Every finding on record at Clarkson Health Care

Based on South Dakota Department of Health (SD DOH) complaint report, record review, observation, interview, and policy review, the provider failed to monitor and implement resident-centered pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (1) who was identified at risk for developing pressure ulcers and developed an unstageable (wound bed not visible due to covering, such as debris, dead tissue, scabbing, or a non-removable dressing) pressure ulcer to her coccyx (tailbone) area and required surgical debridement, and one of one sampled resident (2) who was admitted to the facility with two stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcers on her left buttocks and developed two additional stage II pressure ulcers to her left buttocks. Findings include:1. Review of the 3/4/26 SD DOH anonymous complaint report revealed that resident 1 was admitted to the facility on [DATE] and did not have any skin conditions. She was walking with the assistance of two staff members and used a stand aid lift (a mechanical lift used to assist from a seated to a standing position). A pressure injury was identified on her coccyx area on 1/18/26. She developed a fever and was transferred to the emergency room on 2/11/26 for a suspected infection to that coccyx wound. Resident 1 had surgical debridement to her wound, which then required a wound vac (a portable medical device that uses suction to accelerate healing) treatment. The complaint outlined concern that the resident was not being repositioned in bed frequently enough, which led to the development of a pressure ulcer. 2. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. She had a diagnosis of cerebral infarction (a type of stroke caused by a blockage in blood vessels supplying the brain, resulting in tissue death due to the lack of oxygen) with hemiplegia (a form of paralysis causing total or partial loss of motor function on one side of the body) affecting the right side of her body. A nurse assessed her skin when resident 1 was admitted to the facility and documented in a progress note that resident 1's sacral and coccyx areas were both pink and blanchable (a red area that turns white or pale when pressed, then returns to its original color, indicating temporary constriction of blood vessels). Resident 1 had a 1/18/26 nursing note written by registered nurse (RN) E that indicted she had two non-blanchable (an area that does not turn pale or white when pressed on indicating there was blood leaking from vessels under the skin) suspected deep tissue pressure injuries (SDTI; a form of pressure injury characterized by localized damage to the underlying soft tissue while the skin is still intact) to her coccyx. The first site measured 17 centimeters (cm; length) x 25 cm (width) and the second site measured 8 cm x 7 cm. The area was dark maroon color, slightly boggy [skin tissue with a soft, spongy, or mushy texture usually indicating underlying tissue damage]. RN E initiated a repositioning schedule for resident 1 to be repositioned every 2 hours, and updated resident 1's power of attorney (POA; someone designated on a legal document to act on behalf of a resident), and physician. RN E documented both wounds as pressure ulcers. Resident 1's medication administration record (MAR) included applying a mepilex (a silicone foam dressing) to resident 1's coccyx and to change that dressing as needed ordered on 1/18/26. On 1/20/26 the mepilex order was updated to change the dressing on Tuesdays and Fridays, and to assess for signs/symptoms of infection, IE [such as]: redness, warmth, odor, pain, and drainage, and document as needed. A physician's order to initiate repositioning every 2 hours for offloading (to lessen pressure) was added to resident 1's MAR on 1/23/26. On 1/26/26, RN F assessed resident 1's wound and noted in a skin assessment progress note that the stage cannot be confirmed because it is obscured by 100% black, dry, firmly adherent eschar [a thick, dry, leathery layer of dead, necrotic tissue that forms over severe skin wounds], measuring approximately 8 cm x 3 cm. RN F consulted with the provider's contracted wound specialist and the resident's physician, and resident 1 received a physician's order to apply medihoney (a medical-grade, sterilized honey used to treat wounds and burns) to the wound, cover it with a dry gauze dressing, and change the dressing daily. On 2/11/26 at 6:40 p.m. a nursing note indicated resident 1 had developed a fever of 100.7 degrees F (Fahrenheit). She was sent to the emergency room for that fever to determine if the cause was her coccyx wound. She was admitted to the hospital on [DATE], had surgery for debridement of her coccyx wound, and a wound vac was placed on her coccyx wound for treatment. Nursing progress notes indicate that resident 1 was discharged from the hospital and returned to the facility on 2/20/26. On 3/4/26 she received physician's orders for comfort care (a specialized medical approach focused on relieving pain, symptoms, and stress for patients with serious, terminal illness), and resident 1 passed away on 3/5/26. Her physical therapy evaluation on 1/8/26 indicated resident 1 was able to transfer with the assistance of two staff members and a stand aid lift. The occupational therapy notes from 1/8/26 indicated that resident 1 required a mechanical lift sling for completion of all ADLs [activities of daily living] for positioning. Donned [put on] sling to promote posture and positioning. Occupational notes indicated that she required verbal cues for repositioning. Her 2/11/26 physical therapy note indicated that she used a stand aid lift well and was able to stand for longer periods when the physical therapist supported her right upper extremity. Her right arm and right leg remained flaccid and physical therapy had to assist with passive range of motion (moving a joint through its range without muscle contraction from the resident) exercises for that arm and leg. Resident 1's 1/5/26 baseline care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) included a problem area, I have potential for pressure ulcers related to immobility, incontinence [involuntary urine or bowel leakage], dx [diagnosis] of CVA [cerebral infarction] with hemiparesis/hemiplegia affecting the right side. The interventions listed for this problem area included please complete a Braden assessment on me per facility protocol, please monitor my skin daily during cares and bathing, and report any changes to my nurse, and I have a pressure reducing device, pressure redistributing mattress, and [a] wheelchair cushion. Resident 1's care plan remained the same from her admission to the facility on 1/5/26, to 1/18/26 when the coccyx wound was first identified, to 2/11/26 when the resident was admitted to the hospital and required surgical debridement of her coccyx wound. Resident 1 had a 1/6/26 Braden score (a tool used to assess the risk of developing pressure ulcers) of 14, which indicated that she had a moderate risk of developing pressure ulcers. She had a 1/7/26 physician's order to complete her Braden assessment every week for the first four weeks at the facility. Her second Braden assessment score on 1/13/26 was 15, her third Braden assessment score on 1/20/26 was 16, and her fourth Braden assessment score on 1/27/26 was 15. These scores indicated that resident 1 continued to have a moderate risk of developing pressure ulcers during her first four weeks at the facility. Resident 1's 2/20/26 hospital discharge summary indicated that she was admitted on [DATE] for evaluation of fever and concern for sepsis (a life-threatening emergency in response to an infection) in the setting of a worsening sacral wound. The physician summarized that in the emergency room, resident 1 has laboratory results that revealed evidence of systemic inflammation. A magnetic resonance imaging (MRI; a non-invasice medical imaging technique that created a detailed image of soft tissues, organs, and bones) was performed on 2/12/26 and the results did reveal surrounding cellulitis [a bacterial infection causing red, hot, swollen, and painful skin] and mild reactive edema [excessive fluid buildup caused by an underlying condition] in the coccyx. Surgical services were consulted and she had debridement (the medical removal of dead, damaged, or infected tissue from a wound to promote healing and prevent infection) of her wound on 2/14/26. On She had a bone biopsy (a surgical procedure that removes a small sample of bone tissue to diagnose disease) performed during her surgery that showed multiple bacteria, including Pseudomonas, E. Coli, and Enterococcus. 3. Review of resident 2's EMR revealed that she was admitted to the facility on [DATE]. Her 3/25/26 nursing admission note written by RN G indicated that resident 2 had two stage II pressure ulcers to her left buttock, one measuring 0.5 cm x 0.5 cm and the other measured 3 cm x 5 cm. A 3/28/26 nursing progress note written by RN H indicated that resident 2 had two new open wounds to the left buttock. One was to the outer left buttock and one to the upper left buttock. They both measured 1 cm x 0.5 cm and were labeled as pressure injuries. Resident 2's 3/24/26 care plan indicated that she had a problem area I have potential for pressure ulcers related to immobility, incontinence, and diagnosis of neuropathy (nerve damage often causing numbness, tingling, muscle weakness, and pain typically in the hands and feet). The interventions listed for this problem area included please complete a Braden assessment on me per facility protocol, please monitor my skin daily during cares and bathing, and report any changes to my nurse, and I have a pressure reducing device, pressure redistributing mattress, and [a] wheelchair cushion. She had a problem area on her care plan that listed out her current skin conditions, including pressure injury to right buttocks - stage III (3; open wound with full-thickness skin loss) and pressure injury to left buttock - stage III The approaches for this intervention included please turn and reposition me as appropriate, please assess and document on the condition of my ulcer per facility protocol, and please treat my ulcer per facility protocol. Further review of resident 2's EMR showed no further documented wound measurements or characteristics (measurements, color, drainage, odor,) after the 3/28/26 documentation. 4. Interview on 4/14/26 at 4:10 p.m. with LPN I revealed that the residents received a bath two times a week. The bath aide was responsible for monitoring the resident's skin and would notify a nurse of a skin concern that the bath aide might have seen. LPN I stated that if a resident was admitted to the facility and had a pressure injury, then that resident would be provided with a pressure redistributing mattress. She was not sure who updated the care plan or ordered the specialty mattress. 5. Interview on 4/15/26 at 7:52 a.m. with certified nurse aide (CNA) C and CNA D revealed that the CNAs were responsible for repositioning the residents on the hallways that the CNAs were assigned to. If a resident was on a repositioning schedule, then that information would be provided to the next CNA during their change of shift report. The facility utilized a paper sheet for the CNAs to refer to that had resident information such as the residents' room number, if the resident needed their bed linen changed, a bath, when they took a nap, and special considerations regarding their care on a particular day. Those paper sheets were updated daily by the night shift staff. CNA C and D would write on their paper sheet if a resident was on a repositioning schedule, including the last time that they were repositioned. At the end of their shift, they would document a checkmark on the reposition Q2 [every two hours] task in the resident's EMRs and then the CNAs would shred that paper with resident information on it. CNA C and D stated that they were unable to document every individual time they repositioned the residents in the EMR or MAR. 6. Interview on 4/16/26 at 7:52 a.m. with director of nursing (DON) B and RN F revealed RN F was the skin nurse. The direct care staff were expected to fill out an incident report and checklist when a resident's wound was discovered. The resident's RN was expected to notify the resident's physician, document the wound in their care plan, and indicate the interventions from the physician in that residents MAR. All residents have a bath at least once per week and have their skin checked by the bath aide at that time. If there were concerns with the resident's skin, the bath aide was expected to call a nurse into the shower room so they could perform a skin assessment. There were several different bed options for the residents. The bed option that was chosen for a resident depended on the stage of the resident's pressure ulcer. The facility had beds that could accommodate up to a stage IV (4; open wound with full-thickness skin loss. Bone, tendon, or muscle may be visible) pressure ulcer. When a resident was placed on a specialty mattress, it was expected to be documented in that resident's care plan. The CNA's were expected to document the two hour turns/repositioning in the resident's EMR, and the nurse was expected to document if a resident refused or was unable to be repositioned. 7. Interview on 4/16/26 at 1:33 p.m. with DON B revealed that when a resident was bathed, the bath aide was expected to notify the RN so they could assess the new skin concern. The RN would then relay this information to RN F to assess the wound, help develop a treatment plan, contact the resident's physician to receive orders to treat that wound, and update the resident's care plan. DON B acknowledged that any nurse could document a resident's wound, and it was not just the responsibility of the skin nurse. DON B expected the staff to be repositioning residents who were at risk for developing pressure ulcers. She was not aware that CNAs were only able to document one checkmark per shift on the resident's EMR to indicate the resident was repositioned. DON B acknowledged that the residents who were admitted with a risk for developing pressure ulcers had the same interventions in their care plans. DON B stated that if skin concerns were found during the resident's admission, then she expected the resident's care plans to reflect those concerns. She acknowledged that documenting a dressing change was not the same as documenting an assessment of a wound. She stated that the nurses were not expected to document a full wound assessment when they performed the dressing changes throughout the week, and that there was not a process for the completion of resident wound assessments. DON B did not know how resident 1 developed an unstageable pressure ulcer when she was able to stand and walk with the assistance of two staff members and worked with physical and occupational therapy. She would have expected resident 2's EMR to have weekly wound assessments and she would have expected the care plan to be updated if more pressure injuries were found at the facility. 8. Review of the provider's 6/17/15 Skin Care/Pressure Ulcer policy revealed that all residents were considered at risk upon admission. Some of the listed interventions in the policy for all residents included a pressure reducing mattress, a full-body skin assessment, a review by the registered dietician, incontinence products if applicable, interventions addressed on the care plan as appropriate, and interventions to be implemented based on the resident/responsible party's choice. The policy indicated that the assessment of pressure ulcers included the type of ulcer (pressure or non-pressure), the ulcer's stage, characteristics, progress toward healing and potential complications, if an infection was present, pain, dressings or treatments, and if there wass no improvement in two to three weeks, then the physician would be notified. Weekly pressure ulcer documentation should also include location, stage, size, undermining [a complication where tissue destruction occurs under the skin at the wound edges creating a pocket] /tunneling [a narrow passageway of skin destruction from the wound bed into surrounding tissue or muscle], wound bed color, drainage, peri-wound tissue (color, temp, bogginess, fluctuation) and any need for debridement or presence of odor.

Number of residents sampled:Number of residents cited:Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (30) observed self-administering a nebulizer (device that converts liquid medication into an inhaled mist) treatment in his room, was assessed for the ability to safely self-administer medications according to the provider's policy.Findings include: 1. Observation and interview on 7/23/25 at 8:52 a.m. of a medication pass with licensed practical nurse (LPN) I revealed:*LPN I assembled resident 30's medications taken by mouth, his inhaler, and nebulizer solutions from the Elm/Oak medication cart in the Oak common area.*She brought the medications and supplies to resident 30's room.*Resident 30 was administered his pills and his inhaler.*LPN I put two nebulizer solutions, ipratropium bromide (a medication used to open the airway of people with lung disease), and levalbuterol (a medication for wheezing and shortness of breath) into resident 30's nebulizer administration device, placed the mask on resident 30's face and turned on the nebulizer.*LPN I told resident 30 she would set a timer to remind her to return and take off his nebulizer mask and left the resident's room.*LPN I stated there were not any residents in the facility who self-administered medications.*She confirmed by leaving resident 30 after setting his nebulizer treatment up for administration he was self-administering the medication.*She would not be able to verify resident 30 was administered all of the medication in the nebulizer device because she had not remained in the room while he was taking the nebulizer.*She did not know if resident 30 had a completed assessment for the ability to safely self-administer his nebulizer medications. 2. Review of resident 30's electronic medical record (EMR) revealed:*His 6/5/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact.*He had a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and can make it difficult to breathe).*A 7/1/25 physician's order for Ipratropium bromide 0.02% solution for inhalation [generic]; [physician's name]: Inhale 2.5 ml [milliliters] (0.5 mg [milligrams] total) by nebulization Three Times a Day, and Levalbuterol 1.25mg / 3ml solution for nebulization [generic]; (physician's name): 3 ml (1.25 mg total) by nebulization Three Times a Day.*There was no physician's order for him to self-administer the nebulizer medications.*There was no self-administration of medications assessment completed.*Self-administration of medications was not included in resident 30's 7/23/25 care plan. 3. Interview on 7/23/25 at 3:25 p.m. with resident 30 revealed:*Nursing staff would usually set up his nebulizer medications for administration, leave his room while the nebulizer was being administered, and then return after the nebulizer was complete to clean the nebulizer mask.*He was comfortable self-administering his nebulizer medications. 4. Interview on 7/23/25 at 3:27 p.m. with director of nursing (DON) B revealed resident 30 had not had a self-administration of medications assessment completed. 5. Interview on 7/24/25 at 12:45 p.m. with administrator A and DON B revealed:*No residents in the facility had been assessed to safely self-administer medications.*DON B expected LPN I would have remained in resident 30's room to monitor the administration of the nebulizer medication, if he was not assessed to safely administer them.*She confirmed by LPN I not remaining in resident 30's room during the administration of the nebulizer, resident 30 was self-administering his nebulizer medication. Review of the provider's 10/8/12 Medication Self-Administration policy revealed:* An individual Resident may self-administer drugs if the interdisciplinary team (IDT) has determined that this is a safe practice.* If a resident requests to self-administer drugs, the IDT is responsible for determining if it is safe for the Resident to do so before the Resident may do so.* Documentation of the self-administration plan should be done in the Resident's care plan.* The facility may require that drugs be administered by the nurse of medication aide until the IDT has had an opportunity to obtain information necessary to assess the Resident's ability to self-administer drugs. ,

