Every finding on record at Coal Creek Post Acute & Assisted Living

Based on record review and interviews, the facility failed to prevent accidents and hazards for one (#5) of three residents reviewed for falls out of 23 sample residents. Resident #5 was admitted to the facility on [DATE] after pacemaker placement on 4/27/26 due to episodes of sinus pauses (a brief moment when the natural pacemaker of your heart, the sinus node, stops sending electrical signals for a short time), difficulty walking and progressive dementia. Upon admission to the facility, Resident #5 was assessed to be at a high fall risk. The baseline care plan, initiated 4/29/26, documented the resident was confused and very forgetful. The resident was receiving physical and occupational therapy for walking unassisted with gait training utilizing a single point cane, a device she was unfamiliar with and had never used. Resident #5 required frequent verbal cues and repetition for repetitive tasks while walking, as well as to maintain her pacemaker precautions. On 5/5/26, Resident #5 worked with therapy and walked 140 feet twice, as well as practicing various strengthening exercises. The resident required verbal cuing for safety while walking and using a single point cane, contact guard assistance with a gait belt and rest intervals. During the therapy session, the resident experienced a loss of balance episode when her foot caught on the floor causing her to fall forward. The therapist intervened to prevent her from falling to the floor. In an interview on 8/11/26 with physical therapist (PT) #1, PT #1 said she would have recommended that the nursing staff use a gait belt while assisting the resident to walk (see PT #1 interview below).On 5/5/26 at 1:30 p.m. certified nurse aide (CNA) #1, who was the facility's van driver, took over care of Resident #5 from another CNA in the lobby of the facility and started walking arm and arm on the resident's left side while the resident was holding her cane on her right side; however, post-operative instructions directed limiting weight bearing to the resident's right upper extremity to no more than five pounds. While walking with CNA #1, the resident lost her balance and fell face forward to the ground. Resident #5 sustained significant injuries, and required emergency transport to the hospital for treatment of a broken nose with a visible deformity, extensive bruising and bleeding, along with a laceration to her nose requiring sutures to close the wound, as well as upper and lower lip lacerations. The resident additionally sustained an injury to her left rotator cuff (group of muscles and tendons that surround the shoulder joint) and a left wrist ligament injury, which required splinting for immobilization. The facility failed to notify nursing staff of Resident #5's loss of balance episode in therapy earlier that day (5/5/26), as well as the day prior (5/4/26) where in both cases, the therapist had to intervene to prevent the resident from falling due to a loss of balance. Additionally, the facility did not follow the physician's orders to not allow the resident to use her cane on her right side in order to maintain the resident's weight-bearing restrictions on her right upper arm side to promote healing of the pacemaker insertion site.Specifically the facility failed to:-Prevent a fall resulting in significant injury for Resident #5;-Develop and implement person-centered fall care plan interventions to prevent falls for Resident #5;-Ensure Resident #5's loss of balance episodes that occurred in therapy on 5/4/26 and 5/5/26 (prior to her fall on 5/5/26) were communicated to all nursing staff;-Ensure contact guard assistance was provided with a gait belt to prevent a fall, as was recommended by the physical therapist who treated Resident #5 on the day of the fall; and, -Ensure Resident #5 was provided sufficient assistance to walk safely with a single point cane. Findings include: I. Professional referenceAccording to Occupational Therapy (OT) Mastery's, Contact Guard Assist versus Stand By Assist: A Complete OT Guide To Levels of Assist, dated 2026, retrieved on 8/12/26 fromhttps://www.otmastery.com/resources/contact-guard-assist-vs-standby-assist#what-is-contact-guard-assist, Contact guard assist means the provider maintains light physical contact with the patient, usually a hand resting on a gait belt secured at the waist, while the patient performs the entire task by themselves. The contact is protective not assistive. You are not pulling them up or holding the person bearing any of their weight. You are there so that if their knees buckle or they list to one side, your hand is already in position to steady them or to control a fall. The whole philosophy of contact guard: The belt and your hand exist to guide and stabilize not to haul.II. Facility policy and procedure:The Fall Prevention Program policy, undated, was provided by the nursing home administrator (NHA) on 8/10/26 at approximately 2:00 p.m. It read in pertinent part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standardized risk assessment for determining a resident's fall risk.The risk assessment categorizes residents according to low, moderate, or high risk. High risk protocols: The resident will be placed on the facility's fall prevention program; indicate fall risk on care plan; provide additional interventions as directed by the resident's assessment including: assistive devices; increased frequency of rounds; therapy services.III. Resident #5A. Resident status Resident #5, age [AGE], was admitted on [DATE] and discharged to another facility on 5/12/26. According to the May 2026 computerized physicians orders (CPO), diagnoses included pace maker placement, dementia, difficulty walking and acute respiratory failure with hypoxia.The 5/12/26 minimum data set (MDS) assessment revealed Resident #5 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment indicated Resident #5 did not have symptoms of inattention or disorganized thinking.-However the baseline care plan, dated 4/29/26, documented the resident was confused and very forgetful.The assessment documented Resident #5 could walk 150 feet with supervision or touching assistance and was independent with surface to surface transfers and bed mobility.-However, the PT notes from 5/4/26 and 5/5/26 documented the resident had an episode of loss of balance in the therapy sessions, which required the therapist to intervene to prevent a fall (see record review below). B. Record reviewReview of the fall care plan, initiated 4/29/26 and revised 5/18/26, revealed Resident #5 was a high risk for falls related to generalized muscle weakness. Fall interventions included following the facility's fall protocol and ensuring the resident wore appropriate footwear when ambulating, anticipating the resident's needs, and ensuring the resident's call light was within reach.-The fall care plan did not indicate that the facility reviewed the care plan, following the resident's recorded loss of balance that required the PT's intervention to prevent a fall during therapy sessions on 5/4/26 and on 5/5/26, to ensure the resident's fall interventions remained appropriate.The OT note, dated 4/30/26, documented a trial of a single point cane with Resident #5 to improve stability due to the resident's right upper extremity range of motion and weight restrictions. The resident required verbal cuing to avoid using the right arm when pushing up from a seated position. The resident demonstrated ambulating (walking) approximately 20 feet in the resident's room using a single point cane with stand-by assist requiring verbal cues for sequencing, as the resident had not used the device before. The OT recommended the resident wear her sling to her right arm during the day to serve as a reminder for the resident to follow the activity restrictions imposed by her cardiologist for wound healing after her pacemaker placement just three days prior. Additionally, the OT administered a SLUMS (St. Louis University Mental Status) assessment (screening tool used to evaluate cognition). The resident scored 19/30, indicating a dementia level cognition. The resident displayed deficits in orientation to the day of the week, immediate recall and short-term memory, which contributed to poor carry over of therapy instructions.The PT note, dated 5/4/26, one day prior to Resident #5's fall on 5/5/26, documented Resident #5 was on precautions for high fall risk, pacemaker precautions, and decreased cognition. Resident #5 had a moderate loss of balance where the PT had to reach out to prevent the resident from falling after she caught the ball of her foot on the floor, causing her to lunge forward. The PT note, dated 5/5/26, the day of Resident #5's fall, documented Resident #5 was on precautions for high fall risk, pacemaker precautions, and decreased cognition. Resident #5 participated in lower extremity exercises for range of motion and strengthening. These exercises included lateral weight shifting, heel raises, miniature squats, and sit-to-stand exercises from the edge of bed without the use of her arms for five repetitions. The resident ambulated up to 140 feet twice, requiring cueing for safety and rest intervals. The 5/5/26 PT note documented Resident #5 required cuing for overall safety awareness and her weight-bearing limitations to the right arm. The therapist applied the sling to serve as a reminder for the resident not to use her right arm, due to her cognitive deficits which resulted in an inability to fully comply with her weight-bearing and mobility restrictions to her right arm, per her post-pacemaker activity instructions. The 5/5/26 PT note further documented that during the therapy session, Resident #5 had a mild loss of balance where she caught her foot abruptly on the floor during ambulation, requiring the therapist to intervene to prevent the resident from falling. The nurse progress note, dated 5/5/26 at 2:19 p.m., the nurse was notified by a therapist that Resident #5 was on the floor in the lobby. When the nurse arrived at the lobby, the resident was face down, body extended, with the facility driver (CNA #1) next to her. Blood was noted on the CNA #1's hand and towel. Resident #5 was wearing appropriate footwear and had her cane next to her. CNA #1 told the nurse that the resident was walking next to her and just fell down. Resident #5 reported she fell frontwards while she was walking to get on the facility van for her appointment. The resident denied tripping. The resident had no pain except for her nose. Staff assisted the resident to lie on her side, and a laceration was noted to the top of the bridge of her nose and she had a skin tear to her left hand. The resident was alert and oriented times four and was able to communicate. Blood was noted coming from the resident's nose, laceration and mouth. The director of nursing (DON) applied small pressure to the laceration on the resident's nose with gauze. Emergency medical services (EMS) was called and the resident was transported to the hospital for evaluation.The emergency room note, dated 5/5/26 at 2:43 p.m., documented Resident #5 presented to the emergency room with head and facial trauma with a gross deformity and lacerations to her nose, as well as a superficial laceration to her lower lip and a full thickness laceration to her upper lip. She had a skin tear to her left hand and complained of left shoulder pain. A computed tomography (CT) scan of her face revealed a comminuted bilateral displaced nasal fracture (a severe broken nose where the nasal bones are broken into multiple pieces on both sides and have shifted out of their normal alignment) An Xray of Resident #5's left shoulder demonstrated a possible rotator cuff strain and an Xray of her left wrist revealed a possible scapholunate ligamentous injury (a sprain of the critical ligament that stabilizes the wrist), requiring a velcro wrist splint for immobilization.An interdisciplinary team (IDT) fall investigation note, dated 5/6/26 at 12:02 p.m., documented that on 5/5/26 at 1:30 p.m., Resident #5 was walking with a stand-by assist per the resident's therapy plan of care in the lobby with a staff member. The resident was wearing appropriate footwear and using her cane. The resident was ambulating without difficulty when staff reported the resident fell quickly to the floor. The floor was dry with no obstacles. The resident reported she fell forward while trying to walk to her appointment. The resident was assessed by the registered nurse (RN), who advised staff to leave the resident in a position of comfort on the floor until EMS arrived. First aid was provided and pressure was applied to the resident's nose and right hand for bleeding. The resident was a stand-by assist per therapy. Root cause analysis revealed the resident was ambulating and reported she just fell. She was ambulating, as per therapy recommendations with stand-by assistance from a staff member. After a second interview of the resident the following day, Resident #5 reported she just tripped, but no one believed her. The resident stated she may have tripped on a tile, however there were no tiles in the main lobby and the lobby area was smooth.-However, therapy notes (see OT/PT notes above) and interviews with the therapist (see interview below) revealed Resident #5 needed more assistance for safe walking.A pacemaker report, was received from Resident #5's cardiologist on 8/11/26 at 10:59 a.m. The pacemaker report, dated 5/5/26, revealed the resident's pacemaker showed no episodes, alerts, arrhythmias or pauses were identified since its placement on 4/27/26. IV. Staff interviewsCNA #1 and the DON were interviewed together on 8/5/26 at 10:00 a.m. CNA #1 said she greeted Resident #5 in the hallway near the front lobby (on 5/5/26), as the resident was being assisted there by another CNA. CNA #1 said she was driving the resident to her appointment. CNA #1 said she walked with the resident arm and arm on the resident's left side, by linking elbows while the resident used her cane on her right side. She said the resident was using the cane appropriately. CNA #1 said the resident was not wearing a gait belt. CNA #1 said the notes written on the residents' white boards in their room by therapy advised staff what assistive devices were necessary to assist the residents while walking. CNA #1 said there were no instructions to use a gait belt with Resident #5 written on the resident's white board earlier that day (5/5/26). -However CNA #1 had not been in the resident's room just before the resident's appointment to see if there were any additional recommendations added. CNA #1 said she never saw a gait belt used with Resident #5 and the resident was only using a cane in therapy sessions on the days she observed the resident in therapy. CNA #1 said she was educated on Resident #5's ambulatory status by PT #2.CNA #1 said Resident #5 was talkative and in good spirits, no symptoms of fatigue or pain and appeared in good health (on 5/5/26). She said they took a few steps and Resident #5 fell forward without warning. CNA #1 said she tried to catch her, but the resident fell straight forward and CNA #1 fell to the floor with her. The DON said she responded to the fall immediately, as she was in a closed conference room close to where the incident took place. The DON said Resident #5 did not lose consciousness and was assisted to a position of comfort until EMS arrived. The DON said pressure was applied to the resident's nose to control the bleeding. PT #2 was interviewed on 8/5/26 at 10:30 a.m. PT #2 said he did not work with Resident #5 the day she fell (5/5/26). He said he witnessed the fall outside of the conference room. He said CNA #1 was walking with the resident arm and arm on her left side and the cane was on her right side. He said the resident suddenly fell straight down, face forward. PT #2 said Resident #5 was on contact guard assist and was at a supervision level at the time of the fall and an arm and arm technique was appropriate.-However the resident had two documented episodes of loss of balance requiring the PT's intervention to prevent a fall during therapy sessions (on 5/4/26 and 5/5/26).The medical director was interviewed on 8/5/26 at 11:26 a.m. The medical director said that Resident #5 had a history of significant sinus pauses. He said there was improvement with the pacemaker, but that did not prevent reoccurrence. He said he reviewed the resident's electronic medical record (EMR) and her vial signs were stable leading up to the fall and the resident was getting ready to be discharged to an independent living facility. He said he could not say for sure what caused Resident #5's fall on 5/5/26.-However, the 5/5/26 pacemaker report provided by the resident's cardiologist revealed the resident's pacemaker revealed no episodes, alerts, arrhythmias or pauses were identified since its placement on 4/27/26 (see record review above).PT #1 was interviewed on 8/11/26 at approximately 1:00 p.m. PT #1 said she worked with Resident #5 on 5/5/26, the day of her fall. She said Resident #5 stumbled in therapy that day and her balance was corrected by use of contact guard assist and a gait belt. PT #1 said she recommended that contact guard assist with a gait belt be used with Resident #5 during ambulation and she would have written it on the resident's white board in her room, as that was how therapy communicated a resident's ambulatory and transfer status to nursing staff. She said she did not have a specific memory of writing the recommendation on Resident #5's white board, but she was confident she would have updated the board with the information, as it was her routine to do so with every resident after every therapy session.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#5) of four residents reviewed for grievances out of 23 sample residents.Specifically the facility failed to:- Appropriately respond to a grievance filed on behalf of Resident #5 and offer clear communication and a sufficient description of the events that led to Resident #5's fall with serious injury; and, -Uphold the resident or resident representative's right to obtain a review of the grievance in writing within a reasonable timeframe.Findings include: I. Facility policy and procedureThe Resident and Family Grievances policy, undated, was provided by the nursing home administrator (NHA) on 8/10/26 at approximately 12:00 p.m. It read in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance.II. Resident #5A. Resident status Resident #5 age [AGE], was admitted on [DATE] and discharged on 5/12/26. According to the May 2026 computerized physician orders (CPO), diagnoses included pacemaker placement (4/27/26), dementia, difficulty walking, and acute respiratory failure with hypoxia.The 5/12/26 minimum data set (MDS) assessment revealed that Resident #5 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. B. Record review A formal grievance was filed on 5/12/26, in writing, by the resident's representative. The grievance form documented that the resident representative wanted clear and accurate details of the resident's fall in the facility that occurred on 5/5/26. The grievance documented that the facility had given the resident representative conflicting information about the resident's fall and they were not clearly understanding how the resident fell and sustained such severe injuries (a broken nose, with a visible deformity, extensive bruising and bleeding, along with a laceration to her nose requiring sutures to close the wound, as well as upper and lower lip lacerations. The resident additionally sustained an injury to her left rotator cuff and a left wrist ligament injury requiring splinting for immobilization.) The resident was in the facility for physical and occupational therapy to strengthen and improve her ability to transfer safely after placement of a pacemaker and the resident representative wanted to have information of the facility policies and process for transporting and assisting residents in this condition. The resident representative also wanted clarification on therapy recommendations and why nursing staff were not following the therapist recommendations for the resident while walking. Cross-reference F689 for failure to ensure residents were free from accidents/hazards.The grievance expressed frustration from the resident's representative surrounding a lack of clear communication and an insufficient description of the events leading up to Resident #5's fall. A follow-up statement to Resident #5's grievance, dated 6/2/26, documented that on 5/12/26 the facility received a written grievance from the resident's representative regarding the resident's fall incident. The grievance was initially provided to the director of rehabilitation and then forwarded to the NHA for review.In that follow-up statement the NHA documented that he reviewed the family's concerns and had previously communicated the details of the facility's investigation of the incident to them. The NHA made the decision that an additional response to the representative grievance was not necessary as the concerns had been addressed and discussed multiple times with the resident's representative and other family members by himself (NHA) and the director of nursing (DON). C. Resident #5's representative interviewsResident #5's representative and other family members were interviewed on 8/6/26 at 4:00 p.m. One of the representatives said that on 5/5/26, she was to meet Resident #5 at a follow-up cardiologist appointment, one week post-pacemaker placement. She said while she was waiting at the cardiologist's office, she received a call from an unknown staff member at the facility and was informed that Resident #5 was being transferred to the emergency room after a fall. She said she was not given any more information other than that a fall occurred, and the resident was being transferred by ambulance for evaluation. Resident #5's representative said she was not informed and did not understand the severity of the resident's injuries or if the resident would be well enough to make her already scheduled appointment with the cardiologist. The resident's representative said later that same day (on 5/5/26), while at the hospital with Resident #5, she received a call from certified nurse aide (CNA) #1, who was the staff member walking and transporting Resident #5 when she fell. She said CNA #1 was following up to ask about rescheduling the resident's cardiologist appointment. The representative said she asked CNA #1 about the resident's fall. She said CNA #1 told her that Resident #5 just went down and did not provide further information. The representative said after that phone call, she called the facility and spoke to the social services case manager asking for details about the resident's fall. She said the social services case manager could not provide information about the incident and did not know if video footage was available. The representative said the social services case manager transferred her call to the director of nursing (DON). She said the DON did not answer the phone so she (the representative) left a voice message requesting information and a call back. The representative said she left an additional message on the NHA's phone line requesting a call back. The representative said the DON called her back the next day (on 5/6/26) at approximately 12:00 p.m. She said the DON provided limited information and said she would investigate Resident #5's fall further and get back to her with additional information. The representative said an hour later, at 1:00 p.m., the NHA called her and gave her details of the resident's fall. She said the NHA did not have any direct observational information about the resident's fall and suggested that the representative interview Resident #5 to obtain information from her since she was her own witness to the fall. The resident's representative said the conversation was mostly argumentative and she felt that the NHA was being deceptive and vague with details related to Resident #5's. She said the phone call was disconnected in the middle of the conversation so she immediately called the NHA back but he did not answer. She said she left another voice message; however, neither the NHA or the DON ever called her back.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/5/26 at 12:00 p.m. LPN #1 said she did not witness Resident #5's fall on 5/5/26. She said emergency medical services (EMS) were on the scene by the time she made the initial call to notify the resident's representative of the fall. She said she told the representative that Resident #5 had a fall and was being assessed. LPN #1 said the resident's representative asked if Resident #5 would still make her scheduled appointment. LPN #1 said she told the representative that the resident was being transferred to the hospital and would not make her appointment. She said she did not give any further details and the call lasted approximately two minutes. The DON was interviewed on 8/11/26 at 11:30 a.m. The DON said LPN #1 called Resident #5's representative after the resident's fall on 5/5/26 to inform her of the incident and the resident's change of condition immediately after the incident. She said the case manager also spoke to the representative that day but could not say whether the case manager reached out to the representative or if the representative reached out to her. The DON said she did not have details about the conversation between the case manager and the representative. The DON said she was the third person to call the representatives about Resident #5's fall and she gave them the information she had at the time. She said the conversation turned combative and the representatives were accusatory. The DON said she did not plan on calling the representative back after that conversation and requested the NHA to follow-up with the representatives. The NHA was interviewed on 8/11/26 at 12:00 p.m. The NHA said he called Resident #5's representatives on 5/6/26 after they spoke to the DON. He said the representatives expressed that they were frustrated and were receiving misinformation regarding the resident's fall from different sources. The NHA said the representatives were under the impression that the fall took place in the parking lot but it happened in the hallway leading to the main lobby. He said the representatives accused the NHA of being deceptive and withholding information. He said the representatives insisted on seeing video footage of the fall because they believed that CNA #1 may have tripping Resident #5 causing her to fall. The NHA said they did have cameras in the facility but they did not record data the systems only had viewing capacity. The NHA said he offered to arrange and pay for a third party transportation service for the resident so as to satisfy the representatives request to no longer allow CNA #1 to transport the resident. The NHA said he discussed arrangements with the representative to accommodate a longer stay for Resident #5 as her insurance coverage was expiring.The NHA said Resident #5's family filed the formal grievance on the day of the resident's discharge from the facility. He said when he received the grievance two days later, he did not feel it was necessary to contact the resident's family again because it was his opinion there were no new questions or information to discuss.

