor nutritional status, obtain and monitor lab work as ordered, air mattress and report decline and improvements to the physician. -The care plan did not document which buttock (right or left) Resident #143 had pressure injuries (stage 3 and unstageable) to. 2. Admission assessment The 5/13/22 admission assessment documented Resident #143 had three pressure ulcers to his right buttock, two to mid to lower buttock and one to lateral lower buttock; however there was only one measurement of 2.4 cm (centimeters) x (by) 2.2 cm x 2.5 cm. -Additionally, it was not documented which of the three wounds the measurement belonged to. -The assessment did not include tissue type, stages of the three wounds, surrounding skin, if the wounds had any drainage, signs of infection or documentation of the surrounding skin. Furthermore, it was documented Resident #143 had stage 2 pressure wound to his buttock. A [MEDICATION(S)] (absorbent dressing) was applied per hospital treatment with a verbal report to leave dressing on and the wound team would follow-up. 3. CPO and treatment administration record (TAR) -Review of the May 2022 CPO revealed there were no treatment orders initiated for any of the wounds (see above) until 5/17/22 and treatment was not performed until 5/19/22 according to the TAR, which was six days after admission. -Additionally, on 6/8/22 Resident #143's wound treatment was not completed (see interviews below). 4. History and physical (H&P) The 5/19/22 H&P documented per patient, buttock wound stage 2 healed, the resident had an air mattress overlay and a wound consult. -However, documentation above revealed Resident #143 had a stage 3 and unstageable wound to his right buttock and coccyx per the wound physician (see below). 5. Wound assessment The 5/24/22 wound assessment revealed Resident #143 had an abrasion to his right hip which measured 1 cm x 1 cm with zero depth, no drainage and 100% epithelialization. He had a stage 3 pressure injury to his right buttock which measured 0.5 cm x 0.5 cm x 0.1 cm, minimal drainage and 100% granular tissue. He had an unstageable pressure injury to his coccyx which measured 2 cm x 1 cm x 0.2 cm, minimal drainage and 10% granular tissue and 90% slough. The wound assessment documented the three wounds decreased in measurement (prior dimensions to Resident #143's right hip was 2 cm x 1.5 cm x 0.1 cm, prior dimensions to Resident #143's right buttock was 1 cm x 1 cm x 0.2 cm and prior dimensions to Resident #143's coccyx was 2.5 cm x 1 cm x 0.2 cm). -However, prior to the 5/24/22 wound assessment, there was no other assessments available in the resident's clinical record to show the wounds had decreased in measurement. 6. Skin assessments The skin assessments for 5/20/22, 5/27/22 and 6/3/22 were reviewed, there was no assessment of Resident #143's wounds documented on the skin assessments. 7. Nutrition assessment The 5/17/22 Nutrition Risk Review documented Resident #143 did not have any unstageable pressure injuries and Resident #143 had a stage 2 pressure ulcer to his buttock. 8. Progress notes Review of progress notes from 5/13/22 to 6/9/22 revealed no documentation of Resident #143's wound status of a stage 3 pressure ulcer to right buttock or unstageable pressure ulcer to his coccyx. The 5/17/22 Nutrition Risk Review note documented Resident #143 having a stage 2 pressure ulcer to his buttock. D. Staff interviews Licensed practical nurse (LPN) #8 was interviewed on 6/8/22 at 3:21 p.m. She said she worked PRN (as needed) and picked up the evening shift from 2:00 p.m. to 10:00 p.m. She said LPN #6 (the day nurse) changed Resident #143's dressing before she left. She said she did not receive in her report from LPN #6 that she needed to complete the treatment on 6/8/22. The director of nursing (DON) and nursing home administrator were interviewed on 6/8/22 at 3:24 p.m. They said the facility had four residents with facility acquired wounds. The DON said the nurses should complete a head to toe assessment, on admission, contact the physician and confirm and follow orders. She said a registered nurse (RN) needed to assess wounds, document the pressure wound stage, what the wound bed looked like, if the wound had drainage or signs and symptoms of infection. She said if an LPN was completing the assessment he/she would ask the house RN to complete the assessment, and the interdisciplinary team (IDT) would add the resident to the wound rounds. They acknowledged there were concerns with assessing, monitoring and obtaining treatment orders in a timely manner for resident wounds. The DON said the nurse received in his/her report to leave the dressing intact. She acknowledged the expectation would be to notify the physician and obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she felt the wound physician assessed Resident #143's wounds sooner than 11 days after admission, but needed to track down the assessment. Physician assistant (PA) #1 was interviewed on 6/8/22 at 3:39 p.m. She said she would expect the admitting nurse to complete a full skin assessment and contact the physician for wound treatment orders. She said if the nurse received orders from the hospital to leave Resident #143 dressed intact, she would expect the nurse to obtain an order from the physician. LPN #6 was interviewed on 6/9/22 at 10:10 a.m. She said she was not able to complete Resident #143's wound treatment on 6/8/22 before she left and she passed it on to LPN #8 (the evening nurse) to complete. She acknowledged it was not completed. E. Facility follow-up On 6/8/22 at 5:48 p.m. the DON provided an action plan for wounds. The action plan dated 5/9/22 documented the concern that staff were not utilizing (name of electronic system) for documentation of wounds as expected by the facility. There was miscommunication between the provider and facility expectations. The wound nurse's end date was 12/25/21 and the wound physician position was implemented in March 2022. Interventions included the following: -Create onboarding program (completed 6/7/22); -Started wound care, following wound physician with wound pictures and documentation (ongoing); -A full house audit to ensure treatment orders were in place and evaluations were completed start date 6/7/22 and estimated date of completion 6/13/22; and, -Wound certification start date 5/1/22 and estimated date of completion 10/1/22. -The action plan did not include any training or education being provided to the nursing staff. The DON said she was not sure if education was initiated. -There was no additional information provided by the facility during survey (6/6/22 to 6/15/22) to include nurse education or wound assessments for Resident #143 prior to the wound physician assessment 5/24/22.

Based on interviews and record review, the facility failed to ensure the residents' environment remained free from accident hazards as possible, affecting one resident (#264) out of 64 sample residents. The facility failed to develop and implement an effective system of oversight and safety interventions to prevent and reduce the risk of Residents #264 having a smoking accident. Failures included a lack of identification that Resident #264 continued to smoke despite telling the intake coordinator he would not. Failure to assess Resident #264's risks for potential injuries and side effects from smoking. Failure to implementing appropriate interventions to promote Resident #264 being a safer independent smoker; and offering supplies for safer smoking. The facility's failure to identify that Resident #264 would continue to smoke, even with the facility being a non-smoking facility, when admission documentation and physician's notes indicated the resident was an active smoker. The facility failed to develop a smoking care plan with interventions to promote safe smoking for the resident. Due to the facility's failures, on 5/29/22 Resident #264 sustained second degree [CONDITION(S)] to his head, face and neck with burning pain around his face and lips and hypoxemia (an abnormally low concentration of oxygen in the blood) these injuries required hospital treatment over several days. Findings include: I. Facility policy The Smoking Policy Agreement, updated 4/18/18, was provided by the director of nursing (DON) on 6/8/22 p.m. at 12:06 p.m., it read: To ensure the safety of the community, (facility name) is smoke free. All residences, including but not limited to private units of residents, will be smoke free. Smoking includes the use of cigarettes and electronic cigarettes (e-cigs or personal vaporizers). So as not to impede resident rights, each community will make available a designated area where residents, staff, and visitors can smoke. 1. Smoking is strictly prohibited in any interior area, including your apartment, at all times by you, visitors, other residents, and staff. 2. Smoking is allowed only in designated areas. These areas have signage indicating such. 3. Residents who smoke must appropriately dispose of cigarette butts and associated garbage. 4. Residents who display unsafe smoking habits may not be permitted to smoke. 5. Residents who do not agree to and/or comply with smoking regulations will not be permitted to reside at this assisted living residence. Smoking Violation Procedure Step 1: Upon moving in, all residents will receive a copy of the Smoking Policy. They will sign the policy. It will be kept in their file and they will be given a copy. Step 2: In the event the resident violates any of the above listed requirements, they will be counseled by a supervisor. This will be documented with a date and written note in file. Step 3: The resident's cigarettes will be kept at the front desk for smoking outside in appropriate areas. Step 4: If the resident violates the smoking policy again, the resident will be given a written warning that indicates that the next violation will result in a 30-day notice. Step 5: If the smoking policy is violated a 3rd (third) time, the resident will be issued a 30-day notice of discharge. II. Resident #264 A. Resident status Resident #264, [AGE] years of age, was admitted to the facility on [DATE], after a couple of discharges and readmissions the resident was readmitted on [DATE] and discharged to a hospital on 5/30/22. According to the May 2022 computerized physician orders (CPO), diagnoses included chronic respiratory failure with [CONDITION(S)], chronic obstructive pulmonary disease ([CONDITION(S)]), heart failure, and hypertension. According to the 3/14/22 minimum data set (MDS) assessment, the resident had intact cognition with a brief interview for mental status (BIMS) score 13 out of 15. The resident had no signs of [CONDITION(S)], no negative aggressive behavioral expressions and did not reject care. The resident required supervision and oversight encouragement and cuing in order to complete all areas of activities of daily living (ADLs). The resident was able to walk with a walker. The resident was on oxygen therapy. B. Record review Admission order dated 3/7/22 documented the resident had tobacco dependence and was still smoking. Admission progress notes read in pertinent part: -3/10/22 at 2:14 a.m. Evaluation summary: Daily skilled charting for (resident name) .has a history of smoking, . impaired mobility and impaired ability to care for himself, he needs one person limited to extensive assistance with ADLs. -3/11/22 at 11:59 a.m. Medication administration note (MAR). Nicotine patch 24 hour 21mg (milligrams) for 24 hours. Apply 21 mg transdermally in the morning for smoking cessation for 4 (four) weeks. -3/23/22 at 9:48 a.m. Summary for providers-Situation: The change in condition reported on this evaluation are/were: Altered mental status functional decline (worsening function and/or mobility). Other change in condition-seems different than usual. -4/12/22 at 5:09 p.m. Physician progress note: Physical examination. Stable today at facility visit. Patient with repeated hospitalization s due to inability to care for himself and take his medications. Tobacco dependence-Still smoking. Refilled on 4/12/22, nicotine 21 mg/24 hour transdermal patch for smoking cessation. -5/7/22 at 11:41 a.m. MAR note: Nicotine patch .for smoking cessation-refused. -5/24/22 at 2:08 p.m. Physician progress note: Follow up visit for issues/symptoms . Facility reports that the patient is doing well however he was recently found to have smoking paraphernalia in his room. Facility also concerned about possible substance abuse as the patient has a lock box he takes with him outside and refuses to allow staff to search the box. The resident's comprehensive care plan revised 6/6/22 revealed the resident had three-care focuses related to the use of oxygen. The care plan focuses read: -I have a potential/actual risk for alteration in cardiovascular status. Goal: I shall have decreased risks for development of cardiovascular and systemic complications such as shortness of breath (SOB), [CONDITION(S)], chest pain ([CONDITION(S)]) and pain. Intervention: I will be free of SOB and/or difficulty breathing. I will have increased ability to participate in activities of my choosing with decreased risks for injury associated with changes in hemodynamic status. I will need my oxygen as ordered and observation for any signs of new onset of shortness of breath, adventitious breath sounds, and oxygen saturation levels less than 90%. -[CONDITION(S)] with oxygen use. Goal: (resident name) will display optimal breathing patterns daily. Interventions: Avoid extremes of hot and cold. Encourage small frequent feedings instead of large meals. Give supplements if needed to maintain adequate nutrition. Encourage good fluid intake. Monitor for difficulty breathing (dyspnea) on exertion. Remind me not to push beyond endurance. Monitor for signs and symptoms of acute respiratory insufficiency and anxiety, confusion, restlessness, SOB at rest, cyanosis, and somnolence. Monitor/document for anxiety. Offer support, encourage me to vent frustrations and fears. Reassure. Give PRN (as needed) medications for anxiety as ordered or per my request. Oxygen settings: Oxygen via NC (nasal Cannula, as ordered or as needed. -I have increased risks for potential ineffective respiratory patterns related to the need of oxygen therapy secondary to:[CONDITION(S)] with chronic respiratory failure. Goal: I shall demonstrate an effective respiratory pattern as evidenced by regular respiratory pattern, unlabored breathing, no complaints of SOB, absence of dyspnea. No interventions listed. None of the care focuses provided interventions for safe use of oxygen. Nor did the interventions including assessing the resident ability to smoke safely or providing the resident education for safe smoking and oxygen use, where smoking was allowed and assessment needs for safe smoking based on needs and smoking habits. The interventions did not include assessing the resident ability to smoke safely or providing the resident education for safe smoking and oxygen use, where smoking was allowed and assessment needs for safe smoking based on needs and smoking habits. III. Smoking injury A. Record review Progress note revealed on 5/29/22 at approximately 11:00 a.m., Resident #264 engaged in unsafe smoking while wearing oxygen. As a result, Resident #264 received superficial [CONDITION(S)] to the face and negative effects to the respiratory tract. The resident was sent to the hospital for assessment and medical treatment. Progress notes read in pertinent part: -5/29/22 at 11:10 a.m. Summary for providers-Situation: The change in condition reported on this evaluation are/were: Other change in condition . Nursing observations, evaluation, and recommendations are: [CONDITION(S)] to face. -5/29/22 at 12:25 p.m. Resident got face burned, called physician, got order to transfer patient to emergency department, called 911 for transport. The 5/29/22 Smoking Data Collection form documented the resident was not able to communicate why oxygen must always be shut off prior to lighting cigarettes and was not able to communicate the risks associated with smoking. Based on observation the resident did not smoke safely. The conclusion is that the resident is an unsafe smoker. Summary of evaluation Resident must be supervised by staff, volunteers or family members at all times when smoking. B. Facility investigation The facility investigation, dated 5/30/22, documented on 5/29/22 the resident went off the facility property to the park behind the facility to smoke and returned at approximately 11:00 a.m. with superficial [CONDITION(S)] to his face. The resident said he left facility property to smoke because he knew the facility did not permit smoking on facility property. The resident returned to the facility with superficial [CONDITION(S)] on his face and told facility staff he burnt himself while smoking. The nursing staff assessed the resident, applied burn ointment and sent the resident to the hospital for further assessment and treatment. Following the incident, the resident was referred to another nursing facility for placement where staff could provide supervised smoking as part of his care plan. C. Hospital treatment records Hospital records revealed resident injury from smoking while using oxygen. Notes read in pertinent part: 5/29/22 Hospital note Initial greet date/time 5/29/22 at 11:38 a.m. -Chief Complaint: facial burn, lighting a cigarette on 02 (oxygen). History: [CONDITION(S)] on 4-5 L (liters) of 02 at baseline .presented by EMS (emergency medical service) for sudden onset of difficulty breathing through his nose after lighting a cigarette while on 02. The lighter ignited the tubing and ran up and through his nares. Incident occurred an hour and 20 minutes ago. Patient reports associated constant, burning pain around his face and lips. He denies associated difficulty swallowing, throat pain, tongue swelling, chest pain, or abdominal pain. - Exam: Superficial [CONDITION(S)] to the nose and upper lip, moist mucous membranes, no meningismus (clinical syndrome of headache, neck stiffness, and photophobia, often with nausea and vomiting). Differential Diagnosis: Superficial [CONDITION(S)], partial-thickness [CONDITION(S)], airway obstruction, hypoxemia. He had [CONDITION(S)] with his baseline oxygen, likely because of nasal swelling. Discussed with burn surgery, we will admit for observation, burn management. Smoking status: Current everyday smoker. Years smoked 50. 5/31/22 Hospital note: Seen today sitting up in a chair. States he is doing ok overall, still some issues with breathing through nose-feels stuffed up, but breathing through mouth ok. Tolerating PO (oral), pain present but controlled. Afebrile. Oxygen requirements remain at baseline. 6/1/22 Hospital note: Pain mostly in throat when swallowing. Hard for him to chew/swallow due to pain with moving lips. 6/6/22 Hospital note: Discharge 6/6/22 at 5:28 p.m. Problems: Admitting diagnosis: Burn of unspecified degree of the head, face and neck. Working diagnosis: [CONDITION(S)] involving less than 10% of body surface; nicotine dependence. General appearance: awake, no acute distress, no respiratory distress Head: 2nd (second) degree superficial [CONDITION(S)] to cheeks, mouth, chin. IV. Staff interview Licensed practical nurse (LPN) #3 was interviewed on 6/7/22 at 3:56 p.m. LPN #3 said Resident #264 violated the smoking policy. On 5/29/22, Resident #264 was discovered in the parking lot with [CONDITION(S)] to his face underneath and around his oxygen tubing. He said he had been smoking and caught himself on fire. Nursing staff assessed Resident #264s injuries and treated superficial [CONDITION(S)] to the nares (nose), cheeks and upper lips. His injuries were treated with burn cream and he was sent to the hospital for further assessment and treatment. He was short of breath and was visibly upset. The nursing home administrator (NHA) and director of nursing (DON were interviewed on 6/7/22 at 11:33 a.m. The NHA said they were a non-smoking facility and they told Resident #264 when he admitted that the facility did not permit smoking in the facility. When Resident #264 admitted to the facility he was informed he could not smoke in the facility; he told us he understood and would not smoke. The NHA said the facility did not conduct a smoking assessment or see the need for a smoking care plan because we took him on his word that he would not smoke. The NHA said if the resident had cigarettes in his possession in the facility, he probably convinced his family to bring them into him, but as far as he knew the day the resident got the facial [CONDITION(S)], he got cigarettes from a person in the park behind the facility. The DON was interviewed on 6/15/22 at 1:02 p.m. The DON said the facility did not perform smoking assessments on any residents admitted to the facility because the facility was a non-smoking facility and did not have the supplies to test a residents' smoking ability. The DON said upon admission they provide every resident with the facility's smoking policy and get verbal agreement that the resident would not smoke while they were at the facility. If the staff found smoking paraphernalia in a resident's possession they would take it away; ask the resident's family to take the supply away; and educate the resident and the resident family that smoking while in the facility was not permitted. The DON said going forward the facility would continue to offer residents who chose to start or continue smoking referrals to smoking facilities; if the resident wanted to remain in the facility and was unable to stop smoking the nursing staff would contact the resident's physician to discuss a smoking cessation treatment options.