Number of residents sampled:Number of residents cited:Based on observation, interview, record review, and policy review, the provider failed to ensure: *Medication labels matched the current physician orders for one of one randomly observed resident (28) according to the provider's policy. Findings include: *Medications with shortened expiration dates [medications that, after opening, expire prior to the manufacturer's expiration date] were labeled properly and disposed of after having outdated for one random resident (18) in one of two medication carts, (Maple/Aspen cart) and a provider stock medication in one of one medication room. 1. Observation and interview on [DATE] at 8:21 a.m. with certified medication aide (CMA) N during medication pass revealed:*Resident 28's artificial tears eye drops (medication for dry eyes) medication administration order (MAR) read, Artificial Tears (dextran 70- hypromellose) eye drops (Dextran 70-hypromellose) - 1 drop Opthalmic [related to the eye] Four Times a Day, and the pharmacy medication label read one drop to both eyes four times per day as needed.-The MAR did not indicate which eye the artificial tears eye drops were to be administered into.-The MAR order indicated the artificial tears were scheduled to be administered four times per day while the pharmacy label indicated the artificial tears were to be administered four times a day as needed.*CMA N indicated she gave the artificial tears in both of resident 28's eyes because resident 28 had always told her to put it in both of her eyes.*CMA N verified there was no direction on the MAR to indicate which eye the artificial tears were to be administered into, and the directions on the pharmacy label and in the MAR did not match.*RN clinical care coordinator F asked resident 28 which eye she was to receive the artificial tears into and resident 28 stated she received in both of her eyes. Interview and record review on [DATE] at 8:30 a.m. with registered nurse (RN) clinical care coordinator F revealed:*She verified the artificial tears order on resident 28's MAR did not indicate which eye the drops were to be administered into and the MAR instructions for administration did not match the pharmacy label instructions.*She verified the pharmacy label should have reflected the accurate administration instructions in order to complete the medication administration checks prior to administration of a resident's medication.*RN clinical care coordinator F retrieved the original physician's order for the administration of the resident's artificial tears, which indicated the artificial tears were to be administered into both eyes four times daily. Interview on [DATE] at 9:23 a.m. with CMA N revealed:*She had been a CMA at this facility for about one month.*She was a CMA prior to beginning her CMA position at this facility.*She had not noticed resident 28's MAR did not include which eye the artificial tears were to be administered into because she trusted the training she was provided by the nurses, and that was to administer resident 28's artificial tears into both eyes.-Additionally resident 28 had always told her that she received the artificial tears in both eyes.*If she would have noticed resident 28's MAR for artificial tears did not contain which eye the medication was to be administered into she would have asked the nurse to clarify the order. 2. Observation and interview on [DATE] at 10:40 a.m. of the medication room with RN clinical care coordinator F revealed:*Inside the refrigerator in the medication room was an opened vial of tuberculin solution (an injectable medication used to test for tuberculosis).*There was no date documented on the vial or the box the tuberculin solution was stored in to indicate when the vial was opened or when it use-by date after opening.*RN clinical care coordinator verified the tuberculin solution was open, and did not contain a date to indicate when it was opened or when it expired.*She stated the tuberculin solution was to be destroyed 30 days after the vial was opened, but she was unable to determine when the 30 days would have been because there was no date to indicate when the vial was opened.*She stated the tuberculin solution was used last week to test one staff member that was unable to have his blood drawn for the Gold test (a laboratory test for tuberculosis) that the facility routinely used. 3. Observation and interview on [DATE] at 11:40 a.m. of the Maple/Aspen medication cart with licensed practical nurse (LPN) K revealed:*Resident 18's latanoprost (medication used to treat increased pressure in the eye) eye drops were documented as opened on [DATE] and did not have an used-by date after opening identified on the bottle or box the eye drops were stored in.*LPN K confirmed that resident 18's latanoprost contained an opened date of [DATE], and that there was not an used-by date after opening indicated on the bottle or box that contained the bottle of latanoprost.*She was not sure how long latanoprost was able to be used for after opening before it needed to be destroyed.*She indicated there was a reference related to medications with shortened expiration dates in the narcotic binder on each medication cart.*The narcotic binder for the Maple/Aspen cart was not on the medication cart at that time for her to reference. 4. Review of the provider's undated Expiration Dates of Medications resource revealed:*Tuberculin solution was to be destroyed 30 days after opening.*Latanoprost eye drops were to be destroyed 6-weeks after [the] bottle has been opened or expiration date on the box; whichever comes sooner. 5. Review of resident 18's [DATE] MAR revealed he was administered latanoprost eye drops nightly from [DATE] through [DATE]. Those administrations occurred after the bottle should have been discarded since they were after six weeks from the date the bottle was opened on [DATE]. 6. Interview on [DATE] at 12:45 p.m. with administrator A and director of nursing (DON) B revealed:*It was DON B's expectation that the pharmacy labels on the resident's medication match the physician's order in the resident's MAR.*Resident 28's MAR should have indicated which eye an eye drop should be administered into to ensure the physician's order was followed.*The tuberculin solution should have been dated when it was opened to determine when it would have needed to be destroyed.*The latanoprost should have been destroyed six weeks after it was opened.-She verified resident 18's latanoprost should have been destroyed on [DATE]. Review of the provider's [DATE] Medication Procurement/Labeling policy revealed:* To ensure all medications (prescriptions, over-the-counter, and homeopathic) are obtained and administered in accordance with State and Federal regulations.* All medication coming into the facility must have:-1. Physician's order containing:--a. Resident name--b. Name of medication--c. Dosage--d. Route (i.e. oral). For topical medications, site must also be specified.--e. Frequency (i.e. one hour before meals)-2. Proper labeling (must match all elements of [the] physician [physician's] order with no variances) Any exceptions to the above requirements must be addressed with nursing services prior to [the] administration of medications.

Number of residents sampled:Number of residents cited:Based on observation, interview, and manufacturer's manual review, the provider failed to assess the safety for one of one sampled resident's (10) side rail to be sure it was fastened securely to the bed and for possible risk of entrapment. Findings include: 1. Observation and interview on 7/22/24 at 2:47 p.m. with resident 10 in his room revealed:*He had a black upside-down U-shaped side rail on the left side of his bed.*It was located about halfway between the foot and the head of his bed.*The D shaped opening at the top of the side rail measured eight inches wide by four and a quarter inch high.*He stated he used the side rail to reposition himself while he was in bed.*He had been educated on how to use the side rail by staff.*He had an electronically adjustable bed. 2. Review of resident 10's electronic medical record revealed:*He was admitted on [DATE].*His 5/8/25 Brief Interview for Mental Score (BIMS) assessment score was 14, which indicated he was cognitively intact.*His 7/23/25 care plan indicated:- I require assistance with my ADL's [activities of daily living] related to a history of falls, physical limitations, depression, incontinence, and antidepressant use.- I use a bed cane [side rail] to reposition in bed.*The 4/22/25 Negotiated Risk-Side Rail assessment reflected, Update maintenance to install the side rail device. Maintenance installs side rails per manufacturer guideline and compatible with bed/mattress. Maintenance will complete quarterly checks of the side rail for ongoing appropriate installation and secure fit. Maintenance will be advised if side rails need to be removed, if the become loose, or if there are any other apparent concerns with physical installation of the device. 3. Interview on 7/23/25 at 12:03 p.m. with director of nursing (DON) B revealed:*The provider did not have a policy related to side rails.*She referred to the provider's 8/13/12 Restraint policy when the provider's side rail policy was requested. 4. Continued observation and interview on 7/23/25 at 12:20 p.m. with resident 10 in his room.*He had chosen and purchased the side rail, that his son-in-law installed on the.*The side rail had been on his bed for about four to five months.*To get out of bed he would use the side rail to lean his back against, then he pulled himself forward to the other side of the bed.*At times he would push against the side rail while he was seated on the bed to get out of bed.*The side rail could be moved towards the foot and the head of the bed.*Resident 10 stated that at times the strap that secured the side rail to the bed would loosen, as it was at that time, which made it possible to move the side rail around on the bed. 5. Interview on 7/23/25 at 3:27 p.m. with physical therapist H revealed:*Resident 10 was currently working with physical therapy due to an increased number of falls.*Resident 10 was independent with getting in and out of bed.*She had not witnessed how resident 10 used the side rail to get in and out of bed.*She was not aware of where the side rail was attached to the bed, that it was loose, or how resident used the side rail.*He had been educated by therapy to use the head of the bed adjustments to assist himself into a seated position in the bed to make the transfers out of bed easier for him.*The therapy department had not completed an assessment on resident 10 for entrapment risks or his side rail. 6. Interview on 7/23/25 at 4:20 p.m. with certified medication aide (CMA) O revealed:*Resident 10 used the side rail to get in and out of bed by pulling on the side rail to sit himself up.*He was independent with getting in and out of bed.*She had not noticed resident 10's side rail being loose.*If she had noticed it was loose she would notify maintenance to have it secured.*She was aware of the risks of entrapment related to side rail use but did not feel resident 10 was at risk related to his side rail.*She indicated it was the provider's protocol to have a resident or resident's representative sign a release of liability if they requested the use of a side rail. 7. Interview on 7/23/25 at 3:27 p.m. with plant manager E revealed:*He oversaw maintenance for the facility.*The therapy department was responsible for the installation of bed rails.*Resident 10 had purchased his own bed rail on his bed, but plant manager E was not sure who completed the installation of the bed rail on resident's bed.*He completed bed rail checks when he did the routine room checks.-He checked the tightness of the bed rail, and clearance of the bedrails on the adjustable beds.*He had not taken measurements in the zones of entrapment or completed an entrapment assessment for resident 10's side rails. 8. Interview on 7/24/25 at 12:45 p.m. and continued interview at 1:40 p.m. with administrator A and DON B revealed:*Facility staff had not installed resident 10's side rail onto his bed. The DON entered his room to find it already installed on 4/22/25.*An entrapment assessment had not been completed for resident 10 related to the side rail.*She did not consider that side rail a risk of entrapment because of resident 10's cognition.*No measurements had been taken to assess for entrapment risk related to his side rail.*The provider did not have a formal process or policy to assess for entrapment risk.*When asked about the opening dimensions at the top of resident 10's side rail, related to the entrapment prevention guidelines, DON B stated those measurements were recommendations not requirements.*DON B did not consider resident 10's side rail to be a restraint but had referred to the restraint policy when a bed rail policy was requested.*DON B indicated there was not a side rail policy.*It was the DON's expectation that if staff noticed a side rail was loose, they were to notify maintenance to have it tightened to ensure resident safety.*If a resident requested a side rail then an assessment would be completed and the side rail would be reevaluated with the resident's quarterly assessments.*As a facility side rails were discouraged because of recurring assessments that should have been completed for them. Review of the provider's 8/13/12 Restraints policy revealed, It is the policy of this facility not to use physical or chemical restraints for the purpose of disciple or convenience. Review of the undated manufacturer's instructions for the Panacea 3500 Bed revealed:* The Hospital Bed Safety Workgroup (HBSW), in partnership with the FDA, has recognized potential entrapment zones in hospital bed systems and has developed dimensional guidance to reduce the risk of entrapment. The FDA [Food and Drug Administration] considers the term ‘hospital bed system' to encompass the bed frame and its components, including mattress, bed assist rails, headboards and footboards, and any accessories to the bed.* The entrapment zones involve the relationship of components controlled by the healthcare facility or individual user. Compliance to the dimensional guidelines for reducing the risk of entrapment is primarily the responsibility of the healthcare facility or the individual user. Anyone having any involvement with hospital bed systems should review and understand the FDA guidelines. Review of 2/16/24 manufacturer's instructions for the Stander side rail that was the side rail on resident 10's bed revealed:* BEFORE INSTALLING THIS PRODUCT, YOU MUST ENSURE THAT IT IS SAFE TO USE ON YOUR BED AND MATTRESS. This product can only be used on beds and mattresses that comply with the specifications set forth in the enclosed MATRESS CONDITIONS & SAFETY COMPONENETS and ASSEMBLY INSTRUCTIONS.* Stop using immediately if product shifts out of its original position.* If this product is used in a nursing home, assisted living center, or similar facility, follow these instructions and all of the institution's Bed Rail/Handle installation policies.* Always make sure this product is properly secured to bed.* ENTRAPMENT ZONES-Zone 1: Within the Rail- Any open space between the perimeters of the rail can present a risk of head entrapment. The FDA recommended space is less that 4.75 in [inches] (12 cm [centimeters]).* Compatibility: DO NOT use on adjustable beds.

Based on observation, interview and policy review the provider failed to ensure food items were appropriately packaged and safely stored away from cleaning chemicals in [one of one kitchen]. Findings include: 1. Observation on 1/30/24 at 8:00 a.m. in the kitchen revealed: a. In the dry food storage room, the following chemicals were stored on a metal rack alongside metal racks of food: *Prominence Heavy Duty Floor Cleaner *Suma Pan-Clean Detergent *Suma Break Up SC, Heavy Duty Foaming Grease Release Cleaner *Medallion Stainless Steel Cleaner *Suma-Diverpak Dish Detergent *Lime-A-Way Lime Scale Remover *Suma Gloss Concentrated Pre-Soak for silver and stainless steel *Suma Cal X Descaler *Dawn Dish Soap *Monogram Glass Cleaner b. Inside the stand-up freezer there was a bag of frozen donuts that was opened and exposed to the air. c. Inside the upright refrigerator/freezer there were unlabeled and undated frozen bags of pizza, hamburger patties, and chicken nuggets that were opened and exposed to the air. Interview on 1/30/23 at 10:00 a.m. with dietary manager (DM) C regarding the above observation revealed: *The chemicals had been stored since before she had begun her employment. *She thought about moving the chemicals. *She was unsure if there was another location to store those chemicals. *She confirmed the food items observed in the upright freezer and the upright refrigerator/freezer were not dated, labeled, and sealed when they were opened. *It was her expectation that staff would store opened food items in sealed bags that were labeled and dated. Interview on 2/1/24 at 8:10 a.m. with administrator A revealed: *The food storage policy stated that chemicals were to have been stored on a different rack than the food items but did not need to be stored in a different location. *It was her expectation that opened food items be sealed and dated. *The dietary policies were in the process of being reviewed and updated. Review of the provider's undated Food Storage Policy and Procedure Manual revealed: *4. Chemicals must be clearly labeled, kept in original containers when possible, kept in a locked area and stored away from food. *14. c. Frozen Foods: All foods should be covered, labeled, and dated.