Based on interviews and record review, the facility failed to ensure residents were free from any significant medication errors for one (#4) of six residents reviewed out of 23 sample residents.Specifically, the facility failed to ensure Resident #4 did not receive Resident #11's medications in addition to his own medications.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/1/26 to 6/3/26, resulting in the deficiency being cited as past noncompliance, with a correction date of 12/26/25.I. Situation of failure to administer medications as orderedResident #4 was admitted to the facility on [DATE] with a computerized physician's order (CPO) for his medications, which he received correctly on 12/23/25 and 12/24/25. On the morning of 12/25/25, Resident #4 received his medications, plus six medications belonging to Resident #11. On 12/25/25 Resident #4 was transferred to a local hospital, unrelated to the incorrect medication administration, where the medication errors were discovered. Upon investigation of the incident, the facility identified the following:On the afternoon of 12/24/25, the medical records director (MRD) electronically uploaded to the nurse practitioner (NP) what should had been two resident's medical records (Resident #4 and Resident #11). The MRD instead uploaded one resident's (Resident #11) chart twice, once for Resident #11 and once for Resident #4. The NP did not verify the name or date of birth for Resident #4. The NP read Resident #4's correct CPO and made a determination to add eight medication from Resident #11's chart into Resident #4's certified physician's orders. The NP ordered the new medications to begin on 12/25/25.On the morning of 12/25/25, Resident #4 was administered his own medication, plus six of the eight medications from Resident #11's CPO.On 12/25/25 around 1:30 p.m. a nurse noticed Resident 4's PICC line (peripherally inserted central catheter, which was inserted into a vein in the upper arm), was very red, hot, and swollen. Resident #4 was sent to the hospital due to the concern with his PICC line. At the hospital on [DATE], the medication errors were found by the hospital physician, who recognized the medication orders were not the same as from 12/23/26 when the hospital originally discharged Resident #4 to the facility. Resident #4 was immediately placed back on his correct medications at the hospital. Resident #4 only received one dose each of the incorrect medications on the morning of 12/25/25.On 12/25/25 the hospital notified the facility's medical director (MD) of the medication errors.On 12/26/25 the NP who made the error, came into the facility and notified the nursing home administrator (NHA) and the director of nursing (DON) of the mistake. On 12/26/25 the NHA and the DON took immediate action to remedy the situation that had occurred in the facility with Resident #4.On 12/26/25 the facility's MD went to the hospital and met with the hospital's physician, Resident #4, and Resident #4's family representative. The MD determined there was no harm after Resident #4 received one dose of each of the wrong medications. The MD said because it was only one dose, there was no harm done to Resident #4. The MD said the reason Resident #4 went to the hospital on [DATE] was due to his PICC line and not the medication error that occurred in the morning of the same day.On 12/27/25 Resident #4 readmitted to the facility from the hospital. Resident #4's CPO was updated correctly, and Resident #4 received the correct medications until his discharge from the facility on 1/6/26.II. Facility plan of correctionOn 12/26/25 the NHA and the facility's management team met and implemented a plan of action in response to Resident #4's medication errors, in order to ensure that all of the residents in the facility received the correct medications per their physician's orders.A. Immediate actionOn 12/26/25 Resident #4 received his correct medications in the hospital. All residents in the facility had their CPOs reviewed. The DON educated the facility's nursing staff and the MRD. The MD went the hospital to meet with the hospital physician and Resident #4. The MD met and educated all of his providers, including the NP who made the medication error. B. Identification of other residentsOn 12/26/25: The facility printed all current residents' medication discharge summaries, and all current medications. The DON and the prescribing providers reviewed each resident. This was completed on 12/26/25 with all medications verified to be prescribed correctly and orders verified to be current and verified all current orders to be correct as per individual residents. All current order summaries were signed by the provider after review and no variances were noted. All current charts were reviewed for correct documentation uploads and to verify only the resident's documents were uploaded per chart. This was completed on 12/26/25.-All residents admitted within the last 30 days would be audited for provider entered order errors. All providers entered orders to be verified via a chart review and provider note review. Providers to be contacted in case of any variation for collaborative discussion and review. This will be completed no later than 12/31/25.C. Systemic changesOn 12/26/25 the MRD education was completed regarding double verifying uploads were correct as per resident chart. The MRD was to verify all current resident's name and date of birth on all documents and verify they were uploaded to the correct resident's chart. The MD educated his practice (company name) on completing medication reconciliation on admission and any variances were to be communicated to the nursing manager directly for collaborative medication management and reconciliation post discharge.-All admission orders were to be entered by the nursing team with medications verified via two nurse check off prior to order activation. This will be completed on every admission for discharge order reconciliation. The interdisciplinary plan of care (IPOC) check will be completed within 72 hours of admission by the nursing manager for all residents.-The MD's (company name) agreed to only enter new diagnosis/plan of treatment related orders for 72 hours post admission. For any correction to the medication admission orders and discharge medication reconciliation (company name) will not prescribe and enter orders. The (company name) will call the nurse manager directly to discuss, collaboratively manage orders and then nurse manager or designee will enter orders.Beginning 12/26/25, all (resident) discharge documents uploaded to the chart will have a second person's verification of the correct name and date of birth of the resident documents uploaded correctly within 72 hours.D. MonitoringOn 12/26/25: The MD educated that the (company name) providers will not enter any resident discharge orders upon admission to (company name).Starting 12/26/25: The MRD/DON/nurse manager/designees will: document an uploaded review of the resident's discharge summary and an audit to be completed within 72 hours of uploading the discharge summary. The medical records department will do the first audit and the nurse manager or designee is to verify the correct discharge summary uploaded by the medical records department within 72 hours of upload to the resident chart. This will be completed on every resident for 30 days then as determined by the QAPI (quality assurance and performance improvement) committee. This will be documented on an audit tool.A monthly review in the QAPI committee would continue until substantial compliance was achieved.III. Facility policy and procedureThe Medication Administration policy, dated 2022, was provided by the DON on 6/2/26 at 9:00 a.m. via email. It revealed in pertinent part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Identify resident(s) by photo in the MAR (medication administration record).IV. Resident #4A. Resident statusResident #4, age [AGE], was admitted on [DATE], readmitted on [DATE], and discharged on 1/6/26. According to the December 2025 CPO, diagnoses included acute embolism and thrombosis of the superficial veins of the right upper extremities (a blood clot formed near the surface of the skin), sepsis, bacteremia (bacteria in the bloodstream), acute respiratory failure, COPD (chronic obstructive pulmonary disease), type 2 diabetes mellitus and hypertension (high blood pressure).The 12/31/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #4 required maximum assistance with toileting and bathing. Resident #4 required set-up assistance with eating and oral hygiene.B. Record reviewOn 12/23/25 Resident #4 was to receive the following medications per the December 2025 MAR:Atorvastatin calcium 10 mg (milligrams), Ampicillin sodium injection solution 2 gm (grams), Lisinopril 10 mg, Pioglitazone 30 mg, Rosuvastatin 5 mg and Tamsulosin 0.4 mg.On 12/24/25 at 9:49 a.m. the pharmacy progress note documented Resident #4's medication was reviewed with no recommendations.On 12/24/25 at approximately 7:10 p.m. the NP's progress note revealed that Resident #4's medication orders were updated. According to the DON (see interview below), the NP added the incorrect medications and Resident #4 was to receive the updated medications on 12/25/25. (Resident #4 did receive the correct medications on 12/23/25 and 12/24/25.)On 6/2/26 at 10:00 a.m. the MD provided the following medication list of additions that Resident #4 received on 12/25/25.The medication list provided by the MD revealed Resident #4 received the following medications on 12/25/25, which the NP mistakenly added to Resident #4's CPO from Resident #11's medications: Lyrica 100 mg, Spironolactone 25 mg, Losartan 100 mg, Sertraline 100 mg, Sinemet 10-100 mg and Synthroid 88 mcg (micrograms).The 12/26/25 at 1:29 p.m. late entry progress note, written by the DON, documented Resident #4 was sent to the emergency room (ER) (on 12/25/25) for concern for issues with a PICC line. Resident #4 had medication reconciliation completed at the ER with anomalies noted. Upon investigation, root cause analysis revealed the resident had the wrong discharge summary uploaded to the chart and the NP updated orders based on the wrong discharge summary medication list. Resident #4 received minimal doses of the wrong medications with no adverse effects noted. Resident #11 was on correctly ordered medications from his discharge summary medication list.The resident had no adverse effects from medications administered and was subsequently sent to the ER for an unrelated issue. Education to staff and providers was provided on verifying name and resident identifiers in charts prior to entering medication orders. Education was provided to MRD regarding uploads and verifying correct documents in the correct chart.The 12/27/25 hospital physician discharge note documented Resident #4 came to the hospital on [DATE] with right upper arm swelling. There was a concern that Resident #4 had a skilled nursing home medication list which listed medications that were not prescribed. The hospital physician spoke to the nursing home's medical director who indicated that they were aware of the error and had been in the process of correcting the medication list for Resident #4 while he was in the hospital.V. Staff interviewsThe MD was interviewed on 6/1/26 at 3:23 p.m. via the telephone. The MD said he was made aware of Resident #4's medication error when the hospital called and notified him on 12/25/25. The MD said the facility admitted to the error immediately. The MD said on 12/26/25 he went to the hospital where Resident #4 had been admitted . The MD said he personally met with the hospital physician and he and the hospital physician determined there was an error, but the resident did not have any harm with only one dose of the incorrect medications being administered. The MD said he personally met with Resident #4 in the hospital, and talked with Resident #4's family representative about the situation.The DON and clinical resource #1 were interviewed together on 6/1/26 at 4:00 p.m. Both the DON and clinical resource #1 said the problem with the incident with the medication error was that the facility's MRD uploaded into the computer incorrect information. The DON and clinical resource #1 said the MRD, on 12/24/25, uploaded electronically to the NP what was to be two different resident's charts, but instead upload Resident #11's chart for both Resident #11 and Resident #4. The DON said the NP did not verify the name or date of birth for Resident #4. The DON said Resident #11 received his correct medications. The DON said the NP scheduled the new medication changes to begin on 12/25/25. The DON said Resident #4 had received the correct medications on 12/23/25 and 12/24/25, and the incorrect six medications only on the morning of 12/25/25. The DON said when Resident #4 went to the hospital on the afternoon of 12/25/25, the problem was discovered at the hospital and fixed immediately. Clinical resource #1 said the facility immediately fixed the situation on 12/26/25, before Resident #4 returned to the facility on [DATE]. The DON said the NP no longer worked in the facility after the incident.-The DON provided a written and signed statement that the NP wrote on the morning of 12/26/25, which revealed that the NP admitted that she had transcribed another resident's medications in the medical record of Resident #4. The NP notified the DON that the NP's supervisor (the MD) was notified of the mistake.The MD was interviewed again on 6/2/26 at 10:00 a.m. The MD said Resident #4 received the correct medications on 12/23/25 and 12/24/25. The MD said on 12/24/25 the NP had added medications to Resident #4's medical record that belonged to Resident #11. The MD said Resident #4 received his medications on 12/25/25 in the morning plus Resident #11's medications. The MD said on 12/25/25 Resident #4 received one dose of each of the incorrect medications (see above list provided by the MD). The MD said Resident #4 did not receive harm from only one dose of each of the six medications. The MD said had the error gone on for two weeks or a month, there may have been a problem. The MD said he told the NP that the NP should have noticed the medication Sinemet was for Parkinson's disease, and Resident #4 did not have Parkinson's disease. The MD said he had a system in place with the local hospital because the nursing facility was a rehabilitation place. The MD said if the hospital found any problems with any of the residents, the hospital was to call him. The MD said the incident was resolved immediately upon the knowledge of the error, and the medication error had not happened again since the incident with Resident #4. The MD said the follow-up about the medication error continued in the QAPI meetings as well to ensure ongoing compliance.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to:-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination; and, -Ensure safe and appropriate storage of food items in the main kitchen walk-in refrigerator. Findings include:I. Failed to ensure ready-to-eat foods were handled in a sanitary mannerA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/25/25. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. (3-301.11)B. Facility policy and procedureThe Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy and procedure was received from the nursing home administrator (NHA) on 8/21/25 at 1:16 p.m. It read in pertinent part, Gloves are considered single-use items and must be discarded after completing the task for which they are used. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.C. ObservationsDuring a continuous observation of the lunch meal service on 8/20/25, beginning at 11:05 a.m. and ending at 12:09 p.m. the following was observed:At 11:44 a.m. cook (CK) #1 was preparing two grilled cheese sandwiches on the griddle. With gloved hands, CK #1 used one hand to stabilize the sandwiches on top of the spatula as he transferred them from the griddle to a cutting board. With the same gloved hands, CK #1 grabbed the handle of the dish heater and pulled out two plates. CK #1 used his gloved hand to stabilize the sandwiches as he cut them on the cutting board, then picked the sandwiches up with his gloved hands and placed them onto each plate.At 11:52 a.m. CK #2 was wearing a set of gloves. CK #2 used his gloved hand to adjust a piece of toast on a plate to make room for spaghetti noodles. CK #2 had previously handled meal tickets and serving utensils with the same gloved hands.-CK #2 did this two more times throughout meal service.At 11:58 a.m. CK #1 donned (put on) a pair of gloves and began preparing a cheeseburger. CK #1 retrieved a plastic bag of hamburger buns, opened the bag, and grabbed a bun using his gloved hand before placing it on a plate. CK #1 opened the walk-in refrigerator and retrieved a plastic package of cheese slices and two pieces of lettuce, holding the lettuce with the same gloved hand. CK #1 placed the lettuce leaves onto the hamburger bun, opened the plastic packaging for the cheese and retrieved a slice of cheese using his gloved hand.At 11:59 a.m. CK #2 was ladling spaghetti sauce onto a plate of noodles and got some of the sauce on the side of his hand. CK #2 wiped the sauce off of his glove onto the inner rim of the steam table bin containing spaghetti sauce. CK #2 had previously been handling meal tickets and serving utensils with the same gloved hands.At 12:02 p.m. CK #2 used his gloved hands to place the top bun of the cheeseburger onto the rest of the burger. CK #2 then used his gloved hand to stabilize the cheeseburger as he cut it in half. CK #2 was previously handling meal tickets and serving utensils with the same gloved hands.D. Staff interviewThe dietary manager (DM) was interviewed on 8/21/25 at 8:45 a.m. The DM said gloves should be changed from one job to the next with hand hygiene performed between glove changes. The DM said ready-to-eat foods should be handled with utensils and should not be handled by hand. II. Failure to safely and appropriately store food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/25/25. It revealed in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to splash, dust, or other contamination. (3-305.11)B. Facility policy and procedureThe Kitchen Sanitization policy and procedure was received from the NHA on 8/21/25 at 1:16 p.m. It read in pertinent part, All counters, shelves and equipment are kept clean and maintained in good repair.C. ObservationsA tour of the main kitchen was conducted on 8/17/25 at 1:15 p.m. In the walk-in refrigerator, there was a patch of green-grey mold on the floor next to the door to the freezer, approximately six inches square. Two baking sheets, which held plastic containers of cheese shreds and packages of sliced cheese, had small scattered spots of mold along their inner edges and corners.On 8/20/25 at 11:15 a.m., during a second tour of the main kitchen, the baking sheets holding the cheese products had been cleaned. The patch of mold on the floor of the refrigerator was still present.On 8/21/25 at 8:40 a.m., during a final tour of the main kitchen, the patch of mold on the floor in the walk-in refrigerator was still present and unchanged.D. Staff interviewsThe DM was interviewed on 8/20/25 at 11:20 a.m. The DM said she had not seen the mold on the floor or on the baking sheets in the walk-in refrigerator. The DM said the dietary staff deep-cleaned the refrigerators once a month, during which time they took out all of the shelves and scrubbed the refrigerator floor. The DM said the staff were a bit late on cleaning that month because they had been short-staffed. The DM said she had experienced some issues with mold but the maintenance staff were working on trying to fix the fans in the refrigerator. The DM said she was not sure if maybe the issue was trapped deeper within the tubing and components of the refrigerator fans. The DM said their freezer had recently broken down and the ice had melted, so she thought the mold on the floor may have been from the ice melt in the freezer. The DM said she would work with the dietary staff that evening and scrub the floors in the fridge.-However, the patch of mold on the refrigerator floor was observed the following day (see observations above).The DM was interviewed a second time on 8/21/25 at 8:45 a.m. The DM said the issues with buildup on the floor were caused from the freezer breaking down. The DM said she thought the baking sheets on the shelves in the refrigerator were disrupting airflow and therefore causing buildup, so she said she was thinking of removing them and storing food directly on the shelves.

Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#3, #28, #72 and #73) of 24 residents out of 36 sample residents reviewed. Specifically, the facility failed to:-Speak with Resident #3, Resident #28, Resident #72 and Resident #73 respectfully while providing care to the residents; and,-Ensure residents were not discussed by staff in areas where the conversations could be overheard by others.Findings include:I. Facility policy and procedureThe Dignity policy and procedure, revised August 2009, was provided by the nursing home administrator (NHA) on 8/21/25 at 12:30 pm. It revealed in pertinent part, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about what rights and responsibilities he or she has; privacy and confidentiality and voice grievances and have the facility respond to those grievances.II. Resident #3A. Resident statusResident #3, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included epilepsy, cerebral infarction (stroke), left-sided hemiplegia (paralysis of the left side of the body), depression, anxiety and insomnia. The 8/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with repositioning, transfers, toileting, dressing, hygiene and showering.B. Resident interviewResident #3 was interviewed on 8/20/25 at 12:53 p.m. Resident #3 said during the evening of 8/15/25, she tried to use her call light to call for assistance but the call light was out of reach of Resident #3's right side. Resident #3 said she called the facility using her cell phone in order to ask a staff member for help. Resident #3 said she called multiple times from 8:45 p.m. until 9:15 p.m. Resident #3 said registered nurse (RN) #5 answered the phone, spoke rudely to Resident #3 and told her to stop calling. Resident #3 said she did not file a grievance and did not notify the NHA or the director of nursing (DON) because she did not know that she could file a grievance. III. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic kidney disease stage 3, osteoarthritis of the left knee, alcohol use with withdrawal delirium, polyneuropathy, anxiety and insomnia. The 8/17/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #28 required touching assistance with bathing and when ambulating with a walker.B. Resident interviewResident #28 was interviewed on 8/18/25 at 12:06 p.m. Resident #28 said she was waiting for RN #5 to bring her as needed medication for her pain on 8/16/25 at approximately 8:00 p.m. Resident #28 said she heard RN #5 talking loudly in the hallway calling somebody a drug addict. Resident #28 said she asked RN #5 if she was referring to Resident #28 when she said drug addict. Resident #28 said RN #5 replied to her that she was not talking to Resident #28 when she made that statement and RN #5 said she had a hallway full of drug addicts. Resident #28 said RN #5 was rude and dismissive when administering her medication.Resident #28 was tearful recalling the events of the evening (8/16/25) during the interview. Resident #28 said she reported the statements made by RN #5 to the DON on the morning of 8/17/25. Resident #28 said she thought the facility was looking into her concern, but she was not sure. IV. Resident #72A. Resident statusResident #72, age greater than 65, was admitted on [DATE] and discharged from the facility on 6/17/25. According to the June 2025 CPO, diagnoses included heart disease, diabetes type 2, chronic kidney disease stage 2, unspecified falls and syncope (fainting). The 5/29/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #72 required partial assistance with bathing, hygiene, dressing and footwear.B. Record reviewResident grievances were provided by the NHA on 8/21/25 at approximately 08:00 a.m. The resident grievances revealed Resident #72 filed a grievance to the DON on 6/2/25. The grievance revealed an unidentified nurse was argumentative with Resident #72 when discontinuing her intravenous (IV) infusion. When Resident #72 asked the nurse to clean her central IV line with alcohol instead of chlorhexidine (a potent, broad-spectrum antiseptic and disinfectant used to kill bacteria and other microorganisms). The grievance revealed Resident #72 said the nurse told her I'm a nurse and I know what I'm doing. The grievance revealed Resident #72 suffered blisters around the site of her central line after the use of chlorhexidine. The grievance documented the resolution to Resident #72's grievance was that the staff nurse was not to touch any intravenous infusions until additional education was completed and intravenous competency was demonstrated. -However, the grievance did not indicate if the inappropriate way the RN spoke to Resident #72 was addressed by the facility.V. Resident #73A. Resident statusResident #73, age greater than 65, was admitted on [DATE] and discharged from the facility on 7/10/25. According to the July 2025 CPO, diagnoses included wedge compression fractures of the T9 to T12 (thoracic) vertebra with routine healing, lower back pain, difficulty walking, unspecified lack of coordination, depression and insomnia. The 6/17/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. Resident #73 required substantial assistance with bathing, lower body dressing, footwear and toileting. Resident #73 required moderate assistance with hygiene, upper body dressing, repositioning and ambulating less than 10 feet.B. Record reviewResident grievances were provided by the NHA on 8/21/25 at approximately 08:00 a.m. The resident grievances revealed Resident #73 filed a grievance about the way a staff member spoke to her. The grievance revealed Resident #73 asked an unidentified certified nurse aide (CNA) to go slower when transferring from her wheelchair to the toilet and back to bed due to pain. The grievance revealed Resident #73 also asked for a second staff member to help with the transfer. The grievance revealed the unidentified CNA told Resident #73 other staff would not come down to help because Resident #73 was too difficult to work with. The grievance revealed the resolution for the grievance was to have the CNA work in a different hall. -However, the grievance did not indicate if the inappropriate way the CNA spoke to Resident #73 was addressed by the facility.VI. Staff interviewsThe DON and the regional director of clinical services were interviewed together on 8/20/25 at 1:48 p.m. The DON said she was aware of the allegations made by Resident #28. She said an investigation of the incident was being conducted. The DON said she interviewed Resident #28 and Resident #28 told her the care she received from RN #5 was rude but she was not tearful during the initial interview. The DON said she was not aware of the additional allegation regarding RN #5 from Resident #3. The DON said she planned to start an additional investigation and to ask all other residents to see if additional residents were affected by RN #5.

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of two units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing direct care for Resident #65, Resident #62 and Resident #29, who were on enhanced barrier precautions (EBP).Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 8/25/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.I. Observations On 8/18/25 at 10:30 a.m. there was a sign on Resident #65's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care.On 8/18/25 at 10:50 a.m. Resident #65, who had an indwelling urinary catheter was being assisted in the bathroom with transfer assistance and catheter care by registered nurse (RN) #1, certified nurse aide (CNA) #1 and CNA #3. RN #1 was wearing a protective gown and gloves. CNA #1 and CNA #3 were wearing gloves but were not wearing gowns.-CNA #1 and CNA #3 failed to don (put on) a protective gown prior to providing direct care for Resident #65. On 8/18/25 at 11:35 a.m. there was a sign on Resident #62's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care.On 8/18/25 at 11:38 a.m. an unidentified nursing staff member and physical therapy assistant (PTA) #1 were assisting Resident #62, who had a surgical wound with staples on her left hip, with her clothing change and transfer to her wheelchair. The unidentified nursing staff member was wearing gloves but did not have a gown on. PTA #1 was not wearing a gown or gloves.-The unidentified nursing staff member failed to don a protective gown and PTA #1 failed to don gloves or a gown prior to providing direct care for Resident #62. On 8/19/25 at 9:00 a.m. there was a sign on Resident #29's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care.On 8/19/25 at 9:20 a.m. CNA #2 entered Resident #29's room and retrieved his morning meal tray. While CNA #2 was retrieving the meal tray, the resident, who had wounds on his legs, a colostomy and an intravenous line (IV), requested assistance with emptying his colostomy bag. CNA #2 donned gloves and proceeded to provide colostomy care. -However, CNA #2 failed to don a gown prior to providing direct care to Resident #29. II. Staff interviewsRN #1 was interviewed on 8/18/25 at 11:00 a.m. RN #1 said Resident #65 was on EBP because he had a superficial pressure wound on his buttocks and had an indwelling foley catheter. RN #1 said all staff should have donned a protective gown in addition to wearing gloves when providing direct care for Resident #65 in the bathroom. She said the reason staff should wear a gown and glove when providing care to the resident was because his Foley catheter and his wound made him highly vulnerable to getting an infection. CNA #1 was interviewed on 8/18/25 at 11:05 a.m. CNA #1 said she was usually informed by the RNs which residents were on EBP. CNA #1 said if a resident was on EBP, the PPE should be available and hanging on the back of the resident's room door. CNA #1 said Resident #65 was on EBP because he had a Foley catheter. She said she thought she did not need to wear a protective gown when assisting him in the bathroom because she was not touching his Foley catheter and was only helping with his transfer assistance. CNA #1 said she should have worn a gown and she would remember to do so the next time she was assisting a resident who was on EBP. CNA #1 said she thought the facility provided her with education on EBP but she was not completely sure.CNA #3 was interviewed on 8/19/25 at 10:42 a.m. CNA #3 said she did not know she needed to put on PPE when she was providing direct care for Resident #65. She said she was not informed by RN #1 that she needed to wear a protective gown. She said she assumed she only needed to wear gloves.CNA #2 was interviewed on 8/19/25 at 9:25 am. CNA #2 said she would obtain a shift- report from the outgoing CNA staff regarding which residents were on transmission-based precautions. She said she would ask the nurses to see what type of PPE needed to be used for each resident. She said EBP was needed to prevent the staff from giving the resident an infection. She said she only needed to wear a protective gown when she was emptying Resident #29's colostomy bag. Licensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 3:29 pm. LPN #1 said residents who were on EBP had signage on the door indicating they were on EBP, along with the type of PPE staff was required to use inside the residents' rooms. She said nurses were additionally able to obtain the same information in the residents' medical records in order to relay the information to the CNAs. LPN #1 Said Resident #62 was on EBP because she had a surgical wound on her left hip. She said all nursing staff should wear a protective gown and gloves with any close-contact activities, including clothing changes and resident transfers.The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 8/21/25 at 10:30 a.m. The IP said she had worked at the facility for two years and obtained her infection prevention certification in January 2025. She said she shared the IP role responsibilities with another staff member who was currently out of the building and unavailable. She said her role as IP consisted of antibiotics stewardship, providing staff education on infection control once a month during staff meetings, providing as needed one-on-one infection control education and providing new staff hire education on infection prevention methods. The DON said all staff were provided with education on the differences between contact precaution and EBP and advised on what PPE to use during which resident care activity. She said nursing staff should wear a gown and gloves with any close contact resident care activities, such as wound care, Foley catheter care and assisting the resident in and out of bed. The DON said Resident #29 had just finished a course of antibiotics because of his medical condition related to his motor vehicle accident. She said he had an IV, a colostomy, a Foley catheter and healing wounds all over his body from the accident. She said it was very important that the staff adhered to EBP to prevent any potential infections. The DON said it was important for all staff to adhere to the designated resident-specific precaution recommendations because the facility wanted to keep the residents safe from developing preventable infections. She said the facility did not want to be the cause of any infection. She said the potential negative outcome to the facility staff of not adhering to EBP could be the resident contracting MDROs and there was a high potential of spreading the infection to another resident.

Based on observations, record review and interviews the facility failed to ensure accurate medical records were kept for one (#28) of five residents out of 36 sample residents reviewed. Specifically, the facility failed to maintain accurate records for Resident #28 of pain reassessments and foley catheter care in the electronic medical record (EMR). Findings include:I. Professional referenceAccording to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 261 and 1067. Assessment is a continuous process that occurs each time you interact with a patient. It involves the collection of new data. Reassessment is not the same as evaluating care or determining a patient's response to an intervention. Instead, it is the gathering of additional information to ensure that the plan of care is still complete, current, and appropriate. Analgesics should be initiated at the lowest effective dose and titrated to achieve pain control with minimal adverse effects; this requires frequent reassessment of patients for pain relief and side effects as doses are adjusted.II. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included chronic kidney disease stage 3, osteoarthritis of the left knee, alcohol use with withdrawal delirium, polyneuropathy, anxiety and insomnia. The 8/17/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #28 required touching assistance with bathing and when ambulating with a walker.B. ObservationsDuring a continuous observation on /19/25, beginning at 8:16 a.m. and ending at 12:09 p.m., the following was observed:At 8:16 a.m. Resident #28's medication administration record (MAR) and treatment administration record (TAR) were incomplete. The documentation for indwelling catheter care was blank at the start of the observation. At 8:38 a.m. RN #2 administered as needed pain medication per the residents request. RN #2 asked Resident #28 to rate their pain on a scale of 1 to10 during the medication administration.At 11:16 a.m. Resident #28's MAR had completed documentation for the pain reassessment score after the as needed pain medication and Resident #28's TAR had completed documentation for indwelling catheter care.-However RN #2 had not returned to Resident #28's room since the time of the pain medication administration and no staff entered the resident's room to provide catheter care. C. Resident interviewResident #28 was interviewed on 8/19/25 at 11:39 a.m. Resident #28 said nobody cleaned her indwelling catheter that morning (8/19/25). Resident #28 said she did not remember seeing RN #2 after RN #2 administered her pain medication this morning and nobody asked her to reassess her pain after taking the pain medication. Resident #28 said the staff reassessed her pain about half of the time she received as needed pain medication. D. Record reviewThe progress note, dated 8/19/25 at 9:35 a.m. documented Resident #28 rated her pain as a 3 out of 10on follow up assessment.-However, based on observations and the interview with Resident #28, this assessment did not occur.E. Staff interviewsThe director of nursing (DON) and the regional director of clinical services were interviewed together on 8/21/25 at 10:59 a.m. The DON said accurate medical records inform staff of the effectiveness of the current interventions in the plan of care. The DON said the time the indwelling catheter care was documented in the TAR was 8:47 a.m. The DON said the time the task was marked as completed in the TAR did not necessarily reflect the time the care occurred. The DON said the nursing staff had to provide multiple avenues of care and may not have documented care at the specific time it was completed. The DON said staff were encouraged to document care as accurately as possible. The DON said in regards to the pain medication reassessment, the DON said she planned to provide individual education to RN #2.

Based on record review and interviews, the facility failed to develop and implement policies and procedures related to COVID-19 immunizations for two (#29 and #62) of five residents reviewed for immunizations out of 36 sample residents.Specifically, the facility failed to offer Resident #29 and Resident #62 the COVID-19 vaccination. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), COVID-19 guidelines (revised 1/7/25), retrieved on 8/25/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html. Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are age [AGE] and older, are at risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine.II. Resident #29 A. Resident status Resident #29, age less than 65, was initially admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included traumatic brain injury, chronic pain, open wound of the right hand, fracture of the left arm and fracture of the pelvis.The 8/1/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial/maximal assistance with shower and bath, supervision/touch assistance with lower body dressing, and dependent with toileting hygiene. He required setup assistance with eating.The assessment did not indicate that the resident was ever offered the COVID-19 vaccine. B. Resident interviewResident #29 was interviewed on 8/19/25 at 9:05 a.m. He said he was admitted to the facility after a motorcycle accident. He said he did not remember being offered a COVID-19 vaccination from the facility and was unsure of his vaccination status.C. Record reviewReview of Resident #29's electronic medical record (EMR) on 8/21/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. III. Resident #62A. Resident statusResident #62, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included fracture of the right femur, joint replacement surgery, anemia, dementia, generalized weakness and cognitive communication deficit.The 8/19/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She was dependent on staff for eating, toileting hygiene, showers/baths and upper body dressing. She required partial/moderate assistance with oral hygiene. The assessment did not indicate that the resident was offered the COVID-19 vaccine. C. Record reviewReview of Resident #62's EMR on 8/21/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. D. Staff interviewsThe director of nursing (DON) and the infection preventionist (IP) was interviewed together on 8/21/25 at 10:30 a.m. The DON said the facility monitored and tracked the residents' immunizations status in the EMR. She said the facility offered and provided education to the residents regarding the COVID-19 vaccinations upon admission after review of their vaccination history. The DON said she did not have documentation indicating Resident #29 or Resident #62 were offered and declined the COVID-19 vaccination She said it was the admitting nurses responsibility to document in the resident's EMR if the resident refused the vaccination.

Based on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for one (#3) of three residents reviewed out of nine sample residents. Resident #3 was admitted to the facility on [DATE] for rehabilitation after surgery on her back. Upon admission, the resident was assessed for fall risk and was identified as a high risk for falls. However, the baseline care plan, initiated on 10/11/24, failed to identify the resident was at risk for falls and person-centered interventions were not put in place to prevent falls for Resident #3. On 10/12/24 Resident #3 sustained a fall which resulted in a laceration to her head and required transportation to the emergency department for further evaluation and staples to close the laceration. Findings include: I. Facility policy and procedure The Fall Management policy, reviewed September 2012, was provided by the nursing home administrator (NHA) on 11/13/24. The policy revealed the facility would identify each resident who was at risk for falls, would plan the care and implement interventions to manage falls. Residents who were at risk for falls, would have interventions to manage falls. The facility would manage falls by providing an environment that was free from potential hazards. II. Fall investigation The 10/12/24 fall investigation for Resident #3 was provided by the NHA on 11/13/24 at 11:00 a.m. Review of the fall investigation revealed Resident #3 was found on the floor near her bathroom. The resident said she walked to the hallway and asked for help but the girl told me to do it myself. The resident returned to her room where she later was found on the floor with a laceration to her head. Resident #3 was transported to the emergency department for further evaluation. The investigation included an interview with certified nurse aide (CNA) #2 who said she assisted Resident #3 to the bathroom and back to her room. CNA #2's written statement indicated Resident #3 continued to say that she was going to fall while CNA #2 was in the bathroom with her. The investigation did not include an interview with the nurse or manager on duty at the time of the incident. The investigation included interviews with three other staff members who were not present during the incident. III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged home on 11/3/24. According to the November 2024 computerized physician orders (CPO), diagnoses included compression fracture of the fourth thoracic vertebrae, diabetes, difficulty walking, communication deficit, lack of coordination and congestive heart failure. The 10/15/24 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score was not conducted. The resident did not display any behaviors or rejection of care. A 10/12/24 nurse progress note revealed the resident was alert and oriented to person, time, place and situation. The assessment documented Resident #3 was independent with all activities of daily living (ADL). B. Record review Per the functional assessment completed on 10/11/24, Resident #3 required assistance with ambulation to the bathroom. The 10/11/24 fall risk assessment revealed Resident #3 was at risk for falls. -However, the baseline care plan, initiated on 10/11/24, failed to identify the resident was at risk for falls and person-centered interventions were not put in place to prevent falls for Resident #3. Per the 10/12/24 daily skilled note, the resident had difficulty walking due to compression fracture. The 10/12/24 nurse progress note documented Resident #3 was found sitting on the floor at 6:05 a.m. and the resident was noted to have a laceration 2 centimeters (cm) by 0.5 cm by 0.1 cm bleeding down her hair and onto her chest. When the resident was asked what happened, Resident #3 said she asked a girl (CNA #2) for help and was told she could do it herself. Resident #3 said she took the walker and went to the bathroom. The resident did not know what happened and said she just fell backwards. A physician's order was obtained to send the resident out to the emergency department for evaluation. The 10/12/24 emergency department records revealed Resident #3 was admitted after a fall at the nursing facility where she asked for help and was refused. The resident sustained a head trauma with a laceration that was secured with two staples and a dressing. The resident was discharged back to the nursing facility the same day (10/12/24). IV. Staff interviews The director of nursing (DON), the assistant director of nursing (ADON) and the regional clincial resource (RCR) were interviewed together on 11/13/24 at 3:30 p.m. The ADON said she received a call from the floor nurse on 10/12/24. She said the floor nurse reported to her that Resident #3 had a fall. She said the floor nurse told her that Resident #3 was assisted to the bathroom by CNA #2. The ADON said she was told Resident #3 later approached CNA #2 again when she was giving a report to another CNA. She said the resident was told to return to her room where she was later found on the floor in the bathroom. The ADON said she did not participate in the formal investigation of the incident. The DON said she did not recall the incident on 10/12/24 and she was not sure if she was included in the investigation. She said every resident was assessed upon admission for fall risk and baseline care plans were initiated to ensure the safety of residents. -The DON was unable to say why Resident #3's baseline care plan initiated on 10/11/24 did not identify the resident was at risk for falls or include person-centered interventions to prevent falls for the resident. The RCR said Resident #3's initial assessment for fall risk should have triggered the baseline care plan for falls and should have included person-centered interventions for the resident. The physical therapist (PT) was interviewed on 11/13/24 at 4:15 p.m. The PT said Resident #3 participated in therapy and reached her full potential at the time of her discharge from the facility on 11/3/24. He said, upon admission, the resident required one-person assistance with transfers. He said the resident was admitted after back surgery and it was very difficult for the resident to get up. He said she required maximum assistance getting off the bed or chair and assistance of one person when ambulating. The NHA was interviewed on 11/13/24 at 4:45 p.m. The NHA said he completed the investigation for the 10/12/24 incident involving Resident #3. He said CNA #2 was suspended from her duties during the investigation and later was dismissed as she did not return the facility's calls. The NHA said he could not substantiate that neglect had occurred for Resident #3 because he could not prove that CNA #2 refused to provide assistance to the bathroom for the resident.