Based on interview, observation and record review, the facility failed to ensure one (#147) of three residents out of 64 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences. Resident #147, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated she had pain in her right hand/forearm with [CONDITION(S)] and right arm weakness. According to the resident's medical record, the facility failed to address right forearm/hand [CONDITION(S)] and pain for Resident #147 through proper pain and positioning management. The facility was aware of Resident #147s right hand/forearm pain and [CONDITION(S)], however, failed to provide person-centered individualized interventions in the care plan and adjust her pain medications accordingly. There was no consistent monitoring or recording of the resident's pain characteristic, no monitoring of quality, severity, anatomical location, onset, duration, aggravating or relieving factors or goal setting related to the resident's pain. Due to the facility's failure to manage Resident #147's pain management, the resident said night time pain was the worst and it was hard to sleep because of the pain. Resident #147 said she told the nurse, but they did not do much except give her Tylenol. Resident #147 said Tylenol did not helped the pain. Resident #147 said she had pain daily, and it was constant. Resident #147 rated the pain at an 8 out of 10 (with 10 being the worst pain on the scale). I. Resident #147 A. Resident status Resident #147, age 86, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/25/22 minimum data set (MDS) assessment revealed the resident with moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required total physical assistance from two staff in order to complete activities of daily living and for transfers. Extensive assistance from one staff member for bed mobility, locomotion on/off unit in a wheelchair, dressing, toilet use, bathing, and personal hygiene. The resident had no behaviors or rejection of care. The pain assessment portion of the MDS assessment revealed the resident was on a scheduled pain medication regimen. A pain assessment interview was conducted. The pain assessment interview documented the resident did no have pain during the past 5 days. There was not documentation if pain ever affected daily function. B. Resident observation and interview On 6/7/22 at 2:40 p.m. observed Resident #147 seated in a wheelchair with the right arm sitting on the seat with the right hand curled into a fist and wrist bent forward (flexed). Resident #147 said the right hand and forearm were painful with swelling. The resident had [CONDITION(S)] in the right hand and forearm. There was no pillow under the right arm or hand, but there was a pillow under the left side which had no pain or [CONDITION(S)]. Resident #147 said when she first moved to the facility an injury caused some pain in her right hand, her physician prescribed her ibuprofen for a couple of days. The ibuprofen was effective for the injury as well as the pain and swelling in her right hand and forearm. However, she no longer has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #147 was interviewed on 6/13/22 at 10:16 a.m. Resident #147 was supine (on back) in bed, her right hand/arm were down by her side. There was no pillow or elevation of the right hand or arm. Resident #147 said her right hand and arm were painful and swollen. The resident's right hand had [CONDITION(S)] on the top of hand and forearm. Resident #147's right hand was curled in a fist with wrist bent (flexed) forward. Unit manager (UM) #1 was notified of the pain and an unnamed CNA placed a pillow under the right arm after bringing it to the CNA's attention. UM #1 said she was not sure if elevating with pillow was the best position for her arm but said she would ask the nurse practitioner (NP) #1 to evaluate. UM #1 asked Resident #147 if her hand was painful and the resident answered yes. Resident #147 was interviewed again on 6/13/22 at 11:00 a.m. She said night time pain was the worst and it was hard to sleep because of the pain. Resident #147 said she told the nurse, and the nurse gave her Tylenol for the pain but it did not help the pain. Resident #147 said she had pain daily. She said it was constant and frequent, 8/10 presently. Resident #147 said she did not remember a nurse asking her about her pain. Resident #147 said she also got tremors in both hands and described her pain as throbbing and achy. -Review of the resident's electronic medical record (EMR) revealed there was no recording of pain levels since admission; it was blank. (see record review below) C. Record review Review of the June 2022 CPO revealed the following pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] capsule 100 milligrams (MG), give two capsules by mouth as bedtime for pain control give total of 200 MG at bedtime, start date 5/19/22. -[MEDICATION(S)] capsule 100 MG, give two capsules by mouth in the afternoon for pain control, give total of 200 MG in the afternoon, start date 5/19/22. -[MEDICATION(S)] capsule 100 MG, give three capsules by mouth in the morning for pain control, give a total of 300 MG in the morning, start date 5/19/22. -Acetaminophen tablet 500 MG, give two tablets by mouth three times a day for pain control, not to exceed three grams/24 hours, start date 5/19/22. -Aspercreme [MEDICATION(S)] cream 4% ([MEDICATION(S)] [MEDICATION(S)]), apply to right hand and fingers topically three times a day for right hand pain, start date 5/23/22. -Ibuprofen 400 mg every eight hours as needed for pain and swelling, for three days, start date 5/23/22, discontinue date 5/26/22. -Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was prescribed ibuprofen for three day from 5/23/22 to 5/25/22 for pain and swelling but the medication was only a temporary remedy to an injury the resident received in the facility and not the resident's ongoing problems with pain, swelling and [CONDITION(S)]. The resident said in interview she felt better when receiving the ibuprofen but her pain levels increased once the temporary order was completed and discontinued. -Review of the resident's comprehensive care plan related to pain revealed there was no care plan specific to assessing, treating and monitoring the resident's right hand and forearm pain or [CONDITION(S)]. -Review of the resident's electronic medical record (EMR) revealed there was no documentation of assessment of Resident #147's pain levels anywhere in the record and the pain assessment field in the clinical weight and vitals section; was blank. -Review of the resident's June 2022 medical administration record and treatment administration record (MAR/TAR) revealed there was no documentation of pain levels when administering pain medications or documentation of the effectiveness of the pain medication treatment. There was no monitoring or recording of pain characteristic, no monitoring of quality, severity, anatomical location, onset, duration, aggravating or relieving factors. -Review of the admission data collection, MDS pain assessment, dated 5/18/22, revealed section four, Pain, was not completed; it was blank. -Review of the resident's computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #147. Review of nurse pain interview instrument, dated 5/23/22, revealed, the resident received scheduled pain medication regimen; did not receive as needed pain medication or if offered was not declined; did not receive non-medication intervention for pain; should pain assessment interview be conducted-yes; Ask resident have you had pain or hurting at any time in the last five days-no; Ask resident, how much of the time have you experienced pain or hurting over the last five days?-occasionally; Ask resident, over the past five days, has pain made it hard for you to sleep at night?-no; Ask resident, over the past five days, have you limited your day-to-day activities because of pain?-no; Numeric rating scale box-no documentation, left blank; verbal descriptor scale-mild; Frequency with which resident complains or shows evidence of pain or possible pain?-no documentation, left blank. -Two assessment areas were left incomplete and there was conflicting data with the resident receiving scheduled pain medications yet assessment documents showed no pain or hurting at any time in the last five days. In addition, the resident said in this assessment that she had pain occasionally, so the documentation of no pain or hurting was not accurate. Review of physician visit note, dated 5/23/22, revealed chief complaint as right hand pain. Documented history of [CONDITION(S)] ([CONDITION(S)], or stroke) with right side [CONDITION(S)] (paralysis of the right side of the body), right arm weakness, and contracture in the right hand. -However the facility failed to update the care plan to monitor right hand pain, or contracture following physician visit. Review of all progress notes revealed the following: 5/21/22 at 7:07 pm New order for aspercreme with [MEDICATION(S)] to right fingers every four hours as needed (PRN) for pain. Resident complained of right finger pain. 5/21/22 at 11:54 p.m.aspercreme not effective to reduce right finger pain, resident asked to speak to provider concerning this. 5/22/22 at 12:01 a.m. Right sided weakness/paresis with new pain to right fingers, Apsercream somewhat effective for pain relief. 5/23/22 at 2:39 p.m. New order for right hand and fingers x-ray for increased pain and swelling, also ibuprofen 400 mg every eight hours as needed for pain and swelling. 5/23/22 at 3:54 p.m. Resident is being monitored related to increased pain and swelling to right fingers and hand. X-ray ordered and started ibuprofen 400 mg by mouth every eight hours as needed for three days. No complaint of pain after she took her night medications during the evening shift . 5/23/22 at 10:40 a.m. Resident is having an x-ray of right fingers and hand for pain and swelling. X-ray had been taken no results yet . 5/24/22 at 5:42 p.m. Received hand/finger x-ray results .no abnormalities noted on results. Resident has no indications of pain or discomfort this shift. 5/24/22 at 6:29 p.m. Resident monitored for swelling and pain at right index finger. X-ray showed [CONDITION(S)], arthritic disease, no fracture. aspercreme with [MEDICATION(S)] applied to right hand and fingers for moderate relief, resident declined ibuprofen. 5/25/22 at 12:48 a.m. Resident is being monitored related to complaint of increased pain and swelling to her right fingers and hand. X-ray revealed no fracture but soft tissue [CONDITION(S)], [CONDITION(S)] and arthritic disease of fingers and hand. No complaint of pain this shift . 5/25/22 at 10:32 a.m. Resident is being monitored for a x-ray to right hand for [CONDITION(S)] and she has had pain. She has [CONDITION(S)] in hand. She is in bed resting and has had her morning medications she is not complaining of pain. 6/13/22 at 4:30 p.m. Aspercreme [MEDICATION(S)] Cream 4 %, Apply to right hand and fingers topically three times a day for right hand pain, refused, ' Doesn't relieve the pain per resident. 6/14/22 at 4:30 p.m. Aspercreme [MEDICATION(S)] Cream 4 %, Apply to right hand and fingers topically three times a day for right hand pain, refused x3 doesn't help. -The facility was aware of Resident #147 right hand/forearm pain and [CONDITION(S)], however, failed to provide a person-centered individualized intervention in the care plan and or review her pain management regimen except adding Aspercreme cream on 5/23/22. According to progress notes above, the resident indicated the Aspercreme cream was not effective to manage her pain. D. Staff interview The director of rehabilitation (DOR) was interviewed on 6/9/22 at 10:24 a.m. The DOR said he was not familiar with Resident #147. The DOR said the therapy department had not discussed therapy for Resident #147, or screened her for a restorative program, although there were standard orders to do so. The DOR said the therapy department, was trying to catch up on physician ordered assessment and therapeutic treatments but they were facing staffing challenges. The DOR said they were using more agency therapy staff and the occupational therapist contract had just ended. The DOR said there was a big increase in facility census and adjusting for therapy had been challenging to keep up with new admissions. The DOR said he would complete a screening of Resident #147 today. NP #1 was interviewed on 6/13/22 at 10:36 a.m. NP #1 completed a visit with Resident #147 per UM#1 request for right hand/arm pain and [CONDITION(S)] after being brought to the facility's attention. NP #1 said she noticed there was increased right hand/arm [CONDITION(S)]/swelling upon evaluation. NP #1 said the pillow elevation did make the resident more comfortable (less pain) from the shoulder to hand. NP #1 said she will call guardian to make her aware. NP #1 said she would also order an ultrasound due to the increased swelling to rule out other concerns. The director of nursing (DON) was interviewed on 6/15/22 at 1:08 p.m. She said there should have been a care plan specific to Resident #147 right hand contracture, and right hand/forearm pain and [CONDITION(S)]. A care plan was established after it was brought to the facility's attention; however it had the wrong information (left side instead of right side). The DON said she would get this information corrected. The DON said that pain levels and effectiveness of pain medication should be tracked by nurse staff. The DON acknowledged, after viewing Resident #147's MAR/TAR and vitals sections, that it had not been done. The DON said if the pain was not adequately controlled the nurse staff should call the provider. II. Facility follow-up New physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Dated 6/13/22. 6/13/22 10:45 a.m. progress note by NP #1 after being brought to the facility's attention, Resident noted with increased swelling and pain to the right hand, the resident has contracture to the right hand. skin remains intact, no discoloration noted. Right hand and arm were repositioned/elevated with a pillow. Resident is on [MEDICATION(S)] for prophylaxis. Medical doctor (MD) notified. New order for ultrasound to right hand. Guardian notified. Will continue to monitor. 6/14/22 at 11:35 p.m. progress note revealed, Doppler results faxed to physician (PHY #1) : no evidence for venous thrombus in visualized right upper extremity (RUE). Right hand knuckles were less swollen this evening shift, continued tender and painful for the resident, Tylenol 650 mg given for partial relief. -After identification of the resident's inadequate pain management during the survey, besides the doppler of her right upper extremity, only Tylenol was administered for partial relief. There was no additional review of her pain medication, or addition of non-pharmacological orders for pain management except for elevating her right hand/arm with a pillow.