Based on observation, interview, review of a Centers for Disease Control (CDC) publication, review of an Association for Professionals in Infection Control (APIC) brief, and policy review, the provider failed to ensure infection prevention and control practices were appropriately followed for: *Glove use by one of one certified nurse aide (CNA) (D) during care provided for one of one sampled resident (21). *Cleaning by medication aide (MA) (F) of shared equipment used between two of two (1 and 14 ) observed residents. *Hand hygiene and glove use by one of one CNA G during care provided for two of two sampled residents (16 and 34). *Cleaning by CNA G of shared equipment used by one of one observed resident (34). Findings include: 1. Observation on 12/20/22 at 9:45 a.m. of CNA D and hospitality coordinator E in resident 21's room revealed: *They provided personal care for resident 21 after she had a bowel movement (BM). *CNA D removed the resident's soiled brief and used a wipe to clean the BM off her skin. *Without changing her soiled gloves she: -Placed a clean brief underneath the resident. -Applied Aloe Vesta protection cream on her skin. -Wiped the excess cream off her soiled glove onto the inside of the resident's brief. -Secured the brief and helped the resident to get dressed. *She removed her gloves and performed hand hygiene. Interview with CNA D on 12/20/22 at 10:50 a.m. revealed she: *Agreed she had not changed her gloves and knew she should have: -Removed her gloves after cleaning resident 21. -Put on new gloves before handling the clean brief and applying the skin cream. Interview on 12/21/22 at 4:13 p.m. with director of nursing (DON) B and infection control nurse (ICN) C regarding the observation above revealed they agreed CNA D should have changed her gloves after cleaning resident 21 and before applying her clean brief and the cream. 2. Observation and interview on 12/21/22 at 9:20 a.m. with MA F revealed she: *Took resident 1's vital signs with the same equipment she took resident 14's vital signs. -Had not cleaned that equipment between residents. *Had cleaned that equipment with a disinfectant wipe at the beginning of her work shift that day. *Stated it was not her usual practice to clean vital signs equipment between resident use. 42558 3. Continuous observation on 12/20/22 from 8:17 a.m. through 9:00 a.m. of CNA G with residents 16 and 34 revealed she: *Entered resident 16's room and without sanitizing her hands or wearing gloves reconnected his oxygen tubing to his continuous positive airway pressure (CPAP) breathing device. -Left his room without sanitizing her hands to assist another CNA with a different resident's care. Further observation on 12/20/22 at 8:28 a.m. with CNA G upon her return to resident 16's room revealed: *Without sanitizing her hands she entered his room, put on a pair of gloves, and emptied his urinal into the toilet. -After wiping the rim of the urinal with a personal care wipe, she removed her gloves. *Without sanitizing her hands she applied a new pair of gloves and put on his support stockings, socks, pants, and shoes. -She moved his wheelchair next to his bed and removed her gloves. *Without sanitizing her hands she: -Repositioned his wheelchair, replaced his oxygen tank with a full tank, handed the resident his oxygen tubing, and placed the empty tank onto the oxygen concentrator. -Placed his CPAP tubing on the bedside table, gave him his hearing aids, placed a clean brief into his walker storage seat, made his bed, adjusted his pillows, adjusted his window blinds, and placed his oxygen concentrator tubing across his bed. *She left his room without sanitizing her hands. Further observation on 12/20/22 at 8:48 a.m. of CNA G in resident 34's room revealed: *After leaving resident 16's room, she entered resident 34's room without sanitizing her hands. *She: -Removed resident 34's clothes from his closet and applied clean gloves. -Flushed his toilet and assisted him with dressing while he sat on his bed side. -Applied his stand lift harness and moved him to the bathroom using the mechanical stand lift. --He had held onto the stand lift bars with his unwashed hands. -Removed his urine soaked undergarment and removed her gloves. *Without sanitizing her hands she touched the mechanical lift and lowered the resident to the toilet. *She: -Wet a washcloth and gave it to the resident to wash his face. -Dried her hands on a paper towel and went into his room to make his bed. -Applied a glove to one of her hands to carry his unbagged soiled laundry to a storage container in the middle of the hallway. -Opened his door and closed his door with her unsanitized hand. *She sanitized her hands while walking down the hallway prior to re-entering the closed door to his room. -This required touching the same door handle she opened with an unsanitized hand. *Without sanitizing her hands she: -Applied a clean pair of gloves and performed peri care to his groin and buttocks. -Removed her gloves and without sanitizing her hands put on a clean brief and pulled up his pants. -Transferred him back to his wheelchair using the mechanical stand lift. *She placed the stand lift in the hallway. *Without sanitizing her hands or the resident's hands she wheeled him down the hallway and into the dining room. -She moved a dining room chair out of the way and put his clothing protector around his neck. *She then returned to the hallway and moved the mechanical stand lift to the storage area in the middle of the hallway. -She did not sanitize the mechanical stand lift. *Without sanitizing her hands she touched a multi-use computer keyboard and a pencil to write on a piece of paper. Interview on 12/20/22 at 9:00 a.m. with CNA G regarding the above observations revealed she: *Had been a CNA since September 2022. *Had received her training at a sister facility by a level two CNA who would follow her around and give her advice. *Passed her skills training at the sister facility. *Received infection control continuing education on the facility computer and during monthly meetings. *Stated mechanical lifts were not cleaned between resident use. -The normal routine for mechanical lift sanitization occurred after breakfast, after lunch, at the end of each shift, and if a resident was sick. -She would be told by the nurse, or in shift report, if a resident was sick. *Felt wearing gloves and hand sanitization were part of a normal routine. -She stated that routine depended on if her hands were dirty, then she would wash or sanitize them. -If she had been wearing gloves then her hands would not necessarily be considered dirty when she removed them. *Fully washed her hands with soap and water after breakfast and at her break time. *Had been unable to identify any missed opportunities for hand sanitization during the above observations. Interview on 12/21/22 at 7:59 a.m. with DON B regarding the above observations revealed: *Hand hygiene was expected prior to, during, and following resident care. -Gloves and hand sanitizers were located in every bathroom. *If staff were unable to wash their hands going from a dirty to clean environment, she expected them to at least use hand sanitizer. *CNA G had passed a hand hygiene audit in July of 2022 while working as a housekeeper. *Agreed CNA G had missed opportunities for hand sanitization and glove use. *Felt there were opportunities for additional staff education regarding hand sanitization and glove usage. *The mechanical stand lifts were cleaned when visibly soiled and periodically through the day. Interview on 12/21/22 at 4:13 p.m. with DON B and ICN C regarding the observations above revealed: *ICN C stated proper hand hygiene and glove use had not occurred but should have unless there were extenuating circumstances. -She would prefer they (caregivers) take the opportunity (to ensure proper hand hygiene and glove use had occurred), but if unable, they do the best they can. *Shared resident equipment including pulse oximeters, blood pressure cuffs, and stand lifts were cleaned based on guidance revised in October 2022 from the State Operations Manual Appendix PP. -If residents were on isolation it (cleaning shared resident equipment) would have been different. *ICN C indicated Our policy is based on current regulations (from the SOM Appendix PP). Unless there was research to identify it (cleaning of shared equipment) had been changed, we are following the regulations as they stand. -Upon request and by end of survey she had not provided those specific infection control references from the SOM Appendix PP she continually referred to above. A Glove Use and/or Personal Protective Equipment (PPE) policy was requested of DON B on 12/21/22 at 2:50 p.m. She stated there were no such policies and PPE expectations were addressed within each specific resident care policy. Review of the provider's 10/23/2 Perineal Care policy revealed: *Equipment expected to be used during this care included gloves. *The procedure made no mention of when gloves were expected to be put on, changed, or removed. *On 12/21/22 at 2:50 p.m. DON B was asked for a specific date of the Perineal Care policy, but that was not provided prior to the end of the survey. Review of the provider's April 2020 Hand Hygiene policy revealed: *Indications: Hand hygiene should be done by staff: -Before and after physical contact with a Resident, whether or not gloves are worn, and between different site/care activities on the same Resident. -After contact with a Resident or Resident's body fluids, including specimen collection. -Before performing invasive procedures and handling devices such as IV's, catheters, urinary closed drainage systems and respiratory equipment. -Before eating, feeding a Resident, preparing food, liquids or snacks. Review of the provider's November 2018 Infection Control Disinfecting Personal Care Items policy revealed: *Purpose -To prevent the spread of infection when using multi resident use personal care items for residents who are on standard precautions. *Non-Critical Items include: vitals equipment, wheelchairs, therapy equipment, and facility owned electronic devices. -These items must be cleaned periodically and when visibly soiled using low-level disinfection techniques, i.e. Sani-cloth or similar product. Review of the CDC publication entitled CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings last reviewed on 11/29/22 revealed: *5f. Reprocessing of Reusable Medical Equipment references and resources: -1. Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled. Review of the 2021 APIC issued brief at : https://apic.org/noncritical-is-critical/ revealed: *Non-invasive portable clinical items shared among patients are part of the patient's immediate surroundings and may pose a threat of pathogen transmission. *The authors concluded that inappropriate disinfection practices increase the risk of HAIs [healthcare aquired infections] transmitted from such items.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were maintained for: *Hand hygiene and glove use by two of two (O and Q) certified nursing assistants (CNA) during resident care for two of two (2 and 36) sampled residents. *Proper disinfectant labeling, storage, and use of shared resident personal care items by two of two CNA's (F and N). *Hand hygiene help for three of three observed residents (2, 36, and 39) after toilet use by three of three CNA's (E, O, and Q). *Cleaning of reusable medical equipment after use by two of two residents (36 and 49) by two of two CNA's (F and Q). Findings include: 1. Observation and interview on 9/14/21 at 4:02 p.m. with CNA O as she helped resident 2 revealed: *Resident 2 was on his commode in his bathroom. *He was helped to his feet and hung onto his walker which was in front of him. *With her gloved hands CNA O wiped the backside of resident 2. -He had a bowel movement (BM). *With those same gloved hands, she pulled up his brief and secured it and pulled up his pants. *She had not reminded or offered to help resident 2 with hand hygiene after toilet use. *She removed her gloves and without washing her hands she: -Slid open the bathroom door fully. -Had ahold of his gait belt. -Opened the room door. -Walked helping resident 2 down the hallway. -At the end of the hallway used hand sanitizer that had sat on the medication cart. -Walked resident 2 past the dining room area and into the Maple/Aspen common area. --It was the men's take-out Tuesday for pizza activity. -He was aided to sit down and began eating his pizza with his hands. Interview with CNA O related to resident 2 revealed: *That had pretty much been her regular procedure for taking him to the bathroom. *When questioned she said she could not wash her hands after removing her gloves due to him wanting to get moving. *BM was on the toilet seat so she had not wanted him to sit down so she could wash her hands. *There had been No good way to do it. *She usually did not have him wash his hands in his bathroom sink after he had used the toilet. -Stated It's not a regular process I do with him. *She usually had him use hand sanitizer once they reached the dining room area. -She had forgotten to have him use the hand sanitizer this time because they passed the dining room and went into the Maple/Aspen common area. *Said she was aware of the need for hand hygiene before placing on or removing gloves and when going into or leaving a resident's room. *Agreed residents needed to perform hand hygiene after using the toilet.2. Observation and interview on 9/15/21 at 10:25 a.m. with CNA Q as she helped resident 36 revealed: *Resident 36 was in her room. *CNA Q used the sit-to-stand mechanical lift to aid resident 36 from her wheelchair into the bathroom. *CNA Q performed hand hygiene but did not put on gloves. *She removed the residents brief tabs. *Lowered her onto the toilet. *Wet a washcloth and drained the water from the resident's denture cup. *While the resident sat on the toilet CNA Q: -Washed her face. *CNA Q washed her hands for four seconds and placed on gloves. *Rinsed the top denture and placed them into her mouth. *Removed her gloves and without performing hand hygiene she picked up a brush and brushed resident 36's hair. *Performed hand hygiene and without placing on gloves *Grabbed a brief and placed it in between resident 36's legs. -Secured the tabs at the resident's thigh area. *Placed an almost empty oxygen container onto the Homefill tank filler. *Straightened out the bedding. *Moved the wheelchair (w/c). *Without performing hand hygiene, she returned to the bathroom and placed one glove onto her right hand. *Used the lift to raise the resident from the toilet. *Grabbed wipes from the container with her ungloved left hand. *Placed the wipe into her gloved right hand. -Cleaned the resident. *Removed the glove and without performing hand hygiene: -Fastened the brief. -Pulled up her pants.*Without encouraging or helping resident 36 with hand hygiene CNA Q: -Moved her from the bathroom and in front of her w/c and lowered her into it. -Removed the sling from under her. -Tied up the trash bag. *Left the room pushing the mechanical lift and holding onto the trash bag. *Pushed the mechanical lift to the Elm hallway alcove. -Other mechanical lifts were stored there. *Without wiping it down put it next to the other lifts. *Threw away the trash. *Performed hand hygiene in the alcove sink for approximately five seconds. Interview on 9/15/21 at 10:56 a.m. with CNA Q revealed she: *Was unaware the mechanical lift needed to be cleaned after resident use. *Was unaware she needed to wash her hands before and after glove use. *Agreed she had missed opportunities to wear gloves and perform hand hygiene. *Had not asked or encouraged resident 36 to perform hand hygiene after using the toilet. Interview on 9/16/21 at 8:50 a.m. with the director of nursing B revealed: *Her expectation was hand hygiene was completed after removing gloves and when exiting and entering a resident's room. *Staff would aid and give residents help and encourage handwashing after toilet use by residents. *Should have used sani-wipes to wipe down the lifts after resident use. -She stated sani-wipes were available in the alcove areas of the hallways either in the cabinet or in the storage area. Review of the providers 4/13/20 Hand Hygiene policy revealed hand hygiene should be performed by staff after performing any personal body function such as using the toilet. 3. Observation and interview on 9/14/21 at 12:54 p.m. of CNA F after cleaning the spa on the Elm hallway revealed: *There was an electric razor plugged in and sitting on the sink. *Said that razor was used by all residents. *They disinfected the razor between resident use. *There was a clear container on the second shelf of a metal rolling cart in the spa. -The container was approximately half full of a clear liquid. *She said that was the disinfectant. *That had not been the disinfectant's original container. *There was no label on the clear container showing what the clear liquid inside of it was. *She said she soaked items that needed to be disinfected into the clear liquid for 30 seconds. -This included the electric razor parts, fingernail clippers, and cuticle clippers. *She was unable to tell me the name of the disinfectant that was in the container. *She said the container had already had the clear liquid in it when she arrived for her shift that morning at 6:00 a.m. -It Looked good and she did not see Anything floating in it so she did not change it. *When questioned how she could be sure of what the clear liquid was in the container she said she could not be sure. -Agreed without knowing the name of the liquid in the container she could not be sure of the required disinfecting soak time. *When she was asked to produce a bottle of the disinfectant, she stated Honestly I don't know if we have any. *She said we would have to go to the shower room to look for a bottle. Observation and interview on 9/14/21 at 1:35 p.m. in the shower room with CNA F and N revealed: *There was an electric razor sitting on the shower sink. *CNA F opened a cabinet door that held towels and cleaning supplies. *She was unable to find a bottle of disinfectant. *She then radioed to CNA N who came into the shower room. *CNA N said she was the bath aide for the shower room that day. *She was unable to locate a bottle of the disinfectant. *Stated there had been some in the closet that morning and she had filled her container with the disinfectant. -She had placed that disinfectant in a denture cup. *She had written in black marker on the denture cup Do not throw away. -There was no label showing the name of the disinfectant or the date it had been put into the denture cup. *She was unable to say the name of the disinfectant she had poured into that denture cup that morning. *Said she had left the empty container of disinfectant sitting on the floor. -The cleaning lady must have come in and thrown it away. *When questioned she said she disinfected the fingernail and cuticle clippers only for I think three minutes. *It was not used to clean the electric razor parts. *The electric razor parts should be cleaned with an alcohol pad. *When questioned about the 30 second disinfectant time CNA F had said she had been using, CNA N said she might have been talking about the old pink disinfectant they use to use. *When asked about the cleaning of the electric razor CNA N said I'm glad you asked me about the razor because I haven't cleaned it today. *She removed the head of the razor from the body. *Walked to the trash can and emptied the whiskers from the razor into it. *She cleaned the inside body part of the razor with one alcohol pad. *Removed the three razor blades from the head of the razor and cleaned those with alcohol pads. *When questioned she said not very many residents used the electric razor. -She had not used that electric razor on any residents that morning. *When questioned why the razor was dirty since she had not used it, she stated she did not know. *She expected it to be clean after every use. Interview on 9/14/21 at 2:55 p.m. with the director of nursing (DON) B revealed: *She said that CNA N had told her I was asking about the disinfectant they used at the facility. *She brought me the November 2018 Infection Control Disinfecting Personal Care Items Policy. *She said the fingernail clippers, cuticle clippers, and electric razor were all defined as semi-critical items. *The policy said for semi-critical items High level disinfection i.e. Cavacide or similar product should have been used to clean those items. *DON B: -Was unable to state the name of the disinfectant used in both the spa and shower room. -Stated disinfectant was unavailable due to running out. -Was unsure of the type of disinfectant that had been used. -Was unsure of the disinfectant time of 30 seconds as said by CNA F or three minutes as said by CNA N. -No baths were scheduled for the next day so she hoped the disinfectant would arrive. -She was unsure if the containers they had poured disinfectant into needed to be labeled. -She said CNA N oversaw training the spa and bath aides. Review of the November 2018 Infection Control Disinfecting Personal Care Items policy revealed: *Purpose -To prevent the spread of infection when using multi resident use personal care items for residents who are on standard precautions. *Semi-Critical Items -Semi-critical items include: -Nail care items, i.e. clippers, files. -Hair combs and brushes. -Electric razors. -After use by each resident, semi-critical items must be meticulously pre-cleaned followed by high-level disinfection, i.e. Cavacide or similar product. 4. Observation on 9/14/21 at 11:10 a.m. of CNA E with resident 39 revealed: *Helped the resident off the toilet with a mechanical lift, transferred her into her wheelchair, and pushed her out of the bathroom. *Had not offered or helped the resident with hand hygiene after toilet use. Review of resident 39's care record revealed she: *Her 8/20/21 Brief Interview of Mental Status (BIMS) score was six. -That indicated severe cognitive impairment. Interview on 9/14/21 at 11:20 a.m. with CNA E revealed she had not reminded or offered to help resident 39 with hand hygiene after toilet use but should have. Interview on 9/16/21 at 8:15 a.m. and 1:30 p.m. with director of nursing (DON) B about resident hand hygiene revealed she: *Had expected staff remind and if needed help all residents with hand hygiene following bathroom use. *Confirmed the provider had no hand hygiene policy that pertained to residents. Review of the providers 4/13/20 Hand Hygiene policy revealed hand hygiene should be performed by staff after performing any personal body function such as using the toilet. 5. Observation on 9/15/21 at 11:04 a.m. of CNA F revealed she: *Removed the mechanical lift from resident 49's room after using it to transfer her off the toilet and onto her bed. *Took that lift to a designated alcove near the middle of a hallway outside of the resident's room. *Had not cleaned that lift after resident use. Interview on 9/16/21 at 8:15 a.m. with DON B about the cleaning of re-usable resident equipment revealed she had expected mechanical lifts had been cleaned with a bleach cloth after each resident use. Surveyor Interview on 9/16/21 at 1:30 p.m. with DON B revealed she was responsible for infection control in the facility and clinical care coordinator C was responsible for some antibiotic stewardship and policies. Review of the provider's November 2018 Infection Control Disinfection Personal Care Items policy revealed: *Purpose: To prevent the spread of infection when using multi-resident use personal care items for residents who are on standard precautions. -A mechanical lift was considered a non-critical item and must be cleaned periodically and when visibly soiled using low-level disinfection techniques, i.e. sani-cloth (bleach based wipe) or similar product.

Based on observation, interview, and record review, the facility failed to ensure true documentation of the sequential compression device (SCD) use in the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Observation and interview on 9/14/21 at 12:33 p.m. in resident 1's room revealed: *An admitted [DATE]. *She was sitting in her recliner. *There was a pair of blue SCD's sitting on her bed near the foot-board. -They were blue and looked worn. *She said this had been her second time in this facility. -She had been here for rehabilitation for a left knee replacement in May of 2021. *In May during her first knee replacement she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -She said the facility did not have SCD's available in May. *She brought her own blue SCD's with her this time. -Her SCD's did not work with the facilities SCD machine. *She was in the facility for rehabilitation for a right knee replacement. *She stated she was supposed to be using the SCD's while she was in bed. *The facility did not have SCD's available. Review of resident 1's September 2021 eMAR revealed: *SCD's on while in bed every shift 6:00 a.m. through 2:00 p.m. and 2:00 p.m. through 10:00 p.m.*Documentation for the 6:00 am through 2:00 p.m. shift revealed:-September 10th, 11th, and 13th had initials indicating the SCD's had been placed on. -September 12th, 14th, and 15th had an (N) documented.*Documentation for the 2:00 p.m. through 10:00 p.m. shift revealed:-September 9th, 10th, 11th, 12th, and 13th had initials indicating the SCD's had been placed on. -September 14th had an (N) documented.Review of resident 1's interdisciplinary notes revealed:*On 9/11/21 at 1:07 a.m. Resident resting in bed eyes closed resps [respirations] even, SCD's in place created by registered nurse (RN) P.*On 9/12/21 at 12:25 a.m. Resident does have SCD's on right leg but not on left created by RN P.*On 9/14/21 at 9:36 p.m. Resident has appointment for ultrasound in am for rule [out] DVT [[CONDITION(S)]]. SCD not placed on RLE [right lower extremity] but placed on LLE [left lower extremity] created by licensed practical nurse (LPN) G.Interview and review of the September 2021 eMAR for resident 1 on 9/16/21 at 10:45 a.m. with the director of nursing (DON) B about documentation of SCD use revealed: *Initials in the eMAR indicated the treatment had been completed. *Agreed the initials documented from 9/10/21 through 9/13/21 indicated SCD's had been placed on resident 1. *The SCD's were not available for resident 1 until approximately 4:00 p.m. on 9/14/21 when a sister facility delivered them. *Based on the eMAR documentation the SCD's were put on the resident when they were not available.*The interdisciplinary notes showed the same. *She would have expected documentation on those days of an (N) saying the SCD's had not been available.*Nursing notes should have shown the SCD's were not available. Interview on 9/16/21 at 11:25 a.m. with LPN K on documentation in the eMAR revealed: *Initials in the eMAR indicated the treatment had been completed. *An (N) meant it had not been completed. Interview on 9/16/21 at 11:27 a.m. with certified nursing assistant L regarding documentation in the eMAR revealed: *Initials in the eMAR indicated the treatment had been completed *An (N) meant it had not been done or was not available. -Related to either the resident or supplies. Interview on 9/16/21 at 1:25 p.m. with RN M about documentation in the eMAR revealed: *The expectation was if initialed it has been done. *An (N) said it had not been given or completed. -There was an area to document notes, and she would have expected documentation as to the reason why it was not given or completed. *An (N) in the eMAR stood for Not administered.Interview on 9/16/21 at 3:30 p.m. with administrator A and DON B revealed:*They did not have a written policy for documentation by nursing staff.*They used MatrixCare as their training tool.*Training was completed verbally from nurse to nurse.