Based on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for two (#9 and #8) of three residents out of nine sample residents. Specifically, the facility failed to ensure Resident #9 and Resident #8 received medications as scheduled according to the physician's orders. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, page 606-607, retrieved on 11/21/24, It read in pertinent part, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Administering Medication policy, revised 2019, was received from the nursing home administrator (NHA) on 11/13/24 at 9:08 a.m. It documented in pertinent part, Medications are administered in a safe and timely manner and as prescribed. Medication errors are documented, reported and reviewed by the quality assurance and performance improvement (QAPI) committee to inform process changes and or the need for additional staff training. Medications are administered within one hour of their prescribed time, unless otherwise specified. III. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included Alzheimer's dementia and hypertension (high blood pressure). The 11/11/24 minimum data set (MDS) assessment the resident had short term and long term memory deficits and was severely impaired with daily decisions per staff assessment. The assessment indicated Resident #9 was receiving an antidepressant, opioid (pain medication) and hypoglycemic medications (used to lower blood sugar). B. Observations Licensed practical nurse (LPN) #1 was observed during medication administration on 11/13/24 at 9:35 a.m. She was preparing medications for Resident #9. She put two 500 milligrams (mg) tablets of Tylenol and squirted Voltaren gel into another cup. She approached the resident at the table near the nurses station and administered the medications at 9:50 a.m. C. Record review The November 2024 medication administration record (MAR) for Resident #9 revealed that all of Resident #9's medications were scheduled for 8 a.m. -Resident #9 received her medications one hour and 50 minutes past its scheduled time and 50 minutes after the allowed medication administration window (see observations above). IV. Resident #8 A. Resident status Resident #8, age greater 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included osteomyelitis (bone infection) and type 2 diabetes. The 10/10/24 MDS assessment revealed Resident #8 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment indicated Resident #8 was receiving an antipsychotic (class of drugs used to treat mental disorders), an antibiotic and an antiplatelet medication (used to prevent blood clots). B. Observations LPN #1 was observed during medication pass on 11/13/24 at 10:00 a.m. S was preparing medications for Resident #8. She put the following medications in the cup: -B-complex vitamin one tablet; -Finasteride (urinary retention medication) five mg one tablet; -Aspirin 81 mg one tablet; -Lactobacillus tablet (probiotic); -Quetiapine (antipsychotic medication) 12.5 mg; and, -Omeprazole (used to treat gastroesophageal reflux disease) 20 mg. She administered the medications at 10:06 a.m. C. Record review The November 2024 MAR for Resident #8, revealed that the B-complex, Finasteride and aspirin were scheduled for 8:00 a.m. The lactobacillus, quetiapine and the omeprazole were scheduled to be administered at 9:00 a.m. -Resident #8 received the B-complex, Finasteride and Aspirin two hours and six minutes past the scheduled time and one hour after the medication administration window. -Resident #8 received the lactobacillus, quetiapine and the omeprazole one hour and six minutes past the scheduled time and six minutes after the medication administration window. V. Staff interviews The director of nursing (DON) and the regional clincial resource (RCR) were interviewed together on 11/13/24 at 4:30 p.m. The RCR said the nursing staff had a one hour window (one hour before and one hour after scheduled time) to administer medications. She said she reviewed the time stamps on the morning medications for Resident #9 and Resident #8 and said their morning medications were administered late. She said the medications were administered late because the morning nurse called off and did not come to work.

Based on record review and interviews, the facility failed to ensure one (#4) of three residents out of nine sample residents were free of significant medication errors. Specifically, the facility failed to ensure Resident #4 was administered his Parkinson's medication per the physician orders. Findings include: I. Professional reference According to the carbidopa/levodopa dosing instructions, retrieved from https://www.goodrx.com/carbidopa-levodopa/dosage on 11/21/24, A combination of two medications: carbidopa and levodopa. Levodopa replaces dopamine, which improves symptoms of Parkinson's disease. And carbidopa helps levodopa stick around longer in the body. If you miss a dose of carbidopa/levodopa, take the medication as soon as you remember. But if you remember when you' re already close to taking your next dose, skip the missed one. Don' t take more than one carbidopa/levodopa dose at a time. Doubling up on doses can be dangerous and lead to more side effects, such as movement problems and mood changes. Taking too much carbidopa/levodopa can be dangerous and increase your risk of side effects. These side effects may include low blood pressure, a fast heartbeat and confusion. According to the carbidopa-levodopa dosing guidelines, retrieved from https://www.drugs.com/medical-answers/carbidopa-levodopa-3562239/ on 11/21/24, It is important to adhere to the schedule closely, and it is recommended that you take the medication at the same time each day. II. Facility policy and procedure The Administering Medication policy, revised 2019, was received from the nursing home administrator (NHA) on 11/13/24 at 9:08 a.m. It documented in pertinent part, Medications are administered in a safe and timely manner and as prescribed. Medication errors are documented, reported and reviewed by the quality assurance and performance improvement (QAPI) committee to inform process changes and or the need for additional staff training. Medications are administered within one hour of their prescribed time, unless otherwise specified. III. Resident #4 A. Resident status Resident #4, age 73, was admitted on [DATE] and discharged on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease (brain disease causing uncontrollable movements and difficulty with motor function), acute respiratory failure and difficulty in walking. According to the 7/21/24 minimum data set (MDS) assessment Resident #4 was cognitively intact with a brief interview for mental status score of 15 out of 15. She required partial/moderate assistance with hygiene, dressing and transferring. B. Record review Review of Resident #4's July 2024 CPO revealed the following physician order: Carbidopa-Levodopa oral tablet disintegrating 25-100 milligrams (mg), give one tablet by mouth four times a day for Parkinson's, ordered on 7/15/24, administer at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. A review the July 2024 medication administration record (MAR) revealed on 7/30/24Resident #4 did not receive Carbidopa-Levodopa at 8:00 a.m., 12:00 p.m., or 4:00 p.m. per the physician's order. The MAR was marked with the number nine for those times, which indicated other and to see the nursing progress note. A nursing progress note from 7/30/24 at 7:24 a.m. revealed Resident #4 was noted to be out of Carbidopa-Levadopa. The nurse called the pharmacy and the pharmacy noted it was in process and would be delivered to the facility that day. The nurse urged the importance of the medication to the pharmacist due to the amount of medication the resident took. A nursing progress note from 7/30/24 at 3:23 p.m. revealed the medication delivery made to the facility did not contain Resident #4's Carbidopa-Levadopa. The nurse spoke to the pharmacy and the pharmacy said they would send it out as STAT (immediately). The nursing unit manager was made aware of the concern at this time. -The nursing staff failed to audit the cart and reorder the medication before the medication ran out. -The nursing staff failed to order the medication as STAT once they noticed it was missing. -There was no documentation that the resident's physician was notified after Resident #4 missed three doses of the Carbidopa-Levadopa. -There was no documentation that the nurse monitored Resident #4 for symptoms that she may have experienced while missing the medication. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 11/13/24 at 1:50 p.m. RN #1 said it was the responsibility of the floor nurses to audit the medication cart each shift and order medications as needed. She said if a medication was due to run out within two to three days, she would reorder it. She said the pharmacy the facility worked with delivered the medications the day after ordering. RN #1 said the medication could also be ordered as STAT and it would arrive within an hour and a half. She said Parkinson's medications should be administered per the physician order. She said if the medication was missed, she would notify the provider and monitor the resident for increased Parkinson's symptoms such as agitation and tremors. She said the number nine on the MAR indicated other and to see the nursing progress note. The director of nursing (DON), the assistant director of nursing (ADON) and the regional clincial resource (RCR) were interviewed together on 11/13/24 at 3:10 p.m. The ADON said it was the expectation for the nursing staff to audit the medication carts on the night shift and reorder any medication that was due to run out in the next five days. She said the pharmacy had a four hour window to deliver medications orders as STAT, but they typically came within an hour. She said if a medication administration was missed for a resident, the process was to notify the provider, notify the unit manager and DON and order the medication as [NAME] She said the nurse should monitor the resident for any symptoms the resident had due to missing the medication. She said the symptoms should be documented in the resident's medical record. She said the number nine on the MAR indicated other and to see the nursing progress note. She said there should be a nursing progress note associated with each documentation of a nine in the MAR. The RCR said there was no documentation that the nurse notified the provider of Resident #3's three missing doses of Carbidopa-Levadopa. The consultant pharmacist was interviewed on 11/13/24 at 4:09 p.m. The pharmacist said the medication was important to take according to the physician's orders unless the resident was experiencing any clinical side effects. She said if the resident missed doses, it could worsen the Parkinson's effect and the resident's motor abilities could not have been managed.

Based on observations, record review and interviews, the facility failed to promote and maintain resident dignity by providing care in a dignified, respectful and individualized manner for three (#1, #5 and #6) of three residents out of 12 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and Resident #6 were treated with dignity and respect when they asked for care assistance; and, -Ensure Resident #5, a resident with a diagnosis of Alzheimer's disease, was provided a dignified experience of receiving sufficient care to maintain good personal health and hygiene. Findings included: I. Facility policy The Dignity policy, revised February 2021, was provided by the corporate nurse consultant (CNC) on 8/27/24 at 11:10 a.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. When assisting with care, residents are supported in exercising their rights. For example, residents are; groomed as they wish to be groomed (hairstyles, nails, facial hair). The Resident Rights policy, revised December 2016, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, Employees shall treat all residents with kindness, respect and dignity. The residents' rights include a dignified experience. The Activities of Daily Living (ADL), Supporting policy, dated 2001, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. II. Resident #1 A. Resident status Resident #1, age 74, was admitted on [DATE] and discharged on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included diabetes and congestive heart failure. The minimum data set (MDS) assessment was not completed. The nursing admission assessment dated [DATE] documented Resident #1 was alert and oriented to person, place, time and situation and was calm and cooperative. The resident was motivated to participate in rehabilitation services and needed assistance with ADLs, including transferring, toileting, dressing and hygiene. The resident was incontinent of bladder and usually had daily bowel movements. B. Record review A review of Resident #1's electronic medical record (EMR) revealed the resident's baseline care plan had not yet been started and there was no CNA task record or Kardex (abbreviated plan of care for the CNA). -The CNC confirmed the facility did not have a Kardex for Resident #1. A social services note, dated 7/29/24 at 11:18 p.m., documented Resident #1 said he wanted to leave the facility due to the caregiver neglecting to provide timely assistance for him to use the bathroom. The facility investigation dated 7/29/24 documented that the resident asked his certified nurse aide (CNA) #2 for assistance to use the bathroom to have a bowel movement and CNA #2 told him to remain in bed, go to the bathroom in his brief and she would clean him up afterward. The resident insisted he be taken to the bathroom. CNA #2 finally took the resident to the bathroom. Staff interviews revealed Resident #1 waited so long for the staff to act that he thought he was not going to make it to the bathroom. The resident was unhappy with the way he was treated and told staff that he was leaving and going home. Resident #1 called the police, rolled himself outside of the facility and was taken to the hospital by ambulance transport. The facility's investigation concluded CNA #2 did not respond to Resident #1 in a dignified and respectful manner when she told him to go to the bathroom in his brief instead of providing him timely assistance to use the toilet as he asked. III. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE] and discharged on [DATE]. According to the August 2024 CPO, diagnoses included Alzheimer's disease, overactive bladder and depression. The MDS assessment was not completed. The nursing admission summary dated 7/26/24 revealed the resident was alert and oriented to person only. The resident was incontinent of bowel and bladder and dependent on staff to complete ADLs and used a mechanical lift for transfers. B. Resident representative interview Resident #5's legal representative was interviewed on 8/26/24 at 10:33 a.m. The representative said she had talked to the facility during Resident #5's admission and several times afterward about the resident's care choices. The representative said Resident #5 spent a lot of time in bed but had requested that staff get her up before lunch so she could spend time with family when they visited. The representative said the resident also requested staff get her up so she could participate in Sunday church services, the one activity she enjoyed. She said there were several occasions when the family would visit and find Resident #5 with poor hygiene and wearing the same clothing as the day before. She said this was out of character for Resident #5. The resident's representative said she was in the facility to see the resident every day at different times of day and she found her mom in poor condition on several occasions making her fear for the resident's health. She said Resident #5 had a pressure injury when she admitted and it started worsening. She said if Resident #5 did not get proper hygiene and hydration assistance, her wounds would worsen. The resident's representative said Resident #5 had always had good hygiene and it was important to her. The representative said Resident #5 was in a total state of helplessness and was dependent on staff to provide good care for her overall wellbeing and happiness. She said staff did not take the time to change soiled linens, provide timely incontinence care or remove the resident's soiled clothing to be laundered. The representative said this left Resident #5 and her room with a foul odor. The resident's representative said it was disappointing to see the resident in a soiled state. The resident's representative said, on 8/4/24, she provided the facility a detailed letter of the family's observations and concerns with action items (interventions) that she and Resident #5 would like to have provided for the resident but she said things still were not corrected by the facility. The resident's representative said her concerns for the resident's well-being deepened when she learned that the nursing home administrator (NHA) had not been provided a copy of her grievance letter and was not informed of her request to meet with the leadership team to discuss the details of her grievance letter. The resident's representative said it was not long after she gave the facility the letter that the family decided to remove Resident #5 from the facility's care. She said they moved Resident #5 out of the facility on 8/11/24, 16 days after she was admitted to the facility. C. Record review A care conference summary dated 8/2/24 revealed the resident and her legal representative were in attendance at the care conference, as were the facility's interdisciplinary team (IDT) members, including the director of nursing (DON) and the social services director (SSD). The summary documented the family planned for Resident #5 to remain in the long-term care setting and for the resident's husband to move to the facility's on-site assisted living community. The psychosocial mood care plan initiated on 8/2/24 revealed Resident #5 was at risk for decreased psychosocial well-being adjustment issues and emotional distress. The goal was for the resident to have no decline in mood or behavior that prevented her from functioning in her daily activities. Interventions included assessing the resident's preferences and choices with activities and encouraging involvement and encouraging friends and family support/visits. A nursing note dated 8/4/24 documented the resident's legal representative voiced concerns about the resident's care. The representative voiced concerns that, despite a request at a care conference, the resident was not up for church that morning (8/4/24) and she had the same shirt on from 8/2/24 (Friday). The representative was additionally concerned because the resident had not had a shower since her admission to the facility on [DATE] and soiled laundry was left on the shower floor. A care conference summary dated 8/8/24 revealed Resident #5, her legal representative and another family member were in attendance at the care conference, as were the facility's IDT members, including the DON, the SSD and the activities director (AD). The care conference summary documented the resident's representative and the other family member brought up concerns about the resident's personal and environmental hygiene. The representative said she had arrived at the facility to assist Resident #5 with the noon meal and found the resident in a darkened room and still in bed. The representative said she had asked the facility staff, upon the resident's admission to the facility, to make sure the resident was up and dressed by 11:00 a.m. so she could eat her meal while seated in her chair and not in bed. According to the care conference summary note, the representative's concerns included finding Resident #5 being left in heavily soiled undergarments and smelling strongly of urine. The sheets of the resident's bed were also stained and soiled with urine. The representative said the resident's bedding was covered with food crumbs from the resident being assisted to eat while in bed. Additionally, the representative was concerned because the resident had not been showered. The IDT's plan for the resident's care was to schedule management follow-up to make an observation of Resident #5 every morning at 9:00 a.m. to ensure the resident was provided assistance to meet her care needs. A comprehensive skin evaluation assessment dated [DATE] documented the resident was placed on a two-hour check and change schedule. -The care plan was not updated to reflect the two-hour check and change intervention. The facility investigation dated 8/14/24 documented that, after investigating the resident's legal representative's concerns, the facility substantiated that CNA #1 failed to provide the resident with a hygienic environment when they left soiled laundry in and around the resident's room. The facility separated from CNA #1 and did not schedule her for additional shifts. CNA #1 was interviewed on 8/14/24. CNA #1 said she checked on Resident #5 in the morning assisted her with breakfast and changed the resident. She did not prove the time that the care was completed. CNA #1 said she continued with rounds assisting her other residents and came back to Resident #5's room to find the family present. CNA #1 said the family was very upset by the condition of Resident #5 and by the presence of a soiled laundry being found on the floor of the resident's shower. -The facility's interview with CNA #1 did not provide answers and details about the exact nature of why the family was upset, the complaint the family voiced and the exact condition of how the resident was found. The investigation did not establish a timeline of events with CNA #1 and failed to provide any substantial evidence about CNA #1's knowledge of the resident's routine or care needs. IV. Resident #6 A. Resident status Resident #6, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the July 2024 CPO, diagnoses included amputation between the left hip and knee, diabetes and pressure-induced deep tissue injury. The 6/10/24 MDS assessment documented the resident had intact cognition with a BIMS score of 15 out of 15. The resident was dependent on staff for toileting hygiene and bathing and substantial assistance with dressing. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. B. Record review The facility investigation dated 7/10/24 documented Resident #6 filed a grievance on 7/3/24 that when she asked her assigned CNA (CNA #3) to assist her in changing her soiled brief, CNA #3 told her You do not need me to change your diaper, you can do it your (expletive word) self. CNA#3 was removed from the care of Resident #6 and another CNA took over the resident's care and provided ADL assistance and emotional support. The investigation documented there were no witnesses to the exchange between CNA #3 and Resident #6 and the facility concluded it was a He said, she said situation. -However, the facility terminated CNA #3 when the investigation revealed there were four other times in the prior two weeks that CNA #3's conduct caused several other residents to request CNA #3 not to provide care for them. V. Interviews A frequent visitor (FV) to the facility was interviewed on 8/26/24 at 2:47 p.m. The FV said she had concerns about the way residents in the facility were treated. She said residents complained that they were not always treated respectfully and others had to wait a long time for care to be completed. The FV said residents had reported that staff did not address them directly and walked away from them in the middle of a conversation when they were asking for staff assistance. The FV said she brought resident-voiced concerns, as well as her observed concerns, to the leadership team and found that it took a long time for the facility to address resident grievances. The FV said the new NHA seemed to be taking things more seriously than the previous NHA and some things had improved. She said several of the problematic staff were no longer working in the facility. Resident #9 was interviewed on 8/26/24 at 3:41 p.m. Resident #9 said she had just filed a grievance concern earlier today (8/26/24) because of the disrespectful way one of the CNAs made her feel. Resident #9 said she never knew how she would be treated from day to day. She said there were good CNAs and then other CNAs were disrespectful and rough with care assistance. Resident #9 said some CNAs would drop off her meal tray and walk out quickly; never speaking to her to see if she needed anything. She said other CNAs would walk away mid-conversation and she did not get what she needed. Resident #9 said today (8/26/24), a CNA came in to take her to the bathroom and she hurriedly assisted her to the toilet. The CNA never apologized or said anything about it. The NHA was interviewed on 8/27/24 at 8:12 a.m. The NHA said he was new to the facility and started working as the NHA on 7/10/24. The NHA said, after becoming familiar with the facility's operating practices, he implemented several quality measures and improvement projects. He said a couple of areas of focus included developing an orientation binder for agency staff that they were to read before working in the facility. He said the binder would provide agency staff information on basic facility policy, expectations for resident care and following the resident care plan. The NHA said. initially, agency staff were not provided access to the resident's plan of care. He said the DON and assistant director of nursing (ADON) would be responsible for reviewing admission intake information and providing a report to staff on the day of admission to ensure appropriate care was provided for all residents. The NHA said he recognized the need for staff to be better educated on the importance of treating every resident with dignity and respect while meeting the resident-assessed care needs and preferences. The NHA said he was saddened when he learned about the care concerns brought forward by several residents and their families. He said poor quality of care should not be the resident experience. The NHA said it frustrated him that members of leadership had not brought the concerns of Resident #5's family members to him when they first voiced grievances because he believed the concerns could have been fixed and the resident could have been happy living in the facility. The NHA said he did not learn of the family's concerns until a few days before the resident was discharged . The NHA said once he started to investigate resident care concerns and grievances, he realized the leadership team needed to make some changes in the staff's approach to resident care and staff's understanding of the facility's expectations to ensure that all resident care needs were met in a dignified and respectful manner. The NHA said he called a mandatory all-staff meeting last night (8/26/24) and early this morning (8/27/24), which was the first of many training sessions where staff would be educated on the importance of customer service and resident care. The NHA said that staff who did not follow facility policies for resident care would be removed from employment. The DON, the unit manager (UM) and the CNC were interviewed on 8/27/24 at 10:56 a.m. The UM said every unit had a nurse-to-nurse report sheet that was updated each shift and the CNAs had access to the residents' Kardex. The UM said the floor nurse should have updated the CNA assigned to Resident #1 about his care needs, especially since the resident had been newly admitted . The DON said she expected the nursing staff to be compassionate, provide good customer service and treat the residents like family. The DON said the facility would be educating staff on the expectations of good customer service.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity and respect for two (#12 and #133) of five residents reviewed for dignity and respect out of 18 sample residents. Specifically, the facility failed to: -Ensure Resident #12 was assisted during meal times in a dignified manner; and, -Ensure Resident #133 was treated with dignity and respect when she requested a cup of coffee. Findings include: I. Facility policy The Dignity policy, revised February 2021, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Individual needs and preferences of the resident are identified through the assessment process. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. II. Resident #12 Resident #12, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs). The 2/14/24 minimum data set (MDS) revealed the resident was unable to complete the brief interview for mental status (BIMS). A staff assessment of the resident's cognitive status revealed the resident's cognitive skills for daily functioning were severely impaired. She required extensive assistance and was dependent on staff for all cares. A. Observations On 2/26/24 at 9:03 a.m., Resident #12 was sitting in the dining room. Two plates with pureed food were in front of her on the tray, covered with plastic. At 9:10 a.m., certified nurse aide (CNA) #1 brought three plastic cups, one with apple juice, one with lemonade and one more with an unidentifiable liquid and placed them on the table in front of the resident. An Ensure (a nutritional supplement) was observed on the tray as well. At 9:16 a.m., CNA #1 opened the Ensure and poured it into a cup. She proceeded to mix part of Resident #12's pureed food into the Ensure. -CNA #1 did not call the resident by her name during the meal and she did not converse with the resident. At 9:35 a.m., CNA #1 got up to answer a call light. She returned to the resident at 9:38 a.m. and offered the resident a mixture of the Ensure and pureed food. At 9:41 a.m., CNA #1 left to find a nurse for another resident. At 9:42 a.m. she returned and offered Resident #12 the mixture of Ensure and pureed food. At 9:43 a.m., CNA #1 left to answer a call light. At 9:48 a.m. she returned and offered the resident the Ensure/pureed food mixture, apple juice, and lemonade. The resident refused. At 9:50 a.m., Resident #12's tray was taken away. At 12:27 p.m., lunch was delivered to Resident #12 in the dining room. Her lunch consisted of two plates of pureed food covered with plastic, applesauce, an Ensure supplement and chocolate cake in a cup. CNA #1 attempted to assist the resident with the meal but the resident appeared sleepy and was sitting with her eyes closed. At 12:36 p.m., CNA #1 offered a drink to the resident and the resident opened her eyes. CNA #1 mixed the Ensure supplement with the pureed dish in a cup and gave it to the resident. At 1:15 p.m. the resident was taken to her room. -CNA #1 did not interact with Resident #12 when she was assisting with meals. She did not call the resident by her name and did not talk to the resident when she got up in the middle of assisting the resident with her meal to go answer call lights. B. Resident representative interview Resident #12's representative was interviewed on 2/26/24 at 1:15 p.m. The resident's representative said the resident got very little social interaction from the staff. She said the resident was nonverbal and it was important for the staff to converse with her. However, she said she did not see staff talk with the resident while they were assisting her with her meals. C. Staff interview The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 1:45 p.m. The DON and ADON said mixing Ensure and pureed food together was not the resident's preference. The DON and ADON said CNA #1 had not treated Resident #12 with dignity. The DON and ADON said staff was expected to treat all residents with respect and dignity and converse with every resident during resident care. 47150 III. Resident #133 A. Resident status Resident #133, over the age of 65, was admitted on [DATE]. According to February 2024 CPO, diagnoses included hypoglycemia, chronic pain, protein calorie malnutrition, weakness, rheumatoid arthritis and cognitive communication deficit. The 2/23/24 MDS assessment had not been completed for the resident at the time of the survey. B. Resident observation On 2/26/24 at 9:44 a.m. Resident #133 was sitting on her bed. She was rearranging her items on the bedside table. -At 9:46 a.m., dietary aide (DA) #1 arrived in the resident's room to pick up a breakfast tray. Resident #133 asked DA #1 for a cup of warm coffee. DA #1 told the resident to ask her nurse and walked away from the resident's room without providing the cup of warm coffee. C. Resident interview Resident #133 was interviewed on 2/27/24 at approximately 10:14 a.m. Resident #122 said she did not receive the cup of warm coffee she asked for after finishing her breakfast the previous day (2/26/24). The resident said she asked the wrong staff member and she was disappointed that she could not get a cup of warm coffee when she needed it. D. Staff interviews DA #1 was interviewed on 2/27/24 at 10:22 a.m. DA #1 said she was informed she was not to provide any resident services including providing water and coffee for any of the residents in the facility. DA #1 said she informed the nursing staff about the resident's request for warm coffee, however, she did not recall who she talked to about the resident needing assistance with a cup of warm coffee. DA #1 said she did not know if the resident received the coffee. Licensed practical nurse (LPN) #3 was interviewed on 2/27/24 at 10:31 a.m. LPN #3 said she was not informed about the resident needing assistance with getting a cup of coffee. She said the dietary staff usually would notify the floor nurse about a resident's request and ask if they could assist. Unit manager (UM) #1 and the ADON were interviewed together on 2/28/24 at 10:15 a.m. The ADON and UM #1 both said they did not understand the reason DA #1 told Resident #133 to ask her nurse as the resident was recently admitted to the facility and did not know who the nurse was. The ADON said every staff member, regardless of position, had been trained to be able to assist residents. The ADON said she would ensure staff education was provided to prevent the incident from occurring again. UM #1 said DA #1 should have informed the nurse or the CNA about the resident's request for coffee.

Based on observations, record review, and interviews, the facility failed to ensure residents who entered the facility with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (#12) of five residents reviewed for range of motion out of 18 sample residents. Specifically, the facility failed to ensure Resident #12 was assessed for a restorative program for her contracted right hand. Findings include: I. Facility policy The Prevention of Decline in Range of Motion policy, revised March 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy stated in pertinent part, The facility in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care. II. Resident status Resident #12, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs). The 2/14/24 minimum data set (MDS) revealed this resident had severe cognitive impairment with a brief interview for mental status was unable to be completed. It was documented that cognitive skills for daily functioning were severely impaired. There were no behaviors or refusals of care documented. She required extensive assistance and was dependent on staff for all cares. The assessment coded the resident as not having an upper extremity impairment. -However, according to observations and interviews (see below) she did have an upper extremity impairment. The assessment did not code the resident as having therapy or restorative services. III. Observations Resident #12 was observed on 2/26/24 at 9:03 a.m. She was sitting in a geri chair in the dining room holding a towel roll in her right hand. Resident #12 was observed again on 2/26/24 at 1:00 p.m. Staff were changing her brief and put a stuffed animal in her right hand once she was back up in the geri chair. -Although Resident #12 had items in her right hand during the observations, there was no formal restorative program in place for her contracture (see interviews and record review below). IV. Resident's representative interview Resident #12's representative was interviewed on 2/26/24 at 1:00 p.m. She said she had requested restorative therapy upon admission. She said she had not witnessed the resident receiving therapy. She said the nursing staff sometimes put towel rolls in her contracted hand. V. Record review -The comprehensive care plan, initiated on 2/9/24 and revised on 2/14/24, did not mention the resident's contracture. There were no listed interventions in place. VI. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/27/24 at 4:00 p.m. She said Resident #12 had a contracture to her right hand and she was unable to move it on her own. She said the nursing staff put a towel in her right hand to prevent the contracture from worsening. She said there was currently no formal restorative therapy program. The director of rehabilitation (DOR) was interviewed on 2/28/24 at 12:03 p.m. She said there was currently no restorative program in place for long term care residents. She said the facility started accepting long term care residents about two months ago. She said contracture care was important because it helped maintain the ability to care for oneself. She said contractures could be very painful and appropriate care could help to alleviate the pain. She said every resident should be assessed for contractures and providing flexion, extension and splints to contracted areas in part of the treatment. The director of nursing (DON), assistant director of nursing (ADON) and NHA were interviewed on 2/29/24 at 1:45 p.m. They said the facility currently did not have a restorative therapy program in place and they should have a program in place. They were aware of Resident 12's contracture and failed to provide her with appropriate treatment.