Based on interviews and record review, the facility failed to ensure two (#19 and #17) of three residents reviewed had the right to a dignified existence out of 20 sample residents. The facility failed to ensure residents experienced a dignified living experience by not being subjected to staff laughing at Resident #19 and she suffered a fall and needed staff assistance to get up from the floor. Additionally, Resident #17 was observed crying, yelling out for help, and questioning why staff were not providing care; leaving the resident waiting for care (i.e. incontinent care) when they asked for and needed assistance. The feelings of dehumanization and being treated in an undignified manner were evidenced by the residents' and interviews. Resident #17 was recently admitted to the facility (3/16/22). She was able to perform some care on her own but needed assistance with some activities of daily living (ADL). The resident specifically needed assistance with toilet use, and was concerned that staff would not promptly answer her call light and assist her to the bathroom. On 3/21/22 at 10:51 a.m. the resident was heard yelling out and crying for staff help. The resident was interviewed on 3/21/22 at 10:51 a.m. she said she had been waiting for what felt like a long time for staff to assist her to the bathroom. She said she was unable to wait for staff and had a bowel movement in her adult brief. She said it made her feel awful and embarrassed and it did not feel good sitting here dirty. Resident #19 was recently admitted to the facility 1/20/22. She was sent to the hospital emergency roiagnom on [DATE] and readmitted back to the facility on [DATE]. She was able to perform some care on her own but needed assistance with some activities of daily living (ADL). The resident specifically needed assistance with toilet use, and was concerned that staff would not promptly answer her call light and assist her to the bathroom. On 3/23/22 at 4:15 a.m. the resident was heard yelling out and crying for staff help as she had fallen. The resident was interviewed on 3/24/22 at 2:00 p.m. she said she had fallen and the staff came in her room and laughed at her on the floor. She said she felt bad and humiliated and had to ask the staff to please quit laughing at me. Findings include: I. Facility policy and procedure The Resident Rights policy, effective 9/1/18, was provided by the nursing home administrator (NHA) on 3/24/22 at 4:00 p.m. It read in pertinent part, Each resident has the right to be treated with respect and dignity and cared for in a manner and environment that promotes maintenance or enhancement of his or her quality of life and that recognizes the resident's individuality. II. Resident #17 A. Resident status Resident #17, under age 70, was admitted to the facility on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/23/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance from two staff members to perform bed mobility, and transfers. She required assistance of one staff member for dressing, eating, toilet use, and personal hygiene. She required extensive assistance from one staff person for personal hygiene. She was continent of bowel and occasionally incontinent of bladder. The resident did not have any rejections of care. B. Resident interview and observations Resident #17 was interviewed on 3/21/22 at 10:51 a.m. Her call light was going off, she was sitting in her wheelchair in her room. She was crying and visibly upset, there was an odor of bowel movement in her room. She said she had only been in the facility for about a week, and there did not seem to be enough staff in the facility to answer her call light timely. She said she frequently had to wait for an extended amount of time for staff to answer her call light, but today was the worst. She said she had put on her call light awhile ago and staff still had not responded. She said she had been waiting for what felt like a long time for staff to assist her to the bathroom. She said she was unable to wait for staff and had a bowel movement in her adult brief. She said it made her feel awful and embarrassed and it did not feel good sitting here dirty. She said not only was she sitting in her bowel movement, she had not been offered or given a shower since she was admitted to the facility. Cross-reference F677; ADLs provided to dependent residents. C. Record review The resident's comprehensive care plan identified the following care needs: The activities of daily living (ADL), care plan, initiated 3/16/22, documented the following: Resident #17 is able to make most needs known, some of her needs are anticipated and met by staff, she needs one person limited to extensive assistance with ADLs, initiated on 3/16/22. The goal was for staff to assist the resident to help her maintain her functional status and decrease her risk for functional decline to perform and/or assist with completing her ADLs. The pertinent approaches included encouraging the resident to use the call bell to call for assistance. The bladder and bowel care plan, initiated 3/16/22, documented the following: Resident #17 was able to most needs known, some needs were anticipated and met by staff, she was at risk for functional incontinence. The goal was for the resident to remain free from skin breakdown due to incontinence and brief use. The pertinent approaches included check on rounds as required care for incontinence. D. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 3/21/22 at 10:55 a.m. as she answered Resident #17's call light. She said there were only two CNAs for the hallway, and they were very busy trying to answer all the call lights. She said many of the residents on the hallway required two staff members to provide care, and since they only had two CNAs, it was hard to meet all the residents' needs timely, like providing showers. Cross-reference F725; sufficient nursing staff. The CNA left the room, to retrieve the second CNA working the floor, as well as a mechanical lift to assist the resident. Registered nurse (RN) #1 was interviewed on 3/21/22 at 11:00 a.m. He said he tried to assist the CNAs as much as possible, but often times he had too much work to complete and was not able to offer much assistance. He said the facility used to have unit managers for each of the hallways, but there had not been consistent unit managers for about two months. He said that left him with approximately 36 residents that he was responsible for passing medications, proving treatments, and documenting on. He said it was nearly impossible to assist the CNA staff. Cross-reference F725. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 3/24/22 at 3:20 p.m. They said all residents needed to be treated with respect and dignity. The DON said she was unaware of the situation which occurred on 3/22/22 with Resident #17, she would begin an investigation immediately. The medical director (MD) was interviewed on 3/24/22 at 3:38 p.m. She said what happened in regards to Resident #17 was unacceptable. She said her expectation was for staff to provide timely incontinence care, so residents were never left sitting in their soiled undergarments. The NHA was interviewed on 3/28/22 at 3:00 p.m. He said all residents needed to be treated with respect and dignity. III. Resident #19 A. Resident status Resident #19, age 79, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/27/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident required a two plus persons' physical assist for transfers between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). The resident required a one-person physical assist for toileting, locomotion in and out of the bedroom. B. Resident interview Resident #19 was interviewed on 3/24/22 at 2:00 p.m. Resident #19 stated she fell at night after going to the bathroom coming back to bed. She stated she did not ring for help that night as she thought she could make it to the bathroom. She stated she fell towards the end of her bed and hit her head on the floor (cross-reference F689 for falls). She said when the staff came into her room they laughed at her. She said the laughing made her feel bad and humiliated and she had to ask them not to laugh at her. She stated please stop laughing, I am in a lot of pain. She said they tried to get her up and they could not so they tried with the hoyer lift. The hoyer lift sling did not work so she asked to stay on the floor until and insisted 911 be called. She said the paramedics took her to the hospital. C. Record review The quality assessment performance improvement (QAPI) investigation dated 3/23/22 indicated the resident fell as a result of not using the call light (cross-reference F689). An employee interview form with registered nurse house supervisor (RNS) #1, was provided by the DON on 3/28/22 at 2:00 p.m. The interview was conducted by the staff development coordinator (SDC) via telephone on 3/24/22. The interview stated, Came in after fall. Staff only discussed her fall. An employee interview form with certified nursing assistant (CNA) #8, was provided by the DON on 3/28/22 at 2:00 p.m. The interview was conducted by the SDC via telephone on 3/25/22. The interview stated, I was sitting in hallway with nurse rounding and was talking about me going home and I made a joke about it and we were laughing when we heard a loud thump. The nurse and I got up and went to check it out and we found the resident on the floor next to her walker. I said what happened and the resident told me that her legs gave out as she was coming back from the bathroom. I said you know we have discussed you needing to call for help because you have been struggling. An employee interview form with registered nurse (RN) #2, was provided by the DON on 3/28/22 at 2:00 p.m. The interview was dated 3/24/22, which documented, At nurses' station, heard noise, went into room and was on floor. Patient appeared more anxious on shift about upcoming surgery and inconsistency of staff not knowing what to do. D. Staff interviews The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 3/24/22 at 3:20 p.m. They said all resident's needed to be treated with respect and dignity. They said they had just became aware of the incident with Resident #19 and would immediately begin an investigation into the incident. The medical director (MD) was interviewed on 3/24/22 at 3:40 p.m. The MD stated she had just spoke with the resident about her fall. The MD stated the resident told her about the staff laughing. She stated the resident told the MD that her leg gave out on the way back from the restroom and she had fallen and hit her head. The MD said as soon as she learned of the incident she informed the DON of the situation. The MD stated that all of the residents in the facility deserved to be treated with respect and dignity, and at no time should any staff members laugh at any of the residents. The DON was interviewed on 3/28/22 at 1:30 p.m. She said she had begun an investigation into Resident #19 fall, (cross-reference F689) and the concern with the CNAs laughing at the resident. She said as part of her investigation she interviewed the CNAs, who stated they had been laughing in the hallway, not about the resident, and entered the room joking and laughing. The DON said it was her expectation that the CNAs would not enter a resident room laughing, or talking amongst themselves, because of the way a resident could perceive that. The DON said she had not yet begun dignity training with the CNAs involved but she planned on completing training by the end of the day (3/28/22).