Based on observation, interview, policy review, and Centers for Disease Control and Prevention (CDC) publication Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html related to COVID-19, the provider failed to follow CDC's guidelines related to the COVID-19 pandemic by failing to: *Remove personal protective equipment (PPE) prior to exiting a sampled resident's room (2) who had been diagnosed with [REDACTED]. *Close all doors to rooms of residents who had tested positive for COVID-19 (2, 3, and 4). Findings include: 1. Observation on 12/3/20 at 2:55 p.m. outside of resident 1 and 2's shared room revealed: *Signage instructing how to put on and remove PPE. *A plastic container with drawers containing PPE. Observation and interview on 12/3/20 at 2:55 p.m. of housekeeper C coming out of resident 1 and 2's shared room revealed she: *Was wearing PPE, which had included a gown, gloves, N95 mask, and face shield. -She was observed twice with the same PPE on coming out into the hallway to the housekeeping cart. *Revealed she had seen other staff come into the hallway wearing contaminated PPE so thought it was appropriate. *Had agreed the PPE she was wearing would have been contaminated so she should have removed her gown and gloves prior to coming out of the resident room. Observation and interview on 12/3/20 at 3:15 p.m. of RN D coming out of resident 2's room revealed: *Resident 2 had COVID-19. *She was wearing a gown, gloves, N95 mask, and face shield. *She had removed her gloves and gown and placed them into a clear plastic garbage bag she had carried out of the resident room. *Without performing hand hygiene, she reached into her pants pocket to retrieve her phone. -She shut the ringer off and returned it to her pocket. *She agreed she should have removed the gown and gloves prior to exiting the room. *She agreed she should have performed hand hygiene after removing her gloves and touching her phone. Interview on 12/3/20 at 3:56 p.m. with administrator A and director of nursing B revealed they agreed: *Staff should have removed their gown and gloves prior to exiting room. *The RN should have performed hand hygiene after removing her gloves and before reaching into her pocket. On 12/3/20 at 3:56 p.m. the administrator was asked for a policy regarding putting on and removing PPE. She provided an undated CDC publication titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19. This revealed: *The gloves and gown should have been removed prior to exiting the resident's room. *Hand hygiene should be performed after exiting a resident room. 2. Observations on 12/3/20 between 3:00 p.m. to 3:20 p.m. revealed: *The doors to resident 2, 3, and 4's rooms had been left open. Interview on 12/3/20 at 3:20 p.m. with CNA E regarding the above open doors revealed: *Resident 2, 3, and 4 had been diagnosed with [REDACTED]. *The doors should have been closed. Interview on 12/3/20 at 3:56 p.m. with director of nursing B regarding the above observation of the doors revealed: *The doors were to be closed on rooms occupied by residents diagnosed with [REDACTED]. *Residents 2 and 3 had been a fall risk so those doors should be left open. -The surveyor had asked for documentation on interventions attempted prior to leaving the doors open. -Documentation was not provided prior to exiting the facility at 5:45 p.m. Review of the provider's 11/7/20 COVID Isolation Unit(s) policy and procedure had not addressed the doors being open or closed. Review of the updated 11/4/20 CDC publication Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html accessed on 12/7/20 at 3:00 p.m. revealed a resident with suspected or confirmed COVID-19 should be placed in a private room with the door closed.

Based on observation, record review, interview, and policy review, the provider failed to ensure 1 of 13 sampled residents' (24) care plans were updated and revised to reflect the resident's current status and care needs. Findings include: 1. Random observations on 8/12/19 between 1:03 p.m. and 5:30 p.m. of resident 24 revealed: *She had required assistance from one staff person to transfer her from wheelchair to bed. -She had been in bed most of that afternoon. *Staff had pushed her in the wheelchair to the dining room for dinner at 5:05 p.m. -She had required verbal and physical assistance from staff to eat. -She had hung her head and kept her eyes closed for most of the meal. -Her intake was poor. Random observations on 8/13/19 from 7:30 a.m. until 10:58 a.m. of resident 24 revealed: *She was asleep in bed between 7:30 a.m. and 9:35 a.m. *She had been pushed in her wheelchair by staff to a common area at 10:58 a.m. to listen to staff read the news. -Her head was down, and her eyes were closed during that activity. Review of resident 24's medical record revealed: *Her [DIAGNOSES REDACTED]. *She had weighed 92 lb (pound) on 3/23/19 and had weighed 82.5 lb the week of 8/5/19. *She had become physically weaker in the last few months. *On 7/24/19 her physician had ordered all nutritional supplements be stopped and had continued only medications that had helped the resident remain comfortable. Review of resident 24's 6/22/19 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status score was three indicating severe cognitive impairment. Interview on 8/14/19 at 1:30 p.m. with clinical care coordinator A included review of resident 24's last updated 7/29/19 care plan and revealed: a. Activities of Daily Living Function: *I have a restorative program d/t (due to) decreased endurance and balance precautions, overall weakness and lack of motivation. Start date was 10/18/18. -That program had included mobility, standing, wheelchair leg press, pivot transfers, and upper extremity exercises two to three times per week. *The clinical care coordinator confirmed there had been no restorative program documentation from 8/1/19 to 8/14/19. *She was uncertain if the program was still implemented. *It was expected if a restorative program was no longer provided it would have been removed from the care plan. b. Mood State: *I am visited by spiritual support to assist with my mood. Start date was 4/8/15. -The clinical care coordinator had found no documentation to indicate the resident had been seen for spiritual support. -She agreed spiritual support was appropriate for the resident due to recent changes in her treatment goals. c. Behavior Problem: *My behaviors are wandering, inappropriate behaviors and rejecting care. Start date 12/28/15. -The clinical care coordinator confirmed there was no documentation from 8/1/19 to 8/14/19 in the plan of care daily charting of wandering behavior. -She was uncertain if the resident had still exhibited wandering behavior. -She agreed the care plan should have been reviewed and updated if wandering was no longer a behavioral concern. d. Falls: *I self transfer despite fall risk and I do not use my call light to seek staff assistance. Promote my success when I self transfer by placing my bed at natural height and locking my wheelchair next to bed when I lay down. No floor mats. Start date 4/10/15. *Low bed with mat in place when in bed. Start date 7/11/19. *The clinical care coordinator had stated approaches should be consistent throughout the care plan. e. Pressure Ulcers: *I have a pressure-relieving device air mattress overlay, gel cushion to wheelchair. Start date 3/24/15. *The resident had a non-removable wedge in the middle and front edge of her wheelchair seat. -The clinical care coordinator had thought a physical therapist had fitted the resident's wheelchair with that device sometime in (MONTH) 2019. -It was the expectation of the clinical care coordinator if the wedge was used for positioning it should have been care planned. *I receive 2 cal (nutritional supplement) per MAR (medication administration record) for nutritional support and to facilitate skin integrity. Start date 5/25/15. -There was no physician's order on the resident's (MONTH) 2019 MAR for 2 cal. -The clinical care coordinator agreed that care plan approach was not accurate and should have been discontinued. Continued interview at 2:10 p.m. revealed: *The facility had two clinical care coordinators who were responsible for the scheduling, completion, and submission of residents' MDS assessments. *They were responsible for developing, updating, and discontinuing nursing and therapy related resident care plan problems, goals, and approaches. *They each had a specific caseload of residents they were responsible for, but they were expected to fill each others roles as needed. *It was expected care plans were reviewed and updated when MDS assessments had been completed. *Care plan changes were made more frequently based on resident information shared during daily stand up meetings. *Resident 24's plan of care had not been updated to reflect her current care needs. Review of the provider's 6/17/15 Care Plan/RAI (Resident Assessment Instrument) Process policy revealed: 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Based on observation, interview, record review, and manufacturer's review, the provider failed to assess side rails for safety for ten of ten (1, 8, 9, 10, 14, 19, 27, 37, 38, and 41) residents who were randomly observed with side rails on their beds. Findings include: 1. Random observation on 5/21/18 from 12:30 p.m. through 5:45 p.m., on 5/22/18 from 7:00 a.m. through 5:45 p.m., and on 5/23/18 from 7:00 a.m. through 5:30 p.m. of residents 1, 8, 9, 10, 14, 19, 27, 37, 38, and 41 rooms revealed side rails were in the up position on each of their beds. Interview and record review on 5/23/18 at 8:00 a.m. with clinical care coordinator/licensed practical nurse E regarding side rails revealed: *The side rail assessments were done quarterly. -They used to be in paper format, but now were in the electronic medical record. --Both forms had the same questions. *The assessments had not clearly identified what safety aspects were reviewed. *Review of the regulations related to side rails with him confirmed the assessments had not addressed whether: -Appropriate alternative interventions had been attempted prior to their use. -Appropriate installation and maintenance had occurred. -The risk of entrapment had been evaluated. -The risks and benefits had been reviewed with the resident or their representative. -Consent for use had been done prior to installation. -Manufacturers' instructions had been followed for the type of side rails being used. *He confirmed side rails should have been evaluated for their safe use. Interview on 5/23/18 at 9:15 a.m. with clinical care coordinator/LPN E and clinical care coordinator/registered nurse (RN) F regarding side rail assessments revealed: *They completed the side rail assessments quarterly. -Most residents used them for positioning and mobility. *They had not discussed taking side rails off the beds of those residents who were not using them appropriately. *They had not documented the safety aspects and risk of entrapment in the residents' medical records. *RN F was unsure what role maintenance staff had in the documentation for proper installation, inspection, and maintenance of the side rails. *All residents had some type of side rail on their beds. *They confirmed side rails should have been assessed appropriately for safety. Interview on 5/23/18 at 2:45 p.m. with the director of plant operations revealed he: *Never removed the side rails from the residents' beds unless they needed repair. *Had not checked the side rails for safety on a routine basis. *Had not included side rails on a preventative maintenance schedule. *Agreed side rails should have been on his preventative maintenance schedule. Interview on 5/23/18 at 10:31 a.m. with the director of nursing (DON) regarding side rails revealed: *She was aware the assessment had not clearly identified what safety aspects had been assessed. *The assessment had been changed from paper to electronic format, but the questions remained the same. *She confirmed the side rail assessment had not addressed all the areas required from the regulations such as: -Risk of entrapment. -Risk and benefits. -Proper consent for use. -Appropriate installation, inspection, and maintenance. *The safety assessments had not been clearly documented or assessed. *All residents had some type of side rail on their bed. -They had done quarterly assessments of side rails. Interview on 5/23/18 at 3:27 p.m. with the administrator, DON, previous administrator, and clinical care coordinator/LPN E revealed the provider had no policy regarding bed or side rails or the use of them.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (38) had documentation to support [MEDICAL CONDITION] medications had been administered appropriately. Findings include: 1. Observation on 5/22/18 of resident 38 revealed: *At 7:37 a.m. he was sleeping in his bed. *At 8:38 a.m. he was sleeping in his bed. *At 10:18 a.m. he was sitting in his wheelchair in his room. Review of resident 38's medical record revealed: *He was admitted on [DATE]. *He had [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behaviors. -Muscle weakness. -Unsteadiness when on his feet. -Anxiety. -Dementia with behaviors. -Altered mental status. Review of resident 38's 12/19/17 psychiatric examination revealed: *He Continues to have behavioral issues with resisting cares at times and agitation. *He is given the prn (as needed) [MEDICATION NAME] and the prn [MEDICATION NAME] most days at least one time and sometimes more. *He will continue on these medications and staff should monitor his medication use and behavioral response. Review of resident 38's (MONTH) (YEAR) consultant pharmacist's medication regimen review (MRR) revealed: *I was reviewing his (MONTH) (YEAR) eMar (electronic medication administration record) to follow the use of [MEDICATION NAME] and [MEDICATION NAME]. -The use of these 2 agents appear to coincide with no time between doses to allow for 1 agent or the other to work. -This results in not knowing what, if anything is working. -We should use 1 agent at a time and document the results. *Hand written note in Follow through area of document stated Education provided to staff. (name) LPN (licensed practical nurse) 4/10/2018. Review of resident 38's (MONTH) (YEAR) consultant pharmacist's progress note revealed: *[MEDICATION NAME] use for (MONTH) (YEAR) was eighteen tablets, and [MEDICATION NAME] use was thirteen tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was fifteen tablets, and [MEDICATION NAME] use was twenty tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was fourteen tablets, and [MEDICATION NAME] use was twenty-two tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was twenty-one tablets, and [MEDICATION NAME] use was twenty-two tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was twenty-four tablets, and [MEDICATION NAME] use was twenty-five tablets. *[MEDICATION NAME] and [MEDICATION NAME] use appear to coincide with no time between doses. -Results in not knowing what, if anything is working. -Should use 1 agent at a time to monitor the success of treatment. -Sent nursing a note in 4/2018 MRR. -Noted pt. (patient) (resident) continues to get these medications simultaneously. Review of resident 38's (MONTH) (YEAR) physician's orders [REDACTED].>*[MEDICATION NAME] 0.5 mg tablet PO (by mouth) Q (every) 6 hour's prn for agitation. *[MEDICATION NAME] 50 mg tablet. -Give ½ tab of 50 mg to equal 25 mg by mouth every 6 hours as needed for agitation. Review of resident 38's (MONTH) (YEAR) medication record revealed: *Between 4/1/18 and 4/30/18: -[MEDICATION NAME] and [MEDICATION NAME] tablets were given together twenty-three of twenty-four times. -They were given within a minute of each other one of twenty-four times. -They were given between the hours of 8:00 p.m. and 12:15 a.m. Review of resident 38's (MONTH) (YEAR) medication record revealed: *Between 5/1/18 and 5/22/18: -[MEDICATION NAME] and Trazadone tablets were given together eleven of eighteen times. -They were given within a minute of each other four of eighteen times. -They were given between the hours of 5:19 p.m. and 11:53 p.m. Interview on 5/23/18 at 10:35 a.m. with clinical care coordinator F revealed: *She did not know why two prn meds were being given at the same time.*She would research it and get back to this surveyor.*On 5/24/18 at 3:00 p.m. no response from care coordinator F had been received regarding resident 38's prn orders. Interview and record review on 5/23/18 at 1:10 p.m. with the director of nursing regarding resident 38 revealed: *He usually had behaviors at night. *She agreed both medications had been given together all but six times in April. *There was no documentation two prn medications could not be given together. *She agreed the effectiveness of a prn medication needed to be evaluated. Interview and record review on 5/23/18 at 2:30 p.m. with LPN E revealed: *It was his hand written note on the consultant pharmacist's MMR for (MONTH) (YEAR) Education provided to staff on 4/10/18. *He had only educated one nurse. -He had only reported findings of pharmacist to her. -Had no documentation education with that one nurse had taken place. Review of the provider's 7/19/12 Medication Regimen Review policy revealed: *Purpose: -All residents will have their medication regimen reviewed on a monthly basis and as needed to ensure the regimen is being managed appropriately and is free from unnecessary medications. *Procedure: *Medication management refers to consideration of: -Indications for use of the medication (including initiation or continued use of psychoactive medication). -Monitoring for efficacy and adverse consequences. -Dose (including duplicate therapy). -Duration. -Tapering of a medication dose/gradual dose reduction for antipsychotic medications. -Prevention, identification, and response to adverse consequences.

Based on observation and interview, the provider failed to ensure medical supplies were not outdated in: *One of one therapy room for one two gallon container of ultrasonic gel that had expired [DATE]. *One of one central nurses supply area for: -Five of five sodium chloride 500 milliliter (ml) irrigation solution expired [DATE]. -Three of three bottles of 70% isopropyl alcohol 16 ounces (oz) expired [DATE]. -Five of five hydrogen peroxide 16 oz expired [DATE]. *Two of two treatment carts: -Two boxes filled with 3 ml sodium chloride (NaCl) expired plastic vials. --Those expiration dates ranged from February 2014 through [DATE]. -Two 16 oz bottles of hydrogen peroxide expired [DATE]. *One of one medication room for three of three intravenous (IV) solutions that had expired [DATE]. Findings include: 1. Observation on [DATE] at 3:45 p.m. of one of two therapy rooms revealed an in-use, approximately two gallon plastic flexible container of Ultrasonic Gel that had expired [DATE]. That container had been opened and approximately an eighth of the gel was left. Interview at the time of the above observation with the director of environmental services confirmed: *Expired items should have been discarded. *Therapists were responsible for checking expiration dates on their supplies. Interview on [DATE] at 9:25 a.m. with the occupational therapist revealed: *They used that large container of gel to fill the small squirt bottles throughout therapy. *They had not checked the expiration date before they filled the small squirt bottles. *She was not aware the ultrasonic gel had an expiration date. 2. Observation on [DATE] at 4:25 p.m. of the nursing central supply area revealed the following: *Five sodium chloride irrigation 500 ml bottles had expired [DATE]. *Three 16 oz bottles of 70% isopropyl alcohol had expired [DATE]. *Five 16 oz bottles of hydrogen peroxide had expired [DATE]. Interview at the time of the above observation with the director of environmental services revealed: *Those expired items should have been discarded. *Nursing services was responsible for checking that area for expired medical items. *Items from the nurses supply area would have been used for resident's care. 3. Observation on [DATE] at 2:25 p.m. of both treatment supply carts used for hallways Maple, Aspen, Oak, and Elm revealed: *Both carts contained a box filled with 3 ml NaCl plastic vials. -Several of those NaCl vials had expiration dates from February 2014 through [DATE]. *The bottom drawer of both carts contained a 16 oz bottle of hydrogen peroxide that had expired [DATE]. The bottles had been opened, and three-fourths of the solution had been used. Interview on [DATE] at the time of the above observation with the director of nursing services (DNS) and registered nurse (RN) A revealed: *They were not sure from where and when the above items had been restocked. *The staff had the capability of obtaining supplies from the basement and other supply rooms on the hallways. *They were not aware the above items had expired. *The pharmacist and RN A would have checked the treatment cart every month for outdated supplies. -Any expired items should have been returned to the pharmacy department. 4. Observation on [DATE] at 2:48 p.m. with licensed practical nurse (LPN) E of the medication room revealed: *The cabinets and drawers contained multiple resident use items such as medications, treatment supplies, a container filled with IV supplies, and a locked medication emergency kit (Ekit). *On the shelf next to the Ekit was a small plastic bag. That plastic bag held three 100 ml IV bags filled with 0.9 percent (%) NaCl with the expiration date [DATE]. Interview on [DATE] at the time of the above observation with LPN E revealed: *He confirmed the above observation of the expired IV fluid filled bags. *He had not been aware they were in that cabinet or from where they had been restocked. *The pharmacist should have checked the Ekit and IV supplies for outdates every month. 5. Interview on [DATE] at 4:00 p.m. with the administrator revealed they did not have a policy and procedure in place to ensure outdated items were properly disposed of and replaced. Nursing services and the pharmacist was responsible for checking for expired medical items and medicine. Interview on [DATE] at 6:30 p.m. with the facility pharmacist confirmed he checked the medication carts, treatment carts, Ekit, and IV supplies every month for outdates. He had not been aware of any IV fluid bags located in the cabinet by the Ekit. He was not sure where they had come from and who had placed them there. The only IV supplies he checked for outdates every month were located in the container in the cupboard. He had not been informed of any IV supplies located in the basement of the facility.

