Every finding on record at Fairacres Manor, Inc.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure safe holding temperatures for food items were maintained; -Ensure kitchen staff wore appropriate hair restraints when preparing and serving food to residents; and, -Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination. Findings include: I. Maintain safe holding temperatures for food items A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/10/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Time/temperature control for safety food cold holding shall be maintained at 5 degrees Celsius (C) (41 degrees Fahrenheit) or less. Time/temperature control for safety food that is cooked to a temperature and for a time specified under SS 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 degrees C (135 degrees Fahrenheit) or above. According to the product guidelines for MedPass Fortified Nutritional Shake, retrieved on 6/11/24 from https://www.hormelhealthlabs.com/resources/for-healthcare-professionals/product-protocols/med-pass-fortified-nutritional-shake-medication-pass-program/, MedPass products can safely remain on a medication cart as long as it is kept at refrigerated temperature range 34 to 40 degrees F. Cover, label and refrigerate opened containers of MedPass products and discard after four days as long as the product has been kept at the proper refrigerated temperature range. According to the product guidelines for ReadyCare Nutritional Drink, retrieved on 6/11/24 from https://lyonsreadycare.com/collections/unintended-weight-loss/products/vanilla-2-0, Shelf Life: 9 (nine) months from date of manufacture. Refrigerate after opening and use within 72 hours. B. Facility policy The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions Policy, dated 1/2024, was provided by the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part, Cold foods are kept between 34 to 41 degrees Fahrenheit F before serving and frozen foods are kept at 0 degrees F or below. Hot foods are cooked to above 165 degrees F or per USDA (United States Department of Agriculture) Food Code and held at least 140 degrees F until service. C. Observations On 6/3/24 at 5:04 p.m. initial temperatures were taken of food items that were to be served to residents during dinner service. A tuna melt sandwich, previously heated and meant to be served hot, had a temperature of 133.1 degrees F. Two trays of garden salad were checked for temperatures. One tray, which was sitting on ice on the serving line, had a temperature of 45.5 degrees F. The other tray, which was taken from the refrigerator, had a temperature of 48.9 degrees F. A slice of cheesecake had a temperature of 44.7 degrees F. On 6/4/24 temperatures of food items kept at the nurses' medication carts were obtained. Each medication cart had a small cooler with ice in it. The lid for the cooler on each cart was not able to be closed due to the height of the nutritional supplement bottles inside the coolers. At 1:20 p.m., on the Sagewood wing medication cart, the MedPass nutritional supplement measured 59 degrees F and the ReadyCare nutritional supplement measured 68 degrees F. -The temperatures of both nutritional supplements were above the safe temperature parameter for cold foods of 41 degrees F or less. At 1:27 p.m. on the Pinebrook wing medication cart, the ReadyCare nutritional supplement measured 62 degrees F. -The temperatures of the nutritional supplement was above the safe temperature parameter for cold foods of 41 degrees F or less. D. Staff interviews The nutrition services director (NSD) was interviewed on 6/3/24 at 5:04 p.m. The NSD said the ideal holding temperature for hot foods was 165 degrees F. The NSD was interviewed again on 6/4/24 at 1:20 p.m. The NSD said cold foods should stay under 41 degrees F and food items kept on the medication carts should be below 41 degrees F. The NSD said the kitchen staff had no involvement preparing or maintaining the medication carts' coolers. Registered nurse (RN) #1 was interviewed on 6/4/24 at 1:25 p.m. RN #1 said the facility nurses prepared the coolers for the medication carts at the start of each shift. RN #1 said the nurses did not have any thermometers at their station aside from the ones used to obtain vitals and she had not taken any temperatures of the food items kept on the medication carts. II. Ensure kitchen staff were wearing appropriate hair restraints while preparing and serving food A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/10/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. B. Facility policy The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions Policy, dated 1/2024, was provided by the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part, Staff always wear proper clothing and footwear, preferably uniforms, and hair restraints on. C. Observations On 6/3/24 [NAME] (CK) #1 was observed during a continuous observation of the dinner service, beginning at 4:30 p.m. and ending at 6:25 p.m. CK #1 was preparing and serving food for residents throughout the observation period. -CK #1 had a goatee and mustache and he was not wearing a beard net throughout the observation period. D. Interviews The registered dietitian (RD) was interviewed on 6/4/24 at 2:05 p.m. The RD said kitchen staff members with facial hair should wear beard nets. The RD said CK #1 was normally clean-shaven and she had not noticed his facial hair was longer. III. Inappropriate handling of ready-to-eat foods A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/10/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. B. Facility policy The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions Policy, dated 1/2024, was provided by the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part: Bare hands do not touch ready to eat foods. C. Observations The 6/3/24 dinner service was observed during a continuous observation, beginning at 4:30 p.m. and ending at 6:25 p.m. At several points throughout the observation period, CK #1 touched hamburger buns with his bare hands after handling tray cards and serving utensils. Additionally, CK #1 was observed using his bare hands to shift potato chips to the side of the plates to make room for the garden salad on several occasions. -At 5:45 p.m., dietary aide (DA) #1 was preparing sandwiches during the dinner service. DA #1, with bare hands, untied a bag of bread, pulled out two slices of bread with her hand, closed the bread bag and held the bread with her bare hands as she cut it with a knife. -DA #1 proceeded to place the bread, still with her bare hands, onto a plate. -DA #1 had been touching tray cards, a cart at the end of the tray line and serving utensils prior to touching the bread with her bare hands. At 6:25 p.m. DA #1 again took bread from the bread bag with her bare hands and placed it on a plate. DA #1 added egg salad, then placed another piece of bread on top of the sandwich with her bare hands. -Again, DA #1 had been touching tray cards, a cart at the end of the tray line, and serving utensils prior to touching the bread with her bare hands. D. Staff interview The RD was interviewed on 6/4/24 at 2:05 p.m. The RD said she had not seen staff handling ready-to-eat foods with their bare hands. The RD said ready-to-eat foods should be handled with tongs.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to: -Follow the weekly menu to ensure adequate nutrition was provided to the residents; and, -Ensure Resident #38 and Resident #10 were provided with the correct mechanically altered diet. Findings include: I. Failure to follow the weekly menu to ensure adequate nutrition was provided to the residents A. Observations and record review Review of the menu and the menu extensions for the 6/3/24 lunch meal revealed that 2% (percent) milk was to be served. On 6/3/24 the lunch service was observed during a continuous observation in the main and rear dining rooms, beginning at 10:50 a.m. and ending at 11:58 p.m. -The dietary aides in the main and rear dining rooms did not offer residents milk as a beverage during the observation period, but offered soda and juice instead. Review of the menu and menu extensions for the 6/3/24 dinner meal revealed that a side of tartar sauce was to be served to all residents and 2% milk was to be served The altered texture menu extension revealed residents receiving altered diet textures were to receive pasta salad in place of the regular menu's potato chips. On 6/3/24 the dinner service was observed during a continuous observation in the kitchen, beginning at 4:30 p.m. and ending at 6:25 p.m. Observations revealed the following: -Only one resident was served a side of tartar sauce; and, -Cook (CK) #1 served a scoop of mashed potatoes to the minced and moist, soft and bite-sized and puree altered diet textures as a substitute for the potato chips on the regular menu instead of the pasta salad that was to be served. The 6/3/24 dinner service was observed during a continuous observation in the main and rear dining rooms, beginning at 4:45 p.m. and ending at 5:50 p.m. The dietary aides in the main and rear dining rooms did not offer residents milk as a beverage during the observation period, but offered soda and juice instead. -Menu nutritional information was requested from the regional dietary consultant (RDC) on 6/5/24 at 4:05 p.m. but was not received by the survey exit date on 6/6/24. B. Resident group interview On 6/4/24 at 3:05 p.m. a group interview was conducted with three residents (#15, #42 and #21) who frequently attended monthly resident council meetings and were identified as interviewable by the facility and assessment. All residents in attendance said they only received milk at meals when they asked for it and that no alternative dairy products were offered in place of milk. All residents in attendance said menu items changed without informing the residents, and the residents would not know what they would be eating until it was served. C. Staff interviews Dietary aide (DA) #2 was interviewed on 6/3/24 at 5:45 p.m. DA #2 said the dietary aides asked residents what they wanted to drink. DA #2 said she was not told if a beverage was on the menu. DA #2 said dietary aides did not offer alternatives if a resident did not select milk as their beverage during meals. The registered dietitian (RD) was interviewed on 6/4/24 at 2:05 p.m. The RD said everything on the menu needed to be served. The RD said milk was offered to residents but they did not have to take it. -However, observations revealed residents were not offered a choice of milk during the meals (see observations above). The RDC was interviewed on 6/5/24 at 4:05 p.m. The RDC said tartar sauce was never given during meals, especially not for menu items like tuna melt sandwiches. -However, tartar sauce was listed on the menu for the 6/3/24 dinner meal (see record review above). II. Failure to ensure residents were served the correct mechanically altered diets A. Professional reference The International Dysphagia Diet Standardization Initiative (IDDSI) altered texture diet information, revised 7/31/2019, was retrieved on 6/12/24 from www.iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf. It read in pertinent part, For level six soft and bite sized texture, no regular dry bread, sandwiches or toast of any kind. Level five minced and moist texture meat should be finely minced or chopped. (Pieces of meat should be) equal to or less than four millimeters in width and no more than 15 millimeters in length. Serve in mildly, moderately or extremely thick, smooth, sauce or gravy. B. Facility policy and procedure The Therapeutic Diets policy, revised 4/2023, was provided by the nursing home administrator (NHA) on 6/6/24 at 11:34 a.m. It read in pertinent part, Therapeutic diets must be prescribed by the attending physician. When a therapeutic diet is ordered, it is served correctly. Therapeutic diets are physician orders and must be followed. C. Observations and record review Review of the altered texture menu extensions for the 6/3/24 dinner meal revealed residents receiving altered diet textures were to receive tuna and noodles which had been food processed instead of the regular texture tuna melt sandwich. On 6/3/24 the dinner service was observed during a continuous observation in the kitchen, beginning at 4:30 p.m. and ending at 6:25 p.m. At 5:40 p.m. cook (CK) #1 prepared Resident #38's meal, which included a regular texture tuna melt sandwich served between two pieces of toasted plain white bread. Upon prompting, the registered dietitian (RD) removed the sandwich from Resident #38's plate and replaced it with the soft and bite-sized textured meal item (see menu extension above). At 5:50 p.m. dietary aide (DA) #1 prepared Resident #10's meal, which included a deli ham and cheese sandwich served between two pieces of toasted plain white bread. The ham was sliced deli meat and was not mechanically altered. Upon prompting the RD removed the sandwich from Resident #10's plate and it was replaced with a sandwich with minced and moist meat. -However, without prompting Resident #38 and Resident #10 would have been served a regular texture meal. D. Staff interviews The RD was interviewed on 6/3/24 at 5:40 p.m. The RD said Resident #38 could not have bread due to her prescribed diet texture of soft and bite sized. The RD said the sandwich originally made for Resident #10 did not have the correct texture of meat within the sandwich. The RD was interviewed again on 6/4/24 at 2:05 p.m. The RD said there was a three point system to ensure residents got the correct diet texture that started with the cook, followed by the dietary aide, then the certified nurse aide (CNA) that served the resident's food. The RD said she frequently watched the kitchen tray line and saw the kitchen staff follow the mechanically altered diet orders. The RD was interviewed again on 6/5/24 at 9:13 a.m. The RD said she provided education on 6/5/24 (during the survey) to the kitchen staff on the IDDSI diet textures. The RD said her education emphasized that residents with an IDDSI texture less than seven could not receive bread products. The regional dietary consultant (RDC) was interviewed on 6/5/24 at 4:05 p.m. The RDC said soft and bite-size diet textures should have food pieces approximately 15-17 millimeters in size. The RDC said some residents could tolerate bread and serving bread products was left to the decision of the RD. Licensed practical nurse (LPN) #2 was interviewed on 6/6/24 at 11:24 a.m. LPN #2 said she had not received any education on altered diet textures and what they included. LPN #2 said altered textures prevented aspiration and choking risks for residents with difficulty swallowing. LPN #2 said Resident #38 had issues with swallowing. The speech language pathologist (SLP) was interviewed on 6/6/24 at 12:02 p.m. The SLP said the facility transitioned to IDDSI diet texture structures in October 2023. The SLP said residents often received downgrades in diet textures due to issues with dentition, mentation and of ease of swallowing. The SLP said Resident #38 was ordered for an altered texture diet on 6/8/23 and changed to a soft and bite-size texture diet on 10/16/23. The SLP said bread products were deemed safe for Resident #38 because she was on an IDDSI level six diet, but that the sandwich should have been cut up into pieces 1.5 to 2 inches in size. The SLP said if the cooks and dietary aides did not provide the residents with the correct diet texture it could potentially result in choking, occlusion or aspiration pneumonia. The SLP said he had not done a formal speech evaluation for any of the residents on altered texture diets as they had not had any incidents that indicated they needed an evaluation. The SLP said Resident #10 had issues with his dentition. The SLP said Resident #10 was prescribed to receive an altered meat texture on 5/24/23. The SLP said any kind of meat that was not ground was fibrous and therefore more difficult to chew. The SLP said whenever residents had dentition issues he wanted to make sure things were not getting stuck. He said Resident #10 had not had any choking incidents. The SLP said there were no indicators that Resident #10 would have issues chewing deli slices of meat, but that meat should be ground up because it was easier for him to chew. IV. Performance improvement plan A performance improvement plan and subsequent root cause analysis, initiated 3/15/24, was received from the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part: Problem: Therapeutic diets not followed. Root cause: staff not checking therapeutic menu. Action plan to correct issues identified: education on therapeutic menu. Responsible team members: RD and dietary manager. Start date: 3/20/24. Estimated completion date: 3/25/24. -However, the performance improvement plan addressed concerns with therapeutic diets and not mechanically altered diets.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touch areas (call lights, bed controls and light switches); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; and, -Ensure surface disinfectant dwell times (how long surfaces remained wet with disinfectant) were adhered to. Findings include I. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 6/6/24 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/5/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedure The Cleaning and Disinfection of Environmental Surfaces policy and procedure, revised August 2019, was received from the nursing home administrator (NHA) on 6/6/24 at 12:59 p.m. revealed in pertinent part Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of health care facilities. Manufacturer's instructions will be followed for proper use of disinfecting products including: recommended use-dilution, material compatibility, storage, shelf-life, safe use and disposal. III. Disinfectants used in the facility The [NAME] Bay TableTop Sanitizer product sheet, undated, was provided by the NHA on 6/6/24 at 12:59 p.m. It revealed in pertinent part, Treated surfaces must remain wet for three minutes. The [NAME] Bay Acid Free Disinfectant Restroom Cleaner product sheet, undated, was provided by the NHA on 6/6/24 at 12:59 p.m. It revealed in pertinent part, Treated surfaces must remain wet for 10 minutes. IV. Observations During a continuous observation on 6/4/24, beginning at 8:55 a.m. and ending at 9:39 a.m., Housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER] (a shared resident room). HSK #1 sprayed the toilet and toilet riser with [NAME] Bay Bathroom Disinfectant. HSK #1 waited 10 minutes then took a dry rag and wiped the toilet down, however the surface did not remain wet for 10 minutes. HSK#1 cleaned the bathroom in the following order: starting with the toilet bowl rim, the outside toilet pedestal to the floor, toilet seat, toilet lid, and lastly the water tank reservoir on the back of the toilet. HSK #1 wiped down the toilet riser starting with the toilet seat, toilet lid and then the handle bars. -HSK #1 failed to disinfect the toilet and toilet riser from the cleanest area to the dirtiest area. -HSK #1 failed to allow the toilet and toilet riser surfaces to remain wet for the recommended dwell time. -HSK #1 proceeded to wipe down the grab bars in the bathroom with the same rag used to clean the toilet. She did not spray the grab bars with the disinfectant prior to wiping them with the dirty rag. HSK #1 sprayed a new dry rag four times with [NAME] Bay Tabletop Sanitizer. She wiped the entrance door handles, the door, bedside tables and dressers for both residents in room [ROOM NUMBER]. The surfaces of the items remained wet for approximately 30 seconds. -HSK #1 failed to change rags between each resident's side of the room. -HSK #1 failed to spray the disinfectant on the surfaces and allow the surfaces to remain wet for the recommended dwell time. -HSK #1 failed to clean all high touch surfaces in the resident's room (see professional reference above). During a continuous observation on 6/4/24, beginning at 9:42 a.m. and ending at 10:04 a.m., HSK #1 was observed cleaning room [ROOM NUMBER] (a shared resident room). HSK #1 wiped down the bathroom in room [ROOM NUMBER] with a dry rag after spraying the bathroom with [NAME] Bay Bathroom Disinfectant in the following order: beginning with the sink faucet handles, sink bowl, toilet riser handles, seat of the toilet riser, grab bars on the walls in the bathroom. HSK #1 then wiped down the toilet in the following order: beginning with the toilet bowl rim, toilet seat, toilet lid and water tank reservoir on the back of the toilet. HSK#1 wiped down the paper towel dispenser with the same rag she used to wipe the sink, toilet riser and toilet. -HSK #1 failed to allow the surfaces in the bathroom, including the toilet and toilet riser surfaces, to remain wet for the recommended dwell time. -HSK #1 failed to disinfect the bathroom from the cleanest area to the dirtiest area. At 9:45 a.m. HSK #1 sprayed a dry cloth with [NAME] Bay Tabletop Sanitizer and proceeded to wipe the door handles, bedside tables, night stands and dressers for both residents in room [ROOM NUMBER]. The surfaces of the items remained wet for approximately 15 seconds -HSK #1 failed to change rags between each resident's side of the room. -HSK #1 failed to spray the disinfectant on the surfaces and allow the surfaces to remain wet for the recommended dwell time. -HSK #1 failed to clean all high touch surfaces in the resident's rooms (see professional reference above). V. Staff interviews HSK #1 was interviewed on 6/4/24 at 10:05 a.m. HSK #1 said the [NAME] Bay Tabletop Sanitizer had a two to three minute dwell time and the bathroom disinfectant had a 10 minute dwell time. HSK #1 said the surfaces did not need to remain wet the entire dwell time to be effective. HSK# 1 said she used only two rags to clean resident rooms, one for the bathroom and a second one for the residents' room. HSK #1 said the number of rags used did not change if the resident room was a single resident room or a shared resident room. HSK #1 identified door handles, dresser handles, toilets and grab bars as high touch surface areas which needed to be cleaned daily. HSK #1 said she forgot to clean the call lights, bed controls and light switches in room [ROOM NUMBER] and room [ROOM NUMBER]. HSK #1 said she should have cleaned all high touch surfaces to help prevent infections. The housekeeping laundry manager (HLM) was interviewed on 6/5/24 at 1:07 p.m. HLM said the [NAME] Bay Bathroom Disinfectant had a 10 minute dwell time and the [NAME] Bay Tabletop Sanitizer had a two to three minute dwell time. The HLM said the [NAME] Bay Bathroom Disinfectant had a 10 minute dwell time however most times it would dry before the 10 minutes was up. The HLM said the housekeepers should re-wet the surface to ensure that it stayed wet for the entire 10 minutes. The HLM said dwell times were important to follow to ensure the disinfectant properly disinfected the areas being cleaned for infection prevention. The HLM said the bathroom should be wiped down from the cleanest areas to the dirtiest to prevent moving bacteria from higher soiled areas to a less soiled area. The HLM said bathrooms should be wiped down in the following order: sink handles, sink bowl, light switch, towel racks, and toilet areas last. The HLM said the toilet should be wiped down in the following order: tank reservoir, toilet lid, toilet seat, toilet bowl rim and last the outside pedestal to the floor. The HLM said if the housekeepers were not wiping in the correct order they were contaminating the other areas in the bathroom. The HLM said the housekeepers should use at least two rags in the bathroom to ensure proper cleaning and disinfection. The HLM said high touch areas in resident rooms, such as the call lights, television remotes, bed controls, bedside tables and door knobs/handles, should be disinfected/cleaned daily. -The HLM said housekeepers could use the same rag for both residents in one room as long as they used different sides of the rag for bed A versus bed B. The HLM said she would like to complete audits on housekeepers for proper cleaning and disinfecting techniques at least monthly but she had not been able to complete those audits yet. The infection preventionist (IP) was interviewed on 6/6/24 at 10:40 a.m. The IP said he met with the HLM frequently about potential infections and to ensure correct soap/disinfectants were being used appropriately. The IP did not know the dwell time for the [NAME] Bay Tabletop Sanitizer or bathroom disinfectant. The IP said if the manufacturer's recommendations said the surface needed to remain wet for a certain amount of time, the dwell time should be followed to ensure proper disinfection was completed. The IP identified the bedside tables, grab bars, bed rails, television remotes, bed controla, door handles and resident water cups as high touch surface areas in residents' rooms. The IP said when housekeepers were cleaning a bathroom they should clean it from the cleanest area to the dirtiest area to prevent moving bacteria/germs from the dirtier area to a cleaner area.