Based on observations, record review and interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#137 and #191) of five residents reviewed for supplemental oxygen use out of 18 sample residents. Specifically, the facility failed to obtain a physician's order for the administration of oxygen for Resident #137 and Resident #191. Findings include: I. Facility policy The Oxygen Administration policy, revised October 2010, was provided on 2/27/24 by the nursing home administrator (NHA). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure and review the physician orders or the facility protocol for oxygen administration. II. Resident #137 A. Resident status Resident #137, over age 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease, systolic congestive heart failure, and hypertension. According to the 2/21/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required limited assistance with bed mobility, grooming, and toileting, and one-person assistance with transfers. The resident's assessment was not coded for the use of oxygen therapy. B. Resident observations and interview On 2/26/24 at 9:27 a.m., Resident #137 was sitting on her bed with a nasal cannula receiving oxygen through her nostrils. The resident's oxygen concentrator was set to 3 liters of oxygen per minute (LPM). Resident #137 said she did not normally require the use of oxygen, however, she said her oxygen saturation level (level of oxygen in the blood) dropped from 90 percent (%) to 81% that morning (2/26/24). She said the nurse put her on oxygen to get her oxygen saturation levels back up above 90%. On 2/26/24 at 2:15 p.m., Resident #137 was sleeping in her bed. She continued to have an oxygen nasal cannula in her nostrils and she was receiving oxygen at 3 LPM. C. Record review -The comprehensive care plan, initiated on 2/19/24, did not identify that the resident required the use of oxygen. -There were no interventions included for oxygen therapy. The care plan did not include signs and symptoms to monitor for the use of oxygen. -The February 2024 CPO did not include a physician's order to administer oxygen. -Nursing progress notes written on 2/17/24 and 2/27/24 documented the resident did not require oxygen. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/27/24 at 3:20 p.m. LPN #2 said Resident #137 was not receiving oxygen therapy until the day before (2/26/24)when the resident's oxygen saturation levels dropped below 90%. She said Resident #137 received continuous oxygen at 3 LPM throughout the rest of the day. LPN #2 said she notified the resident's physician about the incident but forgot to request an order for the continued use of oxygen for the resident. Certified nurse aide (CNA) #2 was interviewed on 2/28/24 at 10:30 a.m. CNA #2 said Resident #137 did not normally use oxygen. The CNA said she did not know the reason the resident was on continuous oxygen. She said she had never seen the resident on oxygen since the resident was admitted to the facility. The assistant director of nursing (ADON) was interviewed on 2/29/24 at 2:00 p.m. The ADON said there should be a physician's order for the use of oxygen for every resident who required oxygen therapy. The ADON said she did not know why LPN #2 did not obtain a physician's order for Resident #137's oxygen after she had identified the resident needed oxygen. The ADON said too much oxygenation could slow breathing and heart rate to dangerous levels which could result in death. The ADON said the facility was revising the oxygen administration protocol including providing education to the nursing staff regarding obtaining physician's orders when a resident needed oxygen. 47818 III. Resident #191 A. Resident status Resident #191, age 70, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included aftercare following right hip joint replacement surgery, nausea and tachycardia (heart rate of more than 100 beats per minute at rest). The 2/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance of one to two staff members with transferring, toileting and walking. B. Resident observations and interview On 2/26/24 at 9:41 a.m., Resident #191 was in her room. An oxygen concentrator was continuously providing her with 2.5 LPM of oxygen through a nasal cannula in her nostrils. Resident #191 said she was admitted to the facility on [DATE] from the hospital for physical and occupational therapy after having elective hip surgery. She said the hospital attempted to discontinue the use of supplemental oxygen twice and were unsuccessful so she was admitted to the facility with oxygen. She said prior to having surgery she was not using an oxygen concentrator at home and she was unsure why there was a continued need for it at the facility or how long she was expected to use it. On 2/27/24 at 1:37 p.m., Resident #191 was in her room. She continued to have a nasal cannula in her nostrils and the oxygen concentrator was providing her with 2.5 LPM of oxygen. On 2/28/24 at 9:30 a.m., Resident #191 was again in her room with the oxygen concentrator continuously providing her 2.5 LPM of oxygen through the nasal cannula. C. Record review The 2/24/24 facility admission note revealed Resident #191 admitted from the hospital on three LPM of oxygen through a nasal cannula following right hip replacement surgery. -Review of Resident #191's February 2024 CPO revealed there was not a physician's order for the administration of oxygen. The 2/26/24 physician's progress note revealed Resident #191 had a new need for oxygen use after surgery related to acute respiratory failure and the resident's respiratory status was to be monitored and the oxygen weaned as tolerated. The progress note further indicated Resident #191's oxygen use was decreased to 2 LPM from 3 LPM. -However, the facility failed to have an order for the use of oxygen to include monitoring and weaning as tolerated. -Additionally, Resident #191's comprehensive care plan did not include a care plan focus for the use of oxygen. On 2/28/24, during the survey, the following physician's order was entered, in pertinent part, into Resident #191's electronic medical record (EMR): Oxygen at 2 liters (L) a minute via (through) nasal cannula due to post surgical hypoxia (low levels of oxygen in your body tissues). Attempt oxygen titration as able, respiratory therapist to evaluate and treat one time only for hypoxia. -However, the resident's care plan was still not updated to include the use of oxygen. D. Staff Interviews Registered nurse (RN) #1 was interviewed on 2/28/24 at 9:58 a.m. RN #1 said Resident #191 was using 2.5 LPM of oxygen and she knew this because she had just taken her vital signs. She said supplemental oxygen was considered a medication and required a physician's order. RN #1 was unable to find an order for the use of oxygen in the EMR for Resident #191. Unit manager (UM) #1 was interviewed on 2/28/24 at 10:08 a.m. UM #1 said oxygen was considered a medication and should have a physician's order for use. She was unable to find an order for the use of oxygen listed in the EMR for the resident, nor was she able to identify a diagnosis it was being used for. UM #1 was able to locate an admitting report sheet from 2/24/24 indicating the use of 3 LPM of oxygen for Resident #191. She did not know why the resident was using 2.5 LPM instead of 3 LPM or if she could be weaned off the oxygen. UM #1 said the facility had a respiratory therapist on staff who could work with the physician regarding the appropriateness of oxygen use for Resident #191. The ADON was interviewed on 2/29/24 at 2:29 p.m. The ADON said it was concerning Resident #191 was using oxygen without a physician's order or a diagnosis. She said there was not an order for the respiratory therapist to evaluate and treat the resident for oxygen use and a care plan had not been initiated for the resident's use of oxygen. She said oxygen use was considered a medication and should have a physician's order for use and a care plan in place if a resident was receiving oxygen. The ADON said the facility needed a better system in place to ensure physician orders were obtained for the use of oxygen and that a care plan was initiated for the use of oxygen. She said the facility started an audit on 2/28/24 to ensure other residents who were receiving oxygen had physician orders and a care plan for the use of oxygen in place.

Based on observation, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for two of two medication storage rooms. Specifically, the facility failed to: -Ensure medication storage refrigerators were within acceptable parameters for proper medication storage; -Ensure medication storage refrigerator temperatures were monitored and documented consistently; -Ensure a Schedule IV controlled medication was properly stored in a locked, permanently affixed compartment in the medication storage refrigerator; and, -Ensure expired medications were properly disposed of. Findings include: I. Facility policy The Storage of Medications policy, revised November 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the proper pharmacy or destroyed. Schedule II-V controlled medication are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. The Storage of Medications Requiring Refrigeration policy, revised November 2022, was received from the NHA on 2/29/24 at 1:03 p.m. The policy read in pertinent part, It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. 'Refrigerated' refers to temperature maintained between 36-46 degrees Fahrenheit (F). Temperatures should be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of the person performing the check clearly written. II. Observations On 2/29/24 at 10:00 a.m., the west hallway medication storage room was observed with licensed practical nurse (LPN) #4. The medication storage refrigerator contained vaccines and insulin. -The medication storage refrigerator thermometer read 48 degrees F, which was above the acceptable parameters for safe refrigerated medication storage of 36 degrees to 46 degrees F. On 2/29/24 at 10:15 a.m., the east hallway medication storage room was observed with registered nurse (RN) #1.The medication storage refrigerator contained a lockbox of emergency medications. The medications in the box included Humulin 70/30 insulin, a Lantus Solostar insulin pen, Humulin N insulin, Humulin R insulin, two lorazepam (a Schedule IV controlled medication used to treat anxiety) injectable syringes and a lorazepam multi-dose vial. -The emergency medication box was not locked and had a label on it which indicated the medication kit expired in January 2024. -The lorazepam, a Schedule IV controlled substance, was not stored in a locked, permanently affixed compartment in the medication storage refrigerator. -The medication storage refrigerator thermometer read 30 degrees F, which was below the acceptable parameters for safe refrigerated medication storage of 36 degrees to 46 degrees F. -The temperature logs for the medication storage refrigerator revealed several missing dates of documentation for the months of December 2023, January 2024 and February 2024. III. Staff interviews Registered nurse (RN) #1 was interviewed on 2/29/24 at 10:20 a.m. RN #2 said controlled medications were supposed to be kept under two locked systems. She said the consulting pharmacy was responsible for collecting expired medications and disposing of them properly. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 2/29/24 at 10:43 a.m. She said controlled medications should be stored under a double lock system. She said the refrigerator temperatures were inappropriate for storing medications safely. She said if controlled medications were stored in the medication storage refrigerator they must be in a place permanently affixed to the refrigerator. She said the facility's pharmacy was responsible for tracking and disposing of expired medications.

Based on observations, record review and interviews, the facility failed to ensure residents received and the facility provided food that accommodated resident preferences for one (#12) of three residents reviewed for food preferences out of 18 sample residents. Specifically, the facility failed to ensure Resident #4 was provided with a vegetarian diet per her preference. Findings include: I. Facility policy The Resident Food Preferences policy, revised July 2017, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modification to diet will only be ordered with the resident's or representative's consent. Nursing staff will document the resident's food and eating preferences in the care plan. II. Resident status Resident #12, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs). The 2/14/24 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). The staff assessment for mental status revealed the resident's cognitive skills for daily functioning were severely impaired. She required extensive assistance and was dependent on staff for all cares. III. Observations On 2/26/24 at 9:03 a.m., Resident #12 was sitting in her wheelchair at a table in the dining room. There were two plates of pureed food on a tray in front of her. The plates were covered with plastic. The resident's meal ticket documented the resident was on a puree diet and thickened liquids. -The puree food on the plates was not labeled to indicate what each food item was. -The resident's meal ticket did not document what food the resident received for breakfast. -The meal ticket did not indicate Resident #12 was to receive a vegetarian diet. On 2/26/24 at 12:27 p.m., Resident #12 was sitting in the dining room for lunch. There were two plates with pureed food covered with plastic on the table in front of the resident. -The puree food on the plates was not labeled to indicate what each food item was. -The resident's meal ticket did not document what food the resident received for lunch. -The meal ticket did not indicate Resident #12 was to receive a vegetarian diet. On 2/29/24 at 12:45 p.m., Resident #12 was sitting in the dining room when her lunch was delivered. The food in the dishes delivered to the resident were labeled as beef pot pie, beans and bread. -The resident's meal ticket indicated she was to receive a vegetarian diet, however, the resident was served beef pot pie for lunch. -The resident's meal ticket did not document what food the resident received for lunch. IV. Resident's representative interview Resident #12's representative was interviewed on 2/26/24 at 1:00 p.m. She said she the resident had been assessed for dietary preferences. The representative said she told the facility's registered dietitian (RD) that the resident preferred a vegetarian diet. She said the facility frequently served the resident food which was inconsistent with a vegetarian diet. V. Record review Review of Resident #12's nutrition care plan, revised 2/14/24, revealed she was at a nutritional risk related to hospice. Interventions included providing a diet per physician order, dietary supplements as ordered, monitoring skin for signs of breakdown and for the registered dietitian (RD) to reassess as indicated. -There was no intervention for the resident's food preferences documented on the care plan. -The care plan did not document the resident was vegetarian. VI. Staff interviews The dietary manager (DM) was interviewed on 2/28/24 at 4:30 p.m. The DM said Resident #12t probably received the main dish listed on the menu every day for lunch. He said the resident was not verbal and her meals were communicated by her representative. The DM said he did not know who had contacted the representative for the resident's preferences or where resident's preferences were documented. He said he was not sure what the resident's diet preferences were. The DM said if the resident preferred a vegetarian diet, she should probably receive the main dish option without the meat. He was not sure if Resident #12 was offered a protein substitute as an alternative to the meat portion of the menu. The DM said he did not have a vegetarian menu and it was improvised for every meal. Licensed practical nurse (LPN) # 4 was interviewed on 2/29/24 at 12:50 p.m. LPN #4 looked at Resident #12's meal ticket and said she was not sure what resident received for lunch because her food items were not listed on the meal ticket. After looking at the resident's food tray which was labeled, LPN #4 said the resident was served pureed beef pot pie, pureed beans and pureed bread. LPN #4 said she was not aware the resident was vegetarian. The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 1:45 p.m. The DON and ADON said staff should follow residents' preferences for their diet. The DON and ADON said Resident #12 should be receiving a vegetarian diet if that was her preference and the vegetarian diet preference should be included on the care plan.

Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (#3, and #9) of five residents out of 18 sample residents. Specifically, the facility failed to ensure transmission-based precautions were implemented for Resident #3 and #9. Findings include: I. Facility policy The Transmission-Based (Isolation) Precautions policy, undated, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy stated in pertinent part, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Contact precautions refers to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident of the resident's environment. When implementing transmission-based precautions, the facility will consider the following: the identification of resident risk factors that increase the likelihood of transmission, the provision of a private room, cohorting residents with the same pathogen, and sharing a room with a roommate with limited risk factors. Residents on transmission-based precautions should remain in their rooms except for medically necessary care. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Contact precautions are recommended for multi-resistant organisms, infection or colonization. II. Resident #3 A. Resident status Resident #3, under the age of 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included infection following a procedure and a deep surgical incision site and methicillin-resistant staphylococcus aureus (MRSA) infection (highly contagious infection on the skin). The 2/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required partial/moderate assistance for activities of daily living (ADL) which included dressing, toilet transferring and standing. B. Observations On 2/26/24 at 10:30 a.m., Resident #3 was sitting in her wheelchair in the hallway outside her room. Licensed practical nurse (LPN) #1 was preparing the resident's intravenous (IV) antibiotic infusion and hooked it up to her central line (a tube utilized for the administration of fluids or medications which is surgically placed in the neck, groin, chest or arm and can remain in place longer than a standard IV) in the hallway. Resident #3 remained in the hallway for the entire IV administration of her antibiotic. -LPN #1 wore gloves to administer the IV medication, however, she did not put on a gown. On 2/27/24 at 1:45 p.m., Resident #3 was in her room. LPN #1 gathered supplies for Resident #3's IV antibiotic infusion and entered the resident's room. She set up the IV antibiotic and attached it to the resident's central line. -LPN #1 failed to put on a gown or gloves when she set up Resident #3's IV antibiotic infusion -There was no isolation cart with personal protective equipment (PPE) in it outside of Resident #3's room. -There was no sign on Resident #3's door which informed staff the resident was on transmission-based precautions or what type of PPE should be worn when working with the resident. III. Resident #9 A. Resident status Resident #9, age 78, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included fracture of the neck and pressure injuries to the chin and back of the head. The 11/28/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for most ADLs. B. Record review The wound care note by the wound care physician, dated 12/20/23, revealed the resident's wound on her chin had a MRSA infection. C. Observations Wound care observations for Resident #9 were completed on 2/29/24 at 9:30 a.m. The wound care was completed by wound care nurse (WCN) #1. -WCN #1 did not put on a gown before performing wound care for Resident #9, despite the resident having a MRSA infection in the wound on her chin, which required contact precautions, including the use of a protective gown. WCN #1 entered the room, placed an Ipad (tablet computer) on the resident's table, donned gloves and prepared supplies for the wound. He approached the resident, removed the dressing on the right side of her chin and disposed of the dressing in the trash. The dressing was saturated with yellow drainage. WCN #1 soaked a gauze pad in a wound cleanser solution and used the gauze pad to clean the wound. After cleaning the wound, he picked up the Ipad from the table, logged in, and took a picture of the resident's wound. -WCN #1 did not change his gloves or perform hand hygiene before picking up the Ipad. WCN #1 returned the Ipad to the table and proceeded to apply a clean dressing to the wound. -WCN #1 did not remove his gloves or perform hand hygiene prior to applying the clean dressing to the wound. After applying the clean dressing to the wound, WCN #1 removed his gloves. He applied clean gloves and started the wound care for the second wound on the back of the resident's head. -WCN #1 did not perform hand hygiene prior to starting wound care on the resident's second wound. WCN #1 removed the soiled dressing, which was saturated with yellow drainage, from Resident #9's wound on the back of her head. WCN #1 proceeded to pick up his Ipad and took a picture of the wound. -WCN #1 did not change his gloves or perform hand hygiene before picking up the Ipad. WCN #1 returned the Ipad to the table and proceeded to apply a clean dressing to the resident's head wound. -WCN #1 did not remove his gloves or perform hand hygiene prior to applying the clean dressing to the wound. IV. Staff interviews LPN #2 was interviewed on 2/28/24 at 8:47 a.m. She said she was not aware of any resident on transmission-based precautions. She said she was not aware of any resident with an active MRSA infection. She said residents with MRSA were placed on contact precautions, which included a gown and gloves. LPN #2 said residents on contact precautions should have an isolation cart outside their room and a sign on the door to stop anyone who entered the room to see the nurse before entering. The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 11:07 a.m. The ADON said she was serving as the facility's infection preventionist. She said any resident with an active MRSA infection or a history of the infection were placed on contact precautions. This included wearing a gown, gloves, mask, and goggles or a face shield if splashing was a risk. She said residents on contact precautions should have an isolation cart outside their room with PPE in it. She said there should also be a stop sign on the resident's door stopping anyone from entering without checking with the nurse on duty. She said the facility had an adequate supply of PPE. The ADON said she was unaware of Resident #3's MRSA infection. The ADON said it was inappropriate to set up and run an antibiotic in the hallway for a resident on transmission-based precautions. She said this was because of the potential to spread the infection to other staff members and residents. 37166

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to independently carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#1, #2, and #3) of five residents out of five sample residents. Specifically, the facility failed to: -Provide timely toileting/incontinence care for Residents #1, #2, and #3; and, -Provide scheduled showers for Residents #2 and #3. Findings include: I. Facility policy and procedures A. The Urinary Incontinence Management Practice Guide policy, dated March 2012, was provided by the director of nursing (DON) on 9/27/22 at 2:25 p.m. It read, in pertinent part: Care and comfort is for patients who are incapable of maintaining continence independently or through regular toileting by caregivers and who depend on absorbent products and other measures to contain urine leakage. Skin cleansing and protective care are routinely provided with each incontinent episode. Implementation steps for care and comfort can include checking the patient for incontinence and changing incontinence care products as needed. -The policy did not address management of bowel incontinence. B. The Tub Baths and Showers policy, last revised 5/20/22, was provided by the DON on 9/27/22 at 2:25 p.m. It read, in pertinent part: Tub baths and showers provide personal hygiene, stimulate circulation, and reduce tension for a resident. They also allow observation of the condition of a resident's skin and assessment of joint mobility and muscle strength. II. Resident #1 A. Resident status Resident #1, age 82, was admitted on [DATE], and discharged to the hospital on 7/24/22. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/24/22 minimum data set (MDS) discharge assessment revealed that the resident did not have a memory problem based on staff assessment for mental status. She required limited assistance for bed mobility. She required supervision for transfers, dressing, toilet use and personal hygiene. She was occasionally incontinent of urine. Her bowel continence was not rated. According to the 7/22/22 social services assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. B. Record review Review of Resident #1's 7/20/22 occupational therapy (OT) evaluation revealed the resident required skilled therapy services to address impairments of dressing, bathing, toileting, and independent activities of daily living (ADL) task completion due to weakness, impaired balance, and decreased activity tolerance. -Review of Resident #1's electronic medical record revealed there was no care plan to address the resident's toileting or incontinence care needs. Review of the certified nurse aide (CNA) toileting documentation for Resident #1 revealed the following: -7/19/22 - there was no documentation of toileting from 6:00 p.m. through 6:00 a.m. (the day the resident was admitted to the facility); -7/22/22 - there was no documentation of toileting from 6:00 p.m. through 6:00 a.m.; -7/23/22 - there was no documentation of toileting for the entire 24 hour period; and -7/24/22 - there was no documentation of toileting recorded for the morning prior to her transfer to the hospital at 10:23 a.m. Review of Resident #1's hospital records revealed a nurse progress note dated 7/24/22, which documented in pertinent part: This registered nurse (RN) took the patient to the bathroom and I noticed the patient's brief was old and soiled. Patient stated 'they do not help me go to the bathroom. III. Resident #2 A. Resident status Resident #2, age 85, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/6/22 MDS assessment revealed that the resident had moderate cognitive impairment with a BIMS of 12 out of 15. He required on-person limited assistance for bed mobility, transfers, and dressing. He required two-person limited assistance for toilet use. He required supervision for personal hygiene. Bathing did not occur during the seven day MDS assessment look back period. He had a foley catheter and he was always incontinent of bowel. B. Resident observation On 9/27/22 at 10:40 a.m., Resident #2 was observed lying on his back in bed. His hair was unkempt and sticking up from his head in multiple places. C. Resident interview Resident #2 was interviewed on 9/27/22 at 11:07 a.m. Resident #2 said he thought he had had at least one shower since he was admitted to the facility, however, he could not recall when he received it. Resident #2 said he would give himself sponge baths in the bathroom. D. Record review Review of Resident #2's 9/3/22 OT evaluation revealed the resident required maximum assistance for toilet hygiene and was dependent for bathing. Review of Resident #2's comprehensive care plan, initiated 9/3/22 and last revised on 9/26/22, revealed the resident had an indwelling urinary catheter due to [CONDITION(S)] (enlarged prostate gland) and urinary retention. Pertinent interventions included catheter care, changing the catheter per physician orders, and maintaining the drainage bag below bladder level. -There was no care plan to address the resident's toileting or bowel incontinence care needs. Further review of the care plan revealed the resident had an ADL self care deficit related to disease process, [CONDITION(S)], acute kidney injury, and urinary tract infection with physical limitations secondary to a history of [CONDITION(S)] (stroke). Pertinent interventions included assisting the resident to bathe/shower as needed, and assisting with daily hygiene, grooming, dressing, oral care, and eating as needed. Review of the CNA toileting documentation for Resident #2 revealed the following: -9/2/22 - there was no documentation of toileting from 6:00 p.m. through 6:00 a.m. (the day the resident was admitted to the facility); -9/3/22 - there was no documentation of toileting for the entire 24 hour period; -9/5/22 - there was no documentation of toileting from 6:00 p.m. through 6:00 a.m.; -9/6/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; -9/7/22 - there was no documentation of toileting for the entire 24 hour period; -9/9/22 - there was no documentation of toileting from 6:00 p.m. through 6:00 a.m.; -9/11/22 - there was no documentation of toileting for the entire 24 hour period; -9/12/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; -9/13/22 - there was no documentation of toileting for the entire 24 hour period; -9/14/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; -9/15/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; -9/16/22 - there was no documentation of toileting for the entire 24 hour period; -9/18/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; -9/20/22 - there was no documentation of toileting for the entire 24 hour period; -9/23/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; and, -9/24/22 - there was no documentation of toileting from 6:00 p.m. through 6:00 a.m. -Review of the CNA bath/shower documentation for Resident #2 revealed there were no baths or showers documented for the resident since his admission to the facility. -Review of the bath/shower binder at the nurse's station revealed there were no shower sheets documented for Resident #2 in the binder. -Review of nurse progress notes revealed there were no bath/shower refusals documented for Resident #2. IV. Resident #3 A. Resident status Resident #3, age 81, was admitted on [DATE]. According to the September CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She was totally dependent on the assistance of two staff persons for bed mobility, transfers, dressing, and personal hygiene. Toilet use occurred only once or twice, and bathing did not occur during the seven day MDS assessment look back period. She was occasionally incontinent of urine. Her bowel continence was not rated. B. Family interview Resident #3's daughter was interviewed on 9/27/22 at 11:55 a.m. The resident's daughter said staff were supposed to check her mother's brief every two hours. She said the staff did not usually come to check the resident's brief unless she asked them to. She said she slept in her mother's room at night. The resident's daughter said staff checked the resident's brief at 4:30 a.m. on 9/27/22 and did not check her brief again until 8:30 a.m. She said the next time staff changed the resident's brief was at 11:15 a.m. when RN #1 and CNA #1 came into the room to apply cream to the resident's bottom. Resident #3's daughter said she took care of her mother at home prior to her admission to the facility. She said the resident would only allow bed baths at home. She said the resident had been at the facility for 10 days and had only been given one bed bath. The resident's daughter said she had to ask a nurse for a CNA to give her mother that one bed bath. She said when her mother was admitted to the facility, the staff told her that her mother would have two showers/baths per week, which had not occurred. Resident #3's daughter said she liked the staff at the facility, however, she did not feel she should have to ask them to change her mother's brief or give her a bed bath. C. Record review Review of Resident #3's 9/3/22 OT evaluation revealed the resident was dependent for toilet hygiene and bathing. Review of Resident #3's comprehensive care plan, initiated on 9/17/22 and revised on 9/26/22, revealed the resident had urinary incontinence related to cognition and limited mobility. Pertinent interventions included identifying the resident's voiding patterns and establishing a toileting program, applying barrier creams as needed, and providing incontinence care as needed. -The resident was not on a toileting program. -There was no care plan to address the resident's bowel incontinence care needs. Further review of the care plan revealed the resident had an ADL self care deficit related to disease process, Jackson Pratt (JP) drain ( a drain sutured in place extending to the outside of the body which is used to help empty excess fluid from the body after surgery), diverticulitis (small bulging pouches that develop in the digestive tract), and physical limitations with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the CNA toileting documentation for Resident #3 revealed the following: -9/18/22 - there was no documentation of toileting for the entire 24 hour period; -9/19/22 - there was no documentation of toileting for the entire 24 hour period; -9/20/22 - there was no documentation of toileting from 6:00 p.m. through 6:00 a.m.; -9/21/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; -9/22/22 - there was no documentation of toileting from 6:00 a.m. through 6:00 p.m.; and, -9/23/22 - there was no documentation of toileting for the entire 24 hour period. Review of nurse progress notes revealed one progress note dated 9/21/22 which documented in pertinent part: Resident given bedbath by CNA. Daughter verbalized appreciation. -Review of the CNA bath/shower documentation for Resident #3 revealed there were no baths or showers documented for the resident since her admission to the facility. -Review of the bath/shower binder at the nurse's station revealed there were no shower sheets documented for Resident #3 in the binder. D. DON interview The DON was interviewed on 9/26/22 at 3:30 p.m. The DON said she had added the bathing schedule for Resident #3 to the CNA charting documentation as it had not been added to the electronic medical record (EMR) upon the resident's admission to the facility. She said she had identified that nurses were not always adding the bathing schedules to the CNA charting documentation upon admission, and therefore the CNAs were unable to chart if a bath was given in the resident's EMR. The DON said she was unable to locate shower sheets for Residents #2 and #3, however, she said she would continue to look for them. V. Staff interviews CNA #1 was interviewed on 9/27/22 at 11:35 a.m. CNA #1 said if a resident was incontinent or needed assistance with toileting, staff were supposed to round every two hours and toilet the resident or change their brief. She said CNAs documented the resident was toileted or changed in the resident's EMR. She said if there were blanks in the charting, it did not mean the resident was not provided with toileting or incontinence care. She said it just meant the CNA forgot to chart. However, CNA #1 said if it was not charted, it was difficult to prove that the care had been provided. CNA #1 said residents were provided showers every other day. She said showers were documented in the resident's EMR and on shower sheets that were kept in a binder at the nurses station. She said the DON checked the shower sheets every morning. CNA #1 said if showers were not documented it meant the CNA forgot to chart. However, CNA #1 again said if the shower was not charted, it was difficult to prove that the care had been provided. RN #1 was interviewed on 9/27/22 at 11:48 a.m. RN #1 said toileting or incontinence care for residents should be provided every two hours. She said CNAs charted the care in the resident's EMR. She said showers were provided to residents up to three times per week. RN #1 said showers were also documented by the CNAs in the resident's EMR in addition to being documented on a shower sheet which was in a binder at the nurses station. She said if documentation in the toileting or shower section of the EMR was left blank it did not necessarily mean the care was not completed. However, RN #1 said if there was no documentation she was unable to verify that the care had been completed. RN #2 was interviewed on 9/27/22 at 12:13 p.m. RN #2 said the standard of care for residents was to toilet them or perform incontinent care every two hours. She said CNAs should check on residents every two hours and offer care to them. She said if toileting documentation was left blank it did not mean that the care was not performed, however, she said there was no way to prove that it had been completed. RN #2 said residents were asked how many times a week they preferred to bathe upon admission to the facility. She said the admitting nurse entered that information into the EMR to ensure the CNAs were able to document showers according to the resident's bathing schedule preferences. RN #2 said nurses did not always enter the bathing schedule into the EMR as they were supposed to. She said if showers were not documented in the EMR, it was difficult to prove that one had been provided to the resident. Licensed practical nurse (LPN) #1 was interviewed on 9/27/22 at 12:19 p.m. LPN #1 said residents who required assistance with toileting or incontinent care should be checked on every two hours, or sooner if they used their call light for assistance. She said CNAs documented toileting of residents in the EMR. She said if there were blanks in the documentation, there was no way to tell if the care had been provided to the resident. LPN #1 said showers were also documented by the CNAs in the EMR and on shower sheets which were kept in a binder at the nurses station. She said if the showers were not documented in the EMR or on the shower sheets, there was no way to tell if a resident had received a shower. The minimum data set nurse (MDSN) was interviewed on 9/27/22 at 12:30 p.m. The MDSN said residents should be toileted or checked and changed every two to three hours. She said if a resident had cognitive deficits, the resident should be checked on more frequently. She said CNAs documented toileting/incontinence care in the resident's EMR. The MDSN said if there was toileting documentation missing it was difficult to prove that the care had been provided to the resident. The MDSN said when residents received a shower, CNAs documented the shower in the EMR and on a shower sheet which was kept at the nurses station in a binder. She said if the shower was not documented in the EMR or on a shower sheet, then it was difficult to prove the resident received a shower. She said if a resident refused a toileting or a shower, that information should be documented in the progress notes and on the resident's care plan. The MDSN said she thought the occupational therapist (OT) performed shower assessments with residents as part of their initial therapy evaluation. She said she thought Residents #1, #2, and #3 had each received a shower from the OT. The director of rehabilitation (DOR) was interviewed on 9/27/22 at 1:08 p.m. The DOR said the OT never performed showers with residents on admission during their initial evaluation. She said therapy did not give showers to residents during their stay at the facility unless bathing was one of the resident's therapy goals for discharge. The DOR said if a therapist had conducted a shower evaluation with a resident, that information would be documented in the therapist's notes. She said therapy had not conducted a shower with Residents #1, #2, or #3. The DON was interviewed again on 9/27/22 at 1:30 p.m. The DON said staff should be anticipating the toileting needs for residents who were unable to effectively communicate that they needed to go to the bathroom. She said residents who were incontinent should be checked on every hour and changed if needed. She said incontinence care/toileting was documented in the EMR by the CNAs. The DON said if there was no documentation of toileting by the CNAs, she could not verify that the care took place due to the lack of documentation. The DON said residents were offered showers up to three times per week. She said CNAs documented resident showers in the EMR and on shower sheets which were kept in a binder at the nurses station. She said if a resident refused a shower, it was the expectation of the facility that the CNA notified the nurse so the nurse could document the refusal in a progress note. She said if a resident had consistent refusals of care, that information should be documented on the resident's care plan. The DON said a resident shower sheet was filled out every time a resident received a shower, even if the resident refused. She said she had still been unable to locate the shower sheets for Residents #2 and #3. She said because there was no documentation in the EMR or on shower sheets, she could not verify Resident #2 and Resident #3 had received their showers. The DON said she did not currently have a good process in place to ensure that showers were not missed. She said she was working on getting one of her nurses into a unit manager position which would help with the process of ensuring showers were completed as expected.

Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (#1) of three residents out of five sample residents. Specifically, the facility failed to develop and implement within 48 hours of admission, a person-centered acute/baseline care plan for Resident #1 that included healthcare information necessary to properly care for the resident. Findings include: I. Facility policy and procedure The Interdisciplinary Care Planning policy, last updated March of 2018, was provided by the director of nursing (DON) on 9/27/22 at 2:25 p.m. It read in pertinent part, The facility must develop and implement a baseline person-centered care plan for each patient that includes the instructions needed to provide effective and person-centered care that meets professional standards of quality care. A baseline care plan must be developed within 48 hours of a patient's admission and include the minimum healthcare information necessary to properly care for a patient including, but not limited to: initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Resident status Resident #1, age 82, was admitted on [DATE], and discharged to the hospital on 7/24/22. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/24/22 minimum data set (MDS) discharge assessment revealed that the resident did not have a memory problem based on staff assessment for mental status. She required limited assistance for bed mobility. She required supervision for transfers, dressing, toilet use and personal hygiene. She was occasionally incontinent of urine. Her bowel continence was not rated. She had received pain medication during the five day look back period of the assessment. III. Record review Review of Resident #1's baseline care plan, which was initiated on 7/20/22, revealed the only care plan area included on the baseline care plan was the resident's dietary/nutritional needs. Review of Resident #1's nursing admission assessment, dated 7/19/22, revealed the following: -The resident was admitted to the facility with a hip fracture; -The resident had a potential for pain due to the hip fracture; -The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was admitted with a surgical hip incision and redness to her sacrum; and, -The resident had impairment to her lower left extremity and required supervision with a gait belt for transfers. -Despite the care concern areas identified on the nursing admission assessment, including potential for pain, falls, skin integrity concerns, and need for assistance with activities of daily living (ADLs), none of the concern areas were added to the resident's baseline care plan within 48 hours of her admission to the facility. IV. Staff interviews The minimum data set nurse (MDSN) was interviewed on 9/27/22 at 12:30 p.m. The MDSN said every resident should have a baseline care plan which must be developed within 48 hours of the resident's admission to the facility. She said the baseline care plan should always include dietary, falls, continence, pain, skin integrity, ADLs, and levels of assistance the resident required for ADLs. The MDSN said the care plan was a constantly evolving document, which should be updated as care for the resident changed. She said the baseline care plan was important to have in place as soon as possible after the resident was admitted in order to ensure staff know what was required to take care of the resident. The DON was interviewed on 9/27/22 at 1:30 p.m. The DON said baseline care plans were generated by the nursing admission assessment which was conducted upon a resident's admission to the facility. She said a baseline care plan should be developed within 48 hours after the resident's admission to the facility. She said nurses should mark care plan interventions on any area that was a concern on the nursing admission assessment. She said those interventions were then transferred over to the baseline care plan. The DON said baseline care plans should include, at the very least, falls, skin issues, continence, pain, ADLs, and dietary information. She said it was important to have a baseline care plan so staff knew how to properly care for a resident. She said Resident #1 did not have an appropriate baseline care plan.

Based on observation, interviews, and record review, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for three (#1, #7 and #12) of four residents reviewed for wounds, out of 12 sample residents. The facility failed to prevent, assess, monitor and timely treat a facility acquired sacral pressure injury for Resident #1, who had been assessed as being at risk for pressure ulcers. Additionally, the facility failed to notify the physician of changes to the pressure injury, including signs of infection. The pressure injury worsened and the resident was subsequently admitted to inpatient hospice with [CONDITION(S)] due to a sacral wound, and died . Furthermore, the facility failed to assess, implement interventions and timely treat a sacral pressure injury, and pressure injuries to both heels present on admission, for Resident #7. The sacral and heel wounds worsened. Moreover, the facility failed to assess, implement interventions, and timely treat a pressure injury to the right heel which was present on admission for Resident #12. Observations, record review, and interviews with staff, health professionals, and families demonstrated the facility did not have an effective system in place to implement preventive measures for residents who had been assessed to be at risk for pressure ulcers, admitted with pressure injuries, or developed worsening pressure injuries. Nursing staff did not timely assess, treat, monitor, implement preventive measures, or update the physician on wound changes timely. The facility's failures related to pressure ulcer prevention and care presented a situation of immediate jeopardy that resulted in serious harm. Findings include: I. Immediate Jeopardy A. Findings triggering immediate jeopardy Resident #1 was admitted on [DATE] and assessed to have intact skin. A sacral wound was observed on [DATE] but not measured until [DATE]. The wound measured 1.0 centimeters (cm) by 0.5 cm. Wound orders were not obtained until [DATE], and not implemented until [DATE]. A care plan to address the resident's sacral wound was not developed until [DATE], and was not revised as the wound worsened. Resident #1's sacral wound was measured at 5 cm by 4.8 cm on [DATE] and described as having a foul odor. The physician was not notified of the changes to the wound. On [DATE], the sacral wound measured 5.0 cm by 4.8 cm. with gray necrotic tissue. On [DATE], laboratory results revealed Resident #1's white count was elevated. The wound was again documented with a foul odor. The resident was sent to the wound clinic on [DATE]. There were no physician order changes between [DATE] and [DATE] when wound care clinic treatment and labs were ordered even with the wound having a foul odor. On [DATE], Resident #1 was transferred to the hospital, and diagnosed with [CONDITION(S)] secondary to her sacral wound. The resident was admitted to hospice care on [DATE], at which time the sacral wound was measured at 10 cm by 9 cm by 3 cm. Following the facility's failure to notify the physician, and timely treat the worsening wound, Resident #1 developed [CONDITION(S)] and died . The nursing home administrator was interviewed on [DATE] at 4:00 p.m. He said the facility had to evacuate residents during the wildfires in [DATE]. He said specifically, Resident #1 was evacuated on [DATE] to a sister facility, and returned on [DATE]. He said the resident was transferred with the facility staff to the sister facility and was cared for by their own nursing staff the whole time before, during and after temporary transfer to the sister facility. Resident #1 continued to be cared for by this facility's staff even after returning to this facility. The following two residents were not a part of the wildfires in [DATE] and the facility continued to fail them and their care regarding skin and pressure concerns. Resident #7 was admitted on [DATE] with an unstageable sacral wound, a right heel blister and a left heel deep tissue injury. Treatment orders were not implemented for three days. The resident's sacral wound was measured on [DATE] at 1 cm by 0.2 cm. On [DATE], the sacral wound measured 5 cm by 3 cm by 1 cm. On [DATE] at 9:00 a.m., the resident was observed lying in bed, saturated in urine (cross-reference F677, activities of daily living care for dependent residents). The wound dressing was completely saturated and not attached or covering the wound. Orders to offload Resident #7's bilateral heels had not been implemented. Resident #12 was admitted on [DATE] with a pressure induced, fluid filled dark purple blister to the right heel. Orders were not obtained until [DATE], and treatment was not started until [DATE]. The wound was not measured until [DATE]. Observations on [DATE] revealed the resident's heel was not being offloaded. Interviews with agency nursing staff revealed the facility did not train, educate or ensure competency of staff providing wound care to include assessing, monitoring, implementation of interventions and obtaining effective treatment orders timely (cross-reference F726 competent nursing staff). The facility's failures resulted in the development of new pressure ulcers or worsening of existing pressure ulcers for Residents #1, #7 and #12, as well as an additional resident identified by the facility during their facility-wide skin checks during the survey. The facility's failure to implement an effective wound management program led to serious harm and injury, and was likely to continue for other residents if not addressed immediately. B. Imposition of immediate jeopardy On [DATE] at 4:30 p.m., the nursing home administrator (NHA) and interim director of nursing (IDON) were informed that the facility's failures to prevent the formation of advance stage pressure ulcers, timely assess and treat pressure ulcers, prevent infection of pressure ulcers, and monitor pressure ulcers, created a situation of immediate jeopardy for serious resident harm. C. Facility response to immediate jeopardy On [DATE] at 3:00 p.m., the facility submitted the following plan to remove the immediate jeopardy. The plan read: This serves as the facility's response to the Immediate Jeopardy Notification that the center received on [DATE] at 4:30 p.m. The QAPI (quality assurance process improvement) committee met on [DATE] to review the plan to remove the immediate jeopardy for the alleged deficiency. The medical director was notified on [DATE]. As a result, the following plan to remove the immediate jeopardy has been developed. -Resident #7-The pressure ulcers were reassessed and was documented on [DATE], and treatments reviewed and found to be appropriate. The sacral dressing was changed on [DATE] when noted to not be in place. The care plan was reviewed and revised on [DATE]. -Resident #12-has current orders for pressure ulcer, the wound was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan of care was reviewed and revised on [DATE]. A skin sweep of the current census was initiated and completed on [DATE] by Unit Managers and RNs (registered nurses) to determine if there were any current residents with a pressure ulcer. Additionally four patients noted with intact skin were found to have previously unidentified wounds. Physicians and family were notified. New orders were obtained, interventions put in place and care plans updated. Upon review of patients admitted with pressure ulcers-two patients identified were without treatment orders. Physician orders obtained and interventions and care plans were put in place. Like residents (other residents at risk) are those that have, admit with, new or worsening wounds, or acquire pressure ulcers. Residents who currently reside in the center with pressure ulcers will be reviewed to ensure they have: -A current pressure ulcer assessment documented in PCC (point click care, the electronic medical charting system), -A current pressure ulcer treatment, and that it is in place, -A current plan of care that will be reviewed, updated, and revised based upon the Braden score, -Interventions will be based upon the Braden assess (an assessment to identify resident's risk for pressure ulcers), and -Documentation of physician(s) and responsible party notification of pressure ulcer status. -Weekly wound rounds to be conducted by DON (director of nursing) or designee. Patients at risk for pressure ulcer development will have a weekly skin assessment completed and monitored for accuracy beginning on [DATE]. DON or designee will audit residents with pressure ulcers to ensure their treatment/dressing and their skin interventions are in place. Audits will start [DATE] and be completed by [DATE]. DON or designee will audit Braden scales and update if needed by [DATE]. DON or designee will audit PCC beginning on [DATE] to ensure newly admitted patients with pressure ulcers have assessments documented upon admission, upon development, and at least weekly thereafter with physician notification of a new or worsening wound documented in PCC. Licensed nurses, newly hired licensed nurses and new agency nurses will be educated on pressure ulcer assessment and documentation, timely notification of the physician of new and worsening wounds, obtaining and implementing pressure ulcer treatments timely, and ensuring skin interventions are in place as well as ensuring weekly skin assessments are completed. Education will be initiated on [DATE] by DON/designee, with licensed nurses being educated prior to their next scheduled shift. Education to be completed by [DATE]. Nurse aides will be educated on turning and repositioning, notifying the nurse of any new skin alterations, and incontinence care starting on [DATE] and will be completed by [DATE]. D. Removal of immediate jeopardy On [DATE] at 3:00 p.m., the NHA was notified that the immediate jeopardy had been removed. However, based on observations, interviews, and record review, deficient practice remained at a G scope which was actual harm, isolated. II. Professional references A. According to the NPUAP Pressure Injury Stages,The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. ([DATE]) accessed [DATE] from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages, read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. -Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .). Cambridge Media: Osborne Park, Western Australia [DATE], accessed on [DATE]: Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, periwound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor. The following steps should be taken to prevent the emergence of pressure ulcers in individuals identified as being at high risk: -Scheduled repositioning should be done to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. -Heels should be placed in a position that eliminates pressure, referred to as ' floating ' the heels, by placing a cushion under the full back of the resident's calf. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure injury should be avoided. -For heel ulcers, the heel should be floated. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: Location, Category/stage, Size,Tissue types, Color, Periwound, (the skin around the wound) condition, Wound edges, Any undermining or tunneling, Exudate (pus or clear like fluid), Odor. III. Facility policy The Skin Management Guidelines policy, dated February 2022, was received from the IDON on [DATE] at 11:12 a.m. The policy documented in pertinent part, Skin alterations and pressure injuries are evaluated and documented by the licensed nurse: -Using the Admission/Readmission Evaluation upon admission with a head-to-toe skin evaluation and completion of the Braden Scale for Predicting Pressure Sore Risk -Using the Braden Scale, weekly X 3 (for three weeks) after admission for a total of 4 weekly evaluations -Using the PUSH Tool (pressure ulcer scale for healing, see below) and Skin/wound application in PCC (if enabled) weekly by the wound team for pressure injuries or complex wounds -Using the Skin Alteration Record or Skin/wound application in PCC (if enabled) weekly by the licensed nurse for non-pressure injuries -Whenever there is a significant change in condition or clinically indicated -Quarterly, in coordination with the MDS (minimum data set)/RAI (resident assessment instrument) process Body audits are completed: -By the licensed nurse daily for patients with pressure injuries and documented on the eTAR; new findings are documented in a progress note -By the licensed nurse weekly for patients without pressure injuries and documented on the eTAR (electronic treatment administration record); new findings are documented in a progress note -By the nursing assistant during scheduled baths/showers, and if indicated during routine daily care and documented on the Skin Worksheet. The Pressure Ulcer Scale for Healing (PUSH Tool) is used to document the healing status of pressure injuries. It is initiated upon identification of a pressure injury and is updated weekly by the wound team during wound rounds until the wound heals. The PUSH Tool utilizes the following metrics which are converted to a sub-score which is then calculated to determine healing: -Length X width-provides calculation of overall surface area -Exudate amount-determined after removal of the dressing and before the application of any Topical agents -Tissue type-identifies the most advanced tissue type. Treatments are ordered by the medical practitioner. Wound rounds are completed weekly on pressure injuries and complex wounds. The wound team consists of the unit manager, licensed nurse, and nursing assistant. The director of nursing, medical practitioners, rehabilitation team members and the registered dietitian may participate in wound rounds if available. Wound rounds should be held on a consistent day of the week and time of day to assure wounds are evaluated no less often than weekly. The role of the wound team is to provide assistance with ongoing management and monitoring of pressure injuries and complex wounds, determining wound etiology, selecting the most optimal treatment strategies and evaluation and revision of the patient specific plan of care. One member of the wound team documents wound evaluations in a Pressure Ulcer Weekly Note in PCC or within the Skin/wound application of PCC (if enabled). Documentation should include wound location, etiology, presence of exudate/odor, tissue type, measurements, presence of undermining or tunneling, description of peri-wound, PUSH score, indications of pain or infection, notifications to medical practitioner and patient/responsible party, education provided and any changes in treatment or care plan interventions. Skin prevention strategies that can be implemented upon admission for any patient may include, but are not limited to the following: -Repositioning and off-loading pressure -Continence management - toileting programs, use of barrier cream products to protect skin -Honoring food/fluid preferences -Encouraging adequate nutrition/hydration and offering alternatives -Pressure reducing support surfaces -Skin evaluations -Rehabilitation team referrals -Registered dietitian referral In the event a patient experiences a new pressure injury, -Complete Braden Scale, PUSH Tool and Skin Progress Note. If the patient meets criteria for a significant change in condition, the Pressure Ulcer CAA is completed in coordination with the MDS/RAI -If PCC Skin and Wound application is enabled, complete the comprehensive evaluation, Braden, and PUSH Tool within the application -Notify the attending physician and obtain treatment orders -Notify the patient/family/responsible party -Communicate findings to interdisciplinary team for additional evaluations needed and notify the wound team -Enter the event in the electronic Incident Management system. Determine the root cause and initiate modifications in the patient's plan of care as indicated -Document in the patient's electronic health record and the Daily Interdisciplinary Eagle Room Report. Potential ongoing management strategies may include: -Individualized care planning and consideration of nutrition/hydration needs, mobility and positioning needs, anticipation of needs, treatment options, advance care planning -Comprehensive medical evaluation including wound team evaluation, referral to external consultant -Medication evaluation to determine if medications are contributing to skin risk factors or impaired healing -Environmental modification interventions including pressure reducing support surfaces for bed and chair -Risk factor management interventions including management of comorbidities, review of medications, review of laboratory test results, management of acute changes in patient condition, toileting program, -Referral to rehabilitation team for evaluation and treatment, if indicated, including seating and positioning, gait training, mobility, incontinence management, debridement, therapeutic modalities -Referral to registered dietitian for nutrition/hydration needs evaluation, nutritional /vitamin supplementation. IV. Resident #1 A. Resident Status Resident #1, age 90, was admitted on [DATE] and discharged to the hospital [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) was not completed. On [DATE] at 12:58 a.m., a nurses note documented she was alert and oriented times three (to person, place and time). The MDS assessment further documented, Resident #1 required two person assistance with bed mobility, dressing, and personal hygiene. She required two staff plus (additional staff) assistance with transfers and toileting. The extent of assistance, whether limited or extensive, was not documented. She was always incontinent of urine, and occasionally incontinent of bowel. Resident #1 was at risk for pressure ulcer development, but did not have any pressure ulcers. B. Record review -Throughout the citation, sacral, buttocks and coccyx are used to describe the location of the wound. On [DATE] at 6:17 p.m., the nursing admission assessment documented the Resident #1 had a skin tear to the left forearm, bruising to the lower extremities and left thigh. -There was no documentation of skin breakdown to the sacrum. On [DATE] at 6:17 p.m., the Braden Scale for Predicting Pressure Sore Risk form documented the resident was at risk for pressure injuries with a score of 17. On [DATE] at 2:49 p.m., the nurse notes documented, Physical therapist expressed a decline in resident's status. Explained that resident has increased weakness. Resident unable to walk to the bathroom, needs wheelchair. Resident observed with impaired area to coccyx accompanied with redness. Dr (doctor) notified of change in status, daughter present with mother during therapy session. Wound dressing changed. According to the [DATE] CPO, as of [DATE], the only wound care orders were for the skin tear to the left forearm. -There were no orders for the skin breakdown to the sacrum. There were no new orders obtained for the skin breakdown to the coccyx on [DATE]. There was no measurement or further description of the skin breakdown to the coccyx on [DATE]. On [DATE] at 10:39 p.m., the nurses notes documented in pertinent part, While assisting CNA (certified nurse aide) with incontinent cares this nurse noted a DTI/PI (deep tissue injury pressure injury) to coccyx. The open portion of the wound measures 1 x 0.5 cm (centimeters) and is unstageable. The periwound also has dark discoloration. This nurse spoke to family to find out if they were aware of skin impairment as it was the 1st time this nurse had worked with patient. Family stated they had been informed of skin issue on [DATE]. This nurse updated MD (medical doctor) on skin description, added new tx (treatment) order and placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -However, according to the [DATE] CPO, no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], the orders were Cleanse area to coccyx, pat dry and apply Plurogel (wound gel) and cover with [MEDICATION(S)] (foam padded dressing). The treatment administration record for [DATE] was reviewed. The treatment ordered [DATE] was not started until [DATE]. Seven days after the skin is first documented as impaired on [DATE], and two days after it is identified again on [DATE]. On [DATE] at 6:45 p.m., the nurses notes documented in pertinent part, Open unstageable wound on coccyx with dark purplish discoloration on periwound area. On [DATE] at 10:35 a.m., the nurse notes documented, Coccyx wound- unstageable-scant drainage noted, dark blackish discoloration on the wound itself and peri-wound area observed. Cleaned wound with NS (normal saline), patted dry and applied Plurogel and covered with [MEDICATION(S)] dressing, procedure tolerated well. On [DATE], the skin altercation record documented the wound was 3 x 1 cm (approximately three times the size it was on [DATE]). The wound was documented as dark purplish, with scant drainage, foul odor, and reddened surrounding skin. On [DATE] at 2:46 p.m., the nurses notes documented in pertinent part, while doing wound care on patient's coccyx noted two open spots-abrasion like on buttocks. Coccyx unstageable wound has moderate foul odor drainage, dark purple discoloration on peri-wound area. -There was no documentation that the physician had been updated on the increased size and foul odor of the wound. On [DATE], the skin altercation record documented the wound was 5 x 4.8 cm (approximately five times the size it was on [DATE]). The wound was documented as gray necrotic tissue-slough, with moderate foul odor, and reddened surrounding skin. -The wound had worsened from the last assessment on [DATE]. On [DATE] at 5:28 p.m., the WCN documented in the progress notes, patient's coccyx unstageable wound measuring 5cm x 4.8cm, black discoloration noted in the middle with grayish peeling skin on peri-wound area. Cleaned with NS, patted dry and applied [MEDICATION(S)] instead of plurogel and covered with [MEDICATION(S)] dressing . On [DATE] at 3:22 p.m., the nurses notes documented, This nurse notified MD this morning regarding the patient's coccyx wound that it needs to be seen by a Wound specialist. MD ordered to schedule an appointment ASAP (as soon as possible) at the Wound Care department. This nurse called at 3:10 pm and was told they couldn't set up an appt. for the patient yet as the referral was still pending. Advised to either call later this afternoon or the next morning. MD was informed. On [DATE] there was a physician's order to call wound care and schedule a visit as soon as possible for unstageable sacral decub. -There was no documentation the physician had been updated of the worsening wounds until [DATE]. Additionally, there was no documentation the family was notified after [DATE] of the worsening wounds (cross-reference F580, notification of changes). According to the [DATE] CPO, there were no order changes to the sacral wound between [DATE] and [DATE], however the wound had worsened during that time. On [DATE], the orders were changed to, Cleanse area to coccyx with NS, pat dry and apply [MEDICATION(S)] and cover with [MEDICATION(S)] dressing, every day shift. On [DATE], the wound orders were, Pressure injury on sacrum: Irrigate ulcer ,d+[DATE]cc normal saline, rinse, pat dry. Apply [MEDICATION(S)]/moisture barrier ointment to periwound area. Apply gauze moistened with 0.125% Dakin's solution to wound bed. Cover with ABD pad, secure with diaper (adult incontinence brief). The laboratory (lab) values for [DATE] and [DATE] were reviewed. The labs for [DATE] documented the white blood cell (WBC used to fight infection) count was 4.3 K/mm with a reference range of 4.00 to 11.50 K/mm. On [DATE], after the wound had worsened and had a foul odor, the WBC was 15.9, high. The C-reactive protein (detects inflammation) was high at 28.6 with a reference range of equal or less than 2.0. The pressure ulcer care plan, initiated [DATE], documented in pertinent part, Resident has pressure ulcer to coccyx related to: impaired mobility, incontinence. The goal was, Free from s/s of infection (such as increased drainage/pain/periwound [CONDITION(S)]). Interventions included: Administer treatment per physician orders, Daily body audit, Incontinence management, Pressure redistributing support surface, Repositioning during ADLs. -There were no revisions to the care plan, despite when the wound having worsened. The primary physician (PP) #1 saw Resident #1 at the facility on [DATE] at 5:00 p.m. He documented, Deep tissue injury of the sacrum, Continue wound care and off loading. -There was no documentation the physician was informed the wound was larger, and had a foul odor. The primary physician (PP) #1, saw Resident #1 at the facility on [DATE] at 5:00 p.m He documented, Deep tissue injury of the sacrum, Continue wound care and off loading. -There was no documentation the physician was informed the wound was now even larger, and had a foul odor. On [DATE] at 11:13 a.m., the nurses notes documented, Obtained order to send Patient to hospital dx (diagnosis) possible [CONDITION(S)] and abnormal labs. 911 called family notified they were already in the building. 911 transported resident to hospital family went with her will cont. (continue) to monitor situation. The emergency room (ER) notes dated [DATE] were reviewed. The notes documented Resident #1 arrived in the ER at 10:23 a.m. She had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had shortness of breath and pain. The family did not want any further treatment or laboratory tests. The family requested hospice. The ER staff proceeded to find inpatient hospice. The resident was admitted to hospice on [DATE]. The inpatient hospice notes dated [DATE] were reviewed. The hospice notes documented the resident was admitted for [CONDITION(S)] secondary to decubitus ulcer. The wound measured 9.7 cm x 10.5 cm x 3.6 cm to the sacrum. The wound was documented as necrotic with red thin wound edges and macerated pink skin five centimeters out around the wound. On [DATE] at 11:40 p.m., Resident #1 died . C. Interviews Licensed practical nurse (LPN) #3 was interviewed on [DATE] at 8:55 a.m. She said she shadowed another nurse for one day of orientation. LPN #3 said she was not informed what the facility process was for wounds, but if she found one she would measure it, stage it and notify the physician. Certified nurse aide (CNA) #5 as interviewed on [DATE] at 10:49 a.m. She said she was from an agency, and had no orientation to the facility. CNA #5 said she was buddied with another CNA for about an hour and that was it. She said she did not know how to determine how a resident transferred, if they were incontinent, or needed to be repositioned. She said she usually figured it out, or asked the resident. She said there was no kiosk with information or Kardex (abbreviated care plan) to refer to when providing resident care (cross-reference F726, staff competency). She said if she found a new wound, she would tell the nurse. The wound care nurse (WCN) was interviewed with unit manager (UM) #2 on [DATE] at 3:38 p.m. The WCN said she did wound rounds weekly, and measured and described the wounds. She said she had been doing this for about two months and occasionally the MDS nurse helped her. Otherwise, she did it alone. The WCN said she was not wound certified and the facility did not have a wound physician that came in and saw the wounds. UM #2 said the admitting nurse did a skin assessment and if there was an issue, they should have told the unit manager, called the MD, and implemented a treatment immediately. She said an LPN could describe a wound, including color drainage and odor, b [TRUNCATED]