Based on record review and interviews, the facility failed to ensure one (#1) out of seven sample residents received adequate supervision to prevent accidents with injuries. The facility was aware the resident was admitted with a history of falls, and after admission had a history of self-transferring and falling forward to the floor, and needed frequent monitoring, assistance and supervision. The facility failed to provide sufficient supervision to prevent an unwitnessed fall for the resident on 12/29/21 resulting in hospitalization , a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), bruising and soft tissue damage, and a skin tear to the resident's right elbow. After her hospitalization , on 1/10/22, Resident #1 was found crawling on the floor and her right wrist was discovered to have bruising and swelling. The facility failed to properly investigate the cause of her wrist injury and update her care plan with interventions to prevent further unwitnessed falls. The facility failed to assess, identify and implement fall prevention precautions to prevent two falls with injuries for Resident #1. Findings include: I. Facility policy and procedure The Fall Management and Investigation policy, effective 9/1/18, was provided by the director of nursing (DON) on 1/20/22 at 5:25 p.m. It read, in pertinent part: The facility utilizes all reasonable efforts to provide a system to review residents' potential risk for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize falls and identify residents' continued needs. -All residents are assessed prior to, or shortly after, move-in or admission for fall risk, which includes history of falls. -A care plan or service plan is developed that addresses potential risk factors for falls and recommended interventions. -Residents, family members and staff are educated on fall interventions. -Fall interventions are documented in the resident record. -The residents' family members/responsible persons and physician are notified of falls (cross-reference F580 Notification of Changes). -A care plan regarding falls is developed within eight hours of move-in, admission/readmission, and updated with significant change in status, or otherwise if required by state law or regulation, addressing potential risk factors and suggested interventions. -The fall risk evaluation tool is completed post fall. -The DON is responsible for supervising the process of review, management and monitoring procedures of residents at risk for falls. -Fall interventions and care plan review processes post fall and weekly with community team members. -Managing the processes for prediction, minimization, treatment, monitoring, and calculation of the community fall rates. Post fall procedures include: -A licensed nurse evaluates the resident immediately. The resident is not moved until the evaluation is completed, unless there is an immediate safety concern. -Immediate first aid intervention is provided if indicated. -A determination is made whether the resident requires transfer to the hospital or urgent care. -If a head injury is assessed post fall or the fall was un-witnessed, the resident is monitored, including vital signs, pupil reactions and signs of nausea/vomiting: every 15 minutes x 4, then every 2 hours x 3 then every shift x 3. -Staff determines whether resident actions, if known, prior to the fall can be helpful in identification of intrinsic factors. -The responsible person/family is notified. -The attending physician is notified and asked to review the incident, document and if indicated and make modifications to the resident's treatment and interventions accordingly. -The care plan is reviewed and revised with interventions with the resident/family participation. Post fall management and plan of care -Fall interventions are reviewed for continued effectiveness at the weekly at risk meeting. -Revised interventions are routinely reviewed and updated to ensure effectiveness at the weekly at risk meeting. -Person centered interventions are reviewed with the staff, family and resident for safety awareness and the risk and benefits of fall prevention. Post fall investigations -Falls are investigated, reported, and documented, using root cause analysis concepts. The administrator is responsible for instituting the investigation process. -A careful review and analysis of the possible contributing factors to the fall with or without injuries is completed. II. Resident #1 A. Resident status Resident #1, age 89, was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia with behavioral disturbance, COVID-19, age related [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], unspecified [CONDITION(S)], and seborrheic [CONDITION(S)]. The 12/14/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of three out of 15. She experienced hallucinations and wandering. She required extensive assistance of one or two staff members with her mobility and activities of daily living (ADLs). The resident had experienced two or more falls with no injury at the time of the assessment. B. Record review A fall risk assessment completed upon admission on 9/7/21 revealed the resident had a fall risk score of 75 which was high risk (a score over 45 was high risk). Her last fall prior to admission was on 9/3/21. She was noted to have bilateral lower extremity weakness. She required a wheelchair with maximum assistance for transfers. She was noted to slump in her wheelchair in the mornings. Interventions put into place upon admission were line of sight and close monitoring when awake. A fall risk care plan revised on 11/2/21 read: Resident is at risk for falls. She has impaired balance and impaired safety awareness and is at risk for falls. She has a history of crawling out of bed onto the floor. Mattress placed next to her bed and will observe when she crawls out of bed onto mattress r/t (related to) dementia w/ (with) behaviors. She attempts to self transfer with a modified method that involves getting to the floor and then pulling herself up to stand. She has stated on several occasions that she prefers to crawl to get to different locations in the building and around her room. Goals for the care plan included: My risk for falls will be minimized and My number of preventable falls will decrease. Interventions for the care plan included: 9/8/21 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; Caregivers will ensure that resident is wearing appropriately fitting footwear and clothing; Caregivers will make sure that call device is within reach and in working condition; Caregivers will remind resident to use call light for assistance; 9/8/21: Resident was found on the floor next to her bed three times last night. Crawling out of bed onto the floor mat. No injury. Frequent observation for 72 hours, therapy screen and staff to check on her frequently. Fall mat replaced with mattress.; 9/25/21: Resident was found on the floor in the doorway of room. Resident did not recall what she was doing and noted with minimal footwear. Observations for 72 hours, therapy screen, and staff to check on her frequently and to encourage her to wear non-slip footwear. Staff will encourage her to get up in the wheelchair when awake, especially in the morning; 9/30/21: Resident was found crawling and sitting on the room floor in the doorway. She stated she was going to get the kids and get out. Resident stated she prefers to crawl to get to different locations in the building and around her room. Staff to complete skin assessment when resident is found crawling; 11/29/21: CNA witnessed fall, resident was leaning forward in chair and fell forward out of chair. No injuries were noted. Observations for 72 hours and wheelchair changed to high back wheelchair; 12/8/21: unwitnessed fall in common area, resident was found sitting upright on the floor, leaning on the front of the seat of her high backed wheelchair. No injuries were noted, resident denied pain. Frequent observations for 72 hours. A progress note dated 12/29/21 at 3:37 p.m. read: Dr. (doctor) assessed resident post unwitnessed fall with head contact. Hematoma approximately 3 cm x 4 cm, ice pack applied. Neurological checks and frequent monitoring initiated. Pupils 3 mm reactive, hand grasps equal weak. Resident drowsy but arousable. Continue observation. Dr. will speak with family related to head exam/CT (computed tomography, used to investigate possible internal injuries). A progress note dated 12/29/21 at 9:40 p.m. read: Dr. gave new order to transfer resident to hospital for right elbow evaluation and treatment. Family contact notified. Review of the resident record revealed neurological checks were completed according to fall policy until the resident was transferred to the hospital. A fall investigation was initiated on 12/29/21 and revealed the resident was discovered on the floor at 3:45 p.m. and was previously checked on by the nurse on duty at 2:30 p.m. Her most recent fall was on 12/8/21 and resulted in a skin tear. She had an injury and was transported to the hospital for evaluation. Biological factors indicated included weakness and incontinence. Activity at the time of the incident included sitting and reaching. Ambulatory status and footwear included wheelchair, non-ambulatory, and slippers. Current medications included an antipsychotic, antidepressant, and as needed medications. There were no environmental factors indicated. The resident's medications were last evaluated on 11/29/21 and the resident's antipsychotic dosage was changed within the previous 30 days. There were no noted changes in the resident's laboratory values, functional ability, medical status, vision, continence, or cognitive status. Pertinent conditions at the time of the fall read, Resident, at times, can communicate well and clearly. Reaching behavior continues. Reminders to call for assistance or to not self transfer, may be ignored, or acknowledged and still ignored. Dementia with behavioral disturbance and change in [MEDICATION(S)] (antipsychotic medication) dosage ineffective. Review of the resident's hospital records dated 12/29/21 p.m. revealed the resident was seen in the emergency department and a CT scan showed a small (9 mm) subarachnoid hemorrhage traumatic in nature due to a fall from a seated position. A moderate amount of right periorbital soft tissue swelling and a moderate to large right frontal scalp hematoma were also present. A small left frontal mengioma (benign tumor) was discovered as well. The resident's family did not wish to pursue surgery or treatment and was considering possible comfort care or hospice. A urinary tract infection was also discovered which could have contributed to her fall, though was not septic or severe. On 12/30/21 at 7:04 p.m. a progress note read, Resident returned from hospital with new order for antibiotic for three days for urinary tract infection. No sutures were place in right elbow as skin too fragile to stitch per the hospital reporting nurse. Resident alert and in good spirits, responsive, assisted to bed successfully by two ambulance techs and promptly attempted to self- transfer out of bed. Resident transferred by two assist to high backed wheelchair and spent the remainder of the evening shift in the line of sight of this writer. A fall risk assessment dated [DATE] revealed the resident had experienced one to two falls in the past 90 days and she exhibited behaviors increasing her risk of falls. She needed assistance with toileting, was confined to her chair, was not steady and needed assistance to stabilize. She had one or two diagnoses and received one or two medications that increased her risk of falling. The fall risk assessment indicated high risk for falls. -Line of sight supervision, although identified as an intervention in Resident #1's initial fall risk assessment, was not included in her care plan or her 12/30/21 fall risk assessment. -Additional review of the resident record revealed there were no updates made to the resident care plan and no new interventions were added to the care plan related to the fall with injury on 12/29/21. There was no documentation of more frequent monitoring of the resident nor documentation of any staff education related to the resident's frequent falls and need for increased monitoring. On 1/10/22 at 4:15 a.m. a progress note read, Resident was observed crawling (dragging her body while her buttock was on the floor) in the hallway next to her room doorway. She was resting in her bed prior. On assessment, it was noted that she has a hematoma on her right hand dorsum, 12 x 15 cm. Skin was intact. A nurse supervisor was notified. A non-urgent voice message was left for her primary care physician. The resident was placed on a change of condition board to be monitored per company protocol. A change of condition evaluation was completed on 1/10/22; it revealed the change in condition was a fall on the night of 1/10/22. There were no changes noted in the resident's functional, behavioral, respiratory, cardiovascular, abdominal or gastrointestinal, or [CONDITION(S)] statuses. The resident was noted to have discoloration of skin to the back of her right hand, described as a hematoma 12 x 15 cm. Resident #1 was not noted to have any pain to the area. The evaluation revealed the resident had experienced falls before and became restless and uncontrollable when anxious. The resident's physician was notified at 3:57 a.m. but there was no indication the resident's family or healthcare agent was notified. (Cross-reference F580 Notification of Changes). On 1/11/22 at 4:47 p.m. a progress note read, Right hand x-ray results showed normal joints with [CONDITION(S)] arthritic changes, no fracture in the hand or the joints. Results faxed to physician group and relayed to family contact. Resident denied pain this evening shift. Dorsal right hand with bruising, fingertips to wrist. On 1/12/22 at 3:22 a.m. a progress note read, This resident continues on monitoring for post fall. No pain or discomfort indicated this shift. Vital signs are within normal limits. Resident is in bed resting. Call light and water are within reach. On 1/12/22 at 10:33 a.m. a progress note read, Resident is being monitored for an unwitnessed fall and swelling to the right hand. It is open to air. She has no complaints of pain or discomfort, she is sitting with husband in her room. On 1/12/22 at 6:18 p.m. a progress note read, Resident monitored for unwitnessed fall with hematoma to right dorsal hand. Bruising present, selling has been reduced. Range of motion intact, resident denied pain. Vital signs stable. On 1/13/22 at 9:44 p.m. a progress note read, Resident received all scheduled medications at 7:30 p.m. including [MEDICATION(S)] 9 mg for sleep. Resident wandered throughout the halls and attempted to enter others rooms. She picked up almost every object within reach, attempted to take trash from trash cans, devices off tables, and supplies from carts. She pulled open cabinets and pushed equipment down the hall. She grabbed at doorways to prevent being turned away. She responded, 'I know, I know' or 'Its okay, we'll have it,' to requests to leave items in place. She showed no signs of sleepiness and sat in line of sight of staff. Additional review of the resident record revealed neurological checks were completed for the resident according to the facility's fall policy from the time of the fall at 3:00 a.m. on 1/10/22 to the day shift on 1/11/22. III. Resident observation The resident was observed on 1/19/22. At 1:29 p.m. the resident's door was closed. At 1:39 p.m. a staff member exited the resident's room after providing care. The resident was observed to be well dressed and well groomed in her high backed wheelchair with her head resting on a pillow placed on her right side. She was wearing slipper boots with non-slip soles on her feet. A mattress to be used as a floor mat was observed in her room as stated in her care plan, though was not in use at the time since the resident was up in her chair. The resident's right hand and wrist were mildly swollen with healing bruising. An attempt to interview the resident was unsuccessful due to mental status. IV. Staff interviews The assistant director of nursing (ADON) was interviewed on 1/20/22 at 11:23 a.m. She stated when a resident fell , the staff member who found the resident or witnessed the fall should stay with the resident to ensure they were okay and notify a registered nurse in the building to complete an assessment. She stated the resident should not be moved until an assessment was completed. She stated the assessment should include checking for injury, checking neurological signs, range of motion, skin assessment and pain assessment. She stated the resident was then placed on 15 minute checks and neurological checks, and monitoring for 72 hours. She stated a fall investigation should be completed for each fall and interventions should be added to the care plan for each fall. She stated the investigation was to attempt to identify the cause of the fall and any patterns and the interventions were to attempt to prevent further falls or injury. She stated if a resident was found on the floor and there was not a witness to verify how they got on the floor, it should be considered a fall and all protocols should be followed. The DON was interviewed on 1/20/22 at 11:30 a.m. She stated a fall was any change in elevation for a resident. She stated if a resident was found on the floor and there was no witness to how the resident got on the floor, it should be considered a fall and an investigation should be done. She stated interventions should be added to the care plan for each fall. She stated Resident #1 was a fall risk and also had the known behavior of crawling out of bed onto her floor mat and crawling on the floor at times for mobility. She stated the behavior was care planned and known to facility staff and was not considered a fall. She stated there should have been an update and addition to the care plan for the fall with injury the resident experienced on 12/29/21. She stated there was no investigation and no interventions were added to the care plan for the incident on 1/10/22. She stated she did not consider it a fall because the resident was known to exhibit the behavior of crawling on the floor. She stated there was no formal investigation into the injury to the resident's right hand, though it was assessed, the physician was notified, and x-rays were performed the next day, and revealed no fracture. She stated the bruising and swelling were monitored appropriately. She stated the staff treated the incident like a fall and performed neurological checks and monitoring. The nursing home administrator (NHA) was interviewed on 1/20/22 at 5:35 p.m. He stated a fall was any unintended change of plane (i.e. from chair to floor) for the resident. He stated Resident #1 was a fall risk and had experienced falls in the facility, and there were care plan interventions which were consistently implemented to prevent her from falling and to prevent injuries. He stated he did not think the incident on 1/10/22 needed to be treated as a fall as this was a common behavior for the resident. He stated he understood that there was not a witness to how the resident got to the floor, though due to the behavior of crawling on the floor being a known behavior for the resident, he did not consider the incident a fall. He stated the injury to her hand should have been formally investigated for possible causes, though probably occurred from putting pressure on the wrist while crawling, but could not say with certainty. He stated the wrist injury was assessed, treated and monitored appropriately. -There was no evidence of staff training related to how to identify and take steps to prevent falls, and/or how to anticipate and provide for Resident #1's needs, to prevent further falls with injuries.