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Specifically, the facility failed to: -Ensure staff were following proper personal protective equipment (PPE) guidelines; -Provide hand hygiene opportunities for residents; -Ensure the correct placement for biohazard containers Findings include: I. Failure to provide hand hygiene opportunities for residents A. Observations On 3/31/2020 at 5:21 p.m., certified nurse aide (CNA) #2 was observed to pass a dinner meal to Resident #3. The CNA failed to offer handwashing to the resident. At 5:25 p.m., CNA #3 was observed to pass a dinner meal to Resident #4. The CNA failed to offer handwashing to the resident. At 5:30 p.m., an unidentified CNA served a dinner meal to Resident #5 and failed to offer handwashing to the resident. At 5:32 p.m., CNA #2 was observed to to pass a tray to Resident #6. She failed to offer handwashing to the resident. B. Interview The DON was interviewed on 3/31/2020 at 5:37 p.m. The DON said the residents should be offered and assisted to wash their hands prior to eating. She said that the staff had been trained to assist the residents to wash their hands with either soap and water at the sink, or to use the alcohol based hand rub (ABHR). II. Failure to ensure staff were following proper PPE guidelines A. Observations and interviews On 3/31/2020 at 3:34 p.m., a staff member was in room [ROOM NUMBER]. The sign outside of the door documented the resident was on droplet/contact isolation. The massage therapist was in the room with a gown, gloves, and a face mask. She did not have goggles on as required for droplet/contact precautions. She was observed to touch the resident ' s legs and back. At 3:41 p.m., registered nurse (RN) #1 was notified the staff was in room [ROOM NUMBER] with not all of the correct PPE equipment. She was told that the staff member had no goggles. RN #1 went to observe the staff member and said it was the massage therapist. RN #1 said the resident was on droplet precautions and that meant full PPE which included, mask, gown, gloves and eye protection (goggles or eye shield) to be worn. She said she would provide some education to the massage therapist about wearing the proper PPE. At 4:39 p.m., CNA #1 was observed to go into the semi private room of Resident #1 and #2. The signage on the door read, ISO The CNA #1 was observed to put the gown on in the room, gloves and she had N95 mask on when she entered the room. The CNA was observed to not wear eye protection. The CNA handed Resident #2 a glass, from his bedside table. She then proceeded to go to Resident #1 ' s side of the room and she put the oxygen via nasal cannula onto Resident #1 with the same gloved hands from Resident #2. She then proceeded to Resident #2 and removed some trash from his bedside table. The CNA #1 was interviewed on 3/31/2020 at 4:50 p.m. The CNA said the resident was on droplet precautions and therefore she had to wear the PPE. She realized she did not have eye protection and said she should wear it. The director of nursing (DON) was interviewed on 3/31/2020 at 5:37 p.m. The DON was alerted about the above observations. She said the staff should wear full PPE when in the isolation rooms for droplet precautions. She observed the sign which was hand written and read, ISO. She said housekeeping was responsible for putting the proper notices up on the door. She said she would place a correct sign on the door. The DON said the resident was on isolation for droplet precautions. III. Biohazard container A. Observations On 3/31/2020 at 4:00 p.m., the secured memory unit had a room [ROOM NUMBER] which was on droplet precautions. Outside of the room were two cardboard boxes, which had no lids and had plastic bags inside. The boxes were used for trash, and used linens. The memory unit had 12 residents residing on the unit which the residents were walking in the hallways near the biohazard containers. The boxes were not covered so which put the potential risk for items to be removed from the boxes. At 4:28 p.m., the biohazard cardboard boxes were now in plastic bins with lids outside of the room. B. Interview The infection control preventionist (ICP) was interviewed on 3/31/2020 at 4:45 p.m. The ICP said that they had run out of the plastic biohazard boxes and that they were using the cardboard boxes. However, he said that a few of the plastic boxes were now available so he switched them out.