Based on observation, testing, label review, document review, and interview, the provider failed to ensure: *One of one sampled resident (1) on isolation precautions was treated in a manner to control and prevent the spread of the disease to other residents, staff, and visitors. *Two of two bath aides (J and K) followed manufacturer's directions for disinfection of two of two whirlpools. *Dishware, utensils, cookware, and extra kitchen items were protected from possible contamination from an overhead sewer line in one of one basement kitchen storage room. *One of one [MEDICATION NAME] wax hand therapy basin was cleaned in accordance to the manufacturer's directions. *Medical supplies, resident hygienic use items, wound care supplies, and medication pass supplies were stored protected from possible contamination in one of one basement nursing supply storage room. *Clean linens from three of three washers were protected from possible contamination by one of one dirty wall mounted oscillating fan. Findings include: 1.a. Observation on 5/23/17 at 7:10 a.m. of resident 1's doorway revealed: *The door to her room was shut. *On top of a plastic cart in the alcove by her room was: -A box of gloves. -A laminated sign with gloves, gown, and a mask written on top of it. -Next to the word glove was a check mark. *Inside the three drawers of the cart were red garbage bags, disposable gowns, masks, and gloves. *There was no signage in the immediate area indicating visitors, staff, and residents should visit with the nurse prior to entering that room. Interview at the time of the above observation with registered nurse (RN) F revealed: *The resident had: -Been placed on isolation precautions on 5/20/17 for a [DIAGNOSES REDACTED]. -Required contact isolation precautions. *She confirmed there was no sign in the immediate area indicating visitors, staff, and residents should have checked with nursing prior to entering her room. But we do have signs. *She stated She just has shingles. *She questioned Don't you think that would reveal to much information? *She agreed: -Shingles was an infectious disease. -Those who were pregnant or never had the chicken pox virus were at risk for acquiring chicken pox should they have been exposed or came in contact with the resident. *She stated A sign would probably be a good idea. Observation on 5/23/17 at 9:50 a.m. of resident 1's room revealed: *The door was open to the corridor. *The above mentioned plastic caddy remained unchanged. *A sign located above that plastic caddy read Please check with nurse before you enter the room. Review of resident 1's medical record revealed: *On 5/17/17 the staff had identified an area of concern on the left side of her breast that had extended down the left side of her [MEDICATION NAME] spine. *On 5/20/17 the area had worsened and the physician had given her a [DIAGNOSES REDACTED]. Surveyor: 1.b. Interview on 5/23/17 at 1:30 p.m. with bath aide/CNA K revealed they used the disinfectant for the whirlpool for all residents. If a resident was diagnosed with [REDACTED]. That was the only time a resident actually received a shower. She stated all residents received a whirlpool. Some may be a little hesitant at first, but after a few times they got used to the whirlpool. She was not aware if the whirlpool disinfectant was effective against shingles. She was aware resident 1 had shingles, but she had not been told to use the shower or another disinfectant. Interview on that same day at 1:45 p.m. with bath aide/CNA J confirmed the above interview with bath aide/CNA K. She too used the whirlpool disinfectant and only gave showers if there was a case of [DIAGNOSES REDACTED]. Continued interview with both bath aides/CNAs J and K revealed they also used MadaCide Germicidal Solution to disinfect fingernail clippers, toenail clippers, toenail nippers, and any other item for resident nail care that could be disinfected. They stated they used the same instruments for nail care on all residents but would disinfect them between use. Review of the MasterCare Bath whirlpool disinfectant label revealed it gave no information it was effective against shingles. Phone interview on 5/23/17 at 3:00 p.m. with the company's chemist for the disinfectant revealed it was not effective against shingles. Review of the Madacide Germicidal Solution label revealed it gave no information it was effective against shingles. Surveyor: Observation and interview on 5/23/17 at 2:50 p.m. of resident 1 with RN F confirmed the resident had just received a bath. Observation on 5/24/17 at 10:45 a.m. of resident 1 with RN F revealed: *She had a loose shirt on that covered her shingles. *The shingles continued to be red. The blistered areas had increased and were filled with yellow colored fluid. Interview on 5/24/17 at the time of the above observation with RN F revealed: *The resident: -Received baths on Tuesday and Friday. -Was the last one to have received a bath that day due to her shingles. *She was not sure: -What type of isolation or contact precautions the resident had required. -If the chemical they were using to clean the tub was appropriate for someone with shingles. *She would have relied upon RN C to ensure the correct infection control processes were in place for the resident. *She was not sure why they would have treated this infectious disease any different than the other types. *She agreed they had been more reactive versus proactive when ensuring the other residents were not exposed to that infectious disease. Interview on 5/24/17 at 11:15 a.m. with the director of nursing services (DNS) revealed: *She had been the infection control nurse for the facility and was aware resident 1 had shingles. *The resident had resided on the Oak hallway, and those twelve resident's received baths on Tuesday and Friday. *She stated A majority of the residents received baths. *She could not confirm if resident 1's shingles had been opened and draining, as she had not done a skin check. *She would have relied upon RN C to determine the amount of restriction required for the resident. *She stated We are not gonna isolate beyond restriction. If the blisters are not draining we would continue to accommodate the resident's wishes. So if she preferred a bath we would give her a bath. I'm not sure if they are draining I would have to check with (RN C's name). Surveyor: Interview on 5/24/17 at 8:00 a.m. with housekeeper I revealed they had been told to use the 3M quaternary disinfectant 5L and 5H for all the resident rooms and at the end of the day in the bathing rooms. They would use Clorox Healthcare Bleach Germicidal Cleaner for rooms with clostridium difficile (C. Diff.). That was the only time they would use the Clorox cleaner was when there was a case of [DIAGNOSES REDACTED]. The 3M disinfectant took care of all other viruses. Review of the technical data information sheet for the 3M product was not effective against shingles (Herpes [MEDICATION NAME]). Interview on 5/24/17 at 2:05 p.m. with the DNS revealed: *She was the infection control nurse for the facility. *They would use Centers for Disease Control (CDC) or the local hospital's infection control program as references. *She was aware resident 1 had been diagnosed with [REDACTED]. *She would not have educated the housekeeping staff or the two bath aides to use a different disinfectant for a [DIAGNOSES REDACTED]. *All the cleaning chemicals we use for housekeeping should take care of body fluids except for [DIAGNOSES REDACTED]. For [DIAGNOSES REDACTED]. we would use bleach. We would use the MasterCare product for the disinfections of the two whirlpools except if a resident has [DIAGNOSES REDACTED]. *She was not aware if any of the staff who provided care to resident 1 had received any precautionary vaccines to prevent shingles. *She had referred to RNs B and C to include infection precautions and education to staff for the care of resident 1. Interview on 5/24/17 at 2:25 p.m. with the RNs B and C revealed they: *Were not aware the 3M products used in housekeeping, the MasterCare whirlpool disinfectant, and the Madacide used for resident nail care was not effective to kill the shingles virus. *Both thought the products they were using took care of everything except [DIAGNOSES REDACTED]. *Had not educated the housekeepers or the bath aides on the use of a different disinfectant as they had been told the above listed products were sufficient in the control of the shingles virus. *Confirmed they had not reviewed the labels of the above listed products or investigated further if those products were suitable for the shingles virus. *Confirmed they used the CDC guidelines for infection control. Review of the Clorox Healthcare on-line information revealed Ultra Clorox Germicidal Bleach was effective at disinfection of [MEDICATION NAME]-[MEDICATION NAME] virus (shingles) with a five minute contact time. 2. Interview on 5/23/17 at 1:30 p.m. with bath aide/CNA K revealed they used the MasterCare Bath disinfectant for the whirlpool for all residents. She was unsure of the contact time for the whirlpool disinfectant but thought it might be around ten minutes. She had received training on how to use and disinfect the whirlpools when she became a CNA at the facility about a year ago. She then proceeded to: *Fill the whirlpool with the disinfectant. *Run the whirlpool jets. *Scrub all surfaces to include the bath chair with the whirlpool disinfectant. *Spray the disinfectant again over all surfaces. *Turn the disinfectant hose off and use the shower hose to rinse the tub and the bath chair. *The entire process from start to finish took one minute and thirty seconds. Interview on that same day at 1:45 p.m. with bath aide/CNA J confirmed the above interview with bath aide/CNA K. She too used the whirlpool disinfectant and thought it might be about a ten minute contact time. She had also been trained on how to use and disinfect the whirlpools when she became a CNA about two years ago. She then proceeded to complete the same above steps for the disinfection of the tub, its surfaces, and the bath chair. Her entire disinfection and rinsing procedure took two minutes and thirty seconds. She stated she and bath aide/CNA K were the only two bath aides. If a bath was needed on the week-ends it was given by another CNA. 3. Observation and interview on 5/23/17 at 3:30 p.m. with the dietary service manager revealed:*Extra dishware, utensils, cookware, and kitchen supply overflow were on shelves in the basement. *Those items were in close contact or located under a sewer line. *She agreed those items had been stored and created a possible contamination from the sewer lines. Review of the provider's undated Care of the Storeroom policy revealed no procedure for keeping items free from possible contamination. Surveyor: 4. Observation on 5/23/17 at 3:45 p.m. revealed a TherabathPRO [MEDICATION NAME] bath unit in a room in the therapy area. The cloudy wax was melted, and there was a very large amount of sediment in varying colors on the bottom of that unit. Interview at the time of the observation with the director of environmental services confirmed that finding. Interview on 5/24/17 at 9:25 a.m. with the occupational therapist revealed she was not aware when the last time the [MEDICATION NAME] wax had been changed and when the unit had been cleaned. She stated it would have been formal protocol to replace the wax when there was sediment in the bottom of the unit. There was no official log to keep track of cleaning the [MEDICATION NAME] bath. Review of the undated on-line Therabath [MEDICATION NAME] bath guidelines revealed Clean the TherabathPRO after every 25 treatments, when the [MEDICATION NAME] is cloudy, or when sediment accumulates on the bottom of the unit. 5. Observation on 5/23/17 at 4:25 p.m. of one of one nursing central supply area in the basement revealed: *Cardboard boxes of oral syringes, toothpaste, volumetric exercisers, urinary collection bags, adhesive dressings, and gauze were stored on the floor. *Two metal shelving units had chipped and peeling paint, rust, areas of spilled liquid debris, and layers of dirt and dust. Those shelves were used to store medical supplies. *Emesis basins, bath basins, graduated measuring containers, specimen hats, plastic drinking cups, plastic teaspoons, and irrigation syringes were stored directly under condensation drainage pipes and sewer lines. Interview on 5/23/17 from 4:40 p.m. to 5:00 p.m. with the director of environmental services confirmed: *Items should not have been stored on the floor. *Shelving with exposed bare metal was not a cleanable surface and created an infection control risk. *The metal shelves needed a deep cleaning and repair. *Drainage pipes should not have had resident use items stored directly under them. 6. Observation on 5/23/17 at 4:55 p.m. of the laundry room revealed: *A wall mounted oscillating fan cover and blades were covered with dust and lint. -That dust and lint covered the white grill and blades and made it gray in color. The dust and lint had layered on the fan, had begun to trail down the outside of the cover, and hung like thick cobwebs from the grill. *That fan was located directly above three washing machines. *Clean linen could have become contaminated when removed from those three machines. Interview on 5/23/17 from 4:40 p.m. to 5:00 p.m. with the director of environmental services confirmed the oscillating fan cover and blades in the laundry area were covered with lint, dust, and debris. He stated it was the laundry staffs' responsibility to keep the fan clean. Interview on 5/24/17 at 3:30 p.m. with the administrator revealed the fan was not on the housekeeping list for the laundry personnel.

Based on record review, interview, policy review, and contract review, the provider failed to ensure communication and documentation for hospice services had been incorporated into the medical records for two of three sampled hospice services residents (4 and 5). Findings include: 1. Review of resident 5's medical record revealed: *He had been admitted on [DATE]. *A hospice referral had been physician ordered on [DATE]. *He had been admitted to hospice services on 3/29/17. *The provider's plan of care (POC) dated 3/31/17 had been revised and had added I am on hospice. Please see hospice care plan for additional options. -That POC was located in his record at the nursing station. *No hospice care plan had been identified in his medical record. Interview on 5/24/17 at 7:40 a.m. with the social services coordinator revealed she: *Expected a hospice care plan to be located in the resident's paper chart at the nursing station. *Confirmed the provider's current POC stated: -The resident was on hospice care. -See the hospice care plan for additional information. Interview on 5/24/17 at 9:35 a.m. with registered nurse (RN) A regarding care for residents who received hospice services revealed she: *Would have looked at the hospice tab in the resident's paper chart to know how to care for the resident. *Was not able to locate a hospice tab in resident 5's paper chart. *Was not sure what services hospice provided or how often they visited the resident. Interview on 5/24/17 at 7:45 a.m. and at 2:50 p.m. with the director of nursing services regarding resident 5's care plan revealed: *The hospice care plan was not in the facility as of 5/23/17 when it had been requested by the surveyor. *The process would have been to have a Hospise care plan in the medical record. *She would have expected to have found it in the paper chart at the nurses station. *They would refer to the hospice care plan when information was needed on hospice services. *She confirmed the POC only stated I am on hospice. Please see hospice care plan for additional options. Review of the provider's 6/17/15 Interdisciplinary Care Plan policy revealed: *The resident's physician and/or other primary health care providers can be integral to this process. *The care plan should be updated When there has been a significant change in the resident's condition 2. Review of resident 4's medical record revealed: *An admission date of [DATE] and a readmission date of [DATE]. *[DIAGNOSES REDACTED]. *physician's orders [REDACTED]. -Comfort care order set to initiate if needed. -Hospice consult. *A RCRH Hospice of the Hills visit dated 2/27/17. -That note stated the hospice physician had not approved the resident for hospice, and to check back on patients status in one week. *There had been no further documentation in the resident's medical record regarding a hospice consult. Interview on 5/23/17 at 2:00 p.m. with RN B revealed: *No further documentation in resident 4's medical record regarding the hospice consultation ordered on [DATE]. *She stated she was pretty sure the hospice nurse had come again to see the resident but had not known when. *She had been unsure of the status of the resident's hospice consult. *She stated she would contact the hospice agency for the information. Interview and record review on 5/23/17 at 2:45 p.m. with RN B revealed she had obtained three hospice notes from the agency. *The first note on 3/7/17 stated the resident had not met the hospice criteria and would be re-evaluated in two weeks. -The above visit had been completed with the Social worker and nurse at facility. -No documentation had been entered into the resident's medical record regarding that visit. *The second note on 3/21/17 stated Explained to pt (resident) that she was ill enough that we had been referred to evaluate her for hospice but that now she has bounced back to her baseline and she is in agreement that hospice is not what she would desire at this time and acknowledges that she has recovered from her post surgery issues. Will request this referral be closed. -No communication with the provider had been identified. *A third note on 5/9/17 stated:- Hospice consult done 5/9/17 at (name) nursing home. She had been seen X3 for previous hospice referrals in Feb and March following hospital stay for fracture of distal femur and difficulty recovering from surgery to stabilize this. -Dr. (name) was spoken with today at 1330 (1:30 p.m.) and does not approve of pt meeting criteria for hospice at this time. -Discussed case with staff at (name), her RN caring for her today and also RNs B and C at the facility. *RN B agreed: -The hospice notes had not been available in the resident's medical record. -The provider had not documented in the resident's medical record about the above Hospice consultation visits. Interview on 5/24/17 at 2:50 p.m. with the director of nurses regarding resident 4 revealed she agreed:*The hospice consult documentation had not been available in the resident's medical record. *Their only documented communication between the provider and Hospice in the resident's medical record had been on 2/27/17. Review of the provider's signed 12/1/8 contract with the Hospice provider revealed: *The Home and Hospice agree to cooperate in the facilitation of open and clear communication in order that the needs of patients are addressed and med 24 hours per day. *Such communication shall include the sharing of all relevant records and other information regarding a patient. *The Hospice shall furnish a copy of such Plan of Care for such resident to the Home at the time of the resident's admission into the Hospice program. *The Hospice shall provide to the Home the following subject to the patient's consent, access to all records of hospice services rendered to the patient.

Based on observation, testing, interview, and record review, the provider failed to maintain the following items in a sanitary and/or safe condition: *One of two beauty shop styling chairs was in need of a deep cleaning. *One of one housekeeping central supply area had chemicals and cleaners stored so as to create possible contamination to hygienic paper goods. Findings include: 1. Observation on 5/23/17 at 9:00 a.m. revealed a yellow vinyl stylist chair in the beauty shop. That vinyl chair had a build-up of dirt and grime in the grooves that made the yellow color appear brown. Testing by running a fingernail across the chair left a clean trail of the color yellow beneath the removed grime. Interview with the beautician at the time of the observation and testing confirmed that finding. She stated she was a substitute that day for the regular beautician, but the chair appeared to need a deep cleaning. Interview on 5/23/17 at 9:00 a.m. with director of environmental services confirmed: *The chair was dirty and appeared brown when the color of the chair was yellow. *Housekeeping was responsible to clean beauty shop furniture and the floor at the end of each day. Review of the weekly room deep cleaning schedule revealed the beauty shop was not listed on any day of the week nor the week-ends. 2. Observation on 5/23/17 at 4:25 p.m. of the housekeeping central supply area revealed wire mesh shelves. Those shelves held large rolls of paper towels used to fill paper towel dispensers in handwashing locations. Those large rolls of paper towels were stored in direct contact and next to stainless steel polish, Clorox urine remover, Clorox bleach germicidal, and Kleenex foam skin cleanser. Interview on 5/23/17 at 4:25 p.m. with director of environmental services confirmed: *Paper products and chemicals should not have been stored together on the same shelf. *Chemicals should not be have been stored above paper products. *The large paper towels could be contaminated from the chemicals 3. Continued interview on 5/24/17 at 3:00 p.m. with the director of environmental services and the administrator revealed: *There were no logs to identify when beauty shop furniture was cleaned or when the beauty shop had received a deep cleaning. *There were no policies for the cleaning of beauty shop furniture. *There were no polices on the storage of hygienic paper products with chemicals.

Based on observation, testing, and interview, the provider failed to ensure housekeeping cleaners and disinfection chemicals were not accessible to residents in the following areas: *One of two therapy rooms (restorative). *One of one shared bathroom between two of two therapy program rooms. Findings include: 1. Observation on 5/23/17 at 3:40 p.m. of the restorative therapy (RT) room revealed: *The corridor door to the room was wide open. *No one was in the room, but residents were noted in the corridor. *A tall wooden cabinet had a key in the door. -Testing of that door revealed it had been left ajar. -A shelf in that cabinet had a container of Sani-Cloth Plus disinfectant wipes. Continued observation of the shared bathroom between the RT program room and the physical/occupational therapy (PT/OT) room revealed: *The corridor door to the PT/OT room was wide open. *No one was in the room, but residents were noted in the corridor. *Both bathroom doors were opened between the two rooms. -All residents had access to that bathroom. *Two containers sat next to each other on the tank of the bathroom toilet. Those containers were: -A flat package of resident personal care wipes commonly used for personal hygiene. -A round container of Sani-Cloth Plus disinfectant wipes. --Review of that Sani-Cloth Plus label revealed: ---They were germicidal disposable cloths. --Precautionary statement read: ---Hazards to human and domestic animals. ---Not for use on skin. Interview on 5/23/17 at 3:40 p.m. with the director of environmental services confirmed: *The disinfection wipes were used on equipment in the therapy programs. *Sani-Cloth Plus wipes should not have been stored accessible to residents. *The wooden cabinet in the RT room should have been locked, and the key removed from the door. *The Sani-Cloth wipes in the bathroom should have been stored in a locked cabinet. Interview on 5/24/17 at 9:25 a.m. with the occupational therapist revealed she: *Was not aware the Sani-Cloth disinfectant wipes should not have been stored in the bathroom. *Confirmed the other disinfectant wipes used throughout therapy were in a locked cabinet. *Concluded the container of Sani-Cloth wipes in the bathroom would be a hazard to residents and also should have been locked and inaccessible with the other disinfectant wipes. *Felt Worried if the wipes were stored with the hygiene wipes in the bathroom, a resident could have mistaken the wrong wipe. Interview and testing on 5/24/17 at 12:05 p.m. with licensed practical nurse H who was the restorative therapist revealed she: *Confirmed the key to the cabinet was still left in the unlocked cabinet, and the door to the RT room was lefted opened. *Usually removes the key and puts it in my pocket. Which she did at that time. *Was aware the cabinet should have been locked and inaccessible to residents, because the disinfectant wipes were stored in that cabinet. Interview on 5/24/17 at 3:00 p.m. with the director of environmental services and the administrator revealed there were no polices on the storage of chemicals and cleaners and their accessibility to residents.