Based on record review, observations, and interviews, the facility failed to keep the residents and resident environment as free from accident hazards as was possible for one (#100) out of four out of 44 total sample residents. Resident #100 required a Hoyer (mechanical) lift for transfers. The facility failed to prevent an injury for Resident #100, who was lifted under the arms during a transfer with the Hoyer lift. The facility failed to thoroughly investigate what occured when the resident complained of pain to her right shoulder. Due to the facility failures, the resident sustained a dislocation of the right shoulder (see x-ray 1/18/21, under record review) and required transfer to the emergency room for evaluation and treatment. Findings include I. Facility policy and procedure The Incident Reporting and Investigation policy, last revised 9/1/18, was provided by the nursing home administrator (NHA) on 5/3/21 at 4:12 p.m. It read in pertinent part, Incident: (i) An unusual or unexpected event that is not consistent with the routine operation of the community or routine care of, or services provided to, a resident; (ii) an event involving a resident or visitor with unintended, undesirable o unexpected results/outcomes; or (iii) a Reportable Incident: A written incident report is completed for all Incidents and Adverse Events during the shift that the Incident or Adverse Event occurred, which includes: a. The date, time and exact location of the Incident/Adverse Event; b. The surrounding circumstances; c. Names of witnesses; d. The date/time the physician and family/personal representative were contacted; e. The outcome of the assessment and first aid rendered; f. The plan of response to the Incident/Adverse Event; and g. The signature, date and title of the team member preparing the Incident Report. h. Immediate interventions provided and changes to care plan/service plan. II. Resident #100 Resident #100, age 71, was initially admitted on [DATE] with readmission on 4/20/2020. According to the May 2021 computerized physician orders (CPO), diagnoses included borderline personality disorder, kidney failure, anxiety disorder, type two diabetes mellitus, and unspecified dislocation of the right shoulder joint. The 2/19/21 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. She required extensive assistance and two person physical assistance with bed mobility, dressing, and toileting. She required two-person total physical assistance and a Hoyer (mechanical) lift for transfers. The behavior section of the MDS assessment revealed the resident had delusions. It revealed the resident had physical behavioral symptoms directed toward others (i.e. as hitting, kicking, pushing, scratching) one to three days during the assessment period and other behavioral symptoms not directed toward others (i.e. physical symptoms such as hitting or scratching self, rummaging, verbal/vocal symptoms like screaming, disruptive sounds) four to six days, but less than daily during the assessment period. It revealed rejection of care was not an exhibited behavior. III. Dislocated right shoulder A. Resident interview Resident #100 was interviewed on 5/4/21 at 11:44 a.m. Resident #100 said she recalled her right shoulder dislocation. She said she received x-rays and went out to the hospital in January 2021 due to this injury. She said she recalled a time, she was not sure exactly when, that she was in the hoyer lift and two certified nurses aides (CNAs) were trying to transfer her into her wheelchair. She said she was not angled properly in the hoyer lift so the CNAs tried to lift her up from under her arms which really hurt and that reignited an old shoulder injury and resulted in the dislocation. She said she went out to the hospital multiple times due to this injury but the injury was unable to be reset. She said she received physical therapy and occupational therapy after the injury and was offered a sling for her shoulder but she only wore it once or twice. B. Record review The behavior section of Resident #100's care plan, last revised 1/19/21, revealed the resident had a variety of psychiatric diagnoses which all played a role in how she perceived herself. The diagnoses affected her psychosocial well being. The resident exhibited marked mood swings or emotional instability, angry outbursts and impulsivity. The resident appeared to have a long standing pattern of poor relationships and would at times exhibit respect for some staff and significant contempt for other staff, though those feelings may change rapidly depending on if she felt her perceived needs were met. The resident would cry and scream out frequently throughout the day/night when she believed staff were not assisting her fast enough. The resident declined any medications to help with mood stability. The resident's behaviors could be disruptive to the unit as she would throw objects around her room and bang on her bedside table with objects creating a potential for self-injury. Pertinent interventions included: -Provide the resident with positive feedback, compliments; -Set boundaries on her screaming out at all times and remind her that it was inappropriate and disruptive to others; -Staff to establish a good rapport with her; and, -Staff to provide active listening The care plan also documented the resident was supposed to receive care in pairs of staff due to the resident's grandiose delusions about male staff members being in love with her. The resident also made accusations toward staff and claimed that staff were the cause of her medical conditions that had no correlation to her diagnoses. The resident tended to ruminate on previous complaints that had been addressed and followed up on. The resident attempted to pit staff against each other and repeat complaints to multiple staff. The resident could be noncompliant with care at times by declining to use the bedpan and Hoyer lift and would rather remain in bed despite her desire to attend activities or get into the shower. Pertinent interventions included: -Care in pairs; -Educate the resident of the possible outcome of not adhering to the care plan; -Encourage the resident's appropriate level of participation/interaction as possible during care activities; -Provide clear explanation of care activities before they occur and during each contact; -Provide opportunities for the resident to make decisions about her treatment regime, to provide a sense of self-control and choice; -Set boundaries with the resident when she exhibits behaviors, leave and return when she has settled down; -Resident will receive counseling services; and, -Whenever possible, negotiate a time for ADL's providing the opportunity for the resident's participation in the decision making process. Provide at the mutually agreed upon time. The 1/18/21 at 2:27 p.m. behavior note revealed Resident #100 started screaming around 1:30 p.m. stating I have pain. The resident received Oxycodone and Aspercreme was applied to both shoulders. Review of the physician's orders revealed an x-ray of the right shoulder was ordered on 1/18/21. The 1/18/21 at 6:34 p.m. health status note revealed Resident #100's x-ray came back and indicated the resident had an anterior and inferior dislocated right shoulder. The 1/19/21 incident report form and 11:27 a.m. health status note revealed CNAs reported Resident #100 was up in her wheelchair on 1/18/21 and was hitting her bedside table with her back scratcher. The resident then began complaining of pain to her right shoulder. The physician was notified and initiated the order for the x-ray which showed the right shoulder dislocation. The resident was scheduled for follow up with orthopedics on 1/20/21. The 1/19/21 incident report form revealed notifications were not made to the State Agency (cross-reference F609 reporting to State Agency). The 1/19/21 physician note revealed the resident was seen by the physician in relation to the reports of shoulder pain and x-ray that noted right shoulder dislocation. The resident noted that she had an increase in pain to her right shoulder on 1/18/21 and the pain was so prevalent that she could no longer move her arm. The resident denied any recent injury to the shoulder, no recent falls or traumatic transfers prior to the pain. The resident did note that about three months prior she was being adjusted in her wheelchair and was taken under her bilateral arms and pulled up in her seat, but had not had pain over the last three months. The 1/20/21 emergency department note revealed Resident #100 had an anterior dislocation of the right shoulder. The resident's right shoulder was reduced by traction/countertraction method (a procedure to place the shoulder joint back into the socket) without complications, however, the physician was unsure if the shoulder was truly relocated (shoulder joint back in the socket) due to the resident's obese body habitus. The resident was considered a poor candidate for operative intervention, so rehabilitation services, a sling, and pain medication were recommended. -No further documentation was found or provided to indicate if an investigation was completed regarding the shoulder dislocation of unknown origin to determine the root cause of the injury (cross-reference F610 for investigations). IV. Staff interviews The unit manager (UM) #1 was interviewed on 5/4/21 at 12:12 p.m. The UM #1 said she recalled Resident #100 complained of shoulder pain in January 2021 and an x-ray was ordered. She said the x-ray revealed the right shoulder dislocation so the resident was sent to the hospital. She said the hospital indicated the shoulder dislocation was a chronic problem. The UM #1 believed an investigation was completed since the facility was unsure how the shoulder had been dislocated, however, she was unable to provide an investigation report. The NHA was interviewed on 5/4/21 at 3:22 p.m. The NHA said she was unaware of Resident #100's shoulder dislocation and the claim that it may have been caused by CNAs during a transfer. She said this would be considered an injury of unknown origin and should have been investigated to determine the cause of the injury.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program that prevented resident exposure to norovirus in the facility. The facility failed to promptly implement county health department recommendations to identify and track the virus and to promptly and consistently implement control measures, sanitation,(and) facility practices to minimize the spread of virus. These failures contributed to a norovirus outbreak that spread to four units of the facility and to residents and staff residing and working there. This created a situation of immediate jeopardy with the potential for serious resident harm. I. Imposition of Immediate Jeopardy On 11/20/17 at 3:14 the nursing home administrator (NHA), the assistant director of nursing (ADON) and the staff development coordinator (SDC) were informed that evidence revealed systemic failures in the facility's infection control program that limited the facility's ability to effectively intervene to prevent future outbreaks of infections. These systemic failures created a situation of immediate jeopardy for serious harm for all current facility residents. A. Facility Response and Removal of the Immediate Jeopardy On 11/21/17 at 2:24 p.m. the facility submitted a final (6th) version of the plan to abate the immediate jeopardy situation. It read: 1. Immediately we will clean all resident rooms and bathrooms and resident areas (hallways, nurses' stations) and dining room will be sanitized per CDC protocol (and) will be used with appropriate dwell time to ensure virucidal action has occurred. The unit manager changed room [ROOM NUMBER] bed linen today. 2. On 11/20/17 The Regional Director of Health Services along with ADON/ Infection Control Nurse reviewed current Outbreak Log with resident records to ensure accuracy and address any issues identified with the tracking of outbreak. This included a review of currently infected residents to ensure appropriate protocols and guidelines are place. The Medical Director was initially informed of Outbreak on 11/17/17 and continually updated throughout and participated in review of Outbreak log. The infection control log was reviewed with him remotely and he was updated daily with the number of any newly symptomatic residents and any notable trends. 3. On 11/20/17 the contracted housekeeping services company, HCSG, Re¿Educated the housekeeping staff beginning with the housekeeping staff that were currently in the facility and continuing until all housekeeping staff were in-serviced. There will be no housekeeping staff who work prior to receiving this education. The education included: a. Cleaning Contaminated Room -Norovirus (See attached policy specifics) b. Disinfecting Norovirus, specifically the use appropriate product (bleach). Staff were educated on PPM utilizing a handout from Tri County Health Department . It is 5000 ppm or 1 cup of plain bleach to 1 Gallon of Water. Education also included appropriate dwell times to be used for (Noro) outbreaks to include the floor cleaner and the toilet bowl cleaner. c. The re-education will also include the appropriate process by which to sanitize an infected room specifically going from dirty to clean and including the changing of cleaning solutions, mop heads and cleaning cloths between infected rooms and between bathroom and resident room. 4. On 11/20/17 the Regional Director of Nursing/ADON/S(NAME) provided re¿ Education of all nursing staff on the following issues: a. Nursing Staff will be provided education on sanitizing rooms per Housekeeping processes in the event housekeeping staff are not available. Education will include: - Cleaning Contaminated Room -Norovirus (See attached policy specifics) - Disinfecting Norovirus, specifically the use appropriate product (bleach). Staff were educated on PPM utilizing a handout from Tri County Health Department. It is 5000 ppm or 1 cup of plain bleach to 1 Gallon of Water. Education also included appropriate dwell times to be used for Noro outbreaks to include the floor cleaner and the toilet bowl cleaner. - The re-education will also include the appropriate process by which to sanitize an infected room specifically going from dirty to clean and including the changing of cleaning solutions, mop heads and cleaning cloths between infected rooms and between bathroom and resident room. - The appropriate use of PPE (personal protective equipment). - Standard precautions and procedures - Providing resident care while in Isolation, including donning and doffing of PPE when appropriate and feeding and dining assistance. The education provided to all staff regarding the care of a resident in isolation included changing bed linen when obviously soiled, per resident request, and on bath days. - Staff will be educated on the necessity of the use of Bedside Commodes during Naro outbreaks for residents who are independent and continent and have a roommate who share a bathroom. This education will include specifics on disinfecting the bedside commodes after each use utilizing the appropriate bleach product. This is monitored daily by the SDC/Designee to ensure ongoing compliance during the outbreak. - Handwashing to prevent cross contamination (including during resident dining assistance), specifically, when hands are visibly soiled, before and after resident contact, after contact with soiled or contaminated articles that are contaminated with body fluids, after contact with an object or source where there is a concentration of microorganisms such as mucous membranes, non-intact skin, body fluids or wounds, before eating or handling food, after toileting or assisting others with toileting, or after personal grooming, before starting work, before donning gloves and after removing gloves. (See attached policy for Method and steps) - Appropriate Linen and Trash Handling specifically. - Wearing standard PPE when handling soiled linen. - Ensuring soiled linen does not have any contact with clean linen. - Ensuring trash in the original liner is placed into a second trash collecting bag. - Ensuring trash and linen are transported away from the staff member's body and not dragged on floor. - Soiled infectious linen is tied into a red biohazard bag in the resident room, placed in a large linen bin and transported directly to the laundry room. - Trash from infected rooms is placed inside red biohazard bag in resident room, tied off, and then taken directly to the dirty utility room and placed in the proper biohazard receptacle. - Bedside commodes were provided for residents who are having signs and symptoms and are sharing a bathroom with another resident. Staff will be educated on the necessity of the use of Bedside Commodes during Noro outbreaks for residents who are independent and continent and have a roommate who share a bathroom. This education will include specifics on disinfecting the bedside commodes after each use utilizing the appropriate bleach product. This will be monitored daily by the SDC/Designee to ensure ongoing compliance during the outbreak. 5. Regional Clinical Director of Health Services will re-educate Nursing Management, specifically the Infection Control Coordinator. On the following items: - Infection Prevention Control program overview, Surveillance of Infections (including logging, trending and mapping) as well as Guide for Infection Prevention and Control Coordinator when to implement isolation precautions. 