Based on observations, record review and interviews, the facility failed to ensure resident care consistent with professional standards of practice, to prevent avoidable pressure ulcers (injuries) for two (#63 and #85) of four residents reviewed out of 39 sample residents. Resident #63 was admitted with dementia and muscle weakness and required extensive two-person assistance for mobility and transfers. This made the resident at risk for skin breakdown. The facility was aware of the resident's condition and failed to implement offloading, pressure relieving interventions until after the resident developed pressure ulcers. The resident had developed five facility-aquired pressure ulcers, two of which were stage 4, and two were unstageable. Furthermore, some interventions that were implemented were not person-centered or effective to assist the ulcers in healing (see observations and physical therapist interview). Additionally, the facility failed to monitor an implemented intervention of a Roho cushion (pressure relief cushion, made of soft flexible aire cells) for Resident #85 to ensure it was inflated and provided the appropriate amount of offloading required to promote healing of a pressure ulcer to the right buttocks. Findings include: I. Facility policies and procedures The Pressure Injury Prevention policy, revised October 2019, was provided by the clinical assistant (CA) on 2/10/2020 at 3:22 p.m. The policy required staff to: -Upon Admission, complete an initial skin risk assessment by utilizing the admission nursing data collection evaluation in the electronic medical record to identify a resident risk factor for development of pressure injuries. -The facility will then complete a Braden scale for predicting pressure sore risk tool upon admission. -The facility will implement a care plan to identify potential risk for development of pressure injuries to include the identified risk (quoted in original) factors. -The facility nursing assistants will complete a skin observation (quoted in original) and document finding by completing the every shift skin observation question in electronic medical record. The skin observation documentation is reviewed by a supervisor or designee daily. An abnormal finding will be reported to the director of nursing (DON) who will initiate additional follow-up. -When a pressure injury is identified, the nurse will obtain a physician order [REDACTED]. -The facility will consult with PT/OT about appropriate wheelchair cushion/ positioning as needed. The Pressure Injury Management policy, revised October 2019, was provided by the clinical assistant (CA) on 2/10/2020 at 3:22 p.m. The policy documented in pertinent part: -The charge nurse or designee will be responsible to complete an initial narrative note in the resident's medical record to describe the residents' identified risk factors and a description of how the pressure injury most probably occurred if known. -Risk factors may include but not limited to impaired/ decreased functional mobility, comorbid conditions, such as diabetes mellitus, drugs such as steroids that may affect healing, impaired diffuse or localized blood flow, undernutrition, malnutrition and hydration deficits etc -A care plan will be initiated to identify actual skin breakdown to include identified related to risk factors (quoted in original) and individualized (quoted in original) interventions to aid in wound healing -The resident's pressure reducing surfaces (wheelchair and mattress) will be re-evaluated. An upgrade will be made if indicated. -Resident will be offered position changes at least every two hours unless otherwise specified per their care plan. -Any resident who has a pressure injury, nursing will be responsible to complete daily documentation on the monitoring of the wound in the progress note section of the medical record. -Weekly, the wound nurse or designee will conduct wound rounds and document the evaluation in the medical record. -The facility will have an interdisciplinary team (IDT) meeting to review current treatment plans and initiate any revisions/ changes to the plan of care as indicated. II. Failure to prevent unstageable pressure injuries for a resident with known risk A. Resident #63 status Resident #63, age 91, was admitted on [DATE], and readmitted on [DATE]. According to the February 2020 computerized physician's orders [REDACTED]. The 1/15/2020 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She required extensive two person assistance with bed mobility, dressing, toileting, personal hygiene and bathing. She was totally dependent on staff for transfers. She required supervision to eat. She had six unstageable, deep tissue injuries (DTIs) due to pressure. Two of the wounds were present on admission. Four of the wounds were acquired at the facility. One of the wounds was covered in eschar (necrotic dead tissue). B. Record review 1. Five facility acquired wounds On 2/13/2020 at 10:15 a.m., the clinical advocate (CA) provided a timeline for five (one more than identified on the MDS on 1/15/2020) facility acquired wounds which documented: -Right posterior medial heel, onset date 10/1/19. Initial measurements 4.0 cm (centimeters) long x 5.0 cm wide x 0 cm deep. Current measurements on 2/10/2020 were 0.8 cm long x 1.6 cm wide x 0.2 cm deep. The current treatment was to cleanse with normal saline, apply skin prep to the periwound, Collagen Alginate, cut to fit wound, cover with Allevyn, wrap with kerlix, change three times per week and as needed. -Left plantar lateral heel, onset date 10/1/19. Initial measurements 3.4 cm long x 3.0 cm wide x (unable to determine depth). Current measurements on 2/10/2020 were 0.5cm long x 0.3 cm wide x 0 deep. Current treatment was skin prep to periwound, cover with [MEDICATION NAME] dressing, change three times per week and as needed. -Left medial first (not marked on any diagram) foot, onset date 12/9/19, initial measurements 0.6 cm long x 0.3 cm wide x (unable to determine depth). The wound resolved 1/27/2020. -Left plantar heel, onset 12/23/19, initial measurements 0.9 cm long x 0.6 cm wide by 0 cm deep, measurements on 2/10/2020 were 0.6 cm long x 0.2 cm wide x 0 cm deep. Current treatment was skin prep to periwound, cover with [MEDICATION NAME] dressing, change three times per week and as needed. -Right distal first toe, onset date 1/6/2020, initial measurements, 0.4 cm long x 0.7 cm wide x 0 cm deep. The wound resolved on 2/10/2020. 2. Delayed treatment after wounds developed The timeline further documented an air mattress was implemented on 10/18/19, 17 days after the heel wounds were identified. Blue lift boots were ordered 10/17/19, 16 days after the heel wounds developed. A nutritional supplement, four ounces three times a day, was added 10/18/19. This was 17 days after the heel wounds developed. Prevalon boots were not ordered until 10/28/19. 3. Facility knowledge of pressure injury risk and failure to implement timely prevention/healing measures The Braden skin risk assessment dated [DATE], prior to the development of the wounds, documented the resident's mobility was very limited and friction and shearing were a problem. The resident scored a 13, moderate risk. The Braden scale documented scores, at risk score were 15-18, moderate risk 13-14, high risk 10-12, very high risk 9 or below. However, the facility failed to implement any repositioning, turning or offloading interventions at that time. The MDS assessment dated [DATE], prior to the onset of the wounds, documented Resident #63 was at risk for developing pressure injuries. She was not on a turning or positioning program. She was on a pressure reduction mattress. She required extensive one person assistance with bed mobility and extensive two person assistance with transfers. However, the facility failed to implement any turning, offloading or repositioning interventions at that time. The CPO dated February 2020 was reviewed. There was an order initiated 10/17/19 to offload heels at all times. Heel lift boots and pillow while in bed. This was 16 days after the wounds developed. There was an order dated 10/18/19 for blue lift heel boots on at all times to both feet. This was 17 days after the heel wounds were acquired in the facility on 10/1/19. There was no order for any kind of air mattress. The care plan initiated 7/21/19, prior to the development of the wounds, was reviewed. The care plan did not document any type of repositioning or offloading of the feet/heels despite the known risk identified in the MDS and Braden risk assessment. The care plan documented potential impairment to skin integrity related to fragile skin and increased use of wheelchair, and reduced walking. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin. The current care plan, initiated 12/10/19, documented Resident #63 had pressure injuries to her bilateral lower extremities. Interventions included: encourage good nutrition, keep skin clean and dry, monitor pain level, obtain lab and diagnostic work as ordered, pressure relieving mattress, weekly skin check by nurse, and wound team. The care plan did not include interventions to offload the heels or use protective offloading boots despite the current orders and known wounds to the heels and feet. The care plan did not include the use of an air mattress. The nurse's note, dated 9/30/19 at 11:02 p.m. (one day before the heel wounds were documented), was reviewed. The nurse's note documented the heels are intact, blanching well, pink and firm. 4. Deep tissue injuries identified to bilateral heels The nurse's note dated 10/1/19 at 3:00 p.m. was reviewed. Deep tissue injury pressure areas noted to bilateral lateral aspect of heels during shower. Left lateral heel 4 x 3 cm, right 4 x 2 cm, both 100 percent deep tissue injuries. -Left heel skin open so dressing applied for protection. Tight fitting shoes removed. Will offload with heel boots during the day and offload with boots and pillows at bed time. These interventions were not included in the care plan. The physician wound notes on 10/7/19, one week after the development of the wounds to the right medial heel and left lateral heel, were reviewed. -The wound notes documented, the resident had an unstageable, DTI of the right, posterior, medial heel for at least six days duration. There was no exudate (drainage). The resident appeared to have associated pain evidenced by restlessness. Measurements were 4.0 cm x 5.0 cm x depth was not measurable. -The left lateral heel was unstageable due to necrosis (dead tissue), there was moderate serosanguinous drainage (clear fluid mixed with blood) and the wound measured 3.4 cm length x 3.0 cm wide x depth was not measurable. -Discussed etiology of her wounds and advised of the importance of offloading her heels. The physician wound notes dated 1/27/2020 were reviewed. The physician documented both heels were stage four wounds. The physician documented off load wounds, prevalon boots instead of bunny boots, pillow between her legs when she is on her sides especially on left which she favors and also under her legs when she is on her sides. However, the care plan and the February 2020 CPO did not document orders for Prevalon boots or offloading the resident with pillows when she was positioned on her side. 5. Additional, unstageable pressure ulcer identified to left plantar heel; bilateral heel wounds assessed as stage IV The physician notes, dated 1/6/2020, for the wound to the left plantar heel, developed 12/23/19 were reviewed. The physician documented the left plantar wound was 0.8 cm long x 0.3 cm wide x not able to measure depth. It was a pressure injury, an unstageable wound, deep tissue injury with intact skin. The wound had no exudate (drainage). Off-load wound. The note summary by the physician on 1/6/2020 documented the right posterior heel was a stage 4 pressure wound, the left lateral heel was a stage four pressure wound, the left plantar foot was an unstageable DTI. 6. Most current wound assessment/condition - two unstageable pressure injuries The nursing pressure injury reports for 2/3/2020 were reviewed. On 2/3/2020, the right medial heel was documented as unstageable, 0.8 cm long x 1.7 cm wide x 0.25 cm depth. The wound had a moderate amount of drainage, serosanguinous.The resident had granulation tissue (pink, red shiny) and slough (yellow white tissue). The resident was to be premedicated before the wound care for pain. On 2/3/2020, the left lateral heel was documented as unstageable, 0.5 cm long x 0.4 cm wide x 0 depth. The wound bed was necrotic tissue with eschar, black brown or tan in color. There was no drainage. The resident was to be premedicated before wound care for pain. On 2/3/2020, the left plantar heel was documented as a stage one, 0.7 cm long x 0.3 cm wide x 0 cm deep. The wound bed had new [MEDICATION NAME] tissue growing, light pink and shiney. C. Observations and interview On 2/10/2020 at 10:30 a.m., the resident was up in a wheelchair with her legs lifted and extended, with soft light blue boots on each foot. Her heels were not off loaded. On 2/11/2020 at 1:09 p.m, the resident was in bed, blue soft boots were noted on both feet. Her heels were floated. On 2/13/2020 at 11:10 a.m., the resident was observed with the physical therapist (PT) in the dining room. Both feet were in soft blue boots which had an opening at the heel. The PT confirmed the boots were lift boots. Her feet were covered with kerlix wrap except the toes which were [MEDICAL CONDITION]. Her heels were not off loaded D. Interviews and record review Registered nurse (RN) #1 was interviewed on 2/13/2020 at 10:37 a.m. She said the resident was basically bed bound at the time the wounds were found, the night nurse found them. She said, They were from pressure on the bed and probably in the wheelchair. She could not move herself. Certified nurse aide (CNA) #6 was interviewed on 2/12/2020 at 10:45 a.m. She said she knew the resident well and had worked on the residents hallway over the last year. She said Resident #63 had never been able to move in the bed. She said she had to be transferred with a lift. CNA #6 said the nursing staff did not put boots on the resident or offload her heels on a pillow until after the wounds occurred despite her immobility in bed. The director of nursing (DON) was interviewed on 2/12/2020 at 10:46 a.m. She said the wounds could not be observed because the treatment had already been done and was not due again until Saturday. The DON was interviewed again 2/12/2020 at 12:47 p.m. She said the wound could not be observed by looking under the dressing because the resident was in too much pain with dressing changes. She said, She is on [MEDICATION NAME] because she has so much pain with dressing changes so I do not want to lift the dressing for you to see it. The pain assessments were reviewed on the Medication Administration Record [REDACTED]. The [MEDICATION NAME] ordered on the February CPO, dated 1/29/2020, documented to give [MEDICATION NAME] sulfate 20mg (milligram)/ml (milliliter), 5mg by mouth before dressing changes weekly. However, the dressing changes were three times a week and as needed. There was no documentation to show the facility requested order clarifications or changes. The CA was interviewed on 2/12/2020 at 1:11 p.m. She said the resident only had pain when the wounds were debrided. She said she would have the [MEDICATION NAME] order clarified. The CA said she had been at the facility for four years and had been doing the weekly wound assessments for this resident. She said she did not know how the wounds occured. She said she did rounds with the wound care physician weekly. The DON was interviewed again on 2/12/2020 at 2:34 p.m. She said the nurses told her the resident had pain with the wound care treatments. She said that may not be totally accurate after reviewing the records for [MEDICATION NAME] and pain. She said the wound could still not be observed because there would be too much risk of infection to look under the dressings. Although the facility was aware of Resident #63's risk for skin breakdown, they failed to prevent unstageable pressure injuries from developing. III. Resident #85 A. Resident status Resident #85, age 81, was admitted on [DATE]. According to the October 2019 computerized physician orders [REDACTED]., type 2 diabetes mellitus with other circulatory complications, encounter for change or removal of nonsurgical wound dressing, pressure ulcer of other site, stage III was added to the list of diseases on 11/26/19. The 1/20/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident required two persons physical assistance with bed mobility, transfers, dressing and toilet use. She also required one person physical assistance with personal hygiene.The assessment identified that the resident was at risk of developing pressure injury. It was further documented that the resident had developed a stage III pressure ulcer. The resident was not on a repositioning program. The resident did not not reject care. B. Resident wheelchair chair observations and record review A physician's orders [REDACTED]. Resident #85's wheelchair was observed on 2/10/2020 at 11:17 a.m. while it was positioned by the resident's bedside. The wheelchair was electric powered and had a roho cushion on it. The roho cushion was deflated and relatively flat to provide any type of cushioning off loading effect See observation below with the therapy program manager. Resident #85's wheelchair was observed on 2/11/2020 at 2:38 p.m. while it was positioned by the resident's bedside. The wheelchair had a roho cushion on it. The roho cushion was deflated and relatively flat to provide any type of cushioning effect. Resident #85's wheelchair was observed on 2/12/2020 at 12:46 p.m. while the resident sat in it. The therapy program manager (TPM) observed the level of inflation of the roho cushion and reported that the cushion was almost completely out of air. Specifically, the therapy manager stated yes the cushion is definitely not cushioning with this level of inflation, there is almost no air in this. The TPM demonstrated the procedure of checking the appropriateness on the inflation of the roho cushion by first seeking and obtaining consent from the resident, he then placed his right hand between the roho cushion and the wheelchair seat, he performed this procedure while the resident sat in the cushion. Therapy program manager was interviewed on 2/12/20 at 12:49 p.m., The TPM verified that the roho cushion was underinflated per his observation as discussed above. He did not recall providing any education to nursing staff on how to check for the proper inflation of the roho cushion. He stated pumping the roho cushion was a primary responsibility of the restorative staff. He verified that nursing staff do not have access to the pump utilized in pumping the roho cushion. He reviewed the resident's PT/OT record and verified that the last time the resident was on their caseload was 10/6/19 through 10/15/19 and that the sessions were primarily for passive range of motion for the residents legs relative to their position while the resident sat in her wheelchair. Certified nurse aide (CNA #8) who transferred the resident to her wheelchair was interviewed on 2/12/20 at 1:03 p.m. about her knowledge of how and when to check the inflation level of the roho cushion. CNA #8 stated she does not know how much air to pump it in, she stated she once tried to pump air in a cushion for another resident, but did the procedure wrong and she pumped too much air which was not beneficial to the resident. She concluded the interview stating she did not recall when last she checked the air in cushions. CNA #9 who assisted CNA #8 with transferring Resident #85 was interviewed on 2/12/2020 at 1:07 p.m. The CNA stated she lacked knowledge of the need to check the roho cushion prior to transferring the resident on it. She said she does not know when to check the inflation level of the roho cushion. She said she does not know where the cushion pump is kept. C. Mattress observation and record review A physician order, dated 6/20/16 revealed to place Resident #85 on low air loss mattress and check air inflation and functioning every shift. The resident's mattress was observed on 2/12/2020 at 9:53 a.m. The mattress had (company name) alternating pressure with 10 low pressure mattress (LPM) compressor. The director of nursing (DON) was interviewed on 2/13/2020 at 10:47 a.m., she stated the mattress currently being utilized by Resident #85 was rented by the facility to accommodate the residents' need. She provided information about the suitability of the mattress to be utilized for a stage 1-4 pressure ulcer. Specifically, the DON provided documentation which reads {company name) CG9900 alternating pressure mattress replaced with probasic satinair alternating pressure low air loss mattress. The document further revealed that the mattress currently in use by Resident #85 had been discontinued. (See follow-up below) D. Record review A review of the Braden scale assessment dated [DATE] (last assessment on the resident's medical record prior to development of the stage III pressure ulcer) revealed a score of 12. The resident had a score of 12 or high risk for the following reasons. Her sensory perception was slightly limited. She responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. The resident is constantly moist. Her skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned. The resident was bedfast (Confined to bed). She has very limited ability to change her body position. She makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. The resident also has potential for skin friction as she moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair or other devices. which was interpreted as high risk for developing pressure ulcer. -There were no changes made to the resident care plan to address the identified risk of diminished sensory perception, inability to adequately communicate discomfort or need to be turned, her limited ability to independently change her position and also her potential for skin friction. Another Braden Scale for predicting pressure sore risk was completed on 1/17/2020 at 1:57 p.m. The scale documented resident risk score as 11, which is interpreted as high risk. Per the facility's pressure injury prevention and management policy, a skin observation was to be conducted daily Q (every) shift and observation documented of any skin issues for at risk residents. However a review of Resident #85's pressure injury initial and weekly monitoring report (The first one done after discovery of the pressure ulcer) revealed that though the pressure ulcer was first identified on 11/26/19, a skin evaluation which revealed the pressure ulcer measurement of 1.5cmx0.8cmx0.1cm was not completed until 12/2/19. There was no prior documentation of any suspected skin issues around the area. The evaluation further identified the pressure ulcer as facility (In-House) acquired. There was no interdisciplinary team (IDT) note which documented investigation to find the root cause and analysis of the now identified in-house acquired pressure ulcer. The site of the ulcer was identified as the right buttocks. Exudate type was characterized as serous, and the amount of exudate was rated as small. There was no odor reported for the assessment. The wound bed was described as granulation tissue - pink or red with shiny, moist granular appearance and slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. The surrounding skin color and surrounding tissue/wound edges were described as normal. The wound summary described the pressure ulcer as 30% slough, 20% granulation, 20% dermis and 30% subcutaneous. A review of the wound doctor's note dated 12/2/19 revealed,a documentation under the history of present illness portion of the assessment which reads ,At the request of the referring provider (Doctors name), a thorough wound care assessment and evaluation was performed today. Resident has a stage III pressure wound of the right buttocks for at least five days duration. There is light serous exudate. There is no indication of pain associated with the condition. Summarized wound care assessment and individualized treatment plan portion of the wound doctor's note reads Plan of care reviewed and addressed, my goal for this wound is healing as evidence by decrease in surface area of the wound and/ or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 42 days. This estimate is made with an 80 percent (%) degree of certainty. The assessment also recommended to off-load wound and reposition per facility protocol. The Resident's primary care physician note dated 1/25/2020 at 12:19 p.m. documented that Resident #85 was quadriplegic with a recent overall decline following pneumonia. The note further documented that the resident was now on hospice. In addition, the note reported that Resident #85 had no feeling on her back side. Furthermore, the note documented that the resident was on a high end air mattress and that her oral intake has been poor and also that resident is provided protein supplement. It was also reported that the resident was up in her electric scooter several times a day but not more than an hour at a time. The report concluded that all appropriate steps were taken by staff but the decubitus pressure ulcer was unavoidable. The pressure ulcer care plan initiated on 2/3/2020 and revised on 2/3/2020 documented that the resident has hx(history) of pressure ulcers, DM and fragile skin, [MEDICAL CONDITION] and history of pressure sores in the same area, with surgical flap previously done. In addition, the care plan further documented that Resident #85 is on aspirin (ASA) causing frail skin increasing the risk of bruising and skin tears. Furthermore, it was documented that the resident at times prefers to sit up in her wheelchair for extended amounts of time. The care plan also identified that Resident #85 had a Stage IV pressure ulcer to her right buttocks and traumatic wounds to her right toes The interventions of the care plan documented to: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Encourage resident to change position and overload pressure by not sitting up in wheelchair for extended amounts of time. -Resident lays in bed without a brief or underwear per her preference. -Resident requires pressure relieving/reducing device on bed and chair -Low air loss mattress, check air inflation and functioning every shift -Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. -Pressure relieving cushion(roho) to wheelchair -Skilled nursing documentation including skin assessments every shift while on skilled care. Weekly skin assessments for integrity and wound documentation while not on skilled care requirement. -Weekly skin check by licensed nurse. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate -Wound team to follow-up E. Wound observation The resident's right buttocks wound was observed on 2/12/20 at 12:13 p.m. with the director of nursing. The wound was approximately 1 cm in diameter, crater-maybe 0.2 cm deep. Wound bed red and moist no drainage, edges pink, no odor. Treatment done-wound cleaned with normal saline (NS), cut to fit calcium alginate, covered with [MEDICATION NAME]. Hand hygiene and clean field maintained. F. Interviews Resident #85 was interviewed on 2/10/2020 at 12:53 p.m., she stated she used to reposition herself in bed several months back but for a severe shoulder pain she has not been able to help herself. She added that she is not currently getting a specialized treatment to address her shoulder pain other than the generalized pain medication she was taken. She also said she does not get assistance with repositioning. Specifically, the resident stated They only come to get me out of bed into my wheelchair with the lift, and also to change out my brief when it was soaked, other than that, I am not offered repositioning. CNA #10 was interviewed on 2/13/2020 at 6:12 p.m. She stated she worked well with Resident #85. She listed the care she performed with Resident #85 which included transfers from wheelchair to bed and vice versa, bathing, toileting, grooming, dressing. She said she considered the moments when the resident's briefs are changed or when she was transferred to wheelchair as repositioning. She stated the resident could reposition herself. The CNA stated she typically applied barrier cream to the resident's groin and abdominal folds. She did not recall having had any directive instructing her to apply barrier cream to the resident's coccyx since the onset of her current stage III pressure ulcer. CNA #11 was interviewed on 2/13/2020 at 6:10 p.m. She stated Resident #85 was cooperative with care. The CNA said she would apply barrier cream to the resident's groin and abdominal folds. She did not recall having had any directive instructing her to apply barrier cream to the resident's coccyx since the onset of her current stage III pressure ulcer. The wound nurse (WN) was interviewed on 2/12/2020 at 1:28 p.m., She said the pressure ulcer to the resident's right buttocks was a facility acquired ulcer that started late November of 2019. She said she took the measurements of the resident's right buttocks wound and placed this information in the PCC. She said the resident's physician and the IDT could review the information in PCC. She said the wound doctor did visit the facility to look at the resident's right buttocks wound. She said the start date for this right heel wound was on 11/26/19. She said she thought the wound developed abruptly because the resident was on aspirin (ASA). She said the resident was independent with positioning while in bed and that she also ut(TRUNCATED)

Based on observations, record review and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions for one of one serving areas. Specifically, the facility failed to ensure: -Food temperatures of cold food was held at the proper temperature to reduce the risk of food borne illness; -Disinfecting chemicals were maintained at appropriate parts per million (PPM); -Dented canned food items were not put in the rotation, ready to be used and served: -Sugar, flour and utensils were stored appropriately; and -Food preparation surfaces were properly sanitized in the bistro area. Findings include: I. Inadequate holding temperatures A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf. It reads in pertinent part; The food shall have an initial temperature of 41 degree Fahrenheit (ºF) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Observation During observations of the evening meal on 2/12/2020 beginning at 5:00 p.m., the following food temperatures were obtained from the steam table with the staff member present: The initial temperature of the egg salad at the beginning of the meal at 5:00 p.m. reads: -44 degrees fahrenheit (F). The egg salad was prepared in a big bowl which sat in a well of ice. The well did not have enough ice in it, thus the egg salad bowl did not have a mechanism to keep its temperature relatively low. Individual portion was served out to the population of residents from the bowl of egg salad. At 6:48 p.m., the temperature of the egg salad was taken immediately after the last tray was served and it reads: -46 degrees F. C. Interview The dietary director (DD) and the dietary consultant (DC) were interviewed on 2/13/2020 at 1:16 p.m. The DC stated egg salads were served cold. Specifically, the DC stated for cold food to be considered served within a temperature of 41 degrees (F) and below. The DD however verified that the initial temperature of the egg salad served during the evening meal on 2/12/202 had an initial temperature of 44 degrees (F) and an holding temperature of 46 degrees at the end of service.The DD stated the mechanism used to preserve the food item in concern was not holding temperature due to not placing the sheet pan in well full of ice or back in the refrigerator and as such could not preserve the temperature. The DD stated she would utilize the refrigerator in the kitchen, specifically, the EC stated cold food items would be placed in the refrigerator in the kitchen and items needed to be served cold would be individually brought out of the refrigerator to preserve and maintain desired temperatures going forward. II. Disinfecting chemicals not maintained at recommended part per million (PPM) A. Observations During observations of the evening meal on 2/12/2020 beginning at 5:00 p.m., the line cook brought out cabinet mats and plastic plate covers from the disinfecting compartment of the the three compartments wash system utilized by the facility. She then placed the same items in the rinse compartment. The DD took the PPM reading of the disinfectant with a PPM test strip and on comparing the color of the test strip with the calibration on the box, the PPM was at zero (0). B. Interviews The DD was interviewed on 2/12/2020 at 5:00 p.m. The DD stated the facility utilized a three compartment sink. She added that the disinfectant was what the facility relied on to disinfect countertops, dishes and other relevant cooking utensils. The DD stated that for the chemical to be at a zero reading, it must have been sitting for several hours. She clarified that it was the duty of the line cook to check and replace the disinfectant as needed. The DD also verified that there was no schedule on file that directs the cooks on when to change out the disinfectants. Finally the DD stated she would educate dietary staff on the need to record the PPM of the disinfectants more frequently to ensure that they were maintained at the recommended level. The EC said the chemical should be at a minimum level of 50 PPM. III. Dented food cans A. Observation During observations of the evening meal on 2/12/2020 beginning at 5:00 p.m., Canned food materials which were dented around the seam were observed on the shelf and ready to be served. The food materials included: -two cans of sauerkraut; and, -one can of mandarina naranja. The DD and the DC were interviewed on 2/13/2020 at 1:16 p.m., the CD verified that the facility cared for vulnerable individuals and that it was essential to ensure food served to such a population were free from contaminants. Specifically, the DC verified that the three identified cans were dented enough to have raised a red flag for dietary staff not to have shelved them ready to serve. In addition, the DC stated the risk associated with canned food dented around the seam is that the dents could result in a pinhole-size opening and that the mixture of air and moisture from the food within the can have the potential to spur bacteria growth hence contaminating the food. She reported that the standard was to store dented cans separately and request credit for them from suppliers. The DC concluded the interview stating she would provide education to dietary staff going forward. IV. Failure to ensure flour, sugar and utensils were stored in sanitary manner A. Observation During observations of the evening meal on 2/12/2020 beginning at 5:00 p.m., the pizza cutter, measuring spoons, spatulas, tongs whisks, sugar bin and flour bin were observed in the kitchen cabinets. The cabinets which housed the pizza cutter, measuring spoons, spatulas and tongs whisks had a mixture of oily and black dustlike particles which were consistent with long standing dirt. The DD examined the said cabinets using her finger to gather the particles and agreed that they were indeed dirty. The flour and sugar bin which had flour and sugar ready to serve in it, had dried up multi colored patches within the bins which were consistent with drainage flowing from the counter-top into the bin. Again the DD examined the flour and sugar and agreed that they needed to be cleaned. V. Follow-up The DD provided a copy of in-service attendant record for the topics: -Cleaning sugar and flour bins properly -Cleaning drawers that hold utensils on prep The in-service attendant reported a start date of 2/13/2020. The document further reported an identified solution which read: All drawers and bins should be fully emptied, scrubbed and sanitized, let fully dry before putting clean utensils or new products in bins. The DD and DC were interviewed on 2/13/2020 at 1:16 p.m. The DD verified that the facility conducted the above mentioned in-service because they were informed during survey of the above observations. VI. Ineffective surface cleaning of a food service area. Cross-reference F880, infection control A. Observation and staff interview AA #1 was interviewed on 2/13/2020 at 11:10 a.m. She said the bistro served concession food to residents, staff and visitors. AA#1 said she cleans food prep and delivery surfaces with a sanitized solution of water and steramine tablets. She said the solution's (PH) level should show 400 to 500 parts per million (ppm). She said she wiped the counter with a cloth and the sanitized solution before she prepared the food for service. AA #1 submerged an orange colored PH test paper strip into the solution. She removed the test strip from the water and compared the color the test strip color coded label. The test strip color was almost unchanged. The test strip remained orange. The very tip of the strip and part of the portion of the strip the AA held in her hand was green. The test strip revealed the PH level of the solution was less than 150 ppm. B. Staff interview The dietary consultant (DC) was interviewed on 2/13/20 at 2:16 p.m. with the dietary director (DD). She said the test strip should clearly read over 150 ppm. She said the bistro was also inspected by the county and have not had concerns related to the sanitized solution. She said the AD monitors the bistro and was primarily responsible for training her staff. The DC said she would order and place posters of safe infect control practices in the bistro. The AD was interviewed on 2/13/20 at 12:30 p.m. She said she has trained how to mix the sanitized solution and the PH level should read between 200 and 400 ppm. She said if the solution does not reach that level, the AA should remix before using.