Based on observation, interview, and procedure review, the provider failed to ensure professional standards were maintained for: *One of one randomly observed resident's (14) nasal spray administration by one of one observed licensed nurse (B). *Two of three randomly observed residents' (15 and 16) eye drop administration by two of three licensed nurses (B and C). Findings include: 1. Observation on 3/8/16 at 7:45 a.m. of licensed nurse B while she administered two different nasal sprays to resident 14. She did not close the other side of the resident's nostril when the resident sniffed the medication in through her nose. Interview on 3/9/16 at 10:30 a.m. with licensed nurse B confirmed she had not closed the above resident's other nostril. 2. Observation on 3/8/16 at 8:30 a.m. of licensed nurse B while she administered eye drops to resident 15 revealed she dropped the eye drop directly onto the resident's eye. Interview on 3/9/16 at 10:30 a.m. confirmed she had dropped the eye drop directly onto resident 15's eye. She agreed she had not administered the eye drop into the resident's lower eyelid. 3. Observation on 3/9/16 at 9:10 a.m. of licensed nurse C while she administered eye drops to resident 16 revealed she dropped the eye drop directly onto the resident's eye. Interview on 3/9/16 at 10:38 a.m. with licensed nurse C confirmed she had dropped the eye drop directly onto the above resident's eye. She agreed she had not administered the eye drop into the resident's lower eyelid. 4. Interview on 3/9/16 at 12:10 p.m. with the director of nurses confirmed: *Licensed nurse B had not administered eye drops and nasal spray correctly. *Licensed nurse C had not administered eye drops correctly. Review of the provider's Specific Medication Administration Procedures for Eye Drop Administration last revised November 2011 stated Use finger of other hand to close the nostril that is not receiving medication by gently pressing the side of the nostril. Review of the provider's Specific Medication Administration Procedures for Eye Drop Administration last revised November 2011 stated With a gloved finger, gently pull down lower eyelid to form pouch while instructing resident to look up. Place other hand against resident's forehead to steady. Hold inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of the eye.

Based on observation, interview, and policy review, the provider failed to ensure dignity was maintained for one of one randomly observed resident (6) who was transferred from the bathing room to her room in a bathing chair. Findings include: 1. Random observation on 3/8/16 at 10:25 a.m. revealed: *Certified nursing assistant (CNA) A was pushing a wheeled whirlpool tub chair from the Oak wing through the common area to the Elm wing. *Resident 6 was in that wheeled tub chair. Her front and sides were covered but her buttocks were visible as she was pushed past this surveyor and a male visitor. *There were also several other residents, visitors, and staff in the common area. Interview on 3/9/16 at 8:40 a.m. with CNA A revealed she was not aware resident 6's buttocks had been visible. She stated she had ensured she had covered resident 6's front and sides but had not ensured her buttocks had been covered. Interview on 3/9/16 at 12:15 p.m. with the director of nursing revealed: *CNA A had not followed the provider's policy for bathing. *She agreed resident 6's dignity had not been maintained during the transfer from the bathing room to her room. Review of the provider's 1/7/15 Bathing policy revealed residents who required assistance to and from the bathing area would be covered to ensure dignity, privacy, and comfort.

Based on observation, interview, and policy review, the provider failed to ensure proper handwashing and glove use was completed during one of two random resident's (17) observations of personal care by one of one certified nursing assistant (CNA) D. Findings include: 1. Observation on 3/8/16 from 8:05 a.m. through 8:25 a.m. of the following regarding resident 17 revealed CNA D: *Entered the soiled utility room on the Maple wing and retrieved the soiled linen cart. *Pushed the cart down the hall and entered a double room and removed the soiled bed linens from both beds. That linen was placed in the soiled linen cart, and the cart was returned to the soiled utility room. *Pushed the total lift to the resident's room. *Without washing her hands or performing hand hygiene CNA D: -Retrieved the resident's clothes from her closet and a clean incontinence brief and wipes from her drawer. -Put on gloves. -Placed socks and pants on the resident. -Called on the portable radio for assistance. -Performed perineal care (cleansing of personal area) for the resident and removed her soiled brief. -Placed the soiled brief and her soiled gloves in the garbage. *Without washing her hands or performing hand hygiene CNA D: -Assisted in pulling up the resident's pants and placed the total lift sling under her. -With the use of the total lift placed her in her wheelchair. -Assisted her with dressing her upper body and then pushed her in the wheelchair into the bathroom. -Took a clean wash cloth, wet it, and then washed the resident's face. -Provided oral care and combed her hair. -Pushed the resident from her room to the common area by the Maple wing. *She then returned to the Maple wing alcove and washed her hands. Interview on 3/8/16 at 8:25 a.m. with CNA D revealed: *She carried alcohol gel in her pocket. *She had been taught if she had gloves on that her hands were clean and she did not need to wash them or complete hand hygiene. Interview on 3/9/16 at 12:15 p.m. with the director of nursing revealed: *CNA D had not followed the provider's policy on glove use and hand hygiene. *She would have expected her to perform hand hygiene before and after glove use. *She would have expected her to use gloves for washing a resident's face and assisting with oral care. Review of the provider's 1/7/15 Hand Hygiene policy revealed hand hygiene would have been performed: *Before and after physical contact with a resident, whether or not gloves were worn. *Between different site/care activities for the same resident.