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to: -Identify and address concerns related to wound care; -Notify the physician timely of changes in wounds and of injuries; and, -Identify infection control concerns with wound care. The facility's failures to identify and address concerns related to pressure ulcer prevention resulted in the development of new pressure ulcers or worsening of existing pressure ulcers for three residents (cross-reference F686 for pressure ulcer prevention and care). The facility's failure to implement an effective wound management program led to serious harm and injury, and was likely to continue for other residents. Findings include: I. Facility policy The Improvement Performance QAPI (quality assurance performance improvement) Practice Guide policy, dated February 2019, was provided by the nursing home administrator (NHA) on 2/15/22 at 4:44 p.m. It documented in pertinent part, The purpose of this guide is to describe the process steps for identification and resolution of actual or potential areas affecting quality. QAPI is a quality assurance process. The purpose of QAPI is to take a pro-active approach to continually improve the quality of care we provide, the quality of life our patient's experience, the ability to honor patient choices and provide care in appropriate clinical environment. QAPI committee: -Collects and evaluates data from a variety of sources, e.g., quality measures, customer satisfaction, performance improvement tool, etc; -Meets monthly to identify opportunities for improvement based on the evaluation of the data; -Assigns a performance improvement project (PIP) and a PIP team to evaluate a process using a small-scale rapid cycle for improvement. PIP [NAME] meets as often as necessary between monthly QAPI committee meetings; -PIP team reports findings to QAPI committee; and -Evaluates ongoing effectiveness of PIP team and sets timetable for follow-up of PIP, if necessary. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct them. F686 During a complaint survey 3/15/21 the facility was cited at a D isolated level. During a complaint survey 2/14/22 the facility was cited at an IJ (immediate jeopardy, serious harm) for not implementing a system to identify risk for pressure ulcer development, obtain timely treatment orders and assessing/monitoring to prevent injuries from developing and/or worsening. F880 During an infection control COVID-19 survey 6/1/2020 the facility was cited at a K (immediate jeopardy) pattern, then again during an infection control COVID-19 survey 12/7/2020 the facility was cited at an E pattern level for failure to have an effective infection control program to prevent the spread of COVID-19. During a complaint survey 2/14/22, the facility was cited at an F pattern level for failing to perform hand hygiene when appropriate and failure to provide aseptic technique during wound care. III. Cross-referenced citations Cross-reference F726: The facility failed to have competent nursing staff. This deficiency was cited at an E scope, pattern, for failure to ensure competent staff performed services according to standard of practice. Cross-reference F677: The facility failed to provide activities of daily living (ADLs) to dependent residents. This deficiency was cited at an E scope, pattern, for failure to ensure staff provided timely incontinence care, showers and hygiene. IV. Record review A performance improvement plan (PIP), titled Wound Care, undated, was received from the interim director of nursing (IDON) on 2/14/22 at 10:50 a.m. The PIP documented in pertinent part, Ensure capture of wounds upon admissions as well as completion of wound care per MD (physician) orders, target date 4/20/22. Nurses are not capturing wounds on admission. Nurses are not performing wound care per MD orders. Spot audit treatment dressings and shower sheets. Second admission check to be done in the morning following admission. Admission skin check to be done at time of admission. The wound care PIP meeting notes on 2/3/22 (five days before survey) documented, Wound sweeps did not note any new wounds. One new facility acquired wound noted by staff and reported appropriately. No missed dressings found. -However, the PIP was requested on 2/10/22 at 10:11 a.m. during an interview regarding resident wound care with the NHA and interim director of nursing (IDON) and it was not provided until 2/14/22 which was four days later (cross-reference F686 failure to timely treat assess and monitor wounds). The PIP did not include audits with dates of completion, residents reviewed in the audit or residents identified with wounds. -Furthermore, the PIP did not capture specific failures that needed to be addressed related to Resident #1, which include the facility's failure to ensure nursing staff competency, education/training with the nursing staff to ensure they were completing assessments, treatments and obtaining treatment orders for wounds, notification of worsening wounds to the physician, training on providing timely incontinent care and repositioning with dates and who was trained. This remained a systemic failure which record review and observations of current Residents #7 and #12, where the facility failed to identify, assess, track, implement preventative measures and timely treat the residents' pressure wounds. V. Interviews The NHA was interviewed on 2/14/22 at 4:07 p.m. He said the QAPI team meeting was held the third Thursday of each month. He said all major departments attended the meeting, NHA, medical director (MD), the director of nursing (DON), social services (SS), pharmacist, human resources, medical records and unit managers. He said each department discussed any concerns that were found in their department and the team would decide if there needed to be a plan implemented based on any recent trends. He said the expectation was for staff to help (provide a service to) the residents and if that was not the employee's priority they would not be an employee. He said the QAPI team completed a table top exercise at their last meeting to review their recent evacuation of the building on 12/30/21 to 1/3/22 and discussed areas for improvement such as communication with staff having the wrong resident's chart and having to look for it. He said they discussed wounds frequently in their quality assurance meetings monthly. He said he would defer to his DON regarding wounds and that was one of the reasons the DON was no longer employed at the facility. He said he would have to go in her office and say let's do rounds and make sure wound treatments were done. He said if he did not insert himself, it would not have gotten done. He said he felt many of the nursing issues were nursing 101 and nursing staff should not have to be trained to do all tasks within their scope. He said certain things were specific to the facility, and the previous DON should have ensured the agency staff were oriented to the facility specifics. He said he thought the system failed because there was no follow-up by the DON and she did not utilize the unit managers well. He said the DON had been gone for three to four weeks now. He acknowledged the systemic failure in wound care and lack of oversight and training/education being provided to nursing staff to ensure standard of care.

Based on record review and interviews, the facility failed to prevent neglect for one (#5) of three residents reviewed for injuries out of 25 sample residents. Resident #5 was admitted to the facility on [DATE]. Resident #5 reported to therapy on 1/4/21 she had a fall on 1/3/21 and she had increased back/hip pain. The facility neglected to complete a thorough investigation after she reported she had fallen which included the causation of her increased complaint of pain and decreased mobility (cross-reference F610 for failure to complete a thorough investigation). Therapy documentation revealed Resident #5 admitted with minimal limitations in mobility and continued to voice complaints of pain and had a decline and decrease in mobility beginning on 1/4/21 (cross-reference F697 for pain management). The facility neglected to assess and review Resident #5's pain timely which led to a delay in treatment where she sustained a newly diagnosed [MEDICAL CONDITION] (see record review below) on 1/8/21 four days after the resident complained of pain from a fall (cross-reference F697). The resident was ultimately transferred to the hospital where she required surgical intervention and she did not return to the facility. Findings include: I. Facility policy The Abuse Prohibition policy, revised on 7/1/19, was provided by the director of nursing (DON) on 3/1/21 at 1:00 p.m. It documented in pertinent part, Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the CED (Center Executive Director) or designee will perform the following. Enter allegation into the Risk Management System (RMS) .Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of resident property not later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect, or mistreatment . Initiate an investigation within 24 hours of an allegation of abuse that focuses on: -whether abuse or neglect occurred and to what extent; -clinical examination for signs of injuries, if indicated; -causative factors; and Interventions to prevent further injury. The investigation will be thoroughly documented within RMS. Ensure that documentation of witnessed interviews is included. -Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. -Enter a summary of the interviews into RMS. The CED or designee will take all necessary corrective action depending on the results of the investigation .Identify situations which have a potential for risk; and determine what preventative measures will be implemented by staff. II. Family interview Resident #5's power of attorney (POA) was interviewed on 2/23/21 at 3:35 p.m. She said she received a call from the physician on 1/5/21 and was informed they completed a pelvic x-ray because her mom stated she had a fall. She said her mom would not have been able to get herself off the ground. She said she was told her mom was declining, had been in bed or up in the wheelchair most of the time and her x-ray was negative. She said the doctor called her again on 1/7/21 stating she was in a lot of pain and declining. They repeated x-rays of Resident #5's right leg, knee, and ankle because it was externally rotated on 1/8/21 and she was found to have a [MEDICAL CONDITION]. She said after the second call from the physician she suspected her mom had multiple falls, because she had increased pain and was fearful of pain to right leg. III. Resident status Resident #5, age 85, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. The 1/3/21 minimum data set (MDS) assessment revealed Resident #5 was moderately impaired with a brief interview for mental status (BIMS) score of 10 out 15. She did not exhibit any behaviors. She required limited one-person assistance with bed mobility and hygiene, supervision one-person assistance with transfers and dressing, and extensive two-person assistance with toileting. IV. Failure to investigate cause of Resident #5's pain and fracture timely (cross-reference F697). A. Record review 1. Care plans Review of Resident #5's activities of daily living (ADL) care plan and pain care plan, initiated 12/31/2020 revealed the facility had not implemented any effective interventions until after the resident was diagnosed with [REDACTED]. -Monitor conditions that may contribute to ADL decline, including: metabolic causes (e.g., [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION] disorder, liver disease, [MEDICAL CONDITION], electrolyte imbalance) respiratory problems, [MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder (s), poor nutrition, hearing or vision impairment, new/acute health problem, exacerbation of a chronic condition (e.g., [MEDICAL CONDITION], diabetes), constipation, infection, head injury, pain, fever, dehydration or alcohol withdrawal; -Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to cognitive loss/dementia, including: [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors; -Monitor for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects; -Evaluate and medicate for pain, as appropriate, prior to activity or rehabilitation program; and -Monitor for complications of immobility (e.g., pressure ulcers, [DIAGNOSES REDACTED], contractures, incontinence, and urinary/respiratory infections). 2. Therapy notes On 1/1/21 Resident #5 had an initial therapy evaluation by physical therapy (PT). It documented Resident #5 needed the following assistance: -Bed Mobility=Contact Guard; -Roll to left=Contact Guard; -Transfers=Minimal Assistance; -Sit to stand=Minimal Assistance; -Stand Pivot=Minimal Assistance; -Stand=Minimal Assistance; -Ambulation=Minimal Assistance; -Assistance Device-Ambulation=Using a Rolling Walker; -Distance on Surface=12 feet; and -Gait Deviations: She was able to ambulate with FWW (front wheeled walker) and minimal assist up to 12 feet x (times) 2 (two), forward trunk lean, step to pattern with Right LE (lower extremity) dragging (difficulty advancing), tends to shuffle, impulsive ambulation. On 1/2/21 Resident #5 was assessed by PT. She was able to ambulate using a FWW with contact guard assist 55 feet x 2 and 35 feet x 2. She demonstrated decreased right lower extremity advancement especially when fatigued. The resident was cooperative with no complaints of pain. On 1/4/21 Resident #5 was assessed by PT. The PT evaluation documented, .Pt (patient) found in bed. Pt agreed to skilled PT, but reported she was in severe pain back/hips. Pt asked for more pain medication stating the medication she had earlier is not working. Pt reported falling yesterday, 1/3/2021, which increased her pain. Consulted with nursing. Nursing reported x-ray has been ordered and Pt already has received all medication at this time. Bed mobility strategies focused on dynamic activities in supine, specifically training in scooting techniques to facilitate repositioning in bed and training in multiple R (right) L (left) rolling dependent, helps 15%, but limited 2nd (secondary) to severe pain. Pt wanted pants on. Pt was assisted donning pants. Pt c/o (complains of) severe pain and needed to stop session at this time. Pt repositioned in bed with all needs in reach . A PTA (physical therapy assistant) note, dated 1/5/21, read nursing staff consulted regarding x-ray that was ordered,.he x-ray was completed earlier in the morning; however, results were not back yet. On 1/7/21 Resident #5 was assessed by PT. The PT evaluation documented, Bed mobility and EOB (edge of bed) attempted to don pants. Pt declined to roll or sit up d/t (due to) c/o pain in back .PROM (passive range of motion) to R LE (lower extremity) to increase ROM and decrease risk for contracture. ' Session ' (sic) limited by Pt. Demonstrates behaviors due to c/o pain that limited session time. 2nd attempt at therapy in the afternoon, pt continued to decline further treatment after education on importance of active participation for safe discharge. 3. Nursing progress notes The nursing note dated 1/4/21 at 10:32 a.m., revealed Resident #5 complained of pain to her groin and a pelvic x-ray was ordered and her pain level severe six out 10. -There was mention of Resident #5 having pain to hip (see therapy note 1/4/21 above), and there was no mention of obtaining an x-ray of the resident's hip. The Post Admission Pt/Family conference note dated 1/4/21 at 12:16 p.m., revealed the IDT (interdisciplinary team) meeting reviewed the residents projected length of stay was seven to14 days for rehabilitation. Resident #5's goals related to transitioning back to the community (memory care facility) were discussed with Resident #5's daughter via phone. -There was no mention of the resident having difficulty participating with therapy due to increased complaints of pain to back/hip, any change in condition, change to plan of care and no change or recommendations to pain management. The nursing note dated 1/4/21 at 10:32 p.m., revealed Resident #5 was impulsive, observed self-transferring without calling for assist and redirection was ineffective. The social services note dated 1/5/21 at 3:06 p.m., revealed staff notified Resident #5's daughter of the resident's decreased ability to participate in therapy due to chronic pain. Met with pt (patient), with assist of CNA (certified nurse aide) and this case manager, pt was able to transfer from bed to w/c (wheelchair) with 2 (two person) assist. -This was a notable decline from the initial therapy evaluations on 1/1/21 and 1/2/21 which the resident needed minimal assist (see therapy notes above). The nursing note dated 1/5/21 at 10:32 p.m., revealed Resident #5 was impulsive, observed self-transferring without calling for assist and redirection was ineffective. There was no nursing documentation completed for Resident #5 on 1/6/21 to include any assessments or review of resident's recent decline or complaints on pain (cross-reference F697 for pain management). It was not until 1/7/21 that the physician assessed the resident's pain and decline in range in motion to her right lower extremity. An x-ray was obtained and the resident was found to have a fracture to her right hip (see investigation below). 4. physician progress notes [REDACTED].>The physician note dated 1/5/21 at 4:37 p.m. documented Resident #5 had complained of hip/pelvic pain but it was not clear if that was a new issue as the resident seemed comfortable in the chair that afternoon, able to move her legs. The resident used narcotics for chronic sacral pain. She had been in bed the last couple of days but up in her chair that afternoon, x-ray negative. The physician note dated 1/7/21 at 1:10 p.m. documented Resident #5 had chronic pain in low back likely multifactorial (involving or dependent on a number of factors or causes) spinal stenosis, OA ([MEDICAL CONDITION]), prior compression fracture. Consider a trial of low dose opioid therapy given limited options for pain management. The note further documented, the resident was still struggling with pain in right leg (vs pelvis per nursing). She required max assistance to get to her chair previously walking short distances. The resident looked comfortable sitting in her chair when assessed two days prior; however, today she is fearful of any movement of right leg (screamed when the physician touched her ankle). today holding leg flexed and externally rotated .ankle and knee are unremarkable in appearance. However will get imaging of ankle, knee and repeat hip/pelvis. -Although the physician note indicated to repeat imaging to the hip/pelvis there was no imaging ordered for the right hip until 1/7/21 (see physician orders [REDACTED]. 5. Facility investigation The facility investigation was provided by the executive director on 3/2/21 at 11:55 a.m. The investigation dated 1/8/21 at 6:38 p.m., consisted of Resident #5's face sheet, copy of the reported incident, therapy notes, two staff interviews, a pelvic x-ray examination date of 1/5/21 at 7:45 a.m. (the 1/8/21 x-ray of the right hip was not included in the investigation), and physician notes. Certified nurse aide (CNA) #6 wrote a statement which documented she cared for the resident the night of 1/3/21 and the resident did not have a fall during the shift. Licensed practical nurse (LPN) #2 wrote a statement which documented the resident had no fall or any other incidents were ever reported to her by nursing or therapists. The physician note dated 1/5/21 at 4:37 p.m., revealed Resident #5 had complaints of unrelieved pain. The note documented patient had been keeping to her bed because of hip or pelvic pain (fall? None documented) but today is up in the chair. Denies complaints for me but volunteers very little information. Looks comfortable. Able to raise each leg of the ground for me .not clear if new issue (uses narcotic for chronic sacral pain). Had been in bed last couple of days but up to chair this afternoon. Denies pain at this time. Able to move legs for me. Xray yesterday negative. No further evaluation at this time. The physician note dated 1/7/21 at 1:10 p.m., revealed Resident #5 had complaints of unrelieved pain. today holding leg flexed and externally rotated. Yelled when I touched her ankle (from fear that I was going to move leg?) as ankle and knee are unremarkable in appearance. However will get imaging of ankle, knee and repeat of hip/pelvis . -The x-ray of the right hip was positive for fracture (see below). The investigation further documented Resident #5 was positive for femoral head fracture and the facility was unable to substantiate due to inability to identify cause of fracture. See therapy notes documented above, which showed Resident #5's decline in mobility. On 3/3/21 at 12:01 p.m. the executive director (ED) sent a list of names of additional staff (11) members who were interviewed regarding Resident #5's alleged fall via email. He said they all reported the resident did not fall; however, it did not include the date or time the staff members were interviewed, what shift they worked, and if the resident reported to nursing staff she fell or if nursing staff were aware Resident #5 had increased complaints of hip pain during their investigation. The investigation failed to include any assessment of the resident during the time of her reported fall, include an assessment of increased complaints of pain, a change in pain management or plan of care other than the physician assessments on 1/5/21 and 1/7/21 (see above). 6. Imaging results Review of the x-ray (pelvis 2 views) report dated 1/5/21 at 8:04 a.m., read No acute fracture or dislocation. The Osseous structures show hip replacement hardware present (right hip). -Although the x-ray documents hip replacement present the x-ray did not document if the right femoral shaft was visible (see x-rays below). Review of the x-ray (pelvis 1 view) report dated 1/8/21 at 3:41 p.m., read A right total hip arthroplasty is present. Right femoral fracture is not included on the field of view of imaging. No acute fracture involving the pelvis is identified. The pubic symphysis and sacroiliac joint spaces are maintained (there were no abnormalities) . Review of the x-ray (Right Femur unilateral 3 views) report dated 1/8/21 at 3:41 p.m., read An acute obliquely oriented displaced proximal to mid shaft femoral fracture is present with fracture plane extending from the greater trochanter to the mid diaphysis, and is associated with the femoral component of the right hip arthroplasty . B. Interviews The director of rehabilitation (DOR) was interviewed on 3/2/21 at 9:36 a.m. She said Resident #5 had an initial evaluation on 1/2/21 and a total of four PT and five OT sessions and a final assessment visit was completed prior to the resident being sent to the hospital. She said on 1/1/21 she walked 12 feet, on 1/2/21 she walked 55 feet, and required max assist with lower body dressing. She said on 1/4/21 the resident reported having a fall. Then the resident had an order for [REDACTED].#5 was not seen on Wednesday 1/6/21. She said therapy consulted with nursing and minimal therapy was completed because the additional x-rays were ordered on [DATE]. The assistant director of nursing (ADON) #1 was interviewed 3/2/21 at 11:20 a.m. She said she has worked at the facility for two months. She said the process for completing a change of condition (fall) was to document it under assessments, or an RMS (risk management system) to be completed RMS. Then falls were reviewed by IDT, she would notify the executive director, and implement an immediate intervention. She said intervention information was usually given verbally, at times, written education would be provided to the staff. Then the resident's care plan and Kardex (internal plan of care used for CNAs to document) were updated and typically the director, designee or minimum data set coordinator (MDSC) would update the care plan for any pertinent changes to care. She said she recently implemented a therapy to nurse communication form but staff had not utilized it correctly. She said there was a huge gap between therapies communicating change in condition to nursing so that was the reason she tried implementing the communication form. Physician (PHY) #1 and the ED were interviewed on 3/2/21 at 1:20 p.m. The physician said as best he recalled he received information Resident #5 was complaining of pain, he said he was not sure of pelvic and hip pain. He said during his assessment on 1/5/21 the resident was sitting up in her wheelchair and was able to move her lower extremities. He said if he was aware the resident had pain to her hip that he would have ordered an x-ray to her hip. He said he could not recall making any changes or adjustments to the resident's pain medications during her stay. He said there was a two view x-ray completed to Resident #5's right hip which showed a [MEDICAL CONDITION] on 1/8/21 and she was sent to the hospital. The ED said Resident #5 had chronic pain and the facility determined the resident did not have a fall with injury and her pain levels never changed. However Resident #5 had complained of right hip pain which was newly identified as early as 1/4/21 and the resident had a significant decrease in mobility (see therapy notes above). He acknowledged fracture pain could be positional (meaning pain could be stable or zero depending on your position) and the resident continued to have complaints of unrelieved pain. RN #5 was interviewed on 3/3/21 at 11:20 a.m. She said she worked for three years on the day shift as a floor nurse. She said she did recall caring for Resident #5. She said therapy reported to her that the resident stated she fell and was complaining of back pain. She said she relayed everything the therapist said to her to the physician and could not recall if the therapist reported the resident complained of hip pain. She said she remembered specifically the resident complaining of back pain but she could not remember if she requested an x-ray of the resident's hip from the physician when she called to obtain x-ray orders. She said she talked with the unit manager and physician about the resident's reported fall. The ED, DON, and medical director were interviewed on 3/2/21 at 4:00 p.m. The ED said Risk management system (RMS) was not completed for Resident #5 because they did not determine the resident had an actual fall. The DON said for any change in condition including falls an RMS (triggered monitoring of the resident) should be completed. She said all falls were reviewed in a clinical meeting. She said there was a report of Resident #5 having a questionable fall, and they completed their investigation. The ED said they interviewed several staff and did not determine her as having a fall. He said several staff observed her trying to self-transfer using her bedside table. He said they should have discussed the resident's care and documented it in the resident's record and in their investigation to include an updated plan of care and any interventions that were implemented. V. Follow-up Additional documentation was provided by the ED on 3/16/21 at 6:28 p.m. via email. The medical director (MD) reviewed Resident #5's clinical record and documented in summary he felt the facility's responded adequately to Resident #5's fall and increased pain. The MD documented on 1/5/21 Resident #5 was having pain involving her right groin, a pelvis x-ray was ordered and hip replacement hardware was seen and no fracture or dislocation was identified. Additionally, nursing notes revealed the resident was impulsive and self transferring, up in a chair and able to move her legs when assessed by the physician. The resident was assessed by a physician on 1/7/21, x-rays were obtained and the resident was transferred to an acute care hospital. Although there was a review of Resident #5's record the facility was unable to provide any follow-up to the resident's reported fall and newly diagnosed complaints of pain to her groin and right hip. Specifically, the facility did not complete a thorough investigation timely of causation of the resident's pain (the resident initially complained of back and hip pain to therapy see therapy documentation 1/4/21 above). The MD also documented the x-ray on 1/5/21 documented hardware (hip replacement) was visible on the pelvic x-ray; however, the pelvic x-ray did not document if the right femoral shaft was visible, which likely would have shown a fracture (see imaging above).