Based on observations, record review and interviews, the facility failed to effectively follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection Specifically, the facility failed to: -Follow proper housekeeping protocols to prevent cross-contamination; -Ensure proper hand sanitation in rooms with residents with transmission based infections, and hand placement and hand hygiene when handling resident food; -Ensure proper use of personal protective equipment (PPE), including the changing of contaminating gloves, the donning and doffing of PPE and disposal of PPE in a room with a resident designated on isolation with contact precautions. -Create a complete program of infection surveillance, that investigated to determine the event of transmission, and causations to the spread of transmission based infections; and -Identify correlation between staff practices and the spread of infections; Cross-reference F812, kitchen sanitation Findings include: I. Improper handwashing and personal protective equipment (PPE) practices Facility policies and procedures The Handwashing/Hand Hygiene policy, revised August 2015, was provided on 2/13/2020 by the facility. The policy read in pertinent part: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors Wash hands with soap and water for the following situations: a. When hands are visibly soiled; and, b. After contact with a resident with infectious diarrhea including, but not limited to infectionions caused by norovirus, salmonella, shigella, and [DIAGNOSES REDACTED]icile Use an alcohol-based hand rub containing at 62% alcohol; or alternatively, soap and water for the following situations before and after contact with residents; after removing gloves; Before and after entering isolation precaution settings; before and after eating or handling food; Before and after assisting a resident with meals Hand hygiene is the final step after removing and disposing of personal protective equipment The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Personal Protective Equipment policy, revised October 2018, was provided on 2/13/2020 by the facility. The policy read in pertinent part: Personal protective equipment (PPE), provided to our personnel includes but is not necessarily limited to: a. Gowns/apron/lab coats (disposable, cloth and/or plastic); b. Gloves (sterile, non-sterile, heavy duty and/or puncture-resistant); c. Masks; and, d. Eyewear Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals. The Personal Protective Equipment - Using Gloves policy, revised September 2010, was provided on 2/13/2020 at by the facility. The policy read in pertinent part: To prevent the spread of infections To protect hands from potentially infectious material Use non sterile gloves primarily to prevent the contamination of the employee hands when providing treatment or services to the patient and when cleaning contaminated surfaces. According to the policy, staff should remove gloves by: -Using of one hand, pull the cuff down over the opposite hand turning the glove inside out; -Discard the glove into the designated waste receptacle inside the room; -With the ungloved hand, pull the cuff down over the opposite hand, turning the glove inside out; -Discard the glove into the designated waste receptacle inside the room; and, -Wash hands. B. Improper practices of PPE and hand washing procedures in isolation rooms 1. Resident #16 Resident #16, age 85, was admitted on [DATE], with a readmission on 1/10/19. According to the February 2020 computerized physician orders [REDACTED]. The CPO verbal orders revealed the resident was on droplet isolation precautions, with a start date of 2/6/2020. The tracking log for respiratory [MEDICAL CONDITION] (RSV), revealed Resident #16 was positive for RSV on 2/6/2020. a Observations Housekeeper (HSK) #1 was observed on 2/10/2020 at 10:50 a.m., cleaning the isolation room of Resident #16. HSK #1 was observed wearing the personal protective equipment (PPE), of mask, gloves and gown as she cleaned the room. HSK #1 removed her PPE, held her mask, gloves and gown in her hands, exited the room and entered the residential hallway. She opened the receptacle bin deemed for contaminated PPE, located outside the room of Resident #16. As she placed the PPE in the bin, she dropped the glove she used to clean the room on to the carpet beside the bin. HSK #1 picked up the glove with her bare hand and placed it into the receptacle bin. She then reached for a container of cleaning wipe clothes from her cleaning cart and proceeded to wipe down the bottom of her shoes. HK #1 did not wash or sanitize her hands after removing her PPE, after exiting the isolation room, after picking up the contaminated glove, and after wiping the bottom of her shoes. HSK #1 moved her cleaning cart to the doorway of the room next door to Resident #16, and proceed to clean the room without washing or sanitizing her hands upon entrance. b. Staff interview HSK #1 was interviewed on 2/13/20 at 10:55 a.m. She said she is a float housekeeper, responsible for cleaning the halls when the other housekeepers have the day off. She said she works on every hall, every week, depending on who was scheduled off. She said gloves need to be donned on entrance and doffed on exit of the room. HSK #1 said hands should be washed or sanitized after removing gloves and other PPE equipment. c. Record review The record of attendance for an all staff inservice held on 1/9/19 and again on 1/11/19, was provided by the facility on 2/13/2020. According to the record, the staff development coordinator (SDC), reviewed infection control procedures related to hand washing with staff. The record revealed HSK #1 attended the inservice. The online course completion log, was provided by the facility on 2/13/2020. The log revealed HK#1 completed the courses of infection control and prevention, transmission-based precautions, and hand hygiene. 2. Resident #204 Resident #204, age 85, was admitted on [DATE]. According to the February 2020 computerized physician orders [REDACTED].Difficile or C.Diff). The CPO revealed the resident was contact isolation beginning on 2/10/2020, related to C.Diff. a. Observations Certified nurses aide (CNA) #2 entered the room of Resident #204 on 2/12/20 at 9:22 a.m. CNA #2 donned PPE gloves and gown from a PPE dresser located outside the door of the resident's room. The CNA removed a tray and plate cover used during food delivery, off the resident's bedside table. She doffed her gown and gloves, and dropped the plate cover onto the resident's floor in front of the bathroom. She wiped down the lid with wipe cloths, left the resident's room, used alcohol based sanitizer gel on her hands, and placed the lid on top of the room tray cart. The CNA did not wash her hands after picking up a cover from the floor and leaving the room of a resident on contact isolation precautions related to C.Diff. -At 9:28 p.m., the speech therapist (ST), donned gloves and gown and entered the room of Resident #204. She did not secure the bottom of the gown, the strings to the gown were left untied. -At 9:40 a.m. CNA #5 handed the ST an oxygen tank for Resident #204. As ST spoke to the CNA, she placed her left gloved hand on the resident's room door frame and held the strap to the oxygen tank with her gloved right hand. -At 9:45 a.m. ST removed her gown and gloves and exited the room of Resident #204. She used alcohol sanitizer gel on her hands as she exited the room. She did not wash her hands. On 2/13/20 at 10:09 a.m. activity assistant (AA) #2 was observed in the room of resident #204. She wore PPE gloves and a gown. The gown was loosely tied with the strings on the bottom portion of the gown. The top of the gown was not secured to AA #2. The strings were not tied, and the gown hung low of the front of her shoulders. -At 10:13 a.m., AA #2 removed her gloves, balling them in her right hand, exposing the outer surface of the gloves to her bare hands. She entered the hallway still wearing the gown, walked around a PPE storage dresser, returned to the resident's room and removed the gown by rolling it into a ball, exposing the outer layer of the gown to her clothing and bare hands. She walked of the room of Resident #204 as she held the balled-up PPE. She did not wash her hands after exiting the room. She walked down the hallway and improperly placed the gown and gloves in a uncovered, small trash bin located next to a nurse medication cart, used to store and administer medications. She did not wash her hands after placing the PPE in the trash bin. AA #2 walked down the hall and walked behind the counter of a Bistro, used to offer food options to residents, guests and staff. AA #2 spoke to AA #1 behind the counter of the Bistro as AA #2 placed her unwashed hand on the surface of the counter. AA #2 left the Bistro and walked through an activity with residents in the living room. She briefly spoke to another activity assistant. She exited the activity and walked down the hall towards the uncovered trash bin next to the medication cart. AA #2 removed the PPE improperly placed in a trash bin, entered the room of Resident #204 without donning new PPE, and placed the used PPE into the receptacle bin deemed for used PPE located in the resident's bathroom. She then exited the room without washing her hands. -At 4:10 p.m., a PPE gown hung on the bathroom door handle in the room of Resident #204. -At 5:48 p.m., the PPE gown remained on the bathroom door handle. Registered nurse (RN) #3, removed the gown from the door, and placed it into the appropriate receptacle bin for PPE in the resident's bathroom. RN #3 said she did not know why the gown was hung on the bathroom door. She said she did not know if the gown was clean or dirty. b. Staff interviews The assistant nursing home administrator (ANHA), was interviewed on 2/13/2020 at 11:58 a.m. According to the ANHA, a staff member reported AA #2 did not follow appropriate infection control procedures after interacting with Resident #204. He said AA #2 was reeducated on PPE removal and disposal. He said AA #2 should not have placed PPE in an uncovered waste receptacle in the hallway, next to the medication cart. He said AA #2 should have not reenter the isolation room of Resident #204 without donning proper PPE. The ANHA said he would ensure AA #2 was aware of the necessity to wash hands after handling potentially contaminated PPE and after exiting an isolation remove for C.Diff. He said he would also ensure all staff understood appropriate hand wash practices, spread of infections. The ANHA said it was very important to appropriately secure PPE to the body without letting it hang loosely on the staff member. He said staff should also be aware of hand placement with potentially contaminated gloves and understand when to sanitize hands and when hand washing. He said he would ensure increased staff education and understanding would be provided to prevent the future of spread of infections and repeat infection control outbreaks. CNA #2 was interviewed on 2/13/2020 at 1:55 p.m. According to the CNA, staff should hand wash with soap and water after contact with a resident with [DIAGNOSES REDACTED] or contaminated surfaces in a room with isolation precautions including [DIAGNOSES REDACTED]. The activity director was interviewed 2/13/2020 at 2:30 p.m. She said her staff was aware of proper hand washing and PPE procedures. She said the SDC provided multiple training on infection control throughout the year. The AD said her staff should be prepared to work with residents with infections, including residents with C.Diff. c. Record review The 1/9/19 record of attendance for an all staff inservice for infection control related to hand washing revealed AA #2 attended the inservice. The attendance record did not indicated CNA #2 nor ST attended the hand washing inservice. The record of attendance for an all staff inservice held on 2/11/20, was provided by the facility on 2/13/2020. According to the record, the staff development coordinator (SDC), reviewed infection control procedures related to isolation precautions. According to the inservice agenda, the SDC addressed how to don and doff PPE correctly, and reminded staff to wash in and out of infected areas. The record revealed AA #2 attended the inservice. The attendance record did not indicate ST nor CNA #2 attended the inservice. The online course completion log, was provided by the facility on 2/13/2020. The log revealed CNA #2 completed the course for hand hygiene. According to the online course log, AA #2 completed courses for infection control and prevention, transmission-based precautions, and hand hygiene. The log did not indicate ST recieved the online training courses for infection control and prevention, transmission-based precautions, and hand hygiene. C. Improper housekeeping cleaning practices 1. Observations The housekeeping supervisor (HS), was observed on 2/12/20 between 9:20 a.m. and 10:55 a.m. During observation, the HS cleaned rooms #101, #103, #105, and #107. HS donned gloves prior to entering each room, and doffed the gloves on exit of the room. She did not change her gloves after scrubbing the toilet in each room, before proceeding to clean high touch surfaces in the residents' rooms. -At 10:27 a.m., HS donned PPE gloves and entered room [ROOM NUMBER]. She sprayed a cleaning agent over the surface areas of the sink, grab bars, and toilet. She removed a scrub brush from her cleaning cart located in the doorway of room [ROOM NUMBER] and entered the bathroom. HS scrubbed the inside of the toilet with the brush. She returned the brush to her cleaning cart. She did not change her gloves. With her contaminated gloved hands she removed a cleaning dry cloth from the cart. The HS sprayed the cleaning agent onto the cloth. The HS proceeded to wipe down high touch surfaces while she wore the same gloves she used to scrub the toilet. With her gloved hands, the HS touched the bathroom door handles and door frame, the drawstring on the window blinds, chair, wheelchair leg rests, the bedside table three times, a lamp, a remote, and a box of tissues. The HS then reentered the bathroom, wiped down the surfaces of the sink, grab bars and toilet. The HS returned to her cleaning cart, doffed her gloves, sanitized her hands and swept and mopped the floor in room [ROOM NUMBER]. She doffed her gloves, sanitized her hands and proceeded to the next resident room. 2. Staff interviews Housekeeper (HSK) #4 was interviewed on 2/12/2020 at 8:44 a.m. She said each housekeeper on duty is responsible for cleaning one hallway except on weekends. She said that on weekends, there were only three housekeepers on duty, compared to four housekeepers during the week. She said the three housekeepers would share the open hall to ensure all resident rooms were clean. She said she had been trained on how to clean a resident's room if they were on isolation precautions related to a transmission based infection. HSK #4 said proper cleaning practices included using designated PPE and limit risk for cross contamination by hand washing, wiping down cleaning supplies after use and disinfecting shoes. The HS was interviewed on 2/12/2020 at 10:48 a.m. She said she sprays down the bathroom scrubs the toilet first when entering a resident room to allow a 10 minute dwell time. She said she then would clean all other high contact surfaces during the required dwell time, and then return to finish the bathroom. She said she removes her gloves after the completion of the bathroom cleaning and before sweeping and mopping the floor. The housekeeping and laundry supervisor (HLS) was interviewed on 2/13/2020 at 11:30 a.m. with the ANHA. She said all of her staff has received training on PPE use and disposal of PPE, isolation protocols, and how to prevent the spread of infections. The HLS said staff should only place PPE used from isolation rooms in a non designated waste receptacle because of the risk of cross-contamination. She said she trains newly hired staff by observing them clean unoccupied rooms. She said she reviews cleaning steps and chemical dwell times to ensure effected cleaning practices are learned. She said staff also receive infection control training in new hire orientation and all staff inservices. The HLS said her staff also went through an inservice on RSV last month, and recently reviewed precautions with C.Diff. She said her staff should be very aware not to contaminate high touch surfaces in resident rooms and provide a proper cleaning. The HLS said the cleaning of the restroom and the scrubbing of the toilet should be the last thing to clean to prevent cross-contamination. She said staff need to change gloves between cleaning areas. She said after they come out of the bathroom they should either wash their hands or use hand sanitizer and then change to a new pair of gloves. She said they should have changed gloves especially after cleaning the restroom. D. Contamination of resident food 1. Observation and resident interview: On 2/12/20 at 9:50 a.m., CNA #5 set down an unpeeled orange in a bowl on top of the PPE dresser before she answered a call light from a room across the hall. She exited the resident room without washing or sanitizing her hands. CNA #5 picked up the bowl by placing the palm of her right hand over the bowl, directing touching the peel of the orange as she walked down the hall. She entered the room of Resident #28 and delivered the orange. Resident #28 was interviewed on 2/12/20 at 9:57 a.m. She said she would peel the orange by slicing it with her knife. 2. Staff interview The dietary director (DD), who identified herself as the facilities registered dietitian, was interviewed with the dietary consultant (DC), on 2/13/20 at 2:16 p.m. The DD said she frequently inservices staff not to spider hand resident cups and bowls. The DD said spider handing referred to staff improperly holding a cup or bowl where the eating surface was touched by a staff member's hand. The DC agreed that the unpeeled orange was contaminated when CNA #5 palmed the peel with her unwashed or sanitized hands. She said the contaminates on the peel would contaminate the inside of the fruit when the resident cut the fruit with a knife. II. Failure to create an effective infection surveillance system A. Professional references The Center for Disease Control and Prevention reference guide for respiratory [MEDICAL CONDITION] (RSV), August 2017, was provided by the facility on 2/13/2020. The reference guide read in pertinent part: RSV infections can be dangerous for certain adults. Adults at highest risk for severe RSV infection include: Older adults, especially those [AGE] years or older; adults with chronic heart or lung disease; and, Adults with weakened immune systems RSV can sometimes lead to serious conditions such as pneumonia Each year an estimated 177.00 older adults are hospitalized and 14,000 of them die in the United States due to RSV infection. The Center for Disease Control and Prevention reference guide for respiratory [MEDICAL CONDITION] (RSV), revised 6/26/18, was provided by the facility on 2/13/2020. The reference guide read in pertinent part: RSV can spread when an infected person coughs or sneezes. You can get infected if you get droplets from the cough or sneeze in your eyes, nose, or mouth, or if you touch a surface that had [MEDICAL CONDITION] on it, like a doorknob, and you touch your face before washing your hands People infected with RSV are usually contagious for three to eight days. However, some infants, and people with weakened immune systems, can continue to spread [MEDICAL CONDITION] even after they stop showing symptoms, for as long as four weeks. RSV can survive for many hours on hard surfaces such as tables and crib rails. It typically lives on soft surfaces such as tissue and hands for shorter amounts of time. B. Facility policies and procedures The Surveillance for Infections policy, revised July 2016, was provided on 2/13/2020 at by the facility. The policy read in pertinent part: The infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections to guide appropriate interventions, and to prevent future infections Infections that will be included in routine surveillance include those with: a. Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection; Clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C.difficile) Infections that may be considered in surveillance include those with limited transmissibility in a healthcare environment; and/or limited prevention strategies If transmission-based precautions or other preventive measures are implemented to slow or to stop the spread of infection, the Infection preventionist will collect data to help determine the effectiveness of such measures. C. Inadequate infection surveillance - record review and staff interviews The staffing development coordinator (SDC) was interviewed on 2/12/2020 at 2:55 p.m. He identified himself as the facility's infection control specialist. He said he was responsible for the surveillance of healthcare-associated infections (HAI). He said a known common factor of the spread of infections was often not washing hands and shared equipment/supplies. The SDC said he had provided staff with training on infection control and preventing the spread of transmission based infections through all staff inservices and online courses. He said department supervisors, such as in housekeeping, provided job specific training related to infection control. The SDC said staff must wash or sanitize their hands before and after resident contact to decrease the risk of potential contaminants from spreading, especially when having contact with body fluids, or surfaces on or around toilets. He said staff should know how to use personal protective equipment (PPE) correctly. He said the staff should also know how when they need to use soap and water to wash as opposed to just sanitizing their hands. He said staff needed to wash their hands with soap and water after contacting a resident with C.Diff. because alcohol based sanitizer gel does not kill the C.Diff. bacteria. The SDC said he currently had one resident on transmission based precautions related to C.Diff., Resident #204. The SDC reviewed his current practice of surveillance for HAIs and implementation of transmission-based precautions. The SDC shared his mapping of HAI for the month of January 2020. According to the mapping, several residents had signs and symptoms of pneumonia. Four of those residents contracted pneumonia within days of each other. Two of the four residents lived directly across the hall from each other. The other two residents out of the four, lived on the opposite hallway, each resident directly across the hall from each other. The SDC said pneumonia was difficult to determine if each of the residents had the same strain of pneumonia so he did not consider the location and timing as conclusively related. However he acknowledged that the location where the residents lived was a connection. The SDC revealed that one of the residents with confirmed pneumonia was bed bound and did not have direct contact with any of the other residents with confirmed cases. He said it was probable to suspect that staff or supplies could have been cross contaminated. He said he did not initiate an investigation on potential causation or implement additional training. He said staff reviewed infection control procedures in December, a month prior. According to the SDC, the facility recently experienced an outbreak of RSV, beginning mid January. He said five of the residents with RSV lived in the 100 hall. Each of the residents was put on isolation precautions and the 100 hall was put on quarantine and the hall closed off to prevent the spread of the contagious infection. He said the staff who worked on the hall stayed in that hall. He said the outbreak lasted four weeks, ending on 2/11/20. The SDC said two of the residents showed symptoms at approximately the same time. He determined the resident's smoking together as the possible connection. He said he was able to determine which of those residents was patient zero but did not fully investigate how patient zero contracted the RSV infection. The SDC said a sixth person acquired RSV in February. He identified Resident #16 as the sixth resident. He said the resident did not live near the isolated residents on the 100 hall. He said Resident #16 lived in the 200 hall where no other residents presented symptoms. The SDC said he did not review all potential causation factors that could have contributed to the spread of the RSV infection to Resident #16. He said he did not review shared staffing with the housekeeping department or directly observe their practices of cleaning resident rooms. He said he would improve his investigative practices to better determine causation and contributing factors that could result in the spread of HAI. He said the knowledge of the causation and contributing factors could prevent or limit the future spread of transmission based HAI. He said the increased knowledge would improve staff training specific to infection control practices. He said he would also incorporate more observation of staff practices that could result in the spread of infections. The housekeeping supervisor (HS) was interviewed on 2/13/20 at 10:03 a.m. The HS confirmed housekeeping staff split halls on the weekends. She said as a supervisor, she frequently cleaned resident rooms on all facility hallways to ensure coverage on either weekends or during the week. HSK #1 was interviewed on 2/13/20 at 10:45 p.m. She said she is a float housekeeper, responsible for cleaning the halls when the other housekeepers have the day off. She said she works on every hall, every week, depending on who was scheduled off. The housekeeping and laundry supervisor was interviewed on 2/13/2020 at 11:30 a.m. with the ANHA. She said housekeepers are usually assigned to a set hallway, including during the RSV outbreak on the 100 hall. She said her staff do not work seven days a week, so other housekeepers were assigned to hall during the four week isolation period. She said all of her housekeeping staff are trained to work in every hall. She said on weekends with only three housekeepers for four hallways, the housekeepers can decide which hall to divide rooms to share the cleaning of each room. She said her staff has been trained on proper cleaning procedures to prevent the spread of infections. She said her staff had the potential for cross-contaminating a resident room, if infection control practices were not practiced. The director of clinical operations (DCO) and director of nursing was interviewed on DON on 2/13/2020 at 3:44 p.m. According to the DCO, the SDC shared the above related concerns regarding infection control surveillance. She said he acknowledged that he needed to improve practices to better identify and investigate all potential causation factors on the spread of transmission based infections and determine event of transmission that would create patient zero. D. Record review The RSV tracking log was provided by the facility on 2/13/2020, confirming information provided by the SDC. According to the log, the first two cases of RSV were discovered on 1/13/2020. Both residents were put on isolation precautions until 2/4/2020. Seven days after the first discovery, a new case RSV was determined on 1/20/2020, and placed on isolation until 2/6/2020. The following day, on 1/21/2020, another resident was placed on isolation because he was positive for RSV. On 1/30/2020, a fifth resident contracted RSV and was placed on isolation. According to the tracking log, all five residents were on isolation and did not have contact with residents on other hallways. All five residents resided in the 100 hall. On 2/6/2020, the last resident was placed on isolation precautions for positive RSV. According to the log, the sixth resident resided down the 200 hall. The facility was cleared for RSV on 2/11/20. E. Facility follow up The director of clinical operations (DCO) and director of nursing (DON) were interviewed on 2/13/2020 at 3:44 p.m. According to the DCO, the facility reviewed and identified contributing factors that led to the above noted observations of poor infection control practices that potentially spread HAI. The DON with DCO said moving forward, they would provide education to all staff, including staff that were identified as a concern. They said management would also conduct their own observations to help identify other areas of improvement related to infection control and prevention.