Based on record review, interview, and policy review, the provider failed to appropriately investigate, assess, document, and report extensive bruising of unknown origin the cause unknown) for one of one sampled resident (1) who was dependent on staff to meet all her mobility needs and required a mechanical lift (equipment to help lift and move residents) for transfers. NOTICE: Notice of immediate jeopardy was given verbally to the administrator and the director of nursing on [DATE] at 5:20 p.m. They were asked for a plan of correction to be given to the surveyors on [DATE] at 8:00 a.m. They were asked that the plan of correction include: *The investigation and reporting of bruises and injuries of unknown origin for all residents. *The assessment and documentation of bruises and injuries of unknown origin for all residents. PLAN: A plan of correction for the reporting and investigation of bruises and injuries of unknown origin was accepted on [DATE] at 8:55 a.m. The plan of correction also included a revised abuse policy that contained the seven required components of abuse and neglect. The immediate jeopardy was abated. The plan was as follows: *Changes were made to the Abuse policy to reflect compliance with regulatory guidelines in regards to: -Screening of potential employees. -Training of employees. -Prevention. -Identification. -Investigation. -Protection. -Reporting/Response. *Investigations going forward would be completed relevant to state and federal regulations. Use paper and electronic nursing policy and procedure manuals. *Initial 24 hour reporting would be completed by the director of operations /director of nursing (DON)/Nurse on duty to comply with state regulations. As warranted a five day reporting will be completed by the director of operations or the DON. *Implementation to achieve compliance: -Interim stand-up meeting would be held to discuss new policy and procedure for abuse at the beginning of each shift change until the formal staff mandatory meeting on [DATE]. Documentation and verbiage provided would be the new policy and procedure for abuse, the initial reporting form, and the Nursing Facility Injury of Unknown Source Reporting Flow sheet. *All staff meeting would be held on [DATE] to include all departments in the facility. *Each staff member who was not able to attend the meeting on [DATE] would be provided with individual education and resources by the DON or DOO by [DATE]. *All staff would sign acknowledgement form of understanding the policy and procedure. *Education to the nursing department would include the expectation that all bruising would be reported to the charge nurse, who would then report to DON/nursing administration/DOO. During the extended survey on [DATE] at 9:30 a.m. the surveyors confirmed removal of the immediate jeopardy and the above plan of correction.Findings included the initial 24 hour reporting had been completed on [DATE] for: *Resident 4; "Bruise noted to bilateral knees, left forearm, right elbow, and right upper thigh. No specific known cause, and resident not capable of participating in interview. Five day report to follow." *Resident 9; "Bruise noted to right arm, left elbow/wrist, and bilateral shins (front of lower legs). No specific known cause and resident not capable to participate in interview. Five day report to follow." *Resident 12; "Bruise noted to right leg and right forearm. Both measure 2.0 by 1.0 centimeter (cm) in size. No specific cause and resident not capable to participate in interview. Five day report to follow." Additional findings included: 1. Review of resident 1's [DATE] through [DATE] interdisciplinary notes by the following staff revealed: *[DATE] at 11:30 a.m. by registered nurse (RN) Q: "Received in report resident became weak during transfer with stand-up lift (lift that requires resident to be able to bear some weight on legs). This morning resident noted to have approximate 18.0 by 17.0 cm bruise to right underarm that extends to the breast. Resident reported area to be tender to touch (TTT). Daughter called with update. Staff made aware and treatment administration record (TAR) updated to monitor every day until resolved. TAR updated related to size of bruise and resident having order for [MEDICATION NAME] (blood thinning medication). Doctor updated via fax. Director of nursing (DON) updated head of bed (HOB) to indicate Hoyer (lift that uses sling and resident does not have to bear any weight on legs) transfer." *[DATE] at 1:20 p.m. by RN Q: "Doctor acknowledged bruise to right underarm. No new orders." *[DATE] at 2:24 p.m. by RN Q: "Received phone call from doctor's office to repeat laboratory tests of complete blood count (CBC), complete metabolic panel (CMP), international normalized ratio (INR), and straight catheter urinalysis. Resident has appointment for [DATE] at 10:00 a.m. for chest x-ray. Daughter aware as she had already called doctor's office." *[DATE] at 10:05 p.m. by RN E: "Resident weak this evening. Remained in bed all shift. Repositioned. Resident assisted with supper. Resident only would eat one-half of jello and refused rest of supper. Resident taking fluids well and offered frequently." (There was no documentation of the bruised area or pain from that area). *[DATE] at 7:38 a.m. by licensed practical nurse (LPN) HH: "Lab here and drew CBC, CMP, and INR from left arm and picked up urinalysis." *[DATE] at 3:14 p.m. by RN D: "Resident this morning with overall worsening of condition, significant bruising to right side, pulses weak and thready (irregular and faint) to all four extremities (arms and legs), color pale and skin cool to touch. Resident arousable (can awaken) but lethargic (sleepy). Respirations (breathing) even but labored with oxygen at 3 liters per nasal cannula. Family called and updated on resident condition. Family to meet with this writer at 10:30 a.m. to discuss current condition and plan of care. Labs (laboratory test results) received at 10:30 a.m. Family present and physician notified via phone of critical abnormals. Physician spoke with daughter and initially provided order for intravenous (IV) hydration and antibiotics. Daughter asked about hospice once off the phone with the physician. Physician called back stating he would be in to meet with the family at 12:45 p.m. IV orders discontinued at this time and hospice ordered. Hospice referral made by social services coordinator and hospice admission expected tomorrow." *[DATE] at 11:04 p.m. by RN II: "Resident is being turned every two hours with oral cares provided. Hospice nurse K here at 7:30 p.m. to talk with family and discussed with nursing here that the admit to hospice will most likely occur tomorrow. Resident has increased heart rate at 120 (normal 60 to 80 beats a minute), and her toes are cold at this time. She is lethargic but arousable. Respiratory rate 20. She is on 3 liters of oxygen. Family was consulted about beginning use of [MEDICATION NAME] (narcotic pain medication) for comfort. Education was given regarding the disease process, progression, and possible pain that would be associated with this process. Resident is wincing during position changing however is not verbalizing pain. She does not wince when lying still. Family decided it would be okay to start the [MEDICATION NAME] at this time." *[DATE] at 6:35 a.m. by RN JJ: "Resident repositioned three times this shift when requested and allowed by family. Resident minimally responsive. Can swallow small sips of water. Comfort cares given." *[DATE] at 2:26 p.m. by RN Q: "Hospice nurse H in to see resident at 9:50 a.m. Daughter reported at 12:15 p.m. that mother was not breathing. No breaths or heart beat and verified by second nurse. Daughter very teary eyed and emotional support given." Review of resident 1's [DATE] at 6:57 a.m. skin assessment form documentation by RN B revealed: *"Blue bruises noted to bilateral shins and purple bruises to bilateral forearms. Circulation, motion, and sensation (CMS) altered to right arm pain." *"Noted to have extensive, deep, purple bruising to right axilla (armpit), right side extending to right hip and right breast with bluish bruising to sternum (breastbone) and 10.0 by 8.0 firm mass (deformity) to right upper chest." *"Resident complains of pain upon movement and palpitation (touching)." *"Conferenced with day nurse regarding appearance of bruising and presence of deformity. Will administer pain medication and follow-up promptly. (Review of [DATE] medication record revealed [MEDICATION NAME] was administered for pain at 7:20 a.m. with no documentation if medication was effective for relieving pain). Interview on [DATE] at 11:20 a.m. with the DON regarding resident 1 revealed: *She did not report or investigate the multiple bruises of unknown origin "because they knew they had happened during an unsuccessful transfer with the stand-up lift." *There was no documentation when the unsafe transfer had happened. Since it had been passed on in report on [DATE] in the morning, it was thought to have happened at bedtime on [DATE]. *An incident report had not been made out by staff working at the time when the bruises had been discovered. They had not utilized incident reports for quite a long time. *The expectation was that the nursing staff would document all pertinent information in the medical record. *She agreed the bruises and the unsafe transfer should have been documented in the medical record when it had happened. *Any investigations would have been also documented in the medical record. The nurse who discovered the bruises should have documented in the medical record. *It had been discussed that she did not tolerate the stand-up lift on [DATE]. She had informed the nursing staff on [DATE] she should be a Hoyer lift for further transfers. *She agreed there was documentation on [DATE] in the interdisciplinary notes the resident had become weak. It stated staff needed to use the Hoyer lift to transfer her. The use of the Hoyer lift was not made a permanent change on [DATE]. *Their policy was staff could always go up with transfers (if a resident was a stand-up lift the staff could use a Hoyer lift if needed), but could not go down with transfers (if a resident was a Hoyer lift than a stand-up lift could not be used). *RN Q had informed the physician of the resident's bruising on [DATE], and it was felt the resident could not tolerate an x-ray. She confirmed RN Q should have documented that. *She did not feel the resident was in pain when lying still on [DATE], so the nurses had not given her any pain medication. The only time the resident was uncomfortable was when the bruised area was palpated. *When the physician had seen the resident on [DATE] he had discussed with the family she was actively dying. The family had decided on hospice care. * She stated,"The reality of the situation (the critical labs) over shadowed the critical condition." *RN D's documentation on [DATE] showed she had done an assessment on the resident and had discussed her deteriorating condition. She had informed the physician at 10:30 a.m. when her laboratory results had come back. *She felt it was following RN D's skin assessment, change in bruising for resident 1, RN D had made the determination not to call the physician. *It was okay for RN D to take over calling the resident's physician and family as she "didn't want three nurses calling." *She confirmed there was no documentation from [DATE] through [DATE] to reflect her progressive declining condition. *"I document only if there is anything in addition to the nurses' documentation." *The resident did not fall or was she dropped. She knew that by the information that had been passed on to her by the nursing staff. Interview on [DATE] at 1:35 p.m. with RN B regarding resident 1 revealed: *On [DATE] she was doing her weekly skin assessments on residents. *She had done the resident's skin assessment about 6:00 a.m. and had RN Q hadf come in the room with her. RN Q had seen the bruising on [DATE], and she had not. *She recalled RN Q making the comment the bruising "was more extensive." *She had been informed the bruising had occurred when the resident had become weak in the stand-up lift, and the Hoyer lift was to be used for transfers. *She was not sure why RN Q had not documented on the bruising on the resident's shins, hip, and right axilla on [DATE]. She would have to check RN Q's notes. *The resident often had bruising on her shins and forearms "because she was on [MEDICATION NAME]." *She confirmed the resident was having pain when the bruised area on her breast was palpated. She had informed RN Q of the pain. She was not sure what medication had been given for pain or that no follow-up was done if the medication ([MEDICATION NAME]) had been effective. *She normally did not measure bruised areas when she did her skin assessments unless "they were significant." She was unable to elaborate what "significant" meant, but she agreed the resident's bruising as noted above was "significant." *She and RN Q had talked about notifying the resident's physician after she had completed her skin assessment. *She had been informed (unsure of by whom) that RN D would be taking over the care of the resident and talking to her family and the physician. She was unsure why RN D was to take over the resident's care since she was not her charge nurse that day. But she had been told RN D knew the family well from working with them during care conferences. She thought RN D "just wanted to help." She thought RN D likely did another assessment of the resident when "she took over her care on [DATE]." *She was not sure what RN D had informed the resident's family or physician but "it would be in her notes." *She was unsure if she and RN Q had talked to RN D about their concerns the physician should have been updated and the resident possibly evaluated in the emergency room . *She was not sure when RN D had informed the physician regarding the significant changes in her bruises. *The resident had been able to visit with her that morning during her skin assessment, but "nothing in depth." She was not entirely sure if the resident at that point could have told her "where she had gotten all the bruises." *The resident had been failing and was more confused. *She was not involved with the resident after her skin assessment on [DATE] at 6:57 a.m. She assumed RN D and the DON were handling things; "I was told RN D was handling things." Interview on [DATE] at 2:30 p.m. with certified nursing assistant (CNA) II C regarding resident 1 revealed: "She didn't really remember caring for the resident that week." (The nursing schedule reflected she worked the day shift on [DATE], [DATE], and [DATE]). *The resident was on the list the "float CNA" took care of, but she was unsure who the float CNA had been those days. She had not been responsible for the resident's care but knew she had assisted the float CNA with repositioning her. *She had taken care of the resident many times before [DATE]. *"I remember the float CNA calling for help to move and reposition her." *"I don't remember using a lift on her. I think she stayed in bed and we turned her." *"She recalled seeing some bruising. The bruising was on one side up to her chest. I thought I heard she had a fall but do not recall anything else." She had gotten report from the CNA who had "worked the shift before her on [DATE]." *She confirmed the resident "had a fast decline from the week before." *"She was not in any distress that I remember." *"Her decline could have possibly started around the time the bruising occurred." Interview on [DATE] at 2:50 p.m. with RN D/Minimum Data Set (MDS) coordinator regarding resident 1 revealed: *She usually worked three to four days a week doing MDS/care plans and one to two days a week as a nurse on the floor. *She usually worked on Elm/Oak wing when she worked as a nurse on the floor. (Resident 1 resided on Aspen wing.) *"Every morning when I come I check with the charge nurse to find out what is going on and if I can help." *"On [DATE] RN B and RN Q had told her there was a change with the resident. I went and did an assessment on the resident and offered to call the family and the physician for them. *She had not been involved with the resident on [DATE] or [DATE]. *"I can't go back and tell you what my conversation with RN B and RN Q on the morning on [DATE] was about. I can not tell you anything outside of what my notes state." *"I informed the family regarding her overall condition after I had assessed her." *The physician was informed of her abnormal laboratory results on [DATE] at 10:30 a.m. She had not thought it necessary to call the physician prior to that on [DATE] after she had spoken to the family. *"It is standard practice to ask the family what they want done for the resident." *She did not comment when asked if she felt the resident's bruising was alarming. *After she had completed her assessment she had felt comfortable calling the resident's family and physician. She had not documented what she had informed the family or physician "just her change in condition." "I would have updated them on her condition and the bruising." *"I think her condition progressively declined from [DATE] to [DATE]." *The physician had called with orders on [DATE], and then came in to see the resident. *"I do not recall either RN B or RN Q telling me on [DATE] they thought she needed to see a physician after their assessment at 6:57 a.m., or otherwise I would have called the physician." *"We do monitor bruises if they are significant." (She was unable to elaborate what significant meant.) *"Her bruising was over shadowed by a declining resident and dying." *"It's up to the family if they want them sent out (referring to the emergency room )." *"We are not obligated to give an opinion but give facts. The family was given information that was provided by me." *The physician felt she was septic (life threatening infection) and was declining rapidly. "Probably multi-system failure." Interview on [DATE] at 4:05 p.m. with RN E regarding resident 1 revealed: *"I am unsure what days I worked with the resident from [DATE] to [DATE]." (The nursing schedule reflected she worked the evening shift on [DATE] and [DATE].) *When she worked she worked on the Aspen wing, where the resident resided. *"I think I remember hearing something that she got weak on the evening of [DATE]." *She thought the CNAs had told her the resident got weak but nothing about a transfer with a mechanical lift. "I can't remember if that was the night she got weak and they went and got the Hoyer lift to transfer her." *Being she was unaware of the resident having problems, she was unsure how it was passed on to the next shift. It was likely the CNAs had passed it on to the next shift of CNAs. *"It's probably something I would have charted on if I had known about it." *"I knew she had bruises on her arms and used protective sleeves. "She always had bruising." *"I don't remember. If something would have happened I would have reported it." *"She was declining everyday I came. She would not eat and she would stay in bed." *It was her expectation with a change in a resident the CNAs would come get her. *"She was on [MEDICATION NAME] and bruised easily. She was weak; very weak." *"She was total care by staff. She did not transfer on her own. She did not do anything for herself." Interview on [DATE] at 4:25 p.m. with CNA F regarding resident 1 revealed: *She had worked the evening of [DATE] and remembered the resident had stayed in her room all the time that night. *She did not remember transferring the resident and thought she had stayed in bed. *She remembered bruising around the resident's chest and thought maybe it had come from a transfer. Interview on [DATE] at 8:00 a.m. with CNA G regarding resident 1 revealed: *She could not remember the dates she had worked on [DATE] through [DATE]. (The nursing schedule showed she had worked the night shift on [DATE] and [DATE].) *The majority of the care she had provided for the resident was turning her and keeping her dry every one to two hours. She knew the last few days of her life the resident had not taken a snack during the night like she always had before. The resident would usually ask for a sandwich and a glass of milk during the night shift around 10:00 p.m. to 10:30 p.m. She had stopped asking for the snack probably two to two and one-half weeks before her death. *The resident never got out of bed at night, and no mechanical lift was ever used during that shift. *She thought she had bruising on her sides closer to her hips on both sides. *She remembered bruising on the sides of her chest, but not the bruises on her legs or arms. *Other CNAs had told her the resident's bruising had come from a lift with a transfer. No nurse had ever talked to her about the resident's bruising. "I was never given a clear answer." *"I was told to turn her more carefully because she had become more fragile." *"She would moan out with moving her." *"I told the nurse she was having pain." She was unsure if the nurse had given her any pain medication. Phone interview on [DATE] at 11:00 a.m. with hospice nurse H regarding resident 1 revealed: *She did not do the hospice consultation on [DATE]; hospice nurse K had. *She did the resident's initial hospice assessment on [DATE]. *She had not documented on the resident's extensive bruising, because very shortly after her assessment the resident had died . If the resident had not died , she would have documented the extensive bruising. *The resident had extensive bruising on her lower legs, hip, shoulder, and breast area. She had not measured the bruising when she had done her assessment. *She was told by the facility the resident's bruising had happened with a transfer from a lift. She could not remember who had given her that information, a nurse or a CNA. *If she had been there longer she would have noted all the bruising in her documentation. *The resident was actively in the dying process,and the family had needed her support. *The resident was unresponsive. She was not moaning with repositioning. *She had felt the bruising was alarming. "That is why she had questioned the nursing staff. Did not feel the reason for the bruising was appropriate." *"The family was aware of the bruising. They had asked her if the fall had precipitated her death." *The family had told her they had been informed by the facility the bruising was caused by a fall with a transfer. *She had informed the hospice physician that had been on call of the resident's condition that included her bruising. Phone interview on [DATE] at 11:20 a.m. with hospice nurse K regarding resident 1 revealed: *She had done the initial hospice consultation with the resident and family on [DATE]. *She had questioned the bruising on the resident's body and was told it had occurred with a transfer and a mechanical lift. *"The resident was tiny and frail." *She thought the family had told her she had been dropped by a lift machine. *The resident's right ribcage and right medial area had purple bruising. There also was bruising on the resident's legs. *She did not remember the resident moaning or showing any signs or symptoms of discomfort. *It did make sense someone that frail would have that kind of bruising if she had been dropped from a lift. *Someone in that frail of state any bruising would have been exaggerated. Interview on [DATE] at 12:40 p.m. with the facility's chief executive officer regarding resident 1 revealed: *They coach and teach the staff to do the right thing. They expected the physician to be informed if there were changes in a resident's condition. *He agreed there was no documentation to support how the bruising had occurred on [DATE] and that should have been documented by the nursing staff. *"We try and take all concerns seriously and not minimize anything." *An investigation was not done due to the resident being on [MEDICATION NAME] and the long history of bruising easily. *Their medical director was very involved and had reviewed the resident's medical record. *He confirmed the primary physician had not documented he had been notified of the bruises, but he knew he had been. *He confirmed the above interviews and the nursing documentation had many discrepancies. Phone interview on [DATE] at 1:20 p.m. with resident 1's primary physician revealed: *When he had seen the resident on [DATE] he had visited with her daughter and son-in-law regarding hospice care. *There was an elderly woman (he thought a friend of the family) that was also in the room and was very concerned about the resident's bruising. He was unsure if the nursing staff or that elderly lady had told him about the resident's bruising, but he was aware of it. He knew she had bruising across her chest, flank, and shoulder. *He had been informed by the nursing staff (unsure who) that they had some problems with a transfer and a mechanical lift. The resident had been unable to maintain her weight in the stand-up lift and had slumped forward. *Initially he considered the bruising alarming but after the explanation it had occurred with transfer issues he was reassured. *The resident was on [MEDICATION NAME] and had a long history of bruising. *"She had gotten more feeble and frail. Her skin was like cigarette paper and very thin. *In the past she had been taken off the [MEDICATION NAME] and aspirin related to her bruising. The [MEDICATION NAME] had to be restarted due to [MEDICAL CONDITION] issues (blood clots). *The resident said a few words to me on [DATE] to yes or no questions. *She did not appear like she was uncomfortable and did not tell me she was having pain. It did surprise me that she was not complaining of pain. *I did not see her on [DATE]. The nursing staff sent me a fax regarding her bruising on her right chest. *I do not recall the nursing staff asking to send her to the emergency room at any time to be evaluated. *She was likely septic related to a urinary tract infection. The family initially wanted IV fluids and antibiotics, but then decided to keep her comfortable with hospice care." *He had not documented in the resident's medical record the bruising and maybe should have. Due to her long history of bruising he was not overly alarmed about it as he would have been in a patient who did not have a history of bruising. *She had been failing for some time. Her condition deteriorated rapidly with the infection process that occurred the same time as the bruising from the transfer. Interview on [DATE] at 10:30 a.m. with CNA P regarding resident 1 revealed: *She had transferred the resident on the evening of [DATE] after supper with the stand-up lift. *"I'm not quite sure what to tell you about that day." *She had done many transfers with the resident before that day. *When the resident was up in the stand-up lift she had gotten weak when she was transferring her to the toilet. She sat her back down and got the nurse (not sure which nurse she got). *The nurse agreed since the resident was slumping it would be best to use the Hoyer lift to get her into bed. *"Noticed the resident had bruising on the front part of her chest, and she reported that to the nurse." Interview on [DATE] at 10:50 a.m. with RN Q regarding resident 1 revealed: *She was unsure what morning it had been but the night nurse told her in report (taped) that the resident became weak with a transfer. (The nursing schedule showed she worked the day shift on [DATE], [DATE], and [DATE].) *Report was taped from shift-to-shift, and she had not recalled speaking personally to the night nurse about the resident's incident. *The CNAs had reported to her the developing bruising. *The resident had no pain when she palpated the bruising on her breast. She agreed she had documented the resident had pain with palpitation. *Either myself or the medication aides give pain medications to the residents. The resident had no more pain after the assessment of the bruise had been completed. *She had talked to the DON, and it was decided the resident should now be transferred with the use of a Hoyer lift. *After she had talked to the DON about the resident "RN D took over." *She was unsure how RN D got involved except she was always willing to help the nurses on the floor. RN D would check with the nurses every morning about staffing and residents' issues. *"I assume I told RN D about the resident's bruising when she took over her care." *"RN D said she was going to call the resident's physician and family. I am not sure what she did." *She could not remember if discussion was done regarding if the resident should be evaluated in the emergency room . *"I can't tell you why RN D took over since I was the charge nurse for the resident on [DATE] and [DATE]. She (RN D) just picked it up and ran with it." *"I believe the physician came and saw the resident on [DATE]." *She had felt the bruising on the resident's breast area had a significant change on [DATE] when she evaluated the area with RN B from [DATE]. *"I think RN B and I discussed having the resident evaluated in the emergency room , but then RN D took over." *"I was not involved with the family conference on [DATE] at 10:30 a.m." *RN D was with the resident when he saw the resident on [DATE]. *"I don't think RN D was involved in other residents' situations like this here before. She has worked here about six to eight months." *She did not think she was on duty on [DATE] when hospice nurse K came to see her. *She did not remember at any time they had asked the resident if she wanted to go to the hospital emergency room to be evaluated. It would have been a reasonable expectation to ask the resident if she was able to answer. She was not sure if RN D had asked the resident. The resident was less talkative at that time. *The resident had slowly been declining, but when she did go it was very rapid. *In the past she had usually taken care of residents' situations like that. *Even though she was the charge nurse on duty [DATE] she was not involved in the resident's care once RN D took over at about 7:00 a.m. Interview on [DATE] at 2:30 p.m. with the administrator regarding resident 1 revealed he: *Was aware of her unsuccessful transfer with the stand-up lift resulting in bruising to her chest. *Knew the nursing staff had updated the physician regarding the bruising, and the decision was made with the family to provide hospice services for her. *Did not feel any further investigation was necessary related to her use of [MEDICATION NAME] and chronic problem with bruising. *Confirmed the nursing staff should have documented on [DATE] when the unsuccessful transfer had happened and the bruising occurred. *Stated there were some discrepancies in their documentation, and the above nursing interviews. *Left the decision up to nursing what mechanical lift should have been used for transfers. *Knew the decision had been made to change her to have been transferred with the Hoyer lift after the bruising incident. Review of the provider's [DATE] Abuse policy revealed: *"To ensure that all incidents involving injuries of unknown origin are immediately called in and investigated to determine probable cause of unknown origin injuries and are reported. (There were no time parameters documented when the initial report should have been completed and when the final investigative report should have been completed." *"Supervisory personnel must report suspicion of a crime to the state survey agency by fax and at least one local law enforcement entity by fax, phone, or e-mail within a designated time frame." *"Supervisory personnel will conduct interviews of staff, resident (s), or other witness' as appropriate to the incident. Supplemental information from other parties, including date and time of the individual's awareness of the incident or suspicion of a crime, will be included with the final report." *"Corrective action based on the investigation will be completed (e.g. change of procedures, training, discipline, or discharge of staff)."