Based on interviews and record review, the facility failed to ensure the pain of one (#5) of three of 25 sample residents was managed in a manner consistent with the resident's goals and preferences. Record review revealed the facility failed to take the necessary steps to evaluate and monitor Resident #5's pain and provide non-pharmacological and/or pharmacological interventions after she reported she had a fall to therapy. On 1/4/21 Resident #5 reported to therapy she had a fall on 1/3/21 and she had increased back/hip pain. The facility failed to complete a thorough investigation as to causation of her increased complaint of pain and decreased mobility (cross-reference F610 failure to investigate). Therapy documentation on 1/4/21 revealed Resident #5 admitted with minimal limitations in mobility and continued to voice complaints of pain and had a decline and decrease in mobility. Resident #5 had a pelvic x-ray ordered on [DATE] which revealed no pelvic fractures and a prosthesis to the resident's right hip. However, an x-ray of the right hip was not obtained until 1/8/21, four days after the resident complained of pain. The x-ray revealed a right displaced proximal to mid shaft femoral fracture (see below). The resident was ultimately transferred to the hospital where she required surgical intervention and she did not return to the facility. The resident's Medication Administration Record [REDACTED]. Record review revealed neither pharmacological nor nonpharmacological interventions were implemented which contributed to the resident's unrelieved pain. The facility's failure to assess and review Resident #5's severe pain timely led to a delay in treatment and care of her newly diagnosed [MEDICAL CONDITION] (see record review below). Cross-reference F600 failure to prevent neglect. Findings include: I. Facility policy The Pain Management Policy, revised on 11/1/19, was provided by the director of nursing (DON) on 3/1/21 at 1:00 p.m. It documented in pertinent part, Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. Pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient's goals and preferences is provided to patients who require such services .Complete a pain evaluation. The nurse will notify the physician/advanced practice provider (APP) as appropriate and obtain treatment orders as indicated. An individualized, interdisciplinary care plan will be developed and include: -Addressing/Treating underlying causes of pain to the extent possible; -Non-pharmacological and pharmacological approaches; -Using specific strategies for preventing or minimizing different levels or sources of pain or pain related symptoms. At minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain .Complete the Pain Presence Monitor .Document pain presence on the Medication Administration Record [REDACTED].g., constipation, sedation) in providing pain relief. Non-pharmacological interventions and effectiveness; Effectiveness of PRN (as needed) medications including interventions, follow-up, and physician/APP notification .Review the non-pharmacological approaches for effectiveness. Revise the care plan as indicated. II. Resident status Resident #5, age 85, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. The 1/3/21 minimum data set (MDS) assessment revealed Resident #5 was moderately impaired with a brief interview for mental status (BIMS) score of 10 out 15. She did not exhibit any behaviors. She required limited one-person assistance with bed mobility and hygiene, supervision one-person assistance with transfers and dressing, and extensive two-person assistance with toileting. -The resident received scheduled pain medication, PRN as needed pain medication, non-pharmacological intervention for pain and reported having frequent pain in the past five days. She reported her worst pain level of seven out of 10 in the past five days. It was documented a staff pain assessment was not be done. III. Record review 1. Care plans Review of Resident #5's activities of daily living (ADL) care plan and pain care plan, initiated 12/31/2020, revealed the facility had not implemented any effective interventions until after the resident was diagnosed with [REDACTED]. -Monitor conditions that may contribute to ADL decline, including: metabolic causes (e.g., [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION] disorder, liver disease, [MEDICAL CONDITION], electrolyte imbalance) respiratory problems,[MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder(s), poor nutrition, hearing or vision impairment, new/acute health problem, exacerbation of a chronic condition (e.g., [MEDICAL CONDITION], diabetes), constipation, infection, head injury, pain, fever, dehydration or alcohol withdrawal; -Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to cognitive loss/dementia, including: [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors; -Monitor for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects; -Evaluate and medicate for pain, as appropriate, prior to activity or rehabilitation program; -Monitor for complications of immobility (e.g., pressure ulcers, [DIAGNOSES REDACTED], contractures, incontinence, and urinary/respiratory infections); -Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors -Utilize pain scale; -Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated; -Monitor frequency of episodes of breakthrough pain to determine the need for pain medication adjustment; and -Assist resident to a position of comfort, utilizing pillows and appropriate positioning devices. 2. Therapy notes On 1/4/21 Resident #5 was assessed by physical therapy (PT). The PT evaluation documented, .Pt (patient) found in bed. Pt agreed to skilled PT, but reported she was in severe pain back/hips. Pt asked for more pain medication stating the medication she had earlier is not working. Pt reported falling yesterday, 1/3/2021, which increased her pain. Consulted with nursing. Nursing reported x-ray has been ordered and Pt already has received all medication at this time. Bed mobility strategies focused on dynamic activities in supine, specifically training in scooting techniques to facilitate repositioning in bed and training in multiple R (right) L (left) rolling dependent, helps 15%, but limited 2nd (secondary) to severe pain. Pt wanted pants on. Pt was assisted donning pants. Pt c/o (complains of) severe pain and needed to stop session at this time. Pt repositioned in bed with all needs in reach . A PTA (physical therapy assistant) note dated 1/5/21 read nursing staff consulted regarding x-ray that was ordered, the x-ray was completed earlier in the morning; however, results were not back yet. On 1/7/21 Resident #5 was assessed by PT. The PT evaluation documented, Bed mobility and EOB (edge of bed) attempted to don pants. Pt declined to roll or sit up d/t (due to) c/o pain in back .PROM (passive range of motion) to R LE (lower extremity) to increase ROM and decrease risk for contracture. ' Session ' (sic) limited by Pt. Demonstrates behaviors due to c/o pain that limited session time. 2nd attempt at therapy in the afternoon, pt continued to decline further treatment after education on importance of active participation for safe discharge. 3. Nursing progress notes The nursing note dated 1/4/21 at 10:32 a.m., revealed Resident #5 complained of pain to her groin and a pelvic x-ray was ordered and her pain level severe six out 10. -There was mention of Resident #5 having pain to hip (see therapy note 1/4/21 above), and there was no mention of obtaining an x-ray of the resident's hip. The Post Admission Pt/Family conference note dated 1/4/21 at 12:16 p.m., revealed an IDT (interdisciplinary team) meeting reviewed the resident's projected length of stay was seven to 14 days for rehabilitation. Resident #5's goals related to transitioning back to the community (memory care facility) were discussed with Resident #5's daughter via phone. -There was no mention of the resident having difficulty participating with therapy due to increased complaints of pain to back/hip, any change in condition, change to plan of care and no change or recommendations to pain management. There was no nursing documentation completed for Resident #5 on 1/6/21 to include any assessments or review of resident's recent decline or complaints on pain. It was not until 1/7/21 that the physician assessed the resident's pain and decline in range in motion to her RLE. An x-ray was obtained and the resident was found to have a fracture to her right hip (see investigation below). 4. physician progress notes [REDACTED].>The physician note dated 1/5/21 at 4:37 p.m. documented the resident had complained of hip/pelvic pain but it was not clear if that was a new issue as the resident seemed comfortable in the chair that afternoon, able to move her legs. The resident used narcotics for chronic sacral pain. She had been in bed the last couple of days but up in her chair that afternoon, x-ray negative. The physician note dated 1/7/21 at 1:10 p.m. documented the resident had chronic pain in low back likely multifactorial (involving or dependent on a number of factors or causes) spinal stenosis, OA ([MEDICAL CONDITION]), prior compression fracture. Consider a trial of low dose opioid therapy given limited options for pain management. -The resident was still struggling with pain in right leg (vs pelvis per nursing). She required max assistance to get to her chair previously walking short distances. The resident looked comfortable sitting in her chair when assessed two days prior; however, today she is fearful of any movement of right leg (screamed when the physician touched her ankle). today holding leg flexed and externally rotated .ankle and knee are unremarkable in appearance. However will get imaging of ankle, knee and repeat hip/pelvis. Although the physician note indicated to repeat imaging to the hip/pelvis there was no imaging ordered for the right hip until 1/7/21 (see physician orders [REDACTED]. 5. Physician orders The physician order [REDACTED]. The x-ray was not ordered STAT (immediately) and the order did not include x-ray of the hip in which the resident complained of back/hip pain. -The x-ray was not ordered until eight hours after the resident's initial complaint of pain documented in the nursing notes at 10:32 a.m. (see above) and it was not completed until 7:45 a.m. the following day on 1/5/21. Although the pelvic x-ray was negative, the resident continued to complain of pain. On 1/7/21 the resident was assessed by the physician to have severe pain; additional x-ray to pelvis, right hip, right knee and right ankle were ordered. The order dated 1/7/21 at 12:32 p.m. read, Xrays of pelvis, right hip, right knee, right ankle one time only for leg pain of unclear etiology for 1 day. This order was not written as STAT and not completed until over 24 hours later on 1/8/21 (see below). According to the January 2021 CPO ordered pain medications were as follows: -[MEDICATION NAME] 1,000 mg (milligrams) by mouth three times a day for pain order date 12/31/2020; -[MEDICATION NAME] 2 mg tablet, give 2 mg by mouth one time a day for chronic pain at 1:00 p.m. order date 12/31/2020; -[MEDICATION NAME] 2 mg tablet, give 4 mg by mouth three times a day for chronic pain order date 12/31/2020; and -[MEDICATION NAME] Patch 5% ([MEDICATION NAME]) Apply to affected area topically in the morning for pain (on 12 hours and remove for 12 hours) order date 1/1/21. 6. Imaging results Review of the x-ray (Right Femur unilateral 3 views) report dated 1/8/21 at 3:41 p.m., read An acute obliquely oriented displaced proximal to mid shaft femoral fracture is present with fracture plane extending from the greater trochanter to the mid diaphysis, and is associated with the femoral component of the right hip arthroplasty . The resident was transferred to the hospital and did not return. 7. Medication Administration Record [REDACTED] Review of the January 2021 MAR indicated [REDACTED] -On 1/3/21 at 8:00 a.m. the resident's pain level was three; -On 1/3/21 at 2:00 p.m. the resident's pain level was nine; -On 1/3/21 at 8:00 p.m. the resident's pain level was four; -On 1/4/21 at 8:00 a.m. the resident's pain level was five; -On 1/4/21 at 2:00 p.m. the resident's pain level was six; -On 1/4/21 at 8:00 p.m. the resident's pain level was six; -On 1/5/21 at 8:00 a.m. the resident's pain level was five; -On 1/5/21 at 2:00 p.m. the resident's pain level was seven; -On 1/5/21 at 8:00 p.m. the resident's pain level was four; -On 1/6/21 at 8:00 a.m. the resident's pain level was four; -On 1/6/21 at 2:00 p.m. the resident's pain level was eight; -On 1/6/21 at 8:00 p.m. the resident's pain level was five; -On 1/7/21 at 8:00 a.m. the resident's pain level was six; -On 1/7/21 at 2:00 p.m. the resident's pain level was six; -On 1/7/21 at 8:00 p.m. the resident's pain level was seven; -On 1/8/21 at 8:00 a.m. the resident's pain level was four; Review of the non-pharmacological interventions included repositioning and at times other; however, other (what other intervention) was not documented in the resident's clinical record. Other than positioning and untimely x-ray, there were no other interventions provided, no further evaluations, monitoring, assessments and no documentation of causation of Resident #5's continued unrelieved pain and there were no pain assessments to indicate what was an acceptable pain level for the resident. IV. Staff interviews The director of rehabilitation (DOR) was interviewed on 3/2/21 at 9:36 a.m. She said on 1/4/21 the resident reported having a fall. Then the resident had an order for [REDACTED].#5 was not seen on Wednesday 1/6/21 and allowed to rest. She said the therapist consulted with nursing and minimal therapy was completed because the additional x-rays were ordered on [DATE]. The assistant director of nursing (ADON) #1 was interviewed 3/2/21 at 11:20 a.m. She said she had worked at the facility for two months. She said the process for completing a change of condition was to document it under assessments, or an RMS (risk management system) to be completed. She said intervention information was usually given verbally, at times, written education would be provided to the individuals. Then the care plan and Kardex (internal plan of care used for certified nurse aides to document) were updated and typically the director, designee or minimum data set coordinator (MDSC) would update the care plan for any pertinent changes to care. She said she recently implemented a therapy to nurse communication form but staff had not utilized it correctly. She said there was a huge gap between therapies communicating change in condition to nursing so that was the reason she tried implementing the communication form. Physician (PHY) #1 and the executive director (ED) were interviewed on 3/2/21 at 1:20 p.m. The physician said as best he recalled he received information Resident #5 was complaining of pain, he said he was not sure of pelvic and hip pain. He said during his assessment on 1/5/21 the resident was sitting up in her wheelchair and was able to move her lower extremities. He said if he was aware the resident had pain to her hip he would have ordered an x-ray of her hip. He said he could not recall making any changes or adjustments to the resident's pain medications during her stay. He said there was a two view x-ray completed to Resident #5's right hip which showed a [MEDICAL CONDITION] (the source of her pain) on 1/8/21 and she was sent to the hospital. The ED said Resident #5 had chronic pain and the facility determined the resident did not have a fall with injury and her pain levels never changed. However, Resident #5 had complained of right hip pain which was newly identified as early as 1/4/21 and the resident had a significant decrease in mobility (see therapy notes above). He acknowledged fracture pain could be positional (meaning pain could be stable or zero depending on your position) and the resident continued to have complaints of unrelieved pain. The ED, DON, and medical director were interviewed on 3/2/21 at 4:00 p.m. The ED said the risk management system (RMS) was not completed for Resident #5 because they did not determine the resident had an actual fall. The DON said for any change in condition, including falls, an RMS (triggered monitoring of the resident) should be completed. They acknowledged it was not done. Registered nurse (RN) #5 was interviewed on 3/3/21 at 11:20 a.m. She said she worked for three years on the day shift as a floor nurse. She said she did recall caring for Resident #5. She said therapy reported to her that the resident stated she fell and was complaining of back pain. She said she relayed everything the therapist said to her to the physician and could not recall if the therapist reported the resident complained of hip pain. She said she remembered specifically the resident complaining of back pain but she could not remember if she requested an x-ray of the resident's hip from the physician when she called to obtain x-ray orders. She said she talked with the unit manager and physician about the resident's reported fall. V. Additional follow-up Additional documentation was provided by the ED on 3/16/21 at 6:28 p.m. via email. The medical director (MD) reviewed Resident #5's clinical record and documented in summary he felt the facility's responded adequately to Resident #5's fall and increased pain. The hospital documentation prior to Resident #5's admission documented the resident's pain regime 12/23/2020 to 12/28/2020. It documented the resident had spinal stenosis of lumbar spine, [MEDICAL CONDITION] of the shoulder and bilateral sacroiliac joints (they link your pelvis and lower spine, there are sacroiliac joints in both the right and left sides of your lower back). From 12/23/2020 to 12/28/2020 the hospital documented the resident's pain was zero to seven which was severe; however the resident only had severe pain three out of fifteen times and she was administered Tylenol 1,000 mg for pain. After administration of Tylenol, Resident #5's pain scale was at or below level four which indicated she received relief from Tylenol. Her pain was located in her back, right shoulder, pain to bilateral knees and bilateral legs. There was no documentation of the resident having right hip pain. -The MD's documented on 1/5/21 Resident #5 was having pain involving her right groin, a pelvis x-ray was ordered and hip replacement hardware was seen and no fracture or dislocation was identified. Additionally nursing notes revealed the resident was impulsive and self transferring, up in a chair and able to move her legs when assessed by the physician. The resident was assessed by a physician on 1/7/21, x-rays were obtained and the resident was transferred to an acute care hospital. Although there was a review of Resident #5's record, the facility was unable to provide any follow-up to the resident's reported fall and newly diagnosed complaints of pain to her groin and right hip. Specifically, the facility did not complete a thorough investigation timely of causation of the resident's pain (the resident initially complained of back and hip pain to therapy see therapy documentation 1/4/21 above). -The physician assessment 1/5/21 documented the resident was comfortable while up in chair and able to move legs,' however there was evidence of increased pain with movement (see physician interview above, progress notes and therapy evaluations above in record review). -The MD also documented the x-ray on 1/5/21 documented hardware (hip replacement) was visible on the pelvic x-ray; however, the pelvic x-ray did not document if the right femoral shaft was visible, which likely would have shown a fracture (see imaging above).

Based on resident, family and staff interviews and record review, the facility failed to develop and implement effective discharge planning for five (#1, #2, #3, #4, and #5) of 5 sample residents discharged while COVID-19 test results were pending or following the residents' exposure to [MEDICAL CONDITION]. Record review and interview revealed the facility failed to consider and address the post-discharge needs of these residents, their families and their communities. The facility conducted facility-wide COVID-19 testing from [DATE] to [DATE] after discovering one resident (#6) tested positive for COVID-19. The facility discharged Resident #1 home to his family on [DATE] while his test results were pending. At discharge, the facility failed to inform the family of Resident #1's pending COVID-19 test and failed to educate the family on COVID-19 precautions. The facility also discharged Residents #2, #3, #4 and #5 to home and the community after possible exposure to COVID-19; two of these residents (#2, #3), while COVID-19 test results were pending and two with exposure but not tested (#4, #5). These residents, too, failed to receive education on precautions to prevent the spread of COVID-19 at discharge. This potentially compromised their health as well as the health of their families and communities. The facility's failures in discharge planning created an immediate jeopardy situation, specifically, the likelihood of family and community spread of COVID-19 and its potentially serious adverse outcomes. Cross-reference 880; Infection Control. Findings include: I. IMMEDIATE JEOPARDY A. Findings of immediate jeopardy Resident #1, moderately cognitively impaired, admitted to the facility on [DATE] for a short-term stay; his planned discharge date was [DATE]. He arrived from a sister facility that was transitioning to an all COVID-19 facility. Resident #1 had tested negative twice when tested for COVID-19 prior to his transfer. Following the discovery that a resident (#6) had tested positive for COVID-19, the facility conducted facility-wide testing for COVID-19 on [DATE]. Resident #1 was administered a test on [DATE], and his test was sent to the lab on [DATE]. The test results were returned to the facility on [DATE], after Resident #1 had discharged home with his wife and daughter. The facility called the Resident #1's wife in the afternoon of [DATE] to inform her the resident's COVID-19 test had come back positive. The resident's wife was shocked to hear of the resident's positive test; she had no idea the resident had been tested for COVID-19. The facility's failure to consider and address Resident #1's post-discharge needs based on COVID-19 created the likelihood of Resident #1 spreading COVID-19 to his family and the community. On [DATE] at 1:35 p.m., the nursing home administrator (NHA) and the director of nurses (DON) were notified its failure to consider and address Resident #1's post-discharge needs created an immediate jeopardy situation. Specifically, the facility had failed to consider delaying the resident's discharge until after receiving the results of his COVID-19 test and failed to address the resident's and his family's need for education on how to ensure the resident's family and community would be safe from the possible transmission on COVID-19. B. Facility plan to remove immediate jeopardy On [DATE] at 10:46 a.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Corrective Action: Effective [DATE] the center will document in the line listing of notification with the family/responsible party. Effective [DATE], discharge paperwork will include handouts with current CDC (center for disease control) guidance and considerations for PPE (personal protective equipment) upon discharge to home. All nursing staff will be re-educated by Center Nurse Executive or designee beginning on [DATE] and completed by [DATE] on proper documentation related to discharge paperwork and PPE guidance for families. To include handouts from the CDC and WHO (world health organization) on how to properly care for people with suspected COVID. On [DATE] Center Nurse Executive/Nurse Managers initiated/performed competency assessments and observations on confirming discharge paperwork to include PPE usage/guidance as appropriate or necessary for families on discharge. On [DATE], Center Executive Director called an immediate QAPI (quality assurance and performance improvement) meeting with (the) facility Medical Director and QAPI members to address concerns identified. Systematic Measures: Center Nurse Executive and/or designee will review discharges of suspected Covid-19 patients during the morning Clinical Meeting to ensure proper discharge paperwork and PPE education was provided to the family and documented. Clinical Quality Specialist or designee will review Covid-19 assessments daily to identify residents with Covid-19 triggers, possible pending tests and discharge date s. Quality Assurance and Monitoring: Quality Assurance Performance Improvement (QAPI) meeting held on [DATE] with Interdisciplinary Team members and the Medical Director specifically related to Covid-19 in the center. The Interdisciplinary Team will review and assess all discharged residents for discharge paperwork and PPE education for families during clinical meetings daily for four weeks, three times a week for four weeks, and then twice weekly for four weeks to monitor and validate compliance. Center Nurse Executive or designee will audit and ensure all residents tested for Covid-19 are notified of status and properly discharged with education five times a week for four weeks, then three times a week for four weeks, then twice a week for four weeks to ensure the facility is in compliance. C. Removal of immediate jeopardy The immediate jeopardy was lifted on [DATE] at 10:46 a.m. However, observations, interviews and record review revealed deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Residents exposure to COVID-19 Record review revealed Resident #6 admitted to the facility on [DATE] from a sister facility that was transitioning to all COVID-19 positive residents. The resident was tested twice for COVID-19 before being transferred and tested negative for COVID-19 on both tests. However, prior to discharge to an assisted living facility, the resident was tested again for COVID-19. On [DATE], the resident's second COVID-19 test result came back positive, and on [DATE], the resident was transferred back to the all COVID-19 positive sister facility. The nursing home administrator (NHA) and director of nurses (DON) were interviewed on [DATE] at 10:55 a.m. The NHA said after Resident #6 tested positive for COVID-19 on [DATE], the corporate team wanted to make sure the facility was following all of the protocols, so they decided to test all of the staff and residents in the building to see if there had been any additional positive COVID-19 residents or staff. The DON and NHA said they had contacted families to inform them of the COVID-19 positive resident, but had not documented that communication in any resident records. III. Failure of the facility to consider and address the post-discharge needs of residents their families and communities following the residents' potential exposure to Resident #6 and COVID-19. A. Resident #1 Resident #1, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The resident admitted for a short-term, rehabilitation stay. The [DATE] minimum data set (MDS) documented the resident was moderately cognitively impaired with a brief interview for mental status score of 11 out of 15. He required extensive assistance with bed mobility, transfers and toilet use. He required limited assistance with dressing and personal hygiene, and supervision with eating. 1. Record review revealed the facility failed to consider and address the post-discharge needs of Resident #1 and his family. a. Record review revealed the facility, the resident, and his representative were planning a [DATE] discharge date . -The medical practitioner note dated [DATE] documented the following: PT (physical therapy) reports nearing rehab potential - SW (social worker) targeting dc (discharge) ,[DATE] home with wife. -The Notice of Medicare Non-Coverage (NOMNC) dated [DATE] documented the following: I explained the last covered day will be [DATE]. Your liability (or an alternate payer) starts on [DATE]. The Discharge Transition Plan for Resident #1, dated [DATE], documented the resident was being discharged home with his wife on [DATE]. b. Further record review revealed no reference to Resident #1's potential exposure to COVID-19, no reference to his COVID testing, and no documentation of resident and family education on transmission precautions. Record review on [DATE] at 12:00 p.m. revealed no documentation of Resident #1's potential exposure to COVID-19 or of facility-wide COVID-19 testing. The resident's Discharge Transition Plan did not document the resident potentially had been exposed to COVID-19, that he had received a test for COVID-19, or that the test results were pending. In addition, there was no documentation in the discharge packet regarding PPE usage while awaiting the test results of the resident's COVID-19 test. A [DATE] general nursing note documenting the resident's discharge read, Patient discharged home with home health services through (name). Patient declined to reviewe (sic) discharge packet and patient family states they will review it at home and call if they have any questions. All personal belongings taken by patient. Patient transported by wife and daughter assisted into vehicle without incident. c. Record review after facility notification of immediate jeopardy at [DATE] at 1:35 p.m. A subsequent review of Resident #1's record revealed a general note, written on [DATE] at 2:56 p.m., identified as a late entry for [DATE]. It read, Spoke with wife (name) to notify her of a patient who had tested positive for COVID-19 in our building. We have notified (name) County and Department of Health of these results. We are taking all the necessary precautions based on CDC guidelines. Staff is wearing all the required protective equipment - gown, gloves, masks, N95's. We are conducting facility wide testing to be done tomorrow. We are focused on the safety of your family member and staff. The NHA, on [DATE] at 12:13 p.m., provided a handwritten family notification note, also dated [DATE], but at 5:40 p.m., which included language similar to the general note above. The NHA said the date and time written on the top of the note ([DATE] at 5:40 p.m.) reflected when the nurse had called Resident #1's family, not the date and time the note was written. The NHA confirmed the family notification note was written after the facility was informed of immediate jeopardy. 3. Interviews revealed failure to consider and address the post-discharge needs of Resident #1 and his family. a. Resident #1's family member (FM #1) was interviewed on [DATE] at 9:57 a.m. She said she and her daughter came to pick up Resident #1 in the afternoon on [DATE]. She said she had been working with the facility case manager prior to the resident discharging and the discharge plan for several days. The family member said the facility had worked with her to coordinate home health services for the resident, and the home health agency planned to come and do the first assessment of the resident on [DATE]. She said the facility had called her prior to Resident #1's discharge to tell her the facility had a positive case of COVID-19 in the building but not to worry; the residents had been isolating. She said the facility never told her they were going to conduct facility-wide testing of all the residents, and she was shocked to learn Resident #1 had been administered a test for COVID-19. She further stated no one had told her during the call or at discharge about using PPE because of the resident's potential exposure to COVID-19. b. Resident #1's second family member (FM #2) was interviewed on [DATE] at 9:23 a.m. She said she had come to the facility on [DATE] to help get Resident #1 home following his discharge. She, too, said the discharge was planned and coordinated with the facility. She said the facility told her Resident #1 had two clean COVID-19 tests, and he had been kept away from everyone, so there was no chance he had been exposed to COVID-19. She said the facility did not inform her or any other family members that Resident #1 had a pending COVID-19 test. She said from the time Resident #1 was discharged on [DATE] until [DATE], she had direct contact with Resident #1; she said she had assisted him out of the wheelchair, in the bathroom, in and out of bed and while eating. She said staff in the facility never communicated to her to using PPE while providing care to Resident #1. She said she was in the room when the call came from the facility informing them Resident #1 had tested positive for COVID-19. She said FM #1 was sent immediately to another family member's home, as she was considered high risk for contracting COVID-19 due to her age. FM #2 said she immediately called Resident #1's primary care physician and he advised her to call 911. Resident #1 was transported to the emergency department where he again tested positive for COVID-19. The FM said Resident #1 was in the emergency room for a few days and then was placed on hospice. Resident #1 died about a week later while in hospice care in the hospital. His Certificate of Death, dated [DATE], listed his cause of death as a. [DIAGNOSES REDACTED] - onset to death: days and b. [MEDICAL CONDITION] pneumonia due to COVID-19 - onset to death: [DATE]. Both family members self-quarantined for 14 days due to their exposure to Resident #1. They said the hospice Chaplin worked with them so they could say goodbye to Resident #1 prior to his passing through the window in his room. 4. Interview with community providers revealed the facility failed to consider and address post-discharge needs related to Resident #1's interactions in the community. FM #1, in her interview on [DATE] at 9:57 a.m., said the home health agency had sent in a physical therapist (PT) to complete the initial assessment with Resident #1 on [DATE] when she received a call from the nursing facility DON letting her know that Resident #1 had tested positive for COVID-19. a. The therapy director for the home health agency was interviewed on [DATE] at 2:36 p.m. The therapy director said the home health agency had received Resident #1's referral information from the facility on [DATE], and at that time, the only indication Resident #1 had been possibly exposed and tested for COVID-19 was when he was discharged from the sister facility on [DATE]. The therapy director said the facility did not contact the home health agency after [DATE], so the agency did not know Resident #1 had possible exposure to COVID-19 or that he had a pending COVID-19 test. The therapy director said the home health agency would still have been able to provide services to Resident #1, but they would have utilized a team equipped with PPE for COVID-19. The therapy director said a pregnant physical therapist went to Resident #1's home to complete the initial assessment on [DATE] and was in the process of completing her assessment when the facility contacted the family of Resident #1 to inform them he had tested positive for COVID-19. The therapy director said she reached out to the facility to ensure after this incident. as she did not want it to happen again. She said she spoke with the registered nurse case manager (RN) #3, and she assured the home health agency that in the future she would communicate if there a COVID-19 test was pending or if the resident had a possible exposure to COVID-19. b. The community liaison with the home health agency was interviewed on [DATE] at 4:07 p.m. The community liaison said she had spoken with RN #3 on [DATE] and was told the resident was COVID-19 negative. She said RN #3 did not call her any time after [DATE] to inform her about Resident #1's possible exposure to COVID-19 or his pending COVID-19 test. The community liaison, in her interview said she followed-up with RN #3 after the [DATE] potential exposure. The community liaison said RN #3 apologized for the lack of communication with the home health agency. c. RN #3 was interviewed on [DATE] at 10:00 a.m. RN #3 said she had communicated with the home health agency prior to Resident #1's discharge from the facility. She said she did not document when she had sent Resident #1's information to the home health agency, but assumed it was [DATE], because of the note she had written stating Resident #1 was using home health. RN #3 said she did not communicate with the home health agency after [DATE], and she confirmed she did not inform the home health agency of Resident #1 potential exposure or pending COVID-19 test. She also confirmed she had communicated with the home health community liaison about a week after Resident #1 had been discharged regarding the importance of informing the home health agency about any potential exposure they could have to COVID-19. 4. Staff interviews confirmed at Resident #1's discharge, the facility failed to communicate to Resident #1, his family and the community health care providers that Resident #1 potentially had been exposed to COVID-19, that he had received a test for COVID-19, and the test results were pending. The interviews also confirmed the facility had not discussed PPE use with the resident or his family. a. RN #3 was interviewed on [DATE] at 10:00 a.m. She said she had spoken with Resident #1's wife prior to his discharge to make sure he had home health set up when he discharged from the facility. RN #3 said she had never spoken with Resident #1's wife regarding the resident's potential exposure to COVID-19 or the fact that he had a pending COVID-19 test at the time of discharge. She reviewed the discharge packet provided to Resident #1 and stated there was no evidence in the packet of the resident's potential exposure to COVID-19 or that he had a pending COVID-19 test. She further said there was no information in the discharge packet about using PPE while providing care for the resident. The RN said the resident had signed the discharge packet, but she said he had cognitive deficits and she did not feel he would have understood what he was signing. b. The DON was interviewed on [DATE] at 1:20 p.m. She said she was not aware Resident #1 was scheduled for discharge on [DATE] with a pending COVID-19 test. The DON said the resident should not have been discharged with a pending COVID-19 test; instead, the facility should have waited until after all of the test results came back to discharge any resident. c. Resident #1's physician (MD) and nurse practitioner (NP) were interviewed on [DATE]. They said they had been part of meetings with Resident #1 during the discharge process and had concerns regarding Resident #1's cognition. They said they had not spoken with Resident #1's wife regarding his pending CVOID-19 test prior to his discharge. d. RN #1 was interviewed on [DATE] at 9:41 a.m. She said she was the staff member who called Resident #1's wife to inform her that another resident in the building tested positive for COVID-19. The RN said she did not document the conversation with Resident #1's wife until [DATE], when she was instructed to type the general note in the resident's electronic medical record and write the handwritten family notification note (see notes above). She said she had contacted three other families about a resident in the building testing positive for COVID-19 and did not document any of these contacts. Rather, she had completed the handwritten family notifications to the other residents' families on [DATE] at the instruction of the facility's corporate team. e. RN #2, who discharged Resident #1, was interviewed on [DATE] at 10:04 a.m. She said she was the nurse who discharged Resident #1 in the afternoon of [DATE]. She said Resident #1 had some confusion, but she had him sign his discharge packet and left it in his room. She said the packet would have been placed with his personal items and sent with him when he left the facility. She said [DATE] was her first day back at work after several days off and said she did not know Resident #1 had been tested for COVID-19, so she never told the family or the resident that he had a pending COVID-19 test. She said she had spoken with Resident #1's wife and had gone over his current medications, but they did not discuss Resident #1 potential exposure to COVID-19 and never discussed using PPE when providing care to the resident. f. The NP was interviewed a second time on [DATE] at 10:04 a.m. The NP said Resident #1 had been scheduled to discharge on [DATE], and the only concerns she and the MD had were related to the resident's dementia and cognition. She said she did not have any discussion with Resident #1's wife (FM #1) regarding the pending COVID-19 test, but looking back, that discussion should have taken place prior to discharging the resident. The NP said the resident was not symptomatic but there should have been a dialogue about the implications of discharging a resident who potentially had been exposed to COVID-19, and had a pending COVID-19 test. The NP said it is always her goal and that of the MD, to ensure a safe discharge for any resident and there should have been more conversations regarding the potential exposure and pending COVID-19 tests for all of the residents that were discharged with pending COVID-19 tests. C. Resident #2 Resident #2, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) documented the resident had a BIMS score of 9 out of 15. She required supervision with bed mobility, transfers, walking in her room, eating and toilet use. She required limited assistance with dressing and personal hygiene. 1. Record review revealed no reference to Resident #2's potential exposure to COVID-19 in her medical record and no reference to her COVID testing, and no documentation of resident and family education on transmission precautions as she prepared for discharge to home. Resident #2's medical record was reviewed on [DATE] at 12:05 p.m. The medical record review revealed there was no documentation in the resident's medical record that she potentially had been exposed to COVID-19 or that she had been tested for COVID-19. A [DATE] general nursing note documented, Patient discharged to home with home health services through the (name). Reviewed medication list and discharge packet and patient states she has no questions or concerns. Patient transported via her daughter and assisted into vehicle without incident. The Discharge Transition Plan for Resident #2 dated [DATE], documented the resident was being discharged home alone on [DATE]. The transportation for the discharge indicated the resident's family was transporting her. The discharge transition plan did not document the resident had potentially been exposed to COVID-19, that she had received a test for COVID-19, or that the test results were pending. There was no documentation about using PPE while in the community or when others came to her home to provide care. 2. Resident and family interview confirmed the facility failure to communicate with the resident and her family about her potential exposure to COVID-19, her test for [MEDICAL CONDITION], or precautions to prevent its transmission. Resident #2 was interviewed on [DATE] at 11:11 a.m. She said she had tested negative for COVID-19 prior to coming to the facility. She said no one in the facility had told her there had been a COVID-19 positive resident in the facility. She said the only reason she knew she was going to be tested for COVID-19 was they were in my room, testing me. She said she never had any additional follow-up from the facility after the test. She stated, I assumed I was negative, otherwise they would not have let me go home. She said the facility never had a discussion with her about using PPE after she left the facility; she said she just thought it was for the staff in the building. Resident #2's family member was interviewed on [DATE] at 3:25 p.m. She said the facility contacted her to inform her there was a resident in the facility who had tested positive for COVID-19. She said the facility told her all of the residents had been in their rooms, so there was no concern about Resident #2 exposed to COVID-19. The family member said no one in the facility told her Resident #2 was going to be tested or had been tested for COVID-19 and she was never informed of the results of such a test. She said she did not think the facility would discharge any resident with a COVID-19 test pending. 3. Staff interview further confirmed the facility's lack of communication to Resident #2 and her family about COVID-19 exposure, testing and precautions. RN #3 was interviewed on [DATE] at 10:00 a.m. She reviewed the signed discharge plan for Resident #2. She said there was nothing documented in the paperwork to indicate the resident had possible exposure to COVID-19, that the resident had been tested for COVID-19, signs or symptoms of COVID-19 to monitor for, or when there would be follow-up from the facility regarding the COVID-19 test. In addition, there was no documentation of discussion about use of PPE after the resident left the facility. D. Resident #3 Resident #3, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) documented the resident was cognitively intact with a BIMS score of 15 out of 15. He required supervision for bed mobility, transfers, toilet use and personal hygiene. He was independent with eating. 1. Record review revealed no reference to Resident #3's potential exposure to COVID-19 in his medical record, and no reference to his COVID testing, and no documentation of resident and family education on transmission precautions as he prepared for discharge to home. Resident #3 medical record was reviewed on [DATE] at 12:10 p.m. The medical record review revealed there was no documentation in the resident's medical record that he potentially had been exposed to COVID-19 or that he had been tested for COVID-19. The [DATE] social services note documented, Patient will DC (discharge) today per request, DOR (director of rehabilitation) and PA (physician assistant) approve. Will DC to second home in (name of city). Referral faxed to (name of home health agency) PT/OT/CNA (physical therapy/occupational therapy/certified nurse aide), rep (representative) states (name of home health) will begin ,[DATE]. Patient and wife updated- state they have no further questions at this time. Wife to p/u (pick-up) at 1400 (2 p.m.). The Discharge Transition Plan for Resident #3, dated [DATE], documented the resident was being discharged home with spouse on [DATE]. The transportation for the discharge indicated the resident's wife was transporting him. The discharge transition plan did not document the resident potentially had been exposed to COVID-19, that he had received a test for COVID-19, or that the test results were pending. There was no documentation about using PPE while awaiting the results of his COVID-19 test. 2. Resident and family interview confirmed the facility failure to communicate with the resident and his spouse about his potential exposure to COVID-19, his test for [MEDICAL CONDITION], and precautions to prevent its transmission while his test results were pending. Resident #3 and his wife were interviewed on [DATE] at 11:00 a.m. He said his wife was contacted about a resident testing positive for COVID-19 in the building. His wife said they did not tell her they would be testing Resident #3, and assured her all of the resident's in the facility had been isolated in their rooms. Resident #3 said he was not told about being tested until some guy I did not know came into my room on 7th and told me I am being tested for COVID-19. He said at that point, he was concerned for his health as well as his wife's health, and thought it best that he leave the facility. He said there were never any discussions with any staff members regarding his possible exposure to COVID-19 or discussions about waiting for his test results before discharging. He said he contacted the DON several times over the following week to obtain the results of his COVID-19 test, and after several messages were left, he finally got his results. He said while his results were pending, he and his wife decided to self-isolate in order to keep the rest of his family and community safe. He said no one in the facility had provided him or his wife any education regarding using PPE while he was awaiting the results of his COVID-19 test. He said he had informed the home health agency about the possible COVID-19 exposure and pending test, and when they came to provide services, they wore full PPE. 3. Staff interview further confirmed the facility's lack of communication to Resident #3 and his spouse about the resident's COVID-19 exposure, testing and precautions. RN #3 was interviewed on [DATE] at 10:00 a.m. She reviewed the signed discharge plan for Resident #3. She said there was nothing documented in the paperwork to indicate the resident had possible exposure to COVID-19, that the resident had been tested for COVID-19, signs or symptoms of COVID-19 to monitor for, or when there would be follow-up from the facility regarding the COVID-19 test. She said there was no documentation regarding PPE use in the discharge plan. E. Resident #4 Resident #4, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) documented the resident was cognitively intact. He required supervision for bed mobility, transfers, walking in his room, toilet use and personal hygiene. He was independent with eating. According to the DON, interviewed on [DATE] at 1:20 p.m., Resident #4 had refused to be tested for COVID-19 during the facility-wide testing [DATE]. 1. Record review revealed no reference to Resident #4's potential exposure to COVID-19 in his medical record, no reference to his refusal to be tested for COVID-19, and no documentation of resident education on transmission precautions as he prepared for discharge to home and family. Resident #4 medical records were reviewed on [DATE] at 12:13 p.m. The medical record review revealed there was no documentation in the resident's medical record that he potentially had been exposed to COVID-19 or that he had refused to be tested for COVID-19. The [DATE] practitioner note documented, Review of patients VS (vital signs), medications, paracentesis scheduling, dc (discharge) plan, and nursing concerns. Patient up independently in room; looking towards dc, understan (TRUNCATED)