Based on record review, observations and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater to include three residents (#105, #12 and #38). Specifically, the medication pass observation error rate was 16.67 percent, or five errors out of 30 opportunities for error. Findings include: I. Facility policy and procedure The Medication Administration policy, revised 11/26/19, was provided on 2/10/2020 at 3:22 p.m. by the clinical advocate (CA). The policy documented in pertinent part, Medications are administered in accordance with written orders of the attending physician. Double check the amount of medication to be administered. Observe that the resident swallows oral drugs. Do not leave medications with the resident. II. Medication error for Resident #105 A. Record Review Resident #105 had physician's orders [REDACTED]. [MEDICATION NAME] ER (extended release) 500 mg (milligram), give two tablets by mouth twice daily. B. Observation On 2/11/2020 at 8:09 a.m., licensed practical nurse (LPN) # 2 was observed preparing and administering medications to Resident #105. LPN #2 was observed to dispense and administer one 500 mg tablet to Resident #105 instead of two tablets as ordered. C. Interview LPN #2 was interviewed on 2/11/2020 at 8:15 a.m. She checked the medication card and and order and said she had administered one tablet and not two tablets as ordered. She said she wished the pharmacy would send a 1000 mg tablet instead. She administered a second 500 mg tablet to the resident. III. Medication error for Resident #12 A. Record Review Resident #12 had physician's orders [REDACTED]. Aspirin EC ([MEDICATION NAME] coated) tablet delayed release 81mg (milligrams). Give one tablet by mouth daily. B. Observation On 2/11/2020 at 8:44 a.m., LPN #3 was observed dispensing and administering medications to Resident #12. She took a bottle of chewable aspirin 81mg out of the drawer and poured it into a cup for resident #12. She administered the medication to Resident #12. C. Interview LPN #3 was interviewed on 2/11/2020 at 8:50 a.m. She reviewed the orders and the bottle of chewable aspirin. She said, I did not think it mattered what kind of Aspirin you gave someone. She said she had not administered [MEDICATION NAME] coated aspirin as ordered. IV. Medication errors (three) for Resident #38 A. Record Review Resident #12 had physician's orders [REDACTED]. -[MEDICATION NAME] powder (Polyethylene [MEDICATION NAME] 3350) Give 17 grams by mouth daily, -[MEDICATION NAME] Respimat Aerosol Solution 1.25 MCG (micrograms) inhaler, two puffs, inhale orally one time daily, -Wixela Inhub Aerosol, Powder Breath Activated, 250-50 MCG (microgram) inhaler, one inhalation, inhale orally two times daily, rinse mouth with water after use. B. Observation On 2/12/2020 at 8:33 a.m., LPN # 3 was observed dispensing and administering medication to Resident # 38. She mixed 17 grams of [MEDICATION NAME] powder in approximately 8 ounces of water. She then took the [MEDICATION NAME] inhaler, Wixela inhaler and [MEDICATION NAME] powder mixed in water to the resident's room. She handed the [MEDICATION NAME] inhaler to the resident and told him to take a puff. He took one puff and handed it back. However, the order was for two puffs. She then handed him the Wixela inhaler and had him take a puff. She then handed him the [MEDICATION NAME] powder mixed in water and left the room. The nurse failed to have the resident rinse his mouth after the Wixela inhaler as specified in the physician's orders [REDACTED]. C. Interview LPN #3 was interviewed on 2/12/2020 at approximately 9:00 a.m. She said she always leaves the [MEDICATION NAME] with the resident to drink and then goes back to check on him later. She said she should not leave medications with residents and should not have left the [MEDICATION NAME] mixed in water at the resident's bedside. She said the resident was able to administer his own inhalers when she had given them to him. She thought he would have taken the correct dose. V. Follow-up interview The director of nursing (DON) was interviewed on 2/12/2020 at 10:39 a.m. She said the nurse should follow the provider's instructions for medication administration. She said she thought LPN #3 was just nervous which contributed to the errors.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two out of two medication rooms and three out of five medication carts. Specifically, the facility failed to: -Remove expired medications from medication rooms and carts to prevent the use of expired medications; -Date medications when opened; and -Ensure medications were labeled with the medication name, dose, strength, expiration date, appropriate instructions and precautions, and route of administration. Findings include: I. Professional references According to Novo [MEDICATION NAME] (January 2019) Storage information and travel tips for [MEDICATION NAME], retrieved 2/14/2020 from: https://www.rapidactinginsulin.com/[MEDICATION NAME]/using-[MEDICATION NAME]/storage-and-handling.html [MEDICATION NAME] insulin, once opened, can be used up to 28 days. According to Lilly USA (January 2020) Humolog insulin, Storage and Disposal of vials, retrieved 2/14/2020 from: https://www.humalog.com Throw away open vials 28 days after first use, even if there is insulin left in the vial. According to Sanofi-Aventis (November 2019) [MEDICATION NAME] Storage instructions, retrieved 2/14/2020 from: http://products.sanofi.us/[MEDICATION NAME]/[MEDICATION NAME].html#section-16.2 [MEDICATION NAME] is good for 28 days after opening. II. Facility policy and procedure The Storage of Medications policy, revised April 2007, was provided by the clinical advocate (CA) on 2/10/2020 at 3:22 p.m. The policy documented in pertinent part, Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. The Medication Storage Guidance policy, dated April 2019 from the facility's pharmacy, was provided by the CA on 2/10/2020 at 3:22 p.m. The guidance documented in pertinent part, [MEDICATION NAME] tests, date when opened and discard after 30 days. In addition, the CA provided an untitled, undated form on 2/10/2020 at 3:22 p.m. that documented, Insulin Expirations: [MEDICATION NAME], 28 days and other insulin 30 days. III. Medication room [ROOM NUMBER] A. Observations Medication room [ROOM NUMBER] was observed on 2/10/2020 at 2:56 p.m. with licensed practical nurse (LPN) #2. Observed in the refrigerator were: -a vial of [MEDICATION NAME] insulin, one half full, labeled with an open date of 12/16/19; the insulin was opened 56 days ago; -a vial of [MEDICATION NAME] insulin, one half hull, labeled with an open date of 11/15/19; the insulin was opened 87 days ago; -Two vials of [MEDICATION NAME] ([MEDICAL CONDITION] skin testing), one half full, labeled with an open date of 12/2/19 and 11/28/19; the medications were opened 70 days and 74 days ago. B. Interview LPN #2 was interviewed on 2/10/2020 at 2:56 p.m. She said she did not know how long insulin or [MEDICATION NAME] were good after opening. LPN #2 looked around the medication room and medication cart and said there was no information for the nurses that documented how long different medications were good after opening. The LPN said she could call the staff development coordinator (SDC), and pulled a cellular phone from her pocket and called someone. She asked the SDC how long insulin and [MEDICATION NAME] were good after opening. She said the SDC said all insulin and [MEDICATION NAME] were good for 30 days after opening. She said the insulin and [MEDICATION NAME] in the refrigerator were no longer good. IV. Medication room [ROOM NUMBER] A.Observations Medication room [ROOM NUMBER] was observed on 2/10/2020 at 2:19 p.m. with LPN #6. Observed in the refrigerator was an open vial of [MEDICATION NAME](no cap), almost full, no date of opening on the box or vial. B. Interview LPN #6 removed the insulin to dispose of it. She said the medications needed to be dated when opened and the insulin was only good for 30 days. She said she did not think the insulin was opened. She said the cap probably fell off the insulin. She looked in the box and did not find the cap. V. Medication cart #1 A. Observations Medication cart #1 was observed with LPN #2 on 2/10/2020 at 1:59 p.m. Observed in the cart were: -A bottle of calcium supplement with vitamin D3, one fourth full, with expiration date of 10/2019. The medication expired over three months ago. LPN #2 removed the bottle for destruction. -Three vials of Humolog insulin open, with no date of opening on the box or vial, -One vial of [MEDICATION NAME], one half full, with no date of opening on the box or vial. LPN #2 removed the insulin and said she would dispose of the insulin because there was no date on the vials. B. Interviews LPN #2 was interviewed on 2/10/2020 at 1:59 p.m. She said she did not know how long the insulin was good after opening and she would find out. She called the CA for assistance. The CA came to the cart. She said she was unable to locate the list from the pharmacy of medication storage guidelines at this cart. The CA said she did not know how long insulin was good after opening and she would find out. VI. Medication cart #2 Observation and interview Medication cart #2 was observed with LPN #6. In the bottom drawer of the cart was a clear cup with a blue lid, a urinalysis specimen cup. The cup contained a white cream. There was no label on the cup. LPN #2 took the cup and disposed of it in the trash can on the cart. She said she did not know what it was. LPN #2 said there should not be medications in the cart that were not labeled. VII. Medication cart #3 Observation and interview Medication cart #3 was observed with LPN #4. In the bottom drawer of the cart was a clear cup with a blue lid, a urinalysis specimen cup. The cup contained a blue cream. There was no label on the cup. LPN #4 said the cream was Deep Blue (cream used for pain), and it was used on several residents. She said the cup should be labeled with the name of the medication and expiration date. She removed the cup for destruction. In addition, a Hemoccult test kit (test for blood in stool) was in the bottom drawer. The test kit had an expiration date of 11/2019, over 3 months ago. The LPN removed the kit and said it should not be used because it had expired the test results may not be accurate. VIII. Follow-up interview The director of nursing (DON) was interviewed on 2/12/2020 at 10:39 a.m. She said the nurse on each cart should be checking the carts for expired medications and ensure items are dated when opened. She said the clinical advocate (CA) should check the carts monthly for expired medications. She said the SDC was responsible for ensuring the [MEDICATION NAME] had not expired. The DON said she did not recall how long insulin was good after opening.

Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for staff convenience and not required to treat medical symptoms for one (#13) of one resident reviewed for restraints out of 39 sample residents. Specifically, the facility failed to: -Perform an initial assessment and subsequent quarterly assessments for the use of a lap belt; -Obtain a physician's order with a specific medical [DIAGNOSES REDACTED]. -Obtain a consent from the resident's medical durable power of attorney (MDPOA) prior to the use of a lap belt; -Develop a monitoring system for the safe utilization of a lap belt; and -Develop a care plan to reflect the interventions that addressed underlying problems that might be causing the symptoms, measures taken to systematically reduce or eliminate the need for the lap belt, and alternatives that were implemented prior to the use of the lap belt. Findings include: I. Facility policy and procedures The Physical Restraint Management policy, revised 12/6/19, was provided by the clinical advocate (CA) on 2/13/2020 at 10:00 a.m. The policy revealed restraints should only be used for the safety and well being of the resident and only after other alternatives had been tried unsuccessfully. Restrains would only be used to treat the resident's medical symptoms and never for discipline, staff convenience or for the prevention of falls. Restraints were reviewed upon admission, quarterly, annually and with a significant change of condition. The physical restraint would be reviewed for its use and appropriateness utilizing the restraining assessment form. Residents using physical restraints would have a pre-physical restraint and reduction assessment completed upon initiation of the restraint, quarterly and with any significant change of condition as long as the restraint was in place. The resident, family member or legal representative would be included in the decision process. They would be fully informed of: how the use of the restraint would treat the resident's medical symptoms and promote the highest practicable level of physical and psychosocial well being; the risks and potential negative outcomes of using a restraint, and alternatives to the use of a restraint. Any resident using a physical restraint must have a signed consent from the resident and/or resident's representative for the use of the restraint to include the risks and benefits of the specific restraint utilized by the resident, the risks/benefits for not using the restraint and the alternatives to the use of a restraint. The resident and/or resident representative would receive ongoing education and updates on the use of the restraint at least quarterly during care conferences and as needed. Any resident requiring a restraint would have a current physician order with the following components: the specific reason for the use of a restraint as it related to the resident's medical symptoms: how and when the restraint was to be used to benefit the resident's medical symptoms; and the type of restraint with the period of time for its utilization. During the times a restraint was in place, the restraint would be periodically removed and the resident would be assisted with a change of position, range of motion, and/or stretching movements. Restraints should always be removed during supervised mealtimes and activities unless clinical contraindication was documented. The care plan would be developed and implemented addressing the restraint usage as well as interventions to promote restraint reduction or elimination. At least quarterly, the interdisciplinary team would review those residents using physical restraints for any changes that may be indicated to determine whether they were candidates for restraint reduction, a less restrictive method of restraint, or total restraint reduction. When changes were assessed, they must be documented in the medical record and care planned as indicated. II. Resident status Resident #13, under age 60, was admitted on [DATE]. According to the February 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 12/4/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment for daily decision making. The resident had both short and long term memory problems. The resident required extensive staff assistance for bed mobility and dressing. The resident also required total staff assistance for transfers, eating, toileting and personal hygiene.The resident utilized a wheelchair for mobility. The assessment did not document the resident utilized a lap belt restraint. III. Record review Care plans The care plan for falls, revised 1/16/19, revealed the resident was at risk for falls requiring two staff member assistance with most activities of daily living (ADLs) related to a [DIAGNOSES REDACTED]. The resident was not able to ambulate but could wiggle in her wheelchair. The resident used a fastened lap belt when she was up in her wheelchair to aid in positioning. One intervention revealed the use of a lap belt for wheelchair positioning. The care plan for ADLs, revised 1/15/19, revealed the resident required total staff assistance secondary to a [DIAGNOSES REDACTED]. Neither of the care plans revealed any assessments for the appropriateness of the use of the lap belt. Neither care plan revealed the resident was unable to unfasten the lap belt. Neither plan reflected on how the lap belt would treat the resident's medical symptoms and promote the resident's highest practicable level of physical and psychosocial well being. Neither plan listed the risks or potential negative outcomes for the use of the lap belt. Neither plan included the measures taken to systematically reduce or eliminate the need for the lap belt. Neither plan provided any alternatives other than the use of the lap belt. Occupational therapy notes An occupational therapy summary note, signed 3/28/19 at 11:43 a.m., revealed the resident needed assistance with repositioning in her wheelchair due to sliding down at times but had improved upright posture when her wheelchair was tilted back. The current recommendation was to have the resident remain in a tilt-in-space wheelchair with a lap belt for tactile sensation that decreased the resident's wiggling actions. The sensation of the lap belt on her body increased the resident's comfort and the resident experienced increased anxiety when the lap belt was removed. IV. Resident observations On 2/11/2020 at 10:55 a.m., the resident sat in a tilted wheelchair in the common area on the 100 hallway. Two staff members sat in chairs on either side of the resident. The lap belt was in place and fastened. On 2/12/2020 at 8:57 a.m., the resident was seated in a tilted wheelchair watching television in her room. The lap belt was in place and fastened. Licensed practical nurse (LPN) # 3 went into the room with the surveyor. She said the lap belt was always in place and fastened when the resident was up in her wheelchair. On 2/13/2020 at 9:55 a.m., the resident was seated in a tilted wheelchair in her room watching television. The lap belt was in place and was fastened. V. Staff interviews The CA was interviewed on 2/12/2020 at 8:57 a.m. She said the lap belt was for positioning only and the resident was unable to unfasten the lap belt. The nursing home administrator (NHA) was interviewed on 2/12/2020 at 4:00 p.m., with the director of nursing (DON) present. The NHA said the current MDS did not reveal the resident utilized a lap belt as a restraint. The NHA said the resident was unable to unfasten the lap belt. The NHA said the facility did not have a consent from the resident's MDPOA for the use of the lap belt. The NHA said the facility did not have a physician's order or a specific medical [DIAGNOSES REDACTED]. The NHA said the care plans did not have any interventions for the reduction or the elimination of the lap belt. The DON said the facility did not have a monitoring system in place for the resident's safety for the utilization of the lap belt. On 2/13/2020 at 11:38 a.m., the minimum data set coordinator (MDSC) was interviewed. She said the 12/4/19 MDS did not code the resident as utilizing any restraints. She said she did not know why the lap belt was not coded as a restraint. She said the lap belt was always in place and fastened when the resident sat in her wheelchair. She said there were no assessments related to the use of the lap belt prior to the survey. She said there was no physician's order or specific [DIAGNOSES REDACTED]. She said she was unable to find documentation the facility staff routinely monitored the lap belt for the resident's safety. She said the resident's care plans revealed the lap belt was used for positioning and there were no interventions for the removal or elimination of the lap belt.

Based on observation, record review and interviews, the facility failed to provide a reasonable accommodation of needs for one (#9) of one out of 39 sample residents reviewed for preferences and needs. Specifically, the facility failed to ensure a touch pad call light system was available to Resident #9 who had impaired function in the upper left and right hand and that his call light was within reach. Findings include: I. Resident #9 A. Resident status Resident #9, less than [AGE] years of age was admitted on [DATE]. According to the February 2020 computerized physician orders, [DIAGNOSES REDACTED]. The 11/24/19 minimum data set (MDS) assessment revealed the resident is severely cognitively impaired. A brief interview for mental status (BIMS) was not completed with the resident. The resident required two persons physical assistant with bed mobility, dressing, toilet use and transfer between surfaces including to or from bed, chair, wheelchair and standing position. He also required a one person physical assistant with personal hygiene, eating, locomotion on and off the unit. B. Observation -Resident #9 was observed in his room while he laid in bed on 2/10/2020 at 9:52 a.m., his call light was on the floor. The call light was observed to be the regular cylindrical with push button type of call light. -On 2/11/2020 at 10:15 a.m., nursing staff were observed going into resident room, they exited at 10:23 a.m., they did not put Resident #9's call light within reach as the call light was observed at the residents' feet. -On 2/12/2020 at 10:28 a.m., nursing staff was observed in the resident's room, she exited the room at 10:35 a.m. Resident #9's call light was left buried within the blanket of the resident, out of reach of the resident. -On 2/12/2020 at 1:46 p.m., the resident's call light was observed entangled in his blanket and right about his feet, out of reach The call light type and position was observed with registered nurse RN #6. On 2/12/2020 at 2:07 p.m., RN #6 replaced the cylindrical push button call light system with the pad like press on call light and Resident #9 was able to use it. C. Record review The fall care plan initiated for Resident #9 on 4/23/19 and reviewed on 2/4/2020 documented one of the fall interventions was to have the residents call light within reach and that the resident be encouraged to use the call light for assistance. The occupational therapy evaluation and plan of treatment for [REDACTED]. Specifically, the assessment recorded the range of motion (ROM) in the RUE as: Shoulder- impaired; elbow/ forearm- impaired; wrist- impaired; hand-impaired; middle finger-imapaired. It also reported the same for the LUE excluding that the middle finger was impaired. D. Interviews RN #6 was interviewed on 2/12/2020 at 1:46 p.m. RN #6 stated that the call light (described above) currently in place could not be utilized by Resident #9 due to impairment in the resident's left and right hands. Specifically, RN #6 stated the call light system the resident had at the time of the observation required fine motor skill to operate which she verified Resident #9 does not. She also verified that the call light was not within reach of the resident. RN #6 immediately called for a replacement on the cylindrical push button call light with a pad-like call light system. She also placed the same within reach of the resident. RN #6 acknowledged that Resident #9 was able to utilize the new call light replacement. She concluded the interview stating she would educate nursing staff on the need for proper call light assessment and the need to have the residents call light within their reach at all times. Resident #9's family member was interviewed on 2/12/2020 at 3:19 p.m. the family member said that he was happy observing Resident #9 utilize his call light for the first time. Specifically, the family member stated I never knew there was a call light like this that he could use. I have never seen him use the former call light before. I am glad he got this one and he was able to use it. II. Follow-up observation and interview -On 2/13/2020 at 10:34 a.m. RN #5 the house supervisor for the 200 hallway accompanied the surveyor and observed the call light was placed at resident feet. She proceeded to place the call light within reach and stated she would follow-up with and educate nursing staff on the need to always ensure residents call light are within reach.

Based on observations, record review, and interviews, the facility failed to ensure the environment remained as free from accident hazards as possible for one (#99) of two residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure the metal bar on the Hoyer lift did not injure Resident #99's shins during transfers, resulting in multiple abrasions. Findings include: I. Facility policy and procedures The SkinTears - Abrasions and Minor Breaks, Care of policy, revised September 2019, was provided by the social services director (SSD) on 2/13/2020 at 4:15 p.m. The policy revealed the purpose was to guide the prevention and treatment of [REDACTED]. -Obtain a physician's orders [REDACTED]. Complete the non-pressure risk management report. -An abrasion was an area on the skin that had been damaged by friction, scraping, rubbing or trauma. A skin tear was the disruption of the epidermis resulting in a lifting or friction of the skin. -Complete an in-house investigation of the causation. Develop a care plan to prevent recurrence and implement interventions in a timely manner. -Interventions implemented or modified to prevent additional abrasions (e.g., clothes that cover arms and legs). -When an abrasion/skin tear/bruise was discovered; complete a Report of Incident/Accident. II. Resident status Resident #99, age 86, was admitted on [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 1/29/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive staff assistance for bed mobility, dressing, eating, toileting and personal hygiene. The resident was totally dependent on staff for transfers with a two-plus person's physical assistance. III. Resident/family interview On 2/13/2020 at 12:23 p.m., the resident and his wife were interviewed. She ambulated her husband into the conference room using his wheelchair. She pulled up the resident's pant legs and asked the three surveyors to observe the multiple abrasions on both the residents' shins. The resident's left shin had one large abrasion with two smaller abrasions just above the larger abrasion. The right shin had multiple abrasions of various sizes. She said the resident scraped both of his shins on the facility's Hoyer lift during transfers. She said she mentioned this to the facility staff about three days ago during the last care conference. She said the facility offered to put cloth sleeves on both of his legs. She said she told the staff she did not want sleeves on his legs; she wanted the staff to stop banging his legs on the Hoyer lift bar during transfers. She said the staff should be more careful with him because he was blind and diabetic. The resident said his left leg was very sore. IV. Record review The care plan, revised on 6/21/19, identified the resident was at risk for falls related to visual impairment and the need to transfer the resident with a Hoyer lift. One of the interventions was to educate the resident/family/caregivers about safety reminders with use of all equipment utilized for caregiving and what to do if a fall occurred. The care plan, revised on 12/23/19, identified the resident with an activities of daily living (ADLs) self-care performance deficit related to visual impairment and impaired strength. The resident was non-weight bearing to his left lower extremity post amputation of his left lateral toe. Some of the interventions revealed the resident needed total assistance from staff for toileting. The resident needed a Hoyer lift for transfers. The care plan, revised on 2/4/2020, identified the resident was at risk for skin breakdown due to staying in bed most of the time. The resident had a recent amputation to the left lateral toe and had a [DIAGNOSES REDACTED]. A second intervention revealed the resident's wife refused the offer for sleeve protectors for the resident's legs on 2/10/2020. The nursing weekly skin documentation (NWSD) form, dated 2/3/2020 at 11:58 p.m. by a registered nurse (RN), revealed the resident had dry skin to his bilateral shins and lotion was applied. The resident had calf measurements of 26 cm for the left and 24 cm for the right. The resident's skin turgor was fair and his oral mucosa was pale and moist. The Complements/Complaints/Concerns Report (CCCR) dated 2/10/2020 at 10:00 a.m., was completed by the social services assistant (SSA). The report revealed the Resident's wife related that the Resident's legs/shins were scraped/skinned during transfers using the Hoyer lift. The wife was told that staff would look into this concern. The solution section in part III of the report revealed, the facility offered skin protector sleeves for the Resident's legs/shins. The wife refused the sleeves. This concern was taken to the interdisciplinary team to determine further interventions. The Hoyer lift was padded with a date of resolution of 2/13/2020. The NWSD form, dated 2/10/2020 at 11:58 p.m. by an RN, revealed the resident's skin was pale and warm. The resident had calf measurements of 26 cm for the left and 24 cm for the right. The resident's skin turgor was fair and his oral mucosa was pale and moist. The skin assessment did not reveal the resident had any abrasions to either of his shins at this time. The knowledge of the abrasions was evident in the aforementioned CCCR dated 2/10/2020 at 10:00 a.m. (above). The February 2020 Documentation Survey Report, printed on 2/13/2020 at 2:20 p.m., was provided by the SSD. The report revealed from 2/11 through 2/13/2020 the resident was toileted/transferred by staff seven times. During this same time period the resident's skin was observed seven times with no documentation of any new skin conditions. The knowledge of the abrasions was evident in the aforementioned CCCR dated 2/10/2020 at 10:00 a.m. (above). The Skin Condition Monitoring for Non-pressure Ulcer Skin Conditions form, dated 2/13/2020 at 4:04 p.m., revealed under the category of other, a right shin 15.2 centimeters (cm) by 2.4 cm with 95% skin and 5% scab. -A second form, dated 2/13/2020 at 4:12 p.m., revealed under the category of other, a left shin measuring 10.7 cm by 0.5 cm with 95% skin and 5% scab. Both skin issues were categorized as newly identified on 2/13/2020. -This was the first set of skin assessments that acknowledged the presence of the abrasions on both of the resident's legs/shins since the CCCR dated 2/10/2020 at 10:00 a.m. Neither form revealed the facility planned to pad the center bar of the Hoyer lift or educate staff on the proper safety precautions to use with this resident during transfers with the Hoyer lift. V. Staff interviews RN #4 was interviewed on 2/13/2020 at 1:48 p.m. She said skin assessments were performed weekly. She said the assessment included observations of the resident's legs and heels looking for abrasions, skin tears, wounds or redness. She said the certified nurse aides (CNAs) also checked the resident's skin in the shower and verbally reported any concerns to the nurse. The minimum data set coordinator (MDSC) was interviewed on 2/13/2020 at 2:27 p.m. She said the care plan for ADLs revealed the staff were to use a Hoyer lift for transfers. She said the intervention for the use of sleeves on both of his legs was initiated on 2/10/2020 by the clinical advocate (CA). The director of nursing (DON) was interviewed on 2/13/2020 at 2:33 p.m. and at 3:25 p.m. She said the resident was totally dependent on staff for transfers using the Hoyer lift. She said today the staff placed padding on the bar in the center of the Hoyer lift. She said none of the staff had mentioned to her that the resident hit his legs on the Hoyer lift. She said she did not know how the abrasions on his legs occurred. The DON said the concern about the abrasions on the resident's legs was voiced by the resident's wife in the CCCR dated 2/10/2020 at 10:00 a.m. The DON agreed the NWSD, dated 2/10/2020 at 11:58 p.m., revealed the nurse measured both of the resident's calves, however the nurse did not describe any abrasions to either of the resident's legs/shins. The DON agreed the NWSD was completed approximately 14 hours after the CCCR. She said she did not look at the resident's legs and did not interview any staff members regarding the concern that the resident had obtained abrasions from being transferred by staff with the Hoyer lift. The DON reviewed and agreed with the documentation on the February 2020 Documentation Survey Report. She said transferring and monitoring of the resident's skin was performed by CNAs. She said a CNA would identify and document a new skin condition in the resident's computerized clinical record. She said if the skin condition persisted for several days it would not be mentioned again in the clinical record because it was no longer a new skin condition. If the CNA found a new skin condition the CNA would inform the nurse. The CA was interviewed on 2/13/2020 at 3:21 p.m. She said protector sleeves for the resident's bilateral legs were offered as an intervention, however the resident's wife refused the offer. She said the offer for the sleeves was based on a CCCR dated 2/10/2020 at 10:00 a.m., related to the complaint the resident's legs/shins were scraped/skinned while being transferred by staff with the Hoyer lift. CNA #7 was interviewed on 2/13/2020 at 2:54 p.m. She said on 2/4/2020 she heard the resident's wife complain to another CNA that the resident's legs were getting banged up during transfers. She said the Hoyer lift was used to transfer the resident and she had seen scars on his shins but no new wounds. CNA #4 was interviewed on 2/13/2020 at 2:58 p.m. She said the resident's legs did not bend and it was difficult to maneuver his legs in the Hoyer lift during transfers. She said transfers required one staff person to guide his legs. She said she knew that his legs had tapped the Hoyer lift during a transfer.