Based on record review, observation, and interview, the provider failed to assess, monitor, and advocate for pain management for: *One of one sampled resident (1) with documented complaints of pain related to a significant injury of unknown origin and acute change of condition. *One of one sampled resident (7) with daily complaints of chronic pain. *One of one sampled resident (9) exhibiting and reporting severe pain related to an acute onset and change in condition. Findings include: 1. Review of resident 1's complete medical record revealed: *An admission date of [DATE]. *A discharge date of [DATE]. *The [DIAGNOSES REDACTED]. *She had been: -Taking the medications [MEDICATION NAME] (blood thinner) and Aspirin (pain and blood thinning) daily. -Taking those two medications to keep her blood thin to help prevent blood clots and keep the heart rate regular. -Dependent upon the staff to meet all of her mobility and activities of daily living (ADL) needs. *She had required the use of a sit-to-stand mechanical lift (lift that required residents to be able to bear some weight on legs) and one staff member to assist her with transfers. *She had become weak during a transfer on 6/17/14. *She had her skin assessed by the skin/wound nurse B every week on Thursdays. *She had been alert with a (BIMS)Brief Interview of Mental Status of 11 indicating moderate memory impairment. *The physician had ordered hospice (comfort) services on 6/19/14. Review of resident 1's interdisciplinary progress notes revealed on the following: *6/18/14 from11:30 a.m. through 10:05 p.m.: -"Received in report that res (resident) became weak during transfer with stand up lift." -"This morning res noted to have an approx (approximate) 18 x (by) 17 cm (centimeter) bruise to right under arm that extends to breast, res reported area to be TTT (tender to touch)." -The physician had been notified of the bruise with no new orders. -Did not mention that any pain medications had been administered or offered to the resident for the discomfort from the bruise. Review of resident 1's 6/19/14 skin assessment form revealed: *She had been assessed by the skin/wound nurse B at 6:57 a.m. *The skin/wound nurse B's documentation at that time revealed: -"Blue bruises noted to bilateral shins (front of lower part of legs), purple bruises to bilateral (both) forearms, cms (circulation, motion, and sensation) altered related to right arm pain." -"Resident noted to have extensive deep, purple bruising to right axilla (armpit), right side extending to right hip and right breast with bluish bruising to sternum (chest) and 10 X 8 cm firm mass (deformity) to right upper chest." -"Resident complained of pain upon movement and palpitation (gentle touch)." -"Conferenced with day nurse regarding appearance of bruising and presence of deformity." -"Will administer pain med (medication) and f/u (follow-up) promptly."(Review of 6/19/14 medication administration record (MAR) revealed [MEDICATION NAME] was administered for pain at 7:20 a.m. with no documentation if medication was effective for relieving pain). Review of resident 1's interdisciplinary progress notes from 6/17/14 through 6/18/14 revealed: *6/19/14 from 7:38 a.m. through 11:04 p.m.: -Laboratory (blood tests) work had been done per the physician's orders [REDACTED]. -The Minimum Data Set (MDS) nurse D documented at 3:14 p.m. she had contacted the doctor regarding the lab work results and had contacted the family regarding her condition. The physician had come to the facility to assess the resident and visit with the family at 12:45 p.m. A hospice (comfort care) consultant referral had been ordered and [MEDICATION NAME] sulfate (MS) 10 mg (milligram) every 2 hours as needed (prn) for pain. -The charge nurse documented at 11:04 p.m. the resident "is wincing during position changing however is not verbalizing pain. She does not wince when lying still. Family decided it would be ok to start the MS at this time." *No documentation to support any of the nursing staff working from 6/18/14 through 6/20/14 had asked the resident if she had been experiencing any pain. Review of resident 1's MAR from 6/18/14 through 6/20/14 revealed on the following: *6/18/14 she had not received nor been offered any pain medications to alleviate the discomfort from the bruise that had been identified. *6/19/14 at 9:30 p.m. revealed: -The first dose of [MEDICATION NAME] sulfate had been administered for pain. -No other documentation was found to support she had received anything after the [MEDICATION NAME] at 7:20 a.m. until 9:30 p.m. for pain. *6/20/14 at 3:45 a.m. she had received a dose of MS for pain. The effectiveness of that medication for her pain had not been documented. Interview on 8/19/14 at 1:35 p.m. with skin/wound nurse B regarding resident 1 confirmed: *Her documentation of the extensive bruising and the mass found on the resident the morning of 6/19/14. *She had been exhibiting pain with any movement or palpitation. *She had been able to visit with her during her assessment. *She had not asked the resident: -If she was experiencing any pain. -Where the location of the pain was. -If she would like anything to help stop the pain. Interview on 8/20/14 at 8:00 a.m. with certified nursing assistant (CNA) G regarding resident 1 revealed: *She had worked the night shift of 6/18/14 and 6/19/14. *Resident 1 had become increasingly weak and fragile when the bruising had occurred. *She would have turned and repositioned her every 1 to 2 hours for comfort. *She had to be careful with repositioning the resident as she moaned and winced with any type of movement. *"She was very uncomfortable." *She had reported the signs and symptoms of pain and discomfort to the charge nurse. *She could not recollect if the charge nurse had provided any pain medication to the resident. *The resident had never appeared to be comfortable when taking care of her. Interview on 8/20/14 at 10:10 a.m. with the director of nursing (DON) regarding the above record review and interviews for resident 1 revealed: * She confirmed the resident had pain upon touching the bruise. *"I think for all of us who went into see her (resident) she had been comfortable at rest." *She would have expected the nursing staff to assess and evaluate the effectiveness of any pain medication given. *No other comment had been offered by the DON for the effectiveness or management of the resident's pain by the nursing staff. 2. Review of resident 7's medical record revealed: *An admission date of [DATE]. *Her occupation had been a nurse. *The [DIAGNOSES REDACTED]. *She had required the use of a sit-to-stand mechanical lift for transfers. *She had chronic pain and had the following medications for pain control: -[MEDICATION NAME] (nerve pain medication) 50 mg at bedtime. -[MEDICATION NAME] (pain medication) 10/325 mg one every 6 hours prn. -[MEDICATION NAME] 500 mg every 6 hours prn. -[MEDICATION NAME] (pain medication) 400 mg every 4 hours prn. Review of resident 7's 7/31/14 MDS and (CAA) care area assessment revealed: *She had required two staff members to meet all of her mobility needs. *She had been alert and oriented to person, place, and time with a BIMS score of 14 (memory intact). *Her speech was clear and could be understood by the staff. *She had rated her pain a 10 on a scale of 1 to 10 with 10 the worst pain. *She had received routine pain medications and prn pain medications/upon request during the assessment period. *"Resident with pain 10/10 at times related to recent surgery, infection, RA (arthritis), and left charot foot ([MEDICAL CONDITION] of the foot). Currently using prn and scheduled pain medications, will proceed to care plan to facilitate adequate pain control." Review of resident 7's 8/4/14 care plan revealed: *A problem area of potential for pain. *A goal area revealed "I would like to remain pain free or have pain identified as it develops and reported to the appropriate provider for treatment through my next review. Goal date 10/22/14." *An approach area with the following interventions listed: -"Please report any verbal complaints of pain that I may have to my nurse." -"Please administer pain medications per physician orders." -"Please ask me about my pain level when you are providing care to me and encourage me to report any pain I am experiencing to staff." -"Please notify my physician of any new, persistent complaints of pain or inadequate pain control." -"Please attempt non-pharmacological (medication) interventions such as repositioning, music and relaxation techniques in conjunction (along with) with prn pain medications as appropriate." Review of resident 7's interdisciplinary progress notes from 7/25/14 through 8/21/14 revealed on the following: *7/29/14 "Resident alert and oriented x (times) 3. Verbalize to make needs known." *8/1/14 "Resident alert and oriented. Resident had [MEDICATION NAME] (pain medication) earlier but still having some abdominal pain." No documentation to support the nurse had offered the resident anything further for pain management. *8/2/14 "At 11:17 a.m. resident requests room tray, stating that she did not want to go to the MDR (main dining room) due to leg pain. Resident received Tylenol ([MEDICATION NAME]) at 9:00 a.m. and [MEDICATION NAME] at 11:00 a.m." *8/4/14 "Resident states almost constant pain to abdomen and left leg that effected ability to sleep and perform day to day activities worst being 10. Resident stated that relaxation, repositioning and music may help with pain." The non-pharmacological interventions had been reviewed and added to the care plan as stated above. *8/5/14 "Upon further questioning, resident admits she does not want to get up because her foot hurts in the morning, and her abdomen bothers her after surgery." *8/11/14 "Resident states almost constant pain worst being a 9/10 effecting sleep and day to day activities with pain medication changes made during assessment period." No documentation had been found to support if those medication changes had been helpful. *No documentation found to support she had been offered anything for further pain control as stated in her care plan. Review of resident 7's MAR from 8/1/14 through 8/23/14 revealed: *She had received [MEDICATION NAME] twelve times during the above time frame. The documentation of the [MEDICATION NAME] revealed: -8/2/14 at 9:00 a.m. effectiveness charted had been "With little relief." -8/4/14 at 11:56 a.m. effectiveness charted had been "Tylenol did nothing." -8/5/14 at 11:49 a.m. effectiveness charted had been "Stated she still had a lot of pain." -8/7/14 at 1:50 a.m. no documentation had been found to support why the pain medication had been given or the effectiveness. -8/7/14 at 11:30 p.m. no documentation had been found to support why the pain medication had been given. *She had received [MEDICATION NAME] sixty-four times during the above time frame. The documentation of the [MEDICATION NAME] revealed: -The effectiveness of the pain medication had not been documented on sevevteen times. -She had continued to have discomfort on eleven occasions with statements of "Little relief," "Did nothing," "Still has some pain," "Resident continues to have pain," "Patient stated it did not help," "Has discomfort," "Some relief," "Relieved some pain," "Not helping much," "Stated it helped some but not much yet," "Resident stated it hasn't helped much 5/10," and "Headache gone but still has foot pain." *No documentation to support if she had been offered anything for further pain control. Interview on 8/25/14 at 10:20 a.m. with registered nurse (RN) GG regarding resident 1 revealed: *The resident had chronic pain from the [MEDICAL CONDITION] to her feet. *The resident was never completely pain free. *She was surprised the resident had not been taking more medication for [MEDICAL CONDITION] pain. The husband had declined anything further for [MEDICAL CONDITION] pain. *The resident had asked for pain medication every morning and evening. *She had offered to ask the physician for an order to put the [MEDICATION NAME] on schedule for better pain control. The husband declined and had wanted the resident to ask for the pain medications. *She had not documented any of the above conversations with the resident's husband. Interview on 8/25/14 at 1:30 p.m. with resident 7 and her husband revealed: *She had chronic pain and had taken [MEDICATION NAME] and [MEDICATION NAME] for years. *Her pain had been worse in the morning upon awakening. *She would have requested a pain pill from the charge nurse around 6:00 a.m. *On several occasions: -She had not received that pain medication until two to three hours later. -The CNA would assist her with getting up without receiving any pain medications first. The CNA had informed her she needed to get up and would receive her pain medication later. *She did not have adequate pain control nor had been free from pain. *She was never asked by the staff if she was having pain, where the pain was, and how much she hurt until she had asked for a pain pill. *She and her husband had not been involved in any conversations offering to put her pain medication on schedule for better pain control. *She would have preferred the pain medication to be placed on a schedule, so she did not have to request the medication. Interview on 8/25/14 at 2:10 p.m. with the DON revealed: *The resident's pain was chronic, and she had times of increase in confusion. *She had not "Believed there had been two to three hours between getting it (pain medication) from when the resident had asked." *She would not put a specific time frame on when the residents should have their pain medication given after requesting it. She stated "It would depend on the situation." *She expected the nurses to explain to the resident why she could not have the pain pill right away. She stated " I believe that they do." *She would have to review the resident in order to determine a pain control goal. *She expected pain control to be based on the resident's goals. *She would have expected the nurses to document why a pain medication had been given and the effectiveness. The provider had not been able to provide a Pain control policy upon reguest. 3. Review of resident 9's medical record revealed: *A 11/22/11 admitted . *[DIAGNOSES REDACTED]. *BIMS score of 1 (indicated severe dementia (memory loss)) on the 7/16/14 MDS. Review of resident 9's August 2014 MAR revealed she received [MEDICATION NAME] 325 mg two tablets daily upon rising in the a.m. and every four hours prn for pain or temperature. Review of resident 9's 8/18/14 through 8/25/14 interdisciplinary notes revealed on the following: *8/18/14 at 2:43 p.m.- "Earlier in shift staff member reported that resident had an increase in back pain. At approximately 12:30 p.m. writer to resident's side and resident denied back pain. Encouraged resident to let staff know if pain should occur. Resident reported understanding." *8/20/14 at 8:59 p.m.- "Bruising with tiny blister noted to right upper arm which she probably got from the lift. Denies pain." *8/21/14 at 6:31 a.m.- "Resident awake at 1:30 a.m. and complaining of back pain. Given two Tylenol. States helped the pain some but has not been able to get back to sleep. Finally got resident up in wheelchair and brought out to commons area to watch TV. Still awake and ready for day when night staff off duty in the a.m." *"8/21/14 at 12:57 p.m.- "RN in to check bruise to right upper arm and also noted 1.0 centimeter (CM) bruise to right forearm, 2.0 cm purple bruise to left elbow, 1.5 cm purple bruise to left wrist, and (2) 1.0 cm purple bruises to bilateral shins (front of lower legs). When writer asked how they had occurred, resident states from you and points at writer. Resident then clarified and reported that her skin bruises easily just by being touched." *"8/21/14 at 9:24 p.m.- "Certified nurse practitioner (CNP) here and saw resident. New order for Perform or another menthol base topical [MEDICATION NAME] to be applied topically to affected areas, back and shoulder four times a day PRN for pain." *8/22/14 at 6:26 a.m.- "Resident awake by 4:30 a.m. and complaining of back pain. Offered Tylenol but resident states does not help and did not want it. Resident wanted to get out of bed so dressed. Up in wheelchair and more comfortable." *8/22/14 at 11:36 a.m.- "Resident teary eyed off and on throughout the shift. Unable to give any specific complaints or concerns but reports that she is just miserable. Denied headache, stomach ache, sore throat, or any other physical difficulties. Did report that she feels so weak. Call placed to daughter with update on order received last evening for topical [MEDICATION NAME]. While visiting with daughter, she agreed that the resident seems to have had a decline with increased confusion at times. Writer suggested starting with a urinalysis and daughter agreed with this plan. CNP gave order at 10:55 a.m. for a straight catheter urinalysis." *8/22/14 at 4:05 p.m. by the assistant DON- "Assessed resident's transfer ability today at 12:10 p.m. this afternoon. Resident transferred from her wheelchair to the toilet in her bathroom. Resident's transfer status is posted as slide board to bed and wheelchair and Hoyer lift to the toilet. Resident demonstrates appropriate ability with use of the slide board and Hoyer lift. Resident follows directions and communicates throughout transfer process. Resident demonstrates appropriate balance and strength for this transfer designation and will remain as a slide board/Hoyer transfer status." *8/23/14 at 5:23 a.m.- "Obtained urinalysis per straight catheter. Resident tolerated well." *8/23/14 at 11:43 a.m.- "CNP gave orders to discontinue [MEDICATION NAME] (blood pressure medication) and to monitor condition [MEDICAL CONDITIONS]. [MEDICATION NAME] was discontinued as it may be causing cough. Today resident has non [MEDICAL CONDITION] (fluid) in bilateral lower extremities. Resident reports she becomes short of breath (SOB) at times but not all the time. Lung sounds are clear throughout. Pulse oximeter (machine to check pulse and level of oxygen in blood) fluctuating between 90 percent (%) and 92% (normal greater than 90%) on room air. Weights are: -7/21/14- 100.3 pounds (lb). -7/28/14- 100.3 lb. -8/4/14- 100.4 lb. -8/11/14- 100.4 lb. -8/18/14- 101.5 lb. Staff reported (this was unwitnessed by writer) that resident had a coughing spell after being transferred to recliner. While assessing resident she reported that she had bilateral shoulder and back pain. Licensed practical nurse provided resident with PRN Tylenol. CNP expected in to see resident later this afternoon, update provided." *8/23/14 at 12:45 p.m.- "Resident slept until approximately 6:45 a.m. then assisted up to wheelchair via Hoyer and two staff members. Staff reports that while placing bra resident reported pain to bra line and especially to under bilateral scapular (shoulder) areas. Therefore bra left unfastened. Resident also reported pain to remainder of back but did report more pain to scapular regions. Applied resident with PRN [MEDICATION NAME] cream at approximately 7:10 a.m. Approximately 45 minutes later resident reported that she thought cream had helped with pain. At 11:30 a.m. received results of urinalysis. Abnormal values noted and call placed to CNP with orders to start [MEDICATION NAME] (antibiotic) 500 mg three times a day for 10 days. Nurses' calendar updated to look for urinalysis culture and sensitivity on 8/25/14. Calendar also updated to offer PRN Tylenol and [MEDICATION NAME] cream frequently related to back pain and to contact CNP/physician on 8/25/14 if back/scapular pain persists. After speaking with staff, pain may be possibly induced/associated to transfers (resident is a Hoyer at times and strap is placed around resident's bra line or resident is transferred with a slide board from recliner to wheelchair and staff assist resident with transfer by placing gait belt during the slide board transfer)." *8/23/14 at 5:28 p.m.- "Resident is not able to participate in interview with most recent BIMS score of 1. Bruises assessed today and staff interviewed for possible insight into cause. Staff note that resident self propels wheelchair in facility, and shin bruises may be related to bumping into corners of walls or other environmental challenges to resident as she navigates. Bruises to arms are possibly related to placement of arms in sling of total lift, as staff report that resident needs physical guidance to correctly position in lift sling." *8/24/14 at 1:09 p.m.- "Earlier in shift daughter and granddaughter in to see resident. They were concerned about resident's pain and audible congestion noted. Writer checked lungs and lung sounds are clear bilaterally throughout. Pulse oximeter is 93% on room air. Resident shows no signs of respiratory distress and when asked resident if she was SOB she stated she did not have a problem with breathing. Family reported her face looked fuller, this is not evident to this writer but this writer takes families opinion to heart. Resident has no [MEDICAL CONDITION] noted to bilateral lower extremities. As of 8/21/14 resident had no significant change in weights. Family thought that a complete blood count (CBC) and chest x-ray would be appropriate to rule out any respiratory problems and then to also look at resident's increased pain. Family stated that waiting for culture and sensitivity of urine would also be appropriate to ensure that bacteria is sensitive to current antibiotic and that back pain was possibly contributing to resident's urinary tract infection. Did review resident's most recent CBC which was done 7/30/14. At that time white blood cells (if elevated indicative of an infection) were within normal limits. PRN and scheduled Tylenol provided as well as [MEDICATION NAME] cream." *8/25/14 at 12:24 a.m.- "Resident on antibiotic therapy with no adverse effects observed. Was medicated with Tylenol PRN." Observation on 8/25/14 at 10:45 a.m. of resident 9 revealed: *Certified nursing assistants (CNA) F and L transferred her to her recliner from her wheelchair using the Hoyer lift and a sling with an opening around her buttocks. The resident complained of pain in the right ribcage area from the sling. *CNAs F and L transferred her back to her wheelchair from the recliner using the Hoyer lift and the same sling. The CNAs put a gait belt around her waist and used the slide board to transfer her into bed. *The resident made comments of "ow" during the transfer into bed and with repositioning. *There was a note on the resident's head of her bed: -"Slide board to bed." -"Slide board to wheelchair." -"Hoyer to the toilet." Interview at that time with RN B who was also present during the above transfer regarding resident 9 revealed: *The resident had her scheduled Tylenol at 6:45 a.m. *She could have Tylenol again at 10:45 a.m. *The resident had been complaining of increased back pain the past few days and was on an antibiotic for a urinary tract infection. *It was on the nurses' calendar to call the physician on her today. She had not called the physician yet. Interview on 8/25/14 at 12:10 p.m. with resident 9 and with RN D present revealed: *"My back hurts so bad." *The resident was coughing frequently and spitting into Kleenex and having difficulty conversing. *She was unable to rate her pain on a 1 to 10 scale (1 being little pain and 10 being severe pain) when questioned by RN D. *She stated her pain was "severe" in her back when questioned by RN D if her pain was no pain, moderate pain, or severe pain. *RN D told the resident she would take her back to her room, and they would put her into bed and give her some cough syrup. Observation on 8/25/14 at 12:30 p.m. of resident 9 with RNs B and D present revealed: *CNAs T and DD transferred her from her wheelchair into bed using the Hoyer lift and a full body sling. *RN B stated she had given the resident some cough syrup. She had given her Tylenol at 10:48 a.m. *RN B stated she was going to update the physician of her pain and cough. Interview on 8/25/14 at 12:35 p.m. with CNA DD and RN B regarding resident 9 revealed: *They had not used the slide board to transfer her from the wheelchair to her bed because of her increased pain. *The decision had been made over the weekend (8/23/14 and 8/24/14) to use only the Hoyer lift for transfers due to her pain. *The full sling should be used with the Hoyer lift transfers as it was less painful than the sling with the buttocks exposed that she had used for toilet transfers. *She was unsure if all the staff had been informed of the above changes when asked why the CNAs in the morning transfer had used the slide board. *RN B did not comment when asked if she was aware of the transfer changes that had been made over the weekend or why the head of her bed with transfer instructions had not been changed. *When RN B was asked why the physician had not been notified on 8/24/14 of the family request for a CBC and chest x-ray she had no comment. Then said, she was not on duty. Review of resident 9's 8/18/14 through 8/25/14 MAR and PRN record revealed: *There was documentation she had received [MEDICATION NAME] 325 mg two tablets every morning upon arising. *[MEDICATION NAME] 325 mg two tablets had been administered PRN thirteen times. -Eight doses of the PRN [MEDICATION NAME] had no follow-up documentation as to the effectiveness of the [MEDICATION NAME] on her back pain. -Five doses of the PRN [MEDICATION NAME] had no documentation as to why it had been administered. -On 8/19/14 the scheduled dose of [MEDICATION NAME] was documented as administered upon arising and a PRN dose of [MEDICATION NAME] was also documented as administered at 6:12 a.m. Review of resident 9's 8/21/14 through 8/25/14 MAR and PRN record revealed Perform or other menthol base topical [MEDICATION NAME] cream: *Had been applied four times with documented results of some relief to relief from 8/23/14 through 8/25/14. (The physician's orders [REDACTED]. *It had not been documented as applied on 8/21/14 or 8/22/24. Review of resident 9's 8/25/14 at 1:00 p.m. fax sent to the physician revealed: *"SOB, cough, and expiratory wheezes with exertion." *"Facial [MEDICAL CONDITION] noted and 1+ [MEDICAL CONDITION] to bilateral calves." *"Confused. Leaning to right in wheelchair. Dry cough." *"Right shoulder and back severe pain." *"Poor appetite." *"Teary eyed and moans with movement." *"Weight 105.4 lb which is up 3.9 lb since 8/18/14." Interview on 8/25/14 at 1:30 p.m. with RN B regarding resident 9 revealed she had received orders to send the resident to the hospital emergency room via ambulance "there is no other way she could get there with her pain." Interview on 8/25/14 at 1:45 p.m. with the DON regarding resident 9 revealed: *Her family had agreed on 8/24/14 to wait for the urine culture and sensitivity report to come back after the nurse had spoken to them. *She was aware the family had requested a CBC and chest x-ray on 8/24/14. She would not have expected the nurse on duty to call the physician regarding that if they were going to wait for the culture results. *She confirmed the laminated sign on the head of her bed had not been changed when the decision had been made over the weekend to not use the slide board but only the Hoyer lift. *She confirmed the PRN [MEDICATION NAME] should have had follow-up documentation if it had helped her back pain. The expectation was that PRN medications should have follow-up documentation within one to two hours. *They did not have a resident change in condition policy.