Based resident, family and staff interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, affecting five of five residents (#1, #2, #3, #4 and #5), as well as their families and communities. Specifically, the facility failed to take steps to limit the development and transmission of COVID-19, a highly infectious virus, through resident and family education and communication with community health care providers. The facility discharged Residents #1, #2, and #3, all of whom had potential exposure to COVID-19, before receiving the residents' COVID-19 test results. The facility and the family of Resident #1 learned of his positive COVID-19 test results after he had discharged home with family and home health services. Record review and interview revealed there were no discussions about Resident #1's potential exposure to COVID-19 and its implications upon discharge, no discussion with the family informing them of Resident #1's pending COVID-19 test results and what precautions should be taken. Finally, there was no notification to the home health agency about Resident #1's potential exposure to and pending test for COVID-19. The facility also discharged Residents #2, #3, #4 and #5 to home and the community after possible exposure to COVID-19, two of these residents (#2, #3), while COVID-19 test results were pending and two with exposure but not tested (#4, #5). These residents, too, failed to receive education on precautions to prevent the spread of COVID-19 at discharge to their families and communities. The facility's failure, when discharging Residents #1, #2, #3, #4 and #5, to take steps to limit the development and transmission of COVID-19, a highly infectious virus, through resident and family education and communication with community health care providers, created the likelihood of family and community spread of COVID-19 and potentially serious adverse outcome. In addition, observations and interviews during resident cares and housekeeping revealed practices not designed to prevent the spread of infection. Cross-reference 660; discharge planning process. The facility failed to have an effective discharge planning process related to their possible exposure to COVID-19 and pending COVID-19 tests for five (#1, #2, #3, #4 and #5) residents. Findings include: I. IMMEDIATE JEOPARDY A. Findings of immediate jeopardy The facility discharged Residents #1, #2, and #3, all of whom had potential exposure to COVID-19, before receiving the residents' COVID-19 test results. The facility and the family of Resident #1 learned of his positive COVID-19 test results after he had discharged home with family and home health services. Record review and interview revealed there were no discussions about Resident #1's potential exposure to COVID-19 and its implications upon discharge, and no discussion with his family informing them of Resident #1's pending COVID-19 test results and what precautions should be taken. Finally, there was no notification to the home health agency about Resident #1's potential exposure to and pending test for COVID-19. The facility also discharged Residents #2, #3, #4 and #5 to home and the community after possible exposure to COVID-19, two of these residents (#2, #3) while COVID-19 test results were pending and two with exposure but not tested (#4, #5). These residents, too, failed to receive education on precautions to prevent the spread of COVID-19 upon discharge to their families and communities. On [DATE] at 1:35 p.m., the nursing home administrator (NHA) and the director of nurses (DON) were notified its failures created a situation of immediate jeopardy for serious adverse outcome. B. Facility plan to remove immediate jeopardy On [DATE] at 10:46 a.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Corrective Action: Center Nurse Executive and/or designee notified the 5 residents/families of possible exposure to COVID-19 and facility wide test results on [DATE] and [DATE]. Center Executive Director or designee mailed a copy of discharge instructions and education related to COVID-19 to the 5 discharged residents/families on [DATE]. Center Executive Director initiated a test based strategy and/or symptom based strategy on [DATE] to be utilized prior to discharge home for COVID suspected and/or COVID positive patients. Effective [DATE], the discharge paperwork to include handouts with current guidance from CDC and WHO regarding use of PPE upon discharge to home. On [DATE] Center Nurse Executive or designee initiated/performed education on Discontinuing of Transmission Based precautions to nursing staff. On [DATE], Center Executive Director hosted an AD HOC Quality Assurance Performance Improvement meeting with facility Medical Director and QAPI members to address discharge protocols as related to infection control processes. Systematic Measures: Regional Vice President of Operations re-educated the Center Executive Director and Center Nurse Executive on the Infection Control/Covid-19 policy, CDC guidelines and procedure to include Discontinuing of Transmission Based Precautions as it relates to discharging patients home on [DATE]. Center Executive Director and/or designee re-educated all department Managers, on the Discontinuing of Transmissions Based precautions policy and procedure as it related to discharging patients home. Center Nurse Executive or designee initiated education on [DATE] to nursing staff on proper education at time of discharge to include notification if COVID test is pending. Quality Assurance and Monitoring: Quality Assurance Performance Improvement (QAPI) meeting held on [DATE] with Interdisciplinary Team members and the Medical Director on Infection Control policy, CDC guidelines as it relates to discontinuing of Transmission Based Precautions and patient/family education at the time of discharge. The Interdisciplinary Team will review and assess all discharged patients during clinical meetings daily for four weeks, three times a week for four weeks, and then twice weekly for four weeks to monitor and validate compliance with proper discharge education as it related to Discontinuing Transmission Based Precautions and patient/family education to include handout from CDC. Center Nurse Executive or designee will audit and ensure all residents who discharge did so without a pending Covid-19 and/or where properly educated at the time of discharge five times a week for four weeks, then three times a week for four weeks, then twice a week for four weeks to ensure facility is in compliance with CDC guidelines and facility Transmission Based Precautions. Nurse Manager will audit all pending tests in con-elation with pending discharges three times a week for four weeks, two times a week for four weeks, then once weekly for four weeks to prevent any discharge with a pending test. Resident's discharged with pending COVID-19 tests without consideration from the resident's clinical care team, without education on signs and symptoms of COVID-19 to monitor for, and PPE usage and when to discontinue transmission-based based precautions C. Removal of immediate jeopardy The immediate jeopardy was lifted on [DATE] at 10:46 a.m. However, observations, interviews and record review revealed deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Discovery of COVID-19 in the facility and facility response Record review revealed on [DATE], Resident #6, admitted to the facility on [DATE] from a sister facility, tested positive for COVID-19. The resident was transferred on [DATE] to an all COVID-19 positive sister facility. The nursing home administrator (NHA) and director of nurses (DON) were interviewed on [DATE] at 10:55 a.m. The NHA said after Resident #6 tested positive for COVID-19 on [DATE], the corporate team wanted to make sure the facility was following all of the protocols, so, on [DATE], they tested all the staff and residents in the building to see if there were any additional positive COVID-19 residents or staff. The DON and NHA said they had contacted families to inform them of the COVID-19 positive resident, although this communication with families was not documented in any resident records. The DON said the facility treated all the residents as if they were COVID-19 positive. She said the nursing staff was utilizing transmission-based precautions when working with any resident. III. Failure of the facility to respond to discovery of COVID-19 in a manner designed to prevent to the spread of infection. Specifically, record review and interview revealed Resident #1, #2, #3, #4, and #5 were discharged [DATE], following the facility's discovery of Resident #6's positive COVID-19 test results and the facility's [DATE] facility-wide resident and staff testing for COVID-19. The facility failed to take steps to limit the development and transmission of COVID-19, a highly infectious virus, through resident and family education and communication with community health care providers. A. Resident #1 1. Resident status Resident #1, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. His [DATE] minimum data set (MDS) documented the resident was moderately cognitively impaired, required extensive assistance with bed mobility, transfers and toilet use. He required limited assistance with dressing and personal hygiene, and supervision with eating. The resident admitted for a short-term, rehabilitation stay. Record review on [DATE] at 12:00 p.m. revealed no reference to Resident #1's potential exposure to COVID-19, no reference to his COVID test, and no documentation of resident and family education on transmission-based precautions. Yet, a subsequent review of Resident #1's record revealed a general note, written on [DATE] at 2:56 p.m. (after immediate jeopardy was called). This note was identified as a late entry for [DATE]. It read, Spoke with wife (name) to notify her of a patient (Resident #6) who had tested positive for COVID-19 in our building. We have notified (name) County and Department of Health of these results. We are taking all the necessary precautions based on CDC guidelines. Staff is wearing all the required protective equipment - gown, gloves, masks, N95's. We are conducting facility wide testing to be done tomorrow. We are focused on the safety of your family member and staff. The NHA, on [DATE] at 12:13 p.m., provided a handwritten family notification note, also dated [DATE], but at 5:40 p.m., which included language similar to the general note above. The NHA said the date and time written on the top of the note ([DATE] at 5:40 p.m.) reflected when the nurse had called Resident #1's family, not the date and time the note was written. The NHA confirmed the family notification note was written after the facility was informed of immediate jeopardy. Review of the resident's Discharge Transition Plan, however, did not document that the resident potentially had been exposed to COVID-19, that he had received a test for COVID-19, or that the test results were pending. In addition, there was no documentation in the discharge packet regarding personal protective equipment (PPE) use while waiting for the results of the resident's COVID-19 test. 3. Interviews revealed the facility failed to take steps to limit transmission of COVID-19; specifically, the facility failed to educate the resident, his family and the community health care provider (HCP) about their possible exposure to COVID-19, what signs and symptoms to monitor for, and what PPE to use while caring for the resident. a. Resident #1's family member (FM #1) was interviewed on [DATE] at 9:57 a.m. She said she and her daughter came to pick up Resident #1 in the afternoon on [DATE] and the home health agency planned to come and do the first assessment of the resident on [DATE]. She said the facility never told her they were going to conduct facility-wide testing of all the residents, and she was shocked to learn Resident #1 had been administered a test for COVID-19. She further stated no one had told her during the call about using PPE while with the resident, and there was never any discussion about using transmission-based precautions or monitoring the resident for any signs or symptoms of COVID-19 when Resident #1 was discharged . She said the home health agency had sent in a physical therapist (PT) to complete the initial assessment with Resident #1 on [DATE] when she received a call from the nursing facility DON letting her know that Resident #1 had tested positive for COVID-19. b. Resident #1's second family member (FM #2) was interviewed on [DATE] at 9:23 a.m. She said she had come to the facility on [DATE] to help get Resident #1 home following his discharge. She said the facility told her Resident #1 had two clean COVID-19 tests, and he had been kept away from everyone, so there was no chance he had been exposed to COVID-19. She said the facility did not inform her or any other family members that Resident #1 had a pending COVID-19 test. She said the resident's home was a high-rise condominium. The resident resided on the 27th floor, so they had to take a communal elevator to get the resident home. She said she was concerned they had exposed hundreds of people living in the condominium by taking the elevator without proper PPE on Resident #1. She said from the time Resident #1 was discharged on [DATE] until [DATE], she had direct contact with Resident #1; she said she had assisted him out of the wheelchair, in the bathroom, in and out of bed and while eating. She said staff in the facility never communicated to her to using PPE while providing care to Resident #1. She said she was in the room when the call came from the facility informing them Resident #1 had tested positive for COVID-19. She said FM #1 was sent immediately to another family member's home, as she was considered high risk for contracting COVID-19 due to her age (over 75). FM #2 said she immediately called Resident #1's primary care physician and he advised her to call 911. Resident #1 was transported to the emergency department where he again tested positive for COVID-19. The FM said Resident #1 was in the emergency room for a few days and then was placed on hospice. Resident #1 died about a week later while in hospice care in the hospital. His Certificate of Death, dated [DATE], listed his cause of death as a. [DIAGNOSES REDACTED] - onset to death: days and b. [MEDICAL CONDITION] pneumonia due to COVID-19 - onset to death: [DATE]. Both family members self-quarantined for 14 days due to their exposure to Resident #1. c. Interview with community HCPs revealed the facility failed to timely notify them of Resident #1's exposure to and pending test for COVID-19. The therapy director for the home health agency was interviewed on [DATE] at 2:36 p.m. -The therapy director said the home health agency had received Resident #1's referral information from the facility on [DATE], and at that time, the only indication Resident #1 had been possibly exposed and tested for COVID-19 was when he was discharged from an all COVID-19 positive sister facility on [DATE]. -The therapy director said the facility did not contact the home health agency after [DATE], so the agency did not know Resident #1 had possible exposure to COVID-19 or that he had a pending COVID-19 test. The therapy director said the home health agency would still have been able to provide services to Resident #1, but they would have utilized a team equipped with PPE for COVID-19. -The therapy director said a pregnant physical therapist went to Resident #1's home to complete the initial assessment on [DATE] and was in the process of completing her assessment when the facility contacted the family of Resident #1 to inform them he had tested positive for COVID-19. The community liaison with the home health agency was interviewed on [DATE] at 4:07 p.m. The community liaison said she had spoken with registered nurse case manager (RN) #3 on [DATE] and was told the resident was COVID-19 negative. She said RN #3 did not call her any time after [DATE] to inform her about Resident #1's possible exposure to COVID-19 or his pending COVID-19 test. c. RN #3 was interviewed on [DATE] at 10:00 a.m. She said she had communicated with the home health agency prior to Resident #1's discharge from the facility. She said she did not document when she had sent Resident #1's information to the home health agency, but assumed it was [DATE], because of the note she had written stating Resident #1 was using home health. She said she did not communicate with the home health agency after [DATE], and she confirmed she did not inform the home health agency of Resident #1 potential exposure or pending COVID-19 test. She said she had spoken with Resident #1's wife prior to his discharge to make sure he had home health set up when he discharged from the facility. RN #3 said she had never spoken with Resident #1's wife regarding the resident's potential exposure to COVID-19 or the fact that he had a pending COVID-19 test at the time of discharge. She reviewed the discharge packet provided to Resident #1 and stated there was no evidence in the packet of the resident's potential exposure to COVID-19 or that he had a pending COVID-19 test. She further said there was no information in the discharge packet about using PPE while providing care for the resident. The RN said the resident had signed the discharge packet. She said there was never a discussion during the discharge process regarding ending transmission-based precautions with Resident #1 or what signs and symptoms of COVID-19 the family should monitor the resident for. b. The DON was interviewed on [DATE] at 1:20 p.m. She said she was not aware Resident #1 was being discharged on [DATE] with a pending COVID-19 test. The DON said the resident should not have been discharged with a pending COVID-19 test; instead, the facility should have waited until after all of the test results came back to discharge any residents. The DON further said there should have been a discussion with the family about the use of PPE while working with Resident #1 at home. c. Resident #1's physician (MD) and nurse practitioner (NP) were interviewed on [DATE]. They said they had been part of meetings with Resident #1 during the discharge process and said they had not spoken with Resident #1's wife regarding his pending CVOID-19 test prior to his discharge. They further stated they never had any discussion with the family regarding using PPE with Resident #1 while at home. d. RN #2, who discharged Resident #1 on [DATE], was interviewed on [DATE] at 10:04 a.m. She said [DATE] was her first day back at work after several days off and said she did not know Resident #1 had been tested for COVID-19, so she never told the family or the resident that he had a pending COVID-19 test. She said she had spoken with Resident #1's wife and had gone over his current medications, but they did not discuss Resident #1 potential exposure to COVID-19 and never discussed using PPE when providing care to the resident. e. The NP was interviewed a second time on [DATE] at 10:04 a.m. She said she did not have any discussion with Resident #1's wife (FM #1) regarding the pending COVID-19 test, but looking back, that discussion should have taken place prior to discharging the resident. The NP said the resident was not symptomatic but there should have been a dialogue about the implications of discharging a resident who potentially had been exposed to COVID-19, and had a pending COVID-19 test. The NP said it is always her goal and that of the MD, to ensure a safe discharge for any resident and there should have been more conversations regarding the potential exposure and pending COVID-19 tests for all of the residents that were discharged with pending COVID-19 tests. B. Additional residents (#2 and #3) discharged with potential exposure to COVID-19 and pending COVID-19 tests, whose families failed to receive education about transmission-based precautions at discharge, as well as one community HCP who failed to receive notification from the facility of the resident's potential exposure to COVID-19. 1. Resident #2 Resident #2, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) documented the resident had a BIMS score of 9 out of 15. She required supervision with bed mobility, transfers, walking in her room, eating and toilet use. She required limited assistance with dressing and personal hygiene. Record review on [DATE] at 12:05 p.m. revealed no reference to Resident #2's potential exposure to COVID-19 in her medical record and no reference to her COVID testing. The Discharge Transition Plan for Resident #2, dated [DATE], documented the resident was being discharged home alone on [DATE]. The transportation for the discharge indicated the resident's family was transporting her. The discharge transition plan did not document the resident had potentially been exposed to COVID-19, that she had received a test for COVID-19, or that the test results were pending. There was no documentation about using PPE while in the community or when others came to her home to provide care. Resident #2 was interviewed on [DATE] at 11:11 a.m. She said no one in the facility had told her there had been a COVID-19 positive resident in the facility. She said the only reason she knew she was going to be tested for COVID-19 was they were in my room, testing me. She said she never had any additional follow-up from the facility after the test. She said the facility never had a discussion with her about using PPE after she left the facility or for how long it should be used; she said she just thought PPE was for the staff in the building. She said there were never any discussions with staff about continuing to monitor herself for any signs or symptoms of COVID-19. Resident #2's family member was interviewed on [DATE] at 3:25 p.m. She said the facility contacted her to inform her there was a resident in the facility who had tested positive for COVID-19. She said the facility told her all of the residents had been in their rooms, so there was no concern about Resident #2 exposed to COVID-19. The family member said no one in the facility told her Resident #2 was going to be tested or had been tested for COVID-19 and she was never informed of the results of such a test. She further stated she had never been part of any discussion regarding using PPE while she was with Resident #2, or that Resident #2 should be using transmission-based precautions, stating she did not even know what that meant. RN #3 was interviewed on [DATE] at 10:00 a.m. She reviewed the signed discharge plan for Resident #2. She said there was nothing documented in the paperwork to indicate the resident had possible exposure to COVID-19, that the resident had been tested for COVID-19, signs or symptoms of COVID-19 to monitor for, or when there would be follow-up from the facility regarding the COVID-19 test. In addition, there was no documentation of discussion about using PPE or discontinuing its use after the resident left the facility. 2. Resident #3 Resident #3, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) documented the resident was cognitively intact with a BIMS score of 15 out of 15. He required supervision for bed mobility, transfers, toilet use and personal hygiene. He was independent with eating. Record review revealed no reference to Resident #3's potential exposure to COVID-19 in his medical record, and no reference to his COVID testing, and no documentation of resident and family education on transmission-based precautions as he prepared for discharge to home. The Discharge Transition Plan for Resident #3, dated [DATE], documented the resident was being discharged home with spouse on [DATE] and home health services. The transportation for the discharge indicated the resident's wife was transporting him. The discharge transition plan did not document the resident potentially had been exposed to COVID-19, that he had received a test for COVID-19, or that the test results were pending. There was no documentation about using PPE while awaiting the results of his COVID-19 test. Resident #3 and his wife were interviewed on [DATE] at 11:00 a.m. He said his wife was contacted about a resident testing positive for COVID-19 in the building. His wife said they did not tell her they would be testing Resident #3, and assured her all of the resident's in the facility had been isolated in their rooms. -Resident #3 said he was not told about being tested until some guy I did not know came into my room on 7th and told me I am being tested for COVID-19. He said at that point, he was concerned for his health as well as his wife's health, and thought it best that he leave the facility. -He said there were never any discussions with any staff members regarding his possible exposure to COVID-19 or discussions about waiting for his test results before discharging. He said he contacted the DON several times over the following week to obtain the results of his COVID-19 test, and after several messages were left he finally got his results. He said while his results were pending, he and his wife decided to self-isolate in order to keep the rest of his family and community safe. -He said no one in the facility had provided him or his wife any education regarding using PPE while he was awaiting the results of his COVID-19 test. He said there had never been any discussion in the facility about transmission-based precautions. -He said he had informed the home health agency about the possible COVID-19 exposure and pending test, and when they came to provide services, they wore full PPE. RN #3 was interviewed on [DATE] at 10:00 a.m. She reviewed the signed discharge plan for Resident #3. She said there was nothing documented in the paperwork to indicate the resident had possible exposure to COVID-19, that the resident had been tested for COVID-19, signs or symptoms of COVID-19 to monitor for, or when there would be follow-up from the facility regarding the COVID-19 test. She said there was no documentation regarding PPE use in the discharge plan and said she did not have any discussion with the resident about transmission-based precautions or if he still needed to use them at home. C. Additional residents (#4 and #5) discharged with potential exposure to COVID-19 whose families failed to receive education about transmission-based precautions at discharge. 1. Resident #4 Resident #4, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) documented the resident was cognitively intact. He required supervision for bed mobility, transfers, walking in his room, toilet use and personal hygiene. He was independent with eating. According to the DON, interviewed on [DATE] at 1:20 p.m., Resident #4 had refused to be tested for COVID-19 during the facility-wide testing [DATE]. Record review on [DATE] at 12:13 p.m. revealed no reference to Resident #4's potential exposure to COVID-19 in his medical record, no reference to his refusal to be tested for COVID-19, and no documentation of resident education on transmission-based precautions as he prepared for discharge to home and family. The Discharge Transition Plan for Resident #4, dated [DATE], documented the resident was being discharged home with family on [DATE]. The transportation for the discharge indicated the resident's wife was transporting him. The discharge transition plan did not document the resident had potentially been exposed to COVID-19, or signs and symptoms of COVID-19 to monitor himself for. There was no documentation in the discharge plan regarding PPE usage. There was no documentation regarding the resident discontinuing transmission-based based precautions. RN #3 was interviewed on [DATE] at 10:00 a.m. She reviewed the signed discharge plan for Resident #4. She said there was nothing documented in the paperwork to indicate the resident had possible exposure to COVID-19 or signs or symptoms of COVID-19 to monitor for. The RN said there was no documentation of PPE usage in the discharge plan for the resident. The RN further stated there never was a discussion with the resident about discontinuing transmission-based precautions. The DON was interviewed on [DATE] at 1:20 p.m. She said there was no documentation in the resident's medical record that indicated he had refused the COVID-19 test or documentation of education regarding possible exposure to COVID-19. The DON said there was never any discussion with the resident regarding using PPE at home, or regarding the discontinuation of transmission-based precautions. 2. Resident #5 Resident #5, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) documented the resident was cognitively intact. He required supervision for bed mobility, transfers, walking in his room, toilet use and personal hygiene. He was independent with eating. According to the DON, interviewed on [DATE] at 1:20 p.m., the resident was out of the facility at [MEDICAL TREATMENT] at the time of the facility-wide COVID-19 testing. Record review on [DATE] at 12:20 p.m. confirmed Resident #5 had been out of the building at the time of the facility-wide COVID-19 testing. It further revealed no reference to Resident #5's potential exposure to COVID-19 and no documentation of resident education on transmission-based precautions as he prepared for discharge to home. There was no documentation about any education to the resident on discontinuing transmission-based precautions at home. The Discharge Transition Plan for Resident #4 dated [DATE], documented the resident was being discharged home alone on [DATE]. The transportation for the discharge indicated the resident's family was transporting him. The discharge transition plan did not document the resident potentially had been exposed to COVID-19, or signs and symptoms of COVID-19 to monitor himself for. There was no documentation in the discharge plan regarding PPE usage. RN #3 was interviewed on [DATE] at 10:00 a.m. She reviewed the signed discharge plan for Resident #5. She said there was nothing documented in the paperwork to indicate the resident had possible exposure to COVID-19 or signs or symptoms of COVID-19 to monitor himself for. She said there was no documentation regarding PPE usage in the discharge plan. The RN said there was never any discussion with the resident about when to discontinue transmission-based precautions. The DON was interviewed on [DATE] at 1:20 p.m. She said she was not part of the testing process, rather, it was completed by the facility corpo (TRUNCATED)