Based on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately, for one (#29) of three, out of 39 sample residents. Specifically, the facility failed to report Resident #29's injury of unknown origin to the administrator of the facility and to the State Survey Agency in accordance with State law. Cross reference F610- The facility failed to thoroughly investigate the injury of unknown origin. Findings include: I. Facility policy The Abuse policy, revised 9/26/13, was provided by the nursing home administrator (NHA) on 2/18/19 at 4:00 p.m. The policy read in pertinent part, The facility will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. II. Resident status Resident #29, age 77, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, pertinent [DIAGNOSES REDACTED]. The 12/14/18 minimum data set (MDS) assessment revealed Resident #29 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no hallucinations, delusions or any behavioral symptoms. She required extensive assistance from two (or more) persons with bed mobility, transfers, dressing, toilet use and personal hygiene, and limited assistance of one person with eating. She used a wheelchair for mobility with one person physical assistance. She had no falls in the facility or falls history. She did not receive an anticoagulant medication. III. Record review The 12/27/18 skilled nursing evaluation documented Resident #29 had a new bruise to the mid-sternum, approximately four inches long, and a large mass on her left chest above her heart which was painful to the touch. The note documented this was new within the last 24 hours. The physician was contacted and the resident was transferred to the emergency room per physician's orders [REDACTED]. The 12/27/18 nursing home to hospital transfer form documented the resident was sent to the hospital with left shoulder pain, new or worsening [MEDICAL CONDITION], bruising to mid-sternum, and swelling to left chest. The form documented an SBAR (Situation, Background, Assessment, Recommendation) acute change in condition note was included, however there was no SBAR form available in the resident ' s record. The transfer form did not document the NHA was notified. The 12/27/18 hospital emergency room admission note read Resident #29 presented with new worsening swelling, bruising and pain above her breast. The note documented the resident denied trauma or falls. The note described the injured area as a firm mass with surrounding bruising, 15 by 10 centimeters on the left upper breast. The note documented Resident #29 had a chest wall hematoma, likely related to acute minor local trauma and a computed tomography angiogram (CT angio) would be complete to ensure there was no need for further treatment. The 12/27/18 CT angio scan impression documented the resident had a hematoma to the left anterior chest wall, and there was no evidence of [MEDICAL CONDITION] embolism or active arterial bleeding. The 12/27/18 hospital discharge instructions read you have a collection of blood (hematoma) on your chest wall. It is unclear what caused this and instructed the primary care physician to follow-up within the next three to four days. The 12/31/18 primary care physician note documented Resident #29 had a hematoma of unknown origin to her left side of her chest. The note read the physician spoke with the resident and her husband, and the husband stated Resident #29 was lifted with something that goes across her chest and about ten minutes after being lifted, the resident started complaining of pain and the lump appeared. The physician documented staff reported the resident was being lifted with the sit-to-stand lift, which went below shoulders, and lifted up the arms. The resident was now being transferred with a total mechanical lift, which did not pull on the resident's arms. The physician documented she suspected the hematoma was caused by the sit-to-stand lift in combination with the resident taking aspirin (81 mg). An investigation on the injury of unknown origin was requested on 2/19/19 at approximately 2:00 p.m. from the director of nursing (DON). The facility failed to provide the investigation. IV. Staff interviews The director of nursing (DON) was interviewed on 2/21/19 at 3:01 p.m in the presence of the assistant nursing home administrator (ANHA) and clinical quality consultant (CQC). The DON said the resident had a hematoma of unknown origin that occurred in the facility on 12/27/18. The DON said the injury of unknown origin had not been investigated or reported as it was considered a medical emergency. The DON said the resident and her husband had reported the resident had not been abused, had not had trauma or a fall, however this was not documented in the resident's medical record until the investigation report was started on 2/19/19 (54 days after the injury occurred). The DON said the injury of unknown origin would not be reported to the State Survey Agency as it was a medical emergency, although emergency room documentation did not support this, and there was no investigation completed to determine the cause of the resident's hematoma. V. Facility follow-up The NHA provided a copy of the initial report to the State Survey Agency on 2/22/19 at 12:23 p.m. The injury of unknown origin was reported to the State Survey Agency by the facility on 2/21/19 at 5:05 p.m., 56 days after the incident. The report did not mention the resident's bruising that was present at the time she was sent to the hospital on [DATE].

Based on interviews and record review, the facility failed to have evidence all alleged violations of abuse and/or mistreatment, including injuries of unknown origin, were thoroughly investigated for one (#29) of three residents investigated for abuse out of 39 sample residents. Specifically, the facility failed to thoroughly investigate an injury of unknown origin for Resident #29. Cross reference F609- The facility failed to report an abuse allegation. Findings include: I. Facility policy The Injuries of Unknown Origin policy, revised 9/27/13, was provided by the director of nursing (DON) on 2/21/19 at 10:00 a.m. The policy read in pertinent part, Initiate an internal investigation to determine if the cause of the injury is known and to rule out any physical abuse. During the investigation a summary of the findings and a conclusion should be reached to determine how the injury occurred and that physical abuse did not occur. If the cause of the injury cannot be determined, document a summary of the findings and draw a conclusion. II. Resident status Resident #29, age 77, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, pertinent [DIAGNOSES REDACTED]. The 12/14/18 minimum data set (MDS) assessment revealed Resident #29 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no hallucinations, delusions or any behavioral symptoms. She required extensive assistance from two (or more) persons with bed mobility, transfers, dressing, toilet use and personal hygiene, and limited assistance of one person with eating. She used a wheelchair for mobility with one person physical assistance. She had no falls in the facility or falls history. She did not receive an anticoagulant medication. III. Record review The 12/18/18 to 12/26/18 daily nursing skin assessments revealed the resident had no bruising present to her chest. The resident ' s status was documented as being alert with some confusion. The12/26/18 certified nurse aide (CNA) shower documentation revealed the resident had no identified skin issues. The 12/27/18 skilled nursing evaluation documented Resident #29 had a new bruise to the mid-sternum, approximately four inches long, and a large mass reported on her left chest above her heart which was painful to the touch. The note documented this was new within the last 24 hours. The physician was contacted and the resident was transferred to the emergency room per physician's orders [REDACTED].>The 12/27/18 nurse progress note documented Resident #29 was sent to the hospital due to having pain to her right upper chest and left arm, extreme swelling, and difficulty moving her left arm. The 12/27/18 nursing home to hospital transfer form documented the resident was sent to the hospital with left shoulder pain, new or worsening [MEDICAL CONDITION], bruising to mid-sternum, and swelling to left chest. The form documented an SBAR (Situation, Background, Assessment, Recommendation) acute change in condition note was included, however there was no SBAR form in the resident's medical record. The 12/27/18 hospital emergency room admission note read Resident #29 presented with new worsening swelling, bruising and pain above her breast. The note documented the resident denied trauma or falls. The note described the injured area as a firm mass with surrounding bruising, 15 by 10 centimeters on the left upper breast. The note documented Resident #29 had a chest wall hematoma, likely related to acute minor local trauma and a computed tomography angiogram (CT angio) would be complete to ensure there was no need for further treatment. The 12/27/18 CT angio scan impression documented the resident had a hematoma to the left anterior chest wall, and there was no evidence of [MEDICAL CONDITION] embolism or active arterial bleeding. The 12/27/18 hospital discharge instructions read you have a collection of blood (hematoma) on your chest wall. It is unclear what caused this and instructed the primary care physician follow-up within the next three to four days. The 12/27/18 nurse progress note documented Resident #29 returned from the hospital with a hematoma of unknown source and will follow up with the primary care physician. The note documented there was a large amount of bruising to the lower half of the resident's left breast, and as a precaution, the resident would be transferred using a total mechanical lift instead of a sit-to-stand lift. The 12/28/18 physical therapy note documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. The physical therapist recommended using the total mechanical lift. The 12/28/18 occupational therapy note documented nursing staff requested therapy to assess the safest mode for transfer to protect the hernia and chest hematoma sites. The occupational therapist had recommended the total mechanical lift as the sit-to-stand lift put too much pressure on the hematoma site. The 12/31/18 primary care physician note documented Resident #29 had a hematoma of unknown origin to her left side of her chest. The note read the physician spoke with the resident and her husband, and the husband stated Resident #29 was lifted with something that goes across her chest and about ten minutes after being lifted, the resident started complaining of pain and the lump appeared. The physician documented staff reported the resident was being lifted with the sit-to-stand lift, that lifts up the arms, and was now transferred with a total mechanical lift, which will not pull on the resident's arms. The physician documented she suspected the hematoma was caused by the sit-to-stand lift in combination with the resident taking aspirin (81 mg). The 1/13/19 skilled nursing evaluation documented the resident had multi-bruising to lower back and across breasts, and that the husband stated the bruising was from the sit-to-stand lift. The resident's comprehensive care plan did not include a care plan or interventions related to the hematoma or increased risk of bleeding or bruising. An investigation on the injury of unknown origin was requested on 2/19/19 at approximately 2:00 p.m. from the director of nursing (DON). The facility failed to provide the investigation. IV. Resident interview Resident #29 was interviewed on 2/21/19 at 8:35 a.m. Resident #29 said she could not recall what had caused her bruises and said she had not been abused and was not fearful of anyone. V. Staff interviews The occupational therapist (OT) was interviewed on 2/20/19 at 9:20 a.m. in the presence of the therapy director (TD). The OT said the resident was previously using a sit-to-stand lift. He said this was changed to the total mechanical lift after she returned from the hospital with a hematoma. The OT said the hematoma should not be caused by the sit-to-stand lift, if the sit-to-stand lift sling was closer to the waist. The OT said the resident was switched to using a total mechanical lift as a precaution to reduce the risk of pressure and pain to the area of the hematoma. The physical therapist (PT) was interviewed on 2/20/19 at 9:57 a.m. The PT said the sit-to-stand lift sling should not be in the area where the resident's hematoma was, unless the sling had been placed incorrectly or the resident became weak during transfer. The PT said the resident was switched to transferring with a total mechanical lift to reduce discomfort and pressure on her chest area. The director of nursing (DON) was interviewed on 2/21/19 at 3:01 p.m in the presence of the assistant nursing home administrator (ANHA) and the clinical quality consultant (CQC). The DON said when the nurse went in to assess the resident, the resident had swelling on her left chest but had no bruising present. The DON said the physician orders [REDACTED].#29 to the emergency room due to swelling and left arm pain. The DON said an SBAR form had not been completed when the resident was sent out to the hospital as the resident's symptoms were so immediate and there had been no time to investigate what caused the hematoma then. The DON said the hematoma did occur in the facility as the skilled nursing evaluation and transfer to hospital form documented. The DON said the injury of unknown origin had not been investigated when Resident #29 returned from the hospital as the resident and her husband said that the resident had not been abused, did not have a fall or trauma, however she had not documented this conversation in the resident's medical record. The DON said the hematoma was not caused by the sit-to-stand lift, and the resident had been switched to using the total mechanical lift as a precaution to avoid pressure and pain to the area of the hematoma. The DON said the emergency room documentation, other than the discharge instructions, had not been received or requested by the facility after Resident #29's return. The DON said she did start an investigation report on 2/19/19 (54 days after the incident). The DON said, in the future the facility would initiate the investigation for injury of unknown origin immediately. She said Resident #29's hematoma was both, a medical emergency and an injury of unknown origin. She said the nursing staff had not thought to investigate the injury of unknown origin, and had been focused on taking care of the resident's immediate needs. VI. Facility response The clinical quality consultant (CQC) provided a copy of the incident report on 2/21/19 at 3:12 p.m. The incident report was dated 2/19/19. The incident report documented the resident had swelling to the left chest wall and the resident and her husband had been interviewed and said no trauma or fall occurred, and the resident was transferred to the emergency room .

Based on interviews and record review the facility failed to complete a timely comprehensive and accurate assessment for one (#18) of three out of 39 sample residents. Specifically, the facility failed to complete the resident's readmission to the facility comprehensive assessment after Resident #18 returned from a hospital with a significant change in condition. Findings include Professional reference According to the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, (MONTH) (YEAR), pg. 2-22 and 2-23: The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an Admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. -When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met. A SCSA is appropriate when: - There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and - The resident's condition is not expected to return to baseline within two weeks. - For a resident who goes in and out of the facility on a relatively frequent basis and reentry is expected within the next 30 days, the resident may be discharged with return anticipated. This status requires an Entry tracking record each time the resident returns to the facility and an OBRA Discharge assessment each time the resident is discharged . However, if the IDT determines that the resident would benefit from a Significant Change in Status Assessment during the intervening period, the staff must complete a SCSA. This is only allowed when the resident has had an OBRA Admission assessment completed and submitted prior to discharge return anticipated (and resident returns within 30 days) or when the OBRA Admission assessment is combined with the discharge return anticipated assessment (and resident returns within 30 days). - A SCSA may not be completed prior to an OBRA Admission assessment. Facility policy and procedure The Changes in Resident Condition policy, revised 9/11/17, was provided by the assistant administrator (AA) on 2/21/19. It read, in pertinent part, Changes in the resident status that affect the problem(s)/ goal(s) or approach on his/her plan of care are documented as revisions and communicated to the interdisciplinary (IDT) team. Examples of Clinical Condition Changes are such things as a Stage II pressure ulcer, onset or recurrent [MEDICAL CONDITION], recent urinary tract infections, significant weight loss, falls, significant change in behaviors, resident is started on antibiotics for any type of infection, any change in resident from resident's baseline/ onset of new concern/incident (i.e skin tear, bruise etc.). Document in the resident's medical record: Response and/or orders received; Assessment of resident condition and ongoing monitoring of resident condition; Care provided; Update the care plan as needed. Resident status Resident #18, age 80, was initially admitted on [DATE]. According the computerized physician orders, [DIAGNOSES REDACTED]. The 1/22/19 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status score of 15 out of 15. The assessment revealed the resident was totally dependent with two person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He used a wheelchair for ambulation. Record review Resident #18's electronic medical records revealed the resident was discharged from the facility on 1/22/19 for a planned surgery with a return anticipated. The facility completed an entry assessment on 1/24/19 upon the resident's return to the facility, however the facility failed to complete an OBRA admission assessment. Staff interviews The minimum data set (MDS) coordinator was interviewed on 2/20/19 at 4:01 p.m. She said she did not complete an admissions assessment for Resident #18 because she did not consider his left leg above the knee amputation a significant change in condition. The director of nursing (DON) was interviewed on 2/21/19 at 1:20 p.m. She said, upon return from the hospital the resident should be reassessed by the nurse, the admission assessment should be completed if the resident was not expected to return to baseline, and the comprehensive care plan should be revised.

Based on record review and staff interviews, the facility failed to ensure one (#18) of four reviewed for care plans out of 39 sample residents had a timely revision of the person centered care plan. Specifically, the facility failed to ensure the resident's comprehensive care plan was revised after a significant change of condition. Findings include Facility policy and procedure The Changes in Resident Condition policy, revised 9/11/17, was provided by the assistant administrator (ANHA) on 2/21/19. It read, in pertinent part, Changes in the resident status that affect the problem(s)/ goal(s) or approach on his/her plan of care are documented as revisions and communicated to the interdisciplinary (IDT) team. Examples of Clinical Condition Changes are such things as a Stage II pressure ulcer, onset or recurrent [MEDICAL CONDITION], recent urinary tract infections, significant weight loss, falls, significant change in behaviors, resident is started on antibiotics for any type of infection, any change in resident from resident's baseline/ onset of new concern/incident (ie. skin tear, bruise etc.). Document in the resident's medical record: Response and/or orders received; Assessment of resident condition and ongoing monitoring of resident condition; Care provided; Update the care plan as needed. Resident status Resident #18, age 80, was initially admitted on [DATE]. According the computerized physician orders, [DIAGNOSES REDACTED]. The 1/22/19 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status score of 15 out of 15. The assessment revealed the resident was totally dependent with two person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. He used a wheelchair for ambulation. Record review The electronic medical records revealed Resident #18 was discharged from the facility on 1/22/18 for a planned surgery for [REDACTED]. He returned to the facility on [DATE]. The hospital discharge physician orders [REDACTED]. The orders included a potassium laboratory draw on 1/25/19. The resident had an order for [REDACTED].>The comprehensive care plan read to treat wounds on Resident #18's left toes and treat his infection to the left knee. The resident had an above knee amputation of his left lower extremity, and required alternative care interventions. The facility failed to update Resident #18's care plan to ensure it remained person centered and accurate with the care he required and received in the facility. Staff interview The director of nursing (DON) was interviewed on 2/21/19 at 1:20 p.m. She said after the resident returned from surgery the resident should have been reassessed and the comprehensive care plan should be completed by the charge nurse. She said care plans were updated quarterly and upon significant change of condition as needed.

Based on observation, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice, the resident's care plan and the resident's choice for one (#32) of one resident reviewed for supplemental oxygen use out of 39 sample residents. Specifically, the facility failed to: - Ensure a current physician's order was in place for the resident's use of supplemental oxygen; - Fully develop a comprehensive care plan to address Resident #32's use and refusals of oxygen therapy. Findings include: I. Resident status Resident #32, age 98, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders (CPO), pertinent [DIAGNOSES REDACTED]. The 12/12/18 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident received oxygen therapy and hospice services. II. Resident observation and interview Resident #32 was observed in her bed on 2/18/19 at 2:29 p.m. She was receiving oxygen at three liters per minute (3L) via nasal cannula. The resident said she required oxygen therapy and said sometimes she removed the nasal cannula when it bothered her. Resident #32 was observed on 2/19/19 at 12:33 p.m. in bed, receiving oxygen at 3L via nasal cannula. III. Record review The 1/3/19 hospice physician orders read to provide medical oxygen at two liters per minute (2L) via nasal cannula for dyspnea (difficult breathing). The 1/17/19 hospice physician note documented to increase oxygen therapy from two liters to three and a half liters per minute (3.5L) due to increased respiratory needs. The 1/24/19 nurse practitioner note documented the resident required supplemental oxygen at 2L continuously. The 1/30/19 hospice nurse progress note wrote Resident #32 was observed in her bed without oxygen on and her oxygen saturation was 78%. The resident was put on 3.5L and her oxygen saturation increased to 91%.The note documented Resident #32 had said she did not think she needed the oxygen so she had removed it. The resident's comprehensive care plan was reviewed on 2/20/19. The comprehensive care plan failed to include a care plan for oxygen therapy. The (MONTH) 2019 computerized physician orders and (MONTH) 2019 medication and treatment administration records revealed there were no orders present for oxygen administration. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 2/21/19 at 11:26 a.m. RN #1 said if the resident was receiving oxygen therapy then the resident should have a physician's order for administration and it should be included on the resident's care plan. RN #1 said there was no physician order or oxygen therapy care plan in Resident #32's chart and it would be added to the resident's comprehensive care plan. The director of nursing (DON) was interviewed on 2/21/19 at 3:10 p.m. The DON said all residents receiving oxygen therapy should have a physician's order for oxygen administration and an oxygen care plan. The DON said a physician's order and care plan for Resident #32's use of supplemental oxygen was added that day. The DON said because the resident was receiving hospice services, they would not include information such as route of administration or flow rate on the resident's care plan as it could change, but they would include an intervention to refer to hospice for oxygen administration orders. The DON said the resident's tendency to remove her nasal cannula should have been included on the care plan. V. Facility follow-up response The comprehensive care plan was updated on 2/21/19 and read Resident #32 has oxygen therapy related to dependence on supplemental oxygen with interventions listed to monitor for signs and symptoms of respiratory distress and report to the physician as needed. The (MONTH) 2019 computerized physician orders revealed an order for [REDACTED].>was added on 2/21/19 after the facility was informed there was no order present. The order read titrate oxygen to be equal to or greater than 90% via nasal cannula. Baseline O2 (oxygen) at 2 (two liters per minute) every shift.