6. The S(NAME) initiated reeducation of the Dietary staff on the following: - Use of paper products during outbreaks - Sanitizing food transport carts - Handwashing - Safe Food Handling 7. For all education a sign in sheet will be utilized and will be reconciled with an active staff roster to ensure that all staff are re-educated. No staff will work until they have received reeducation. Education will be included with new hires annually and prn. 8. DON or designee will review surveillance log daily to identify any new outbreak related issues or trends which may need immediate attention. B. Removal of immediate jeopardy On 11/21/17 at 2:31 p.m. the NHA and regional director of nursing (RDON) were notified the above plan was accepted and the immediate jeopardy was removed. However, based on observations, staff interviews and record review, deficient practice remained at F level, widespread potential for more than minimal harm. II. Norovirus According to the Center for Disease Control (CDC) Norovirus in Healthcare Facilities Fact Sheet found on https://www.cdc.gov/hai/pdfs/norovirus/ 0-ANoroCaseFactSheet508.pdf (November 2017): - (Norovirus) illness is characterized by nausea, acute-onset vomiting, and watery, non-bloody diarrhea with abdominal cramps. In addition, myalgia, malaise, and headache are commonly reported. Low grade fever is present in about half of cases. Dehydration is the most common complication and may require intravenous replacement fluids. - Norovirus infections are seen in all age groups, although severe outcomes and longer durations of illness are most likely to be reported among the elderly. - Healthcare facilities and other institutional settings (e.g., daycare centers, schools, etc.) are particularly at-risk for outbreaks because of increased person-to-person contact. - Avoid exposure to vomitus or diarrhea. Place patients on Contact Precautions in a single occupancy room if they present with symptoms consistent with norovirus gastroenteritis. - Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., increase ward/ unit level cleaning to twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily . According to the CDC, Key Infection Control recommendations for the Control of Norovirus Outbreaks in Healthcare Settings, https://www.cdc.gov/hai/pdfs/norovirus/ 0A-NorovirusControlRecomm508A.pdf, (November 2017): - (When) symptomatic patients (that) cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. These efforts may include placing patients in multi-occupancy rooms, or designating patient care areas or contiguous sections within a facility for patient cohorts. - Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., increase ward/unit level cleaning twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily using EPA-approved products for healthcare settings). III. Facility Census and Layout According to the 11/20/17 Census and Conditions report there were 129 residents in the facility. The facility was comprised of a main floor which contained a dining room, a therapy gym and the 600 unit. Residents who were receiving skilled therapy services resided on the 600 unit. These residents received all of their meals in the dining room, on the main floor as well as all of their therapy services. Residents on who resided on the 600 unit were encouraged to stay on the main floor. There were four units on the upper level, the 100, 200, 300 and 400 unit. Each unit had double fire doors and behind each unit were resident rooms. In the common area of the upper level, there was a nurses' station and a dining room. IV. Facility failure to establish and maintain an infection control program that prevented resident exposure to norovirus throughout the facility's four upper level units. The facility failed to promptly implement county health department recommendations to identify and track the spread of the virus and failed to promptly and consistently implement recommended control measures, sanitation, (and) facility practices. A. Failure to respond to recommendations made by the county health department (CHD) to identify and track residents with symptoms of norovirus. 1. CHD employee (CHDE) interview On 11/20/17 at 10:30 a.m. the CHDE was interviewed at the facility, with a follow up interview on 11/21/17 at 9:30 a.m. over the phone. -She said the facility had contacted her on Friday, 11/17/17, to report the facility had 12 residents and 11 staff with symptoms of norovirus. She said the facility reported its first case of norovirus was on 11/16/17. (please see below surveillance form; the first case was observed on 11/15/17.) -She said she requested a line list of all residents exhibiting symptoms of norovirus and expected to receive a list with resident's name, date of onset, location, room, unit and whether they were hospitalized . She said they had received a list of residents who were exhibiting symptoms of norovirus, but the list was incomplete and she had asked, via email on 11/17/17, to be sent a complete list. She said a facility would usually send a list over the weekend to identify other residents and staff who are exhibiting symptoms of norovirus. As of 11/21/17, the CHDE said she had not received any other list. She said the employee list of staff who had symptoms of norovirus also was received and it, too, was incomplete. 2. Failure to timely and accurately complete surveillance forms identifying and tracking the status of residents with symptoms of norovirus. On 11/20/17 at 7:55 a.m. Registered Nurse (RN) #5 was interviewed. She said the facility had multiple confirmed cases of norovirus. She said after the facility had confirmed three tests, the facility stopped testing. She said on unit 200, there were 16 cases of nausea and vomiting. She said several staff members were out of the facility with symptoms. She said a resident initially had symptoms and then it spread to staff members. She said on unit 100, two residents were sent to the hospital on [DATE] related to symptoms of nausea and vomiting, one with a confirmed case of norovirus. On 11/20/17 at 8:55 a.m. (RN #3 and the nursing supervisor/registered nurse (NS/RN) were interviewed. They said there was norovirus throughout the facility on all four of the upstairs units. a. Documentation of residents with symptoms On 11/20/17 at approximately 10:00 a.m., the ADON and the SDC provided an incomplete form titled Outbreak Surveillance Form - Residents. The form documented: - The initial symptom of norovirus in the facility was resident #24 on 11/15/17 at 10:00 p.m. The resident had emesis four times. - On 11/16/17, 12 residents had symptoms of norovirus (emesis and diarrhea). - On 11/17/17, 11 residents had symptoms of norovirus (emesis and diarrhea). - On 11/18/17, five residents had symptoms of norovirus (emesis and diarrhea). - On 11/19/17, three residents had symptoms of norovirus (emesis and diarrhea). The form did not reveal which room or unit the resident was on, whether they were hospitalized , how long their illness had lasted, and whether a stool sample was collected. Later on 11/20/17 at 1:27 p.m., the SDC provided an updated Outbreak Surveillance Form - Residents form. The form had the list of residents above, the date and time of symptom onset, and date the resident last exhibited symptoms. It also listed the resident, room numbers, and documented whether the resident had gone to the hospital. The updated form read: - Two residents had been hospitalized . - Five residents' last symptoms were on 11/18/17 during the day shift. - Two residents' last symptoms were on 11/18/17 during the evening shift. - Three residents' last symptoms were on 11/18/17 during the night shift. - Two residents' last symptoms were on 11/19/17 during the day shift. - Three residents' last symptoms were on 11/19/17 during the evening shift. - Three residents' last symptoms were on 11/19/17 during the night shift. - Two residents' last symptoms were on 11/20/17 during the day shift. The updated Outbreak Surveillance Form - Residents form revealed the residents above resided on four of four of the facility units. b. Documentation of staff with symptoms On 11/20/17 at approximately 10:00 a.m. the ADON and the SDC provided an incomplete form titled Outbreak Surveillance Form - Staff. The form documented the initial resident symptoms of emesis on 11/15/17 at 10:00 p.m. (See above) The form did not list staff who had become symptomatic since the initial resident symptoms were identified. c. In an interview on 11/21/17 at 5:15 p.m., the ADON said, contrary to CHDE expectation (see above), the facility did not need to send any other information to CHD until 72 hours after the facility's last resident had his or her last symptom of norovirus. B. Failure to respond to recommendations of the CDHE to consistently implement control measures, sanitation, (and) facility practices. 1. Interview with the CHDE on 11/20 and 11/21/17 (see above) revealed CHDEs rarely go to the facility and typically assist the facility over the phone. -She said she discussed with the DON, ADON and the SDC on Friday (11/17/17) over the phone about control measures, sanitation, (and) facility practices. She said they also discussed housekeeping and the use of bleach and the ratio (bleach to water) to use. She said CHDEs went to the facility on [DATE], however, because the number of residents who had symptoms of norovirus was unusually high. -She said, contrary to the recommendations given to the facility on [DATE], while at the facility on 11/20/17, she observed that while cleaning rooms, housekeepers used the mop from room to room without changing the mop head for infected residents. She said she had talked with the housekeeping supervisor about the importance of mopping floors correctly. C. Observations and interviews revealed facility failures in control measures, sanitation, (and) facility practices on 11/20/17, prior to and after notice that these failures created a situation of immediate jeopardy. On 11/20/17 at 11:35 a.m., the ADON and SDC were interviewed about facility procedures to prevent the spread of norovirus. -The SDC said if one resident had a roommate and was positive for norovirus, a bedside commode would be placed in the room for the resident who had symptoms of norovirus whether the roommate was continent or not. -The ADON said we are isolating the unit and not isolating the rooms. He said staff should walk into a unit and don gloves and a gown. He said then staff should doff the gown and gloves and don new gloves and gown when walking into another room. The ADON said they are trying to keep the same staff consistently on each unit. On 11/21/17 at 5:15 p.m., the ADON and SDC were interviewed again. At this time, the SDC said red bins should be in all rooms for residents who have symptoms of norovirus. The ADON said when an employee was sick, they would be sent home immediately and were told they could not return until 48 hours after their last symptom. He said after their last symptom, someone from human resources or their department manager would ask the employee if they were symptom-free for the last 48 hours and determine if they were ready to return to work. Observations and interviews revealed these practices were not being implemented. 1. Unit 100 a. Nursing and Housekeeping failures 10/20/17, prior to facility notice of immediate jeopardy Nursing-related practice failures: Unit observations beginning on 8:15 a.m. - CNA #5 was interviewed on 11/20/17 at 8:15 a.m. She said the resident in room [ROOM NUMBER]B was on isolation and both residents used the toilet. She confirmed there was no bedside commode. She said the resident in room [ROOM NUMBER]B also should be on isolation but confirmed there was no isolation cart outside of the room. - Resident #29, who was the roommate of the resident who resided in room [ROOM NUMBER]B was interviewed on 11/20/17 at 8:20 a.m. He said he was aware there was a virus in the facility and said, I'm glad I haven't gotten sick yet. He confirmed he used the bathroom and was aware that his roommate also used the bathroom. Unit observations from 12:45 p.m. through 12:51 p.m. and again at 1:28 p.m. - A red bin was observed in the hall upon entering the unit and there were two isolation carts observed in the hall outside of room [ROOM NUMBER] and #110. RN #2, however, identified three residents who should be on isolation; the resident who resided in room [ROOM NUMBER]B, the resident in room [ROOM NUMBER]B and the resident who resided in room [ROOM NUMBER]A. She said both residents in room [ROOM NUMBER] were continent and both use the toilet. A bedside commode had only placed in the room recently but during the survey. - Two CNAs were observed feeding residents in unit's common area. They were observed to touch the residents with their bare hands, wipe a resident's mouth then turn and do the same with the resident on the other side of them without using hand sanitizer or washing hands in between residents. This was observed multiple times. - At 1:28 p.m. CNA #2 was overheard being asked by the resident in #114A to change her bed linens; she told CNA #2 that her linens they had not being changed since 11/16/17 when she became sick with norovirus. CNA #2 was observed walking out of resident's room with no PPE and go to linen closet. She retrieved clean linen and held the linen against her chest and then placed the linen in the resident's chair and walked out of the room. -At 1:30 p.m. CNA #2 was observed to enter room isolation rooms #114, #112 and #110, and retrieve the trash; she then proceeded to drag the large clear trash bag with trash from the four rooms down the hall. She proceeded to place trash at the end of the hallway. She did not put on PPE gear, mask or gloves as she entered resident rooms. CNA #2 was interviewed at this time. She said residents' linen should be changed by CNAs immediately after being notified linen was dirty, and CNAs should not change clear trash bags in residents' rooms. She said she changed the bags in residents' rooms because she liked to help. She also said she did not know where bags were supposed to go if they had norovirus items in them. Housekeeping practice failures 10/20/17, prior to facility notice of immediate jeopardy: The facility's housekeeping contract company policy and procedures titled, Contaminated Isolation Room Cleaning Norovirus, dated 11/20, ' read in part: Begin isolation room using guidelines: 1. Empty trash using (double bag method) disinfect the trash cans using the EPA approved solution (e.g. fresh breeze, or 3m #5 & #25 quat. Disinfectant, dispatch bleach) and let air dry, 2. Disinfect horizontal surfaces using approved EPA approved solutions, 3. Clean walls, 4. Clean cubical curtains, drapes, linen, 5. Clean and disinfect the bathroom using EPA approved solution, 6. Dust mop entire room, then bag mop head and double bag, 7. Damp mop entire room then remove mop head and double bag so there is no cross contamination, 8. Exit room, take all double bag items to laundry, mop water must be changed, disinfect all tools utilized to clean using EPA approved solution. At 1:00 p.m. until 1:20 p.m., housekeeper #1(HSK) was observed cleaning isolation room [ROOM NUMBER], and then she entered non-isolation room [ROOM NUMBER]. She put on gloves, mask, and PPE gear and walked directly to the resident bathroom. -She used her gloved hands to wet sink handles and wiped inside of the sink with gloved hands without the use of a cleaning cloth. -She then walked outside of the room with gloves, mask, and PPE to her cleaning cart placed outside of room [ROOM NUMBER], across the hallway and retrieved a cleaning cloth, toilet brush, Brev Blue Crème Cleaner, and Clorox bleach 10 to 1 diluted solution. -She then walked back into room [ROOM NUMBER] and went directly to the bathroom, wearing the same gloves, mask, and PPE gear. -She cleaned the toilet inside with crème cleaner and the toilet brush for one minute, and then went to the sink and sprayed and wiped with a dilution of bleach and water (10 to 1) for 30 seconds using a washcloth. Using the same washcloth, she sprayed the toilet and sink and quickly wiped both the toilet and the sink without letting the cleanser sit on the surfaces. -She then went and swept the floor using the broom from the cleaning cart. -She then returned to the cleaning cart and retrieved the mop which was soaking in the 3-and-1 cleaning solution. She proceeded to mop the floor and put the mop back in the solution at the cart. -She removed the trash bag out of the trash receptacle in the bedroom and placed the trash bag on cleaning cart in the trash receptacle. -She then went to clean room [ROOM NUMBER], which was across the hall and down several rooms. She did not use disinfectant or switch cleaning equipment (toilet brush, broom or mop). She failed to allow chemicals to dwell on contact surfaces for the prescribed amount of time which was ten minutes (see interview below). Neither the housekeeping contractor's policy above nor the U.S Environmental Protection Agency Office of Pesticide Programs, Registered Antimicrobial, Products Effective Against Norovirus, 6/12/17, https://www.epa.gov/pesticide-registration/list-g-epas-registered-antimicrobial-products-effective-against-norovirus (11/27/17) list Brev Blue Crème Cleanser, or 3-and-1- floor Cleaner Concentrate among identified products effective against norovirus. HSK #1 was interviewed on 11/20/17 at 1:25 p.m. She said her manager had trained her on proper precautions when cleaning rooms with norovirus. She said she was not present for the norovirus in-service on 11/17/17 because she was out sick, but had received the in-service on 11/20/17. HSK #1 said she returned to work on 11/18/17 when she felt better in 48 hours after her last symptom. She said she was not checked out by any manager before returning to work. The account manager/housekeeping & laundry (housekeeping manager) was interviewed on 11/20/17 at 1:43 p.m. -She said HSK #1 was responsible for cleaning rooms #101 through #120, shower room, glass area, laundry chute, nursing station, bird room, common area, and dirty utility room. She said she had educated staff on 11/17/17 on proper cleaning for norovirus but had not had staff sign an in-service sheet until 11/20/17. She said HSK #1 was out sick on 11/16/17 with norovirus, and in-serviced on 11/20/17, even though she had returned to work on 11/18/17 (without clearance by a manager). -She said she had in-serviced housekeeping staff to use diluted bleach for ten minutes on cleaning surfaces. She said she had to check with her manager about getting cleaning equipment like different brooms, toilet brushes, and mop heads for each room, as they were not available and staff had not been trained on their use. She said Brev Blue crème cleanser, and 3-and-1 floor cleaner concentrate were not effective in cleaning norovirus. She also provided a copy of Clorox healthcare bleach cleaner efficacy paperwork, a bleach cleaner used in the facility that had a one minute kill time but it did not list norovirus as a microorganism this product was effective against. The District Manager/Housekeeping was interviewed on 11/21/17 at 5:30 p.m. He was asked about being notified about what staff needed to handle the norovirus outbreak, and he said that the housekeeping staff would use bleach to clean the rooms. He said staff should use cleansers other than 3-and-1 floor cleaner and Brev Blue cleaner during norovirus outbreak. The ADON was interviewed on 11/21/17 at 6:00 p.m. He said his expectations were for housekeeping and facility staff to follow infection control procedures. He said this included CNAs changing anything soiled daily like bed linen and letting housekeeping empty resident trashcans. b. Nursing related practice failures on 10/20/17, after facility notice of immediate jeopardy At 3:40 p.m. resident #17, who was identified on the surveillance form with norovirus symptoms, was interviewed in his room. It was observed he did not have red bins in his room to dispose of trash and linens. He said a staff member had entered his room and said they were going to take his red bins and move them into another resident's room who was much sicker than he was. On 11/21/17 at 4:00 p.m. the NS/RN was interviewed. She said resident #17 had his last symptom of norovirus on 11/19/17 at 10:00 p.m. but then he had emesis on 11/20/17. She confirmed the resident should have red bins in his room until 11/21/17 at 10:00 p.m. At 4:09 p.m. the ADON confirmed resident #17 should have red bins in his room and he would ensure they were placed there. 2. Unit 200 a. Nursing-related failures on 10/20/17 prior to facility notice of immediate jeopardy: On 11/20/17 at 7:55 a.m., Registered Nurse (RN) #5 was interviewed. She said on the unit 200, she had a resident with an episode of nausea. She said the resident had a roommate and the resident had not been placed on contact isolation precautions. She said another resident had four episodes of vomiting. She said her roommate was her husband. She said the facility had not placed this resident on contact isolation precautions either. Unit observations and interviews beginning at 12:25 p.m. - There were two sets of red bins in the hall and two isolation bins in the hall, next to room [ROOM NUMBER] and room [ROOM NUMBER]. -CNA #3 and restorative CNA (RCNA) #1 reported the resident in room [ROOM NUMBER]A, the resident in room [ROOM NUMBER] and the resident in room [ROOM NUMBER]B all had symptoms of norovirus. CNA #3 said she thought they all three were on isolation precautions. She said the resident in room [ROOM NUMBER] refused to keep a red bin in her room. She did not think the resident in room in room [ROOM NUMBER] had had any vomiting or diarrhea in the last two or three days. CNA #3 said both residents in room [ROOM NUMBER] used the toilet. She said there was no bedside commode in the room for use by one of the residents. CNA #3 confirmed not all residents who had norovirus symptoms had red bins to dispose of contaminated items. - At 12:26 p.m. RCNA #1 was observed walking out of room [ROOM NUMBER] wearing a gown, mask and gloves. She placed the tray on the mobile cart and walked over to the red bin that was placed in the hall, and removed her PPE while standing in the hall. She then used hand sanitizer. -At 12:27 p.m. RN #2 entered Unit 200 and said out loud to CNA #3 and RCNA #1, that any time you enter any room on the unit you should wear PPE. CNA #3 said she had not heard that upon starting her shift. -At 12:30 p.m., RCNA #1 was interviewed. She said she had been sick on Friday with vomiting and diarrhea and was scheduled to be off over the weekend. She said she had returned to work on 11/20/17. She said she had not been asked by any supervisor whether she had been symptom-free for 48 hours prior to returning to work. 3. Unit 300 Nursing-related failures prior to facility notice of immediate jeopardy: Unit observations and interviews from 12:20 p.m. to 12:38 p.m.: - CNA #4 said the resident who resided in room [ROOM NUMBER]A had diarrhea that morning at 10:00 a.m. She said she was unsure if it was the first episode of diarrhea or not; she said she thought he may have had diarrhea the night before. She said the red bins are never put in the rooms but always in the hall. She said she thought, but was unsure if the resident in room [ROOM NUMBER]B had any symptoms of norovirus. - There was an isolation cart outside of room [ROOM NUMBER] and room [ROOM NUMBER] and one set of red bins in the hall. - Two CNAs were observed feeding residents in the unit's common area. The CNA would feed one resident then turn and feed the other resident after touching the resident's shoulder or wiping the resident's mouth. The CNAs did not wash their hands or use hand sanitizer in between assisting the residents. This was observed multiple times. 4. Unit 400 Nursing-related failures on 10/20/17 prior to facility notification of immediate jeopardy: Unit observations from 12:34 p.m. through 1:00 p.m.<BR

Based on observations, record review, and resident and staff interviews, it was determined that the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for one (#9) of 14 sample residents and one supplemental sample resident (#16). Specifically: For resident #9, a hospice resident with a [DIAGNOSES REDACTED]. These failures contributed to the resident experiencing uncontrolled pain that the assessing nurse described as a "pain crisis." For resident #16, the facility failed to appropriately assess, monitor, document and address resident #16's pain as ordered. The resident voiced that his pain level worsened between the time he asked for his pain medication and the time that the facility provided pain medications. Findings include: I. Expectations for Pain Management A. Professional Reference: "Clearly, for many years clinicians have been placed in a challenging situation ... they had no standards for assessment and treatment (of pain)... Critical to correcting this is establishing a standard for assessing the existence and intensity ... if caregivers do not agree on a standard for assessing pain intensity, each is likely to assess pain differently ... the care of a single patient can vary from one caregiver to another, very likely resulting in unrelieved pain. ... Many studies have shown that either lack of pain assessment or the existence of differences between the clinicians' pain ratings and those of patients is a major cause of inadequate pain management. Source: McCaffery, Margo and Pasero, Chris, "Pain: Clinical Manual," 2nd edition, Mosby, St. Louis, 1999, pp. 5 and 36.) P. 732 in McCaffery M, Pasero C: Pain: Clinical Manual, Copyright 1999, Mosby, Inc. Standards for Pain, Assessment, Treatment, and Documentation, in pertinent part, states: -Patients will be promised attentive [MEDICATION NAME] care by being informed verbally and in writing at the time of their initial interview that effective pain relief is an important part of their treatment that their report of unrelieved pain is essential, and that staff will respond quickly to their reports. -Patients will be taught to use a pain rating scale. When patients are taught to use the pain rating scale, they will be asked to set a comfort (pain relief) goal. Patients will be told that pain rated above the goal . . . will trigger an [MEDICATION NAME] dose increase, additional [MEDICATION NAME], other pain relief intervention. -Pain ratings that are persistently above the comfort goal will trigger interdisciplinary review of the pain management plan and a modification in treatment. B. Facility Pain Management Policy: The facility pain management policy was requested from the Director of Nursing (DON) on 7/7/11. The policy read in pertinent part, "PURPOSE ...To provide a consistent method for the review, planning, development and evaluation of a pain management plan of care ...pain is whatever the experiencing person says it is, existing whenever he/she says it does ...Review pain level prior to administration of ...PRN (as needed) and standard scheduled pain medications and after administration for effectiveness of medication ...Document all findings in the resident's record ...Observe resident for indicators of pain. Indicators include but are not limited to: ...Moaning, crying, and other verbalization ...residents who have dementia and cannot verbalize they are feeling pain ...Symptoms can be manifested by particular behaviors such as ...calling out for help ...Ask the resident to describe the quality of ...pain ...ask the resident what normally relieves or helps his/her pain (pharmacological and non-pharmacological interventions )... MONITORING AND EVALUATION OF PAIN AND PLAN OF CARE ...The Interdisciplinary Team (IDT) will be responsible for monitoring the effectiveness of the plan of care ... -Areas of review include ....effectiveness of current medication regime and need for medication or dose adjustment ...If PRN (as needed) medication is routinely used, medication administration times will be reviewed and a suitable regimen will be established to control the resident's pain to an acceptable level ... -The resident's plan of care will be reviewed /revised as often as indicated, but not less than quarterly ...The resident and family will be encouraged to participate in the care planning process ... -The resident's physician (MD) will be notified of changes in resident's condition and or effectiveness of medication program ...All medication changes and intolerances with recommended interventions are documented with the MD's response in the resident's record... -Document in the clinical record of each resident all pertinent information related to pain management ... -Resident's Pain Review Tool (RPRT) will be completed in the timeframes indicated ... -Medication/pain scale effectiveness will be documented on the resident's MAR (medication administration record) or facility specific pain flow sheet ... -Resident's condition change, notification and implementation of orders will be documented in the residents record ...resident's plan of care will reflect all interventions ...pharmacological ...non-pharmacological ... -An individualized plan of care will be developed according to the level and type of pain experienced by the resident ...Resident's specific requests and refusals of any intervention(s) need to be documented ... POTENTIAL CONSEQUENCES OF INEFFECTIVE PAIN MANAGEMENT ...Can affect the resident's overall quality of life ...Sleep disturbance ...depression ....Agitation/aggressive behaviors ...Adopt the most appropriate administration schedule (around the clock dosing can produce a steady release of the [MEDICATION NAME] effect and minimize side effects) ...Determine the category of the resident's pain (acute, chronic etc.) ...Contact the physician for orders." II. Resident Failures A. Resident #9 Resident #9's closed medical record was reviewed, on 7/5/11 through 7/14/11. Resident #9, [AGE] years old, was admitted to facility on 11/8/10. Her primary admission [DIAGNOSES REDACTED]. On 3/4/11, the resident was admitted to hospice care for pain management. 1. Resident Status The resident's quarterly Minimum Data Set ((MDS) dated [DATE] and the resident's significant change MDS dated [DATE] were reviewed. Both the 1/14/11 and 3/8/11 MDS revealed the following: -The resident's cognition status was alert, oriented and she was able to recall and pay attention. The resident was understood by others and understood others. -The resident needed extensive assistance of one staff for most activities of daily living (ADLs). Both MDS indicated that the resident needed limited assistance with locomotion off the unit. -The resident was incontinent of bowel and bladder. -The resident exhibited no behavioral symptoms. -The resident experienced pain and was on scheduled and as needed (PRN) medications for pain management. No non-medication interventions for pain management were noted. Both the MDS indicated a pain management assessment. -The 1/14/11 MDS pain management assessment revealed that the resident experienced pain frequently at a rate of 9 (severe) out of 10, 10 being the highest level of pain on that scale. The pain made it difficult for the resident to sleep and made day-to-day activities limited. -The 3/8/11 MDS pain management assessment revealed that the resident experienced pain occasionally at a rate of 8 (severe) out of 10 and the pain made it difficult for the resident to sleep and made day-to-day activities limited. 2. Pain Management Care Plans a. Facility Care Plan The resident's facility pain care plan was initiated on 11/19/10 and updated on 3/17/11. It read that the resident was at potential for alteration in comfort related to vertebral fracture and end stage [MEDICAL CONDITIONS]. The care plan indicated that the resident received hospice care services for pain management. -The goal for the resident #9's care plan read, in pertinent, "will state effectiveness of pain meds (medication) using a scale 1-10 X 90 days." -The approaches to care plan read in pertinent part, "ask the resident to describe and rate level of pain ...1-10 ...Medicate appropriately. Document medication use ...Assess effects of pain on resident. NOTIFY DR (physician) AND HOSPICE IF INCREASED PAIN. Monitor for non-verbal signs ...flinching, crying, grimacing ...provide medications as ordered and continually assess effectiveness ...encourage resident to rate pain on a scale of 1-10 ...Educate resident not to wait too long to request needed pain medications ...contact physician prn (as needed) if current pain medication/management appears to be ineffective." b. The Hospice pain care plan was initiated on 3/4/11. A hospice form entitled 'care plan information sheet' dated 3/4/11, read in pertinent part, "Physical Pain Scale (0-10)." The section with a subtitle "Desired level of pain rating," was left blank. The subtitle "Notes" read, "No complaints of pain - she was able to state that she wasn't in pain." 3. Pain Medications a. Routine and PRN Medications prior to 3/10/11 Review of computerized physician orders [REDACTED]. (1) "[MEDICATION NAME] 12MCG/HR (hour) [MEDICATION NAME] ...CHANGE 1 PATCH EVERY 72 HOURS." The patch was scheduled to be changed every 72 hours in the a.m. (morning). The orders further read, "CHECK PATCH PLACEMENT EVERY SHIFT ...10-6 (10:00 P.M. -6:00 A.M.) ...6-2 (6:00 A.M.-2:00 P.M.) ...2-10 (2:00 P.M.-10:00 P.M.) The patch orders were initiated on 1/13/11. (2) "[MEDICATION NAME] 5%...PATCH APPLY 1 PATCH TO AFFECTED AREA ON 12 HRS (leave patch in place for 12 hours), OFF 12 HRS FOR PAIN ? RIB AREA." (3) [MEDICATION NAME]- [MEDICATION NAME] ([MEDICATION NAME]) 5 mg/500 mg give 1 tab orally four times daily. (4) [MEDICATION NAME] 50 mg 1 tab orally three times a daily as scheduled, for a [DIAGNOSES REDACTED]." (5) "[MEDICATION NAME] HCL ([MEDICATION NAME]) 50 MG." The orders indicated that the resident was to receive one tab (tablet) orally every 4 hours as needed for chronic back pain. [MEDICATION NAME] was initiated on 12/17/10. (6) [MEDICATION NAME] ([MEDICATION NAME]) 325 MG TABLETS ... (TYLENOL) 2 TABS ORALLY EVERY 4 HOURS AS NEEDED FOR MILD PAIN." This order was initiated on 10/31/10. (7) [MEDICATION NAME] - [MEDICATION NAME] 5 mg/500 mg; give 1 tab orally every four hours as needed for chronic back pain. This order was initiated on 2/5/11. b. Hospice visit 3/9/11 - routine and PRN medication changes Review of the resident's record revealed "Hospice Nursing Revisit Notes" (HNRN). HNRN, dated 3/9/11, indicated that the resident was unable to describe her pain. -Although the HNRN indicated that the resident's current medication regiment was effective for pain relief, the Hospice Registered Nurse (HRN) discussed pain management options with facility staff. HNRN notes read in pertinent part, "Will ask to change to MS Contin." -The notes indicated patient (resident) teaching in regards to pain management and that the resident expressed understanding of the teaching. The HNRN also indicated, however, that the resident was lethargic and forgetful. -In pertinent part, the HNRN read, "will call PCP (Primary Care Physician) and ask for: D/C (discontinue) [MEDICATION NAME] & [MEDICATION NAME] (all pain medications). Will ask for MS Contin, [MEDICATION NAME] (pain medications) & [MEDICATION NAME] (anti-anxiety medication)." c. Routine medications after 3/10/11 On 3/10/11, the Hospice Nurse Practitioner (NP) wrote new orders for the resident's pain management, as recommended by the HRN. A Hospice agency form entitled "Medication Reconciliation Form (MRF)," dated 3/10/11, indicated 3/10/11 as the start date for all the new pain management medications. The MRF dated 3/10/11, read in pertinent part: "[MEDICATION NAME] mg BID (twice a day) ...PO (by mouth)...Start 12 H (hours) after [MEDICATION NAME] D/C [MEDICATION NAME] (20mg/ml ...Dose...0.25ml-0.5ml PO every 2 H PRN [MEDICATION NAME] 0.5mg tab..1 Tab PO every 6 H PRN ...D/C [MEDICATION NAME] & [MEDICATION NAME]." Review of Physician Telephone Orders (PTO) confirmed the MRF orders. PTO dated 3/10/11, read in pertinent part: -" [MEDICATION NAME]...15 mg BID (twice a day) ...Start 12 hours after [MEDICATION NAME] (patch) has been removed/ discontinued ... -[MEDICATION NAME] (20mg/ml) give 0.25ml to 0.5ml every 2 hours as needed ... -[MEDICATION NAME] 0.5mg tab: give 1 tab Q (every) 6 H PRN ... -Discontinue [MEDICATION NAME] ([MEDICATION NAME]) after new meds ([MEDICATION NAME]& [MEDICATION NAME]) arrive (are delivered from pharmacy)." PRN [MEDICATION NAME] and [MEDICATION NAME] - [MEDICATION NAME] were also discontinued on 3/10/11. d. Implementation of PTO 3/10/11 Review of the resident's record revealed that the resident's pain medications were discontinued on 3/10/11 between 12 and 12:30 p.m. -Review of the orders and 3/11 MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. -In an interview with the LPN who worked the day shift on 3/10/11 (see below), she clarified that she removed the [MEDICATION NAME] on 3/10/11 at 12:00 p.m. Per the LPN, the [MEDICATION NAME] orders were discontinued when the Hospice nurse wrote new pain management orders the morning of 3/10/11. -Review of the 3/11 MAR indicated [REDACTED]. The patch was discontinued, per review of orders, on 3/10/11; no time was documented. However, interview with the LPN who provided care during the day shift 3/10/11 (see below) revealed she discontinued all pain medications at 12:00 p.m., as ordered by the Nurse Practitioner (NP) on that date. -Review of the 3/11 MAR indicated [REDACTED]. -Review of the MAR indicated [REDACTED]. 4. Resident Status Following Medication Changes 3/10/11 - Pain Crisis a. HNRN visit notes dated 3/11/11 at 8:30 - 9:30 a.m., read in pertinent part, "Patient describes pain ...Ok now." -Under the subtitle of notes, the HNRN read in pertinent part, "Patient reports hard time sleeping last night ...change to [MEDICATION NAME](with) Rox ([MEDICATION NAME]) for break through (pain) ...Pt (patient/resident) C/O SOB (shortness of breath) at night ...Lethargic ...tired ...Pt fell back asleep after a little while." -Under the subtitle teaching, the HNRN notes read, in pertinent part, "Pt taught to ask for comfort meds when feeling SOB." -Under the subtitle for the plan for next visit notes, it read in pertinent part, "Assess - follow up ...(with) new meds change of [MEDICATION NAME]& sleep issues ...Pt reports had a hard time sleeping last night, will follow this ...might need new meds R/T (related to) same." Review of the HNRN notes revealed no indication that the hospice RN asked the resident for possible causes of difficulty for sleeping or notified the facility staff of the resident's complaints. b. Pain Crisis 3/11/11 Record review revealed the new pain medications were initiated 3/11/11 at 1900 (7:00 p.m.). At this time, the resident was documented as experiencing a "pain crisis," with the resident stating she might die. Review of nurses' notes dated 3/11/11 at 10:30 p.m., read in pertinent part: -"Resident was having a pain crisis r/t (related to) not having pain meds in system due to switching to meds that were going to be stronger/longer acting. Meds were not here yet @ 1700 (5:00 p.m.) and she (resident #9) asked that her daughter (and medical durable power of attorney/MPOA) be called numerous times stating that she felt like she may die tonight and wanted to see her daughter." -"I (nurse) called (daughter) at (6:06 p.m.), and told her (resident #9) requested her (MPOA) presence. Daughter came a little before 1900 (7:00 p.m.). I also called Hospice to see when new meds would arrive. On call RN (hospice Registered Nurse- HRN) told me (Licensed Practical Nurse -LPN) she would call pharmacy." -"Daughter came out of mom's (resident #9's) room up to nursing cart ... (with) sealed paper bag ... (with) pharmacy label asking if this was what I had been waiting for!" -"On call RN (HRN) ...also called 30 sec (seconds) after discovering white bag to say pharmacy had signed receipt from (resident # 9's name) stating meds had been received. Apparently there was a new med/delivery driver that did not know policy to drop meds off @ nurses' station. Supervisor ...notified." 5. Facility Failure to Timely Address the Resident's Pain a. Failure to properly implement 3/10/11 PTO Although the 3/10/11 PTO read: "Discontinue [MEDICATION NAME] ([MEDICATION NAME]) after new meds ([MEDICATION NAME]& [MEDICATION NAME]) arrive" and "[MEDICATION NAME] 12 hours after [MEDICATION NAME] (patch) has been removed/ discontinued," record review revealed the [MEDICATION NAME] ([MEDICATION NAME]) were discontinued approximately 30 hours before the new meds ([MEDICATION NAME]& [MEDICATION NAME]) arrived and were administered. See above; review of the 3/11 MAR, orders, nurses' notes and LPN interview revealed that the resident's [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) were discontinued 3/10/11 between 12 and 12:30 p.m. and new pain medication was not administered until approximately 30 hours later on 3/11/11 at 7:00 p.m. Interviews with the LPN and Staff Development RN (see below) confirmed this timeline of events. b. Failure to timely address the resident's pain on 3/11/11 Staff interview revealed the resident was in pain as early as 2:00 p.m. on 3/11/11. Staff failed to notify the resident's physician. The LPN who worked the evening shift on 3/11/11 was interviewed on 7/5/11 at 11:00 a.m., in the presence of the Staff Development RN (SDRN). -The LPN stated, "When I came in at 2:00 p.m. she was in pain ...By 5:00 p.m., her (resident #9's) pain was worse - it was beyond being able to verbalize! It is what I called a 'pain crisis' about 8-9 (on a pain scale of 0-10) ...her pain medications were switched (changed/discontinued), because the new medications were not here ...When she was in pain (experienced pain), hospice was changing medications." -The LPN further stated, "At 5:00 p.m., she called, she was in pain ...she was crying out and the medications were not here yet! I gave the [MEDICATION NAME] 7:00 p.m., when her daughter (resident's daughter) found medications in the resident's room." -The LPN stated, -"I do not know when patches (pain medication patches) came off but she had no patches on ...In all honesty, it had been more than 12 hours since current pain medications were discontinued" -The LPN further stated, "...we kept calling hospice pharmacy ...The day nurse called hospice and the medications were still not here by 7:00 p.m. The hospice pharmacy driver made an error by delivering the medications to the resident's room ...There is absolutely no exception for delivering medications to the resident's room ...The pharmacy drivers are aware of that ..." Although LPN interview revealed that the resident started complaining of pain on 3/11/11 at 2:00 p.m. and then complained of severe pain, documented as 'a pain crisis' at 5:00 p.m., and stated she felt like she was going to die, the resident did not receive pain medication until two hours later. The nurses' notes and LPN interview revealed staff continued to contact the hospice pharmacy about the delivery of the new medications. However, contrary to facility policy, as well as the resident's care plan, there was no documentation that the physician was notified of the resident's pain crisis, severe pain, and lack of pain medication since 12:30 p.m. the previous day. No instruction on how to promptly address the resident's pain on 3/11/11 beginning at 2:00 p.m. was sought by staff. In an interview on 7/5/11 at 3:50 p.m., the SDRN stated, "When the resident experienced pain on 3/11/11, the PCP should have been called instead of hospice." c. Failure to clarify orders and implementation of orders The LPN who worked the evening shift on 3/11/11, during the interview on 7/5/11 at 11:00 a.m., further stated that the orders (regarding the new medications) were confusing ...There was no documentation when (time) the patches were taken off (on 3/10/11) ...There is no system to document time of patch removal." In an interview on 7/5/11, at 3:50 p.m., the SDRN stated: -"The NP orders of 3/10/11 at 4:00 p.m., should have been clarified ...The fact that the [MEDICATION NAME] should have been removed 12 hours before giving the [MEDICATION NAME] am not sure when (the pain) patches were removed...there is no documentation as to when the patch was removed, yet MD orders specifically said that the patches were to be taken off 12 hours before giving the new pain medications ..." -"I do not know what time that the patches were taken off on 3/10/11 ...however, the first dose of [MEDICATION NAME] initiated on 3/11/11 at 7:00 p.m. ... over 12 hours before the new medications had been received." -The SDRN further stated, "The [MEDICATION NAME] should have been removed after the new pain management medications came in, then we should have waited 12 hours to give the [MEDICATION NAME] we should have called the PCP for clarification of orders on 3/10/11." On 7/6/11 at 2:10 p.m., per Director of Nursing (DON) and administrator (NHA) requests, the LPN who was familiar with resident #9 and was on duty on the day shift of 3/10/11, was interviewed to clarify the series of events on that date in regard to the resident's pain management changes. -The LPN clarified that although the Hospice NP wrote new pain management physician orders [REDACTED]. The LPN stated that the NP ordered all pain meds discontinued that a.m. -The LPN stated that she (the LPN) discontinued the resident's pain medications including the [MEDICATION NAME] and [MEDICATION NAME]es on 3/10/11 at 12:30 p.m. during the 12:00 p.m., medication administration rounds. The LPN stated, "I removed the patches at 12:30 p.m. That morning the Hospice Nurse stated to me (LPN) that she already ordered new meds from the (hospice pharmacy name.)" -The LPN stated that she was unaware that she was to discontinue current pain medications after the new pain medications arrived. The LPN stated that she discontinued all pain medication on 3/10/11 at 12:00 p.m., prior to the arrival of new pain medication contrary to the physician telephone order (PTO) dated 3/10/11 at 4:00 p.m. -The LPN further stated, "the medications should have come in on 3/10/11 in the afternoon but they did not ...On 3/11/11, at about 7:00 a.m., in the morning, the meds were not here ...I (LPN) and the Unit Manager (UM) called hospice to state that meds had never come ..." -The LPN stated, "That morning the resident did not complain of pain ...The Hospice Nurse came in at 8:30 a.m. (3/11/11) and assessed the resident as well ...The resident had no complaints of pain ...The hospice nurse left at 8:30 a.m., after she called the hospice pharmacy ..." -The LPN further stated, "I visualized the resident between 2:00 and 2:30 p.m. Before I left, I did not know if the meds had come in or not ...The resident denied pain on my entire shift ...She was not medicated at all for pain that entire shift ..." -The LPN stated, "I myself discontinued all (resident #9's) pain medications on 3/10/11 at about 12:30 p.m. ...That is why I called hospice first thing in the morning on 3/11/11. The last documented scheduled pain medications that were administered were on 3/10/11 at 12:00 p.m., and that is when I removed the [MEDICATION NAME] and [MEDICATION NAME]es." The LPN further stated, "I read in the nurses' notes that on 3/11/11, she (resident #9) was having a 'pain crisis' that evening ...that was terrible and disturbing to me ...My expectation is if there is no response from hospice nurse then the PCP should have been called (for pain management orders) ...On 3/10/11 at 2:00 p.m., I gave report to the evening nurse (on that date) that all pain medications were discontinued for the resident ...I clearly took the patches ([MEDICATION NAME] and [MEDICATION NAME]) off on 3/10/11 at 12:30 p.m. ...The hospice NP gave orders at 11:30 a.m. to discontinue the [MEDICATION NAME] and [MEDICATION NAME] ...The hospice nurse stated that she already ordered the new meds from the hospice pharmacy." d. Failure to investigate omissions identified in the management of the resident's pain 3/10/11 - 3/11/11. On 6/12/11 at 11:00 a.m., the DON was asked to provide any incident/concerns regarding the resident's care between 3/1/11 through 4/1/11. On 6/21/11 at 2:20 p.m., the DON stated that no incidents were investigated in regard to the resident's care during that time frame. Throughout the survey ending 7/14/11, no investigations involving resident #9 were provided and none were faxed as requested, after exit. On 7/5/11 at 10:00 a.m., the DON was interviewed about follow up on the incident regarding pain medications for resident #9, who was also a hospice patient. -The DON stated, "Hospice delivered the medications to the resident's room and (resident #9) signed for them ...I followed up with Hospice and told them to follow up with their driver and not to (deliver medications to a resident) again." -The DON further stated, "There was no follow up with staff regarding pain management ...She had the patches taken off on 3/10/11, there was no follow up with staff other than calling hospice. ...Hospice was called ...She was to start taking [MEDICATION NAME] hours after the [MEDICATION NAME] was removed ...There was a new hospice medication delivery driver." -The DON further stated, "(Resident #9) did not complain of pain until 3/11/11 at 5:00 p.m." On 7/6/11 at 11:30 a.m.; the DON was interviewed again. -The DON stated, "I agree pain assessment was not timely and pain medications were not given timely on 3/11/11...My expectation is that nurses look at the chart; they could have medicated her (resident #9) with other pain medications ..." -The DON further stated, "Current pain medications were discontinued (3/10/11), prior to verifying that the new pain medication had arrived ...The current medications should have been discontinued after the other new pain medications had arrived ...The patches ([MEDICATION NAME] and [MEDICATION NAME]) should have been removed after new pain medications were in house ...They could have known to start [MEDICATION NAME] hours ...The nurse used (poor) judgment ..." -The DON concluded, "The bottom line, current pain medications should not have been discontinued until new medications came in ...She (resident) could have been medicated timely." B. Resident #16 On 7/13/11 between 10 and 11 a.m., eight residents chosen by the facility were gathered for a resident group interview. Resident #16, along with three other residents, stated that call light response time was very slow. The residents agreed that it took about 30-45 minutes, at times, for call lights to be answered. All eight residents agreed that the facility was short of staff. The residents were asked what needs were unmet when call light response was untimely. 1. Resident #16 interview Resident #16, interviewed on 7/13/11 between 10 and 11 a.m., stated, "Sometimes when I need pain medications it takes a long time to respond for my Tylenol ...I just stay in pain until they come ..." -He said, "It happens every night ...It happened last night ...they are always apologizing ...Last night I voiced my concerns to (name of LPN) ...she said she was sorry and would try to improve ...My toe pain usually starts at (level) 5 (on a scale off 1-10) and goes to a 7 by the time they (nursing staff) get to me ...They usually ask me to rate my pain ..." -He further stated, "I told (name of LPN) last night ...Sometimes the pain is too much and I get tired of waiting after I call ...I just get up and go the nurses' station after waiting for a long time." Another resident in the group confirmed resident #16's concerns and stated, "I have seen him (resident #16) go to the nursing station after waiting for a long time for his pain medications ...we are on the same unit ...we have to wait for call lights to be answered for a long time at times." 2. Record Review Resident #16's pain care plan was reviewed. The care plan was initiated on 10/19/10 and last updated on 4/17/11. It read that the resident had alteration in comfort related to [DIAGNOSES REDACTED]. On 4/17/11, the care plan was updated and read, "requested 32 PRN pain meds for ? toe pain." -The goal for that care plan read in pertinent part, "Will state effectiveness of pain meds using pain scale 1-10 x 90 days." -The approaches to care plan read in pertinent part, "Ask resident to describe and rate pain level (1-10) ...Medicate appropriately. Document medication use ...Assess effects of pain on resident." Review of Physician order [REDACTED]. The resident MAR indicated [REDACTED]. 3. Staff Interview The LPN who worked with the resident on 7/12/11 on the evening shift and was named by the resident was interviewed via telephone on 7/13/11 at 2:00 p.m., as authorized by the DON and NHA. The LPN stated that she regularly works with the resident on the evening/night shift and agreed that she worked with the resident on 7/12/11. -The LPN stated that almost every night, when she works, the resident asks for Tylenol at about 10:30 p.m., and the LPN had to remind the resident that the resident already had his Tylenol at 8:30 p.m., and was not due to be administered Tylenol till four hours later. -The LPN stated, "Last night at about 10:30 p.m., as usual, he asked for Tylenol and [MEDICATION NAME] ...I told him that he had it at 8:30 p.m. ...He asks for Tylenol for his right toe pain ...He has pain every night and he rates his pain at about 5-6 when he calls, usually at 10:30 p.m. ...he asks for more Tylenol ...but he already had it (Tylenol) at 8:30 p.m., it's too early ...he can have it every four hours ... he is forgetful ...So I go in and remind him that he already had Tylenol at 8:30 p.m." -The LPN further stated that on 7/12/11, "He continued to state that his right toe hurts ...I looked ...the pain was moderate." The LPN further stated, "I think he forgets that he already had it (Tylenol and [MEDICATION NAME]) ... Last week he did the same thing, called almost daily at 10:30 p.m., and told me he wanted Tylenol and [MEDICATION NAME] ...I said you had it already (at 8:30 p.m.) and he said 'never had it ...He called later again and I gave him Tylenol last week." 4. Facility Failures a. Failure to address resident's complaints of ineffective pain relief Review of the resident's "PAIN ASSESSMENT" form dated 7/11 revealed no pain at bedtime on 7/12/11, contrary to the resident a