Based on observations, interviews and record review, the facility failed to ensure two (#60 and #48) of seven residents reviewed for restraints out of 39 sample residents, were free from restraints. Specifically, - The facility failed to timely and appropriately assess functional status and risk for elopement of Resident #60, who resided on the secure unit, and had additionally wander prevention device, watchmate; and - The facility failed to ensure an assessment was completed prior to applying a bolster mattress and barrier to Resident #48's bed. Findings include: I. Professional reference According to the Nursing Home Abuse Guide, Physical Restraints on Elderly (2019) https://nursinghomeabuseguide.com/abuse-injuries/elderly-restraints/physical/ (retrieved 2/25/19): - Federal and state laws urge the use of alternatives in place of physical restraints. - Increased supervision and more specialized attention to suit each resident's needs can be among the most effective alternatives for reducing the need for physical restraints. - Frequent checks of resident areas and rooms are among other forms of alternatives to physical restraints II. Facility Policy According to the facility Elopement & Wandering Policy (developed on 11/4/13, revised on 6/28/18), provided by the assistant nursing home administrator (ANHA) on 2/21/19 at 10:00 a.m., the facility: - Accountability of policy adherence was that of the nursing home administrator (NHA), and responsibility of policy adherence was that of the director of nursing (DON), social service director (SSD), and the nursing department. -Defined 'wanderers' as residents who moved around the facility in a non-goal directed manner, but did not make efforts to leave the premises. -Defined 'elopers' as residents who made an overt or purposeful attempt to leave the facility and did not have the ability to identify safety risks. -Was to provide a safe environment using the least restrictive measure for residents who exhibited elopement behaviors. -Assessed elopement risks as needed. -Obtained a physician order [REDACTED]. The facility Physical Restraint Management policy, revised 2/16/16 was provided by the director of nursing (DON) on 2/20/19. It read, in pertinent part, - Residents are reviewed upon admission, quarterly, annually, and with significant change of condition for use and appropriateness of physical restraints using the pre-restraining assessment form. - Residents using physical restraints will have a pre-physical restraint and reduction assessment, completed upon initiation of the restraint, quarterly, and with any significant change of condition as long as the restraint is in place. - Any resident requiring a restraint will have a current physician order [REDACTED]. symptom and; the type of restraint, and period of time for the use of the restraint. III. Observation The initial tour of the secure unit on 2/18/19 at 9:45 a.m., revealed the residents had watchmate, wander prevention devices on their wrists, ankles or attached to their wheelchair. Resident #89 was observed on 2/18/19 at 11:04 a.m. She had a watchmate on. The resident ambulated independently without assistive device. Resident #91 was observed on 2/18/19 at 12:41 p.m. She had a watchmate on her left wrist. The resident was in a wheelchair. Resident #80 was observed on 2/18/19 at 12:45 p.m. She had a watchmate attached to her left ankle. The resident used a walker for ambulation. Resident #60 was observed on 2/18/19 at 3:46 p.m. She had a watchmate on her right wrist. The resident was in a wheelchair. Resident #53 was observed on 2/18/19 at 4:26 p.m. He had a watchmate on his left wrist. The resident was in his wheelchair. Resident #76 was observed on 2/19/19 at 11:31 a.m. She had a watchmate on her left wrist. The resident was in her wheelchair. IV. Physical Restraint/Safety Device Informed Consents According to the facility Physical Restraint/Safety Device Informed Consents was provided by the ANHA on 2/21/19 at 10:00 a.m., read in parts: - The facility was committed to limiting the use of physical restraint devices only to situations necessary to maximize a resident's physical, mental, and psychosocial well-being, in compliance with federal and state regulations, and facility policy. - If physical restraints were deemed necessary, the least restrictive method were applied for the shortest amount of time possible. - The physical restraints were required to treat the resident's medical symptoms/physical condition as ordered by the physician, and when the less restrictive measures or therapeutic interventions had proved ineffective V. Residents status A. Resident #60 Resident #60, age 85, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/2/19 minimum data set (MDS) assessment revealed Resident #60 had short and long term memory deficits and required one person physical assistance for mobility on and off the unit. She did not wander, and had a wander/elopement alarm which was used daily. Record review The (MONTH) 2019 CPO revealed a physician order [REDACTED]. The 7/19/18 physician order [REDACTED]. The care plan, initiated on 4/26/17 and revised on 8/28/18, identified the resident had deficits and decline of all activities of daily living (ADLs) and self-care due to [MEDICAL CONDITION], and dementia. Interventions included two person assistance with transfers. The care plan, initiated on 4/18/17, identified the resident was an elopement risk due to having dementia, and history of attempts exiting her previous residence. Interventions included a watchmate on her wrist. The care plan, initiated on 7/19/18, identified the resident was on hospice care due to [MEDICAL CONDITION]. Interventions included non-pharmacological comfort measures. The care plan, initiated on 4/18/17 and revised on 12/28/17, identified she resided in the secure unit due to [DIAGNOSES REDACTED]. Interviews Registered nurse (RN) #1 was interviewed on 2/19/19 at 11:58 a.m. She said Resident #60 did not have exit seeking behaviors. The director of nursing (DON) was interviewed on 2/19/19 at 12:00 p.m. She said the secure unit was under video surveillance. The DON and the social services director (SSD) were interviewed on 2/19/19 at 2:47 p.m. They said Resident #60 was declining physically and was on hospice care. The DON was interviewed on 2/20/19 at 8:58 a.m. She said watchmates were placed on all secure unit residents and did not alarm the secure unit doors. She said the watchmates alarmed the main entrance doors to the facility. She said the secure unit doors required codes to exit the unit. RN #3 was interviewed on 2/20/19 at 12:07 p.m. She said Resident #60 used a wheelchair for mobility, could not self-propel, and was on hospice care. RN #3 was interviewed on 2/20/19 at 4:28 p.m. She said the interdisciplinary team (IDT) reviewed Resident #60's condition declining and determined the resident was appropriate to be transferred from the secure unit. CNA #4 was interviewed on 2/21/19 at 11:32 a.m. She said all residents in the secure unit had watchmates. She said the secure unit residents could not leave the unit without staff assistance due to the code controlled exit doors. The medical director (MD) was interviewed on 2/21/19 at 12:40 p.m. She said she was not aware that all the residents in the secure unit wore watchmates since the admission to the unit. She said she was not aware or notified of any residents elopements from the secure unit in the past year. She said not all of the residents in the secure unit should have watchmates. She said residents who were not at risk of elopement, who were non ambulatory, were not exit seeking and their medical condition declined should not wear watchmates. She said the residents on the secure unit should be evaluated frequently for the necessity of double restraints. The SS was interviewed on 2/21/19 at 1:21 p.m. She said all residents in the secure unit had watchmates. Resident #48 Resident #48, age 50, was admitted on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. The 1/2/19 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment and a brief interview for mental status was unable to be completed. The assessment revealed the resident required two or more persons total physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident used a wheelchair for mobility. Observations and interviews On 2/18/19 Resident #48's bed was observed with a bolster mattress and a defined perimeter barrier. The assessment for the resident's bolster mattress and defined perimeter was requested from the director of nursing (DON) on 2/20/19 at 12:14 p.m. On 2/20/19 at 3:29 p.m., the DON and the clinical quality consultant (CQC) said the restraint assessment for the mattress barrier was not completed and there was not a physician order [REDACTED]. Record review Review od the physician orders [REDACTED].

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) resident reviewed out of 10 sample residents. Specifically, the facility failed to investigate, monitor and implement appropriate interventions for a femur fracture in a timely manner for Resident #2. Findings include: I. Resident status Resident #2, age 84, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 7/4/18 minimum data set (MDS) assessment indicated the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive assistance of two staff members for all transfers. II. Record review According to a late entry nursing progress note written the following day (on 7/22/18 at 8:28 p.m.) for 7/21/18 at 4:18 p.m. the certified nurse aide (CNA) reported the housekeeper informed her of the resident attempting to get out of bed by herself. The CNA immediately went to check on the resident and found her halfway on the bed and halfway off the bed with both feet on the floor and her back and shoulders against the mattress. The CNA assisted the resident back to bed. The resident complained of pain to the left side of her body. No bruising or swelling was noted to the upper or lower extremities. [MEDICATION NAME] was administered for pain.This note did not corroborate the findings that were documented at 11:31 a.m. According to a nursing progress note on 7/22/18 at 11:31 a.m. when the staff went to get the resident up she had her left leg hanging over the mattress and the rest of her body on the bed. She complained of pain in her left hip. She complained of pain with movement and the left leg was internally rotated. The daughter was notified. The on-call service was notified and they were waiting on a call back from the on-call physician. She only drank her protein drink and refused to eat breakfast. Her color was pale. According to a nursing progress note on 7/22/18 at 1:25 p.m. the on-call physician called back and ordered a two view x-ray of her left hip and left femur due to increased pain. (According to the x-ray report the x-ray was done at 1:31 p.m.) According to a nursing progress note on 7/22/28 at 3:16 p.m. the resident ' s daughter called back and wanted her mother kept comfortable. She stated she did not want her mother to have surgery as she had had a previous fracture before and it healed with rest. The daughter was told her mother would be kept comfortable and would not allow her to bear weight on that leg. The executive director (ED) and the assistant director of nursing (ADON) were notified of the incident and X-ray results. (According to the x-ray report – the results of the x-ray were not reported to the facility until 3:53 p.m. however, the notation was made at 3:16 p.m.) According to the 7/22/18 x-ray report, there was a fracture involving the left distal femur with minimal displacement. According to a nursing progress note on 7/22/18 at 9:31 p.m. the resident was lying in bed with her lower extremities elevated. The left knee and leg had slight swelling. According to a nursing progress note on 7/23/18 at 4:48 a.m. the resident was being monitored for a fracture to the left distal femur. (This was the first mention of the resident ' s fracture in the progress notes). Tylenol was given for signs of discomfort with movement. The left leg was elevated and has some swelling noted to the left knee area. According to a nursing progress note on 7/23/18 at 3:59 p.m. the resident had been up in her wheelchair most of the day with her feet elevated. The left leg had an internal rotation. This note did not document the resident's left leg was immobilized, if the resident was NWB during the transfer or if a lift had been used to get this resident in her wheelchair. There was no further documentation of the resident ' s status for over 24 hours. According to a nursing progress note on 7/24/18 at 4:43 p.m. the resident was transported via ambulance to the emergency room accompanied by her daughter. There was no documentation in the nursing progress notes for the reason the resident was sent to the emergency room , what time or the residents status when leaving the facility on 7/24/18. She was not sent to the ER until two days after the reported fall. According to the 7/24/18 emergency room report, the resident was seen at 2:02 p.m. She arrived at the emergency room with a cardboard splint placed by the emergency medical technician (EMT). No orthotic device was being used at the nursing home. The orthopedic surgeon recommended a short knee immobilizer for a subacute impacted distal femur fracture. According to the 7/24/18 nurse practitioner (NP) progress note the on-call service received a call from a facility nurse reported increased pain to the resident ' s left hip with internal rotation. Left hip and femur x-rays were ordered with the results showing a minimally displaced distal femur fracture. The family was notified and requested comfort measures. The patient was placed on non-weight bearing status to the left lower extremity and [MEDICATION NAME] (liquid [MEDICATION NAME]) was added if needed for comfort. The patient reports her leg hurts with movement and pain was observed with repositioning. The resident has dementia and was requesting to be up in the wheelchair every day. The options were discussed with the daughter and she agreed to transfer the resident to the emergency department for an immobilizer. Changes to the care plan included ice to the left knee three times a day for three days, continue non-weight bearing status to left lower extremity with a lift for transfers. The staff was to be educated on managing her left lower leg with repositioning and transfers and skin assessments every shift. She was not to wear pants until the immobilizer was removed. She was managed on [MEDICATION NAME] three times a day with as needed daily times six weeks. She was to receive [MEDICATION NAME] (a non-steroidal anti-[MEDICAL CONDITION] drug) twice a day for three days then as needed. The residents care plan indicated the resident had chronic pain related to a history of multiple surgeries and general discomfort. Interventions included: -Monitor and document for probable causes of each pain episode. Remove/limit causes where possible; -Monitor and document side effects of pain medication; -Monitor/record/report any signs and symptoms of non-verbal pain; -Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss; -Monitor/record/report resident ' s complaints of pain or requests for pain treatment; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; and -Report any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaints of pain or discomfort. The residents care plan was not updated until 8/9/18 (during the survey) to include the fracture to the left distal femur fracture. Interventions added were: -Pre-medicate the resident with Roxinol prior to all transfers and movement; -Non-pharmacological interventions for pain to include warm blanket, diversional activities and re-positioning; and -Resident needs a Hoyer lift for transfers. The care plan did not include the use of a knee immobilizer at all times or the need for three staff members during a transfer. The facility did not initiate an investigation to find out the cause of the resident ' s fracture until 7/25/18, three days after the fracture was diagnosed . The facility also did not initiate proper interventions as noted by the NP on 7/24/18 and precautions for a resident with a femur fracture until after the resident was seen in the emergency room three days after the fracture was diagnosed . The order for NWB was written 7/25/18. According to the facility investigation, it was revealed that a CNA had transferred the resident ' s using the stand and pivot method instead of a mechanical lift and two staff members to assist. III. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 8/16/18 at 1:38 p.m. She said she got the resident up on 7/23/18 because the resident requested to get up. She said the resident ' s daughter asked her about immobilizing the leg before moving her but she told the daughter they did not do that without a doctor ' s order. She said she did not think a splint or immobilizer was even available in the building. She said the therapy department might have one but she said therapy could not do it without an order either. She said she did not contact the physician to request an order for [REDACTED]. She was not sure why the resident was not documented on from the afternoon of 7/23/18 until the afternoon of 7/24/18. The physical therapist assistant (PTA) was interviewed on 8/16/18 at 2:55 p.m. He said if a resident had a fractured femur the leg wound need to be stabilized and supported during any transfer. He said, he had not had to get a brace or splint for a resident but he said if it was needed he would figure out how to get one. The director of rehabilitation (DOR) was interviewed on 8/16/18 at 3:10 p.m. She said she would expect a femur fracture to be immobilized quickly after the fracture was identified to support the leg and offer comfort and relief to the resident. Interview with clinical manager on 8/16/18 at 3:47 p.m. she said according to their records the x-ray results were called into the on-call physician by the facility on 7/22/18 at 5:00 p.m. Orders were given to keep the resident non-weight bearing and ordered as needed [MEDICATION NAME] for pain. She said she would expect the resident ' s fractured extremity to be supported/stabilized during any transfers. The Quality improvement specialist (QIS), the assistant nursing home administrator (ANHA) , the director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 8/16/18 at 6:15 p.m. The ANHA said the facility started an investigation into the fracture on 7/24/18 after the resident returned from the emergency room with the daughter who was questioning the cause of the fracture. He said the investigation was started by the NHA and the ADON. Then the DON and ANHA continued the investigation. After the investigation was complete, they could not determine how the fracture occurred. The facility went ahead and did training for the staff to include the definition of a fall and how to transfer/reposition a resident with a fracture and immobilizer. The DON and ANHA agreed that the expectation would be for the investigation to begin when they found the definitive change on 7/22/18 when the fracture was identified. The DON said she expected any change of condition, including a new fracture to be documented on every shift for at least 72 hours.

The facility failed to ensure that each resident received an accurate assessment, reflective of the residents' status at the time of the assessment for four (#97, #103, #1 and #41) of 27 sampled residents. Specifically, the facility failed to ensure the minimum data set assessments accuracy of: -Sections C, D and E on quarterly assessment for resident #97; -Sections C and E on 30 day perspective payment system (PPS) assessment for resident #103; -Sections C, D, E and J on admission assessment for resident #1; and -Sections C and E on 14 day PPS assessment and Section C on 30 day PPS assessment for resident #41. The findings included: I. Residents Status A. Resident #97 Resident #97, age 79, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 12/3/17 minimum data set (MDS), admission assessment the resident had clear speech, made self-understood and was able to understand others. Section C (Cognitive Patterns), the brief interview for mental status (BIMS) score was 15 out of 15 and indicated intact cognition. Section D (Mood), PHQ-9 (9-item patient health questionnaire that screens for symptoms of depression) score was three out of 27 and indicated minimal depression. Section E (Behaviors) revealed the resident did not have hallucinations, delusions, other behavioral symptoms or rejection of care. The resident required two + (plus) persons extensive assistance with bed mobility, dressing and toilet use, one person extensive assistance with personal hygiene, and setup help only with eating. He was totally dependent on staff with all transfers. Review of the MDS, quarterly assessment, dated 12/21/17 revealed that Section C, D and E were was not completed. B. Resident #103 Resident #103, age 92, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 12/5/17, admission MDS assessment, the resident had clear speech, made self-understood and was able to understand others. BIMS score was 12 out of 15 and indicated moderately impaired cognition. Section D documented PHQ-9 score was one out of 27, which meant minimal depression. She had no hallucinations, delusions or rejection of care. The resident required two plus persons extensive assistance with bed mobility, transfers, dressing and toilet use, one person extensive assistance with personal hygiene, and setup help only with eating. She used walker and wheelchair for ambulation. Review of the MDS, 30 day PPS (Medicare part A, Prospective Payment System) assessment, dated 12/26/17, Section C and E were not completed. C. Resident #1 Resident #1, age 67, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 1/2/17, admission MDS assessment, the resident had clear speech, made self-understood and was able to understand others. Section C was not completed, not assessed. Section D Mood was not completed, not assessed. Section E documented the resident had no hallucinations or delusions. Section E, however Behavioral Symptoms were not completed, not assessed. Section J, Pain Management, not assessed/no information. Section N revealed the resident was receiving daily (7 days during the assessment period) insulin injections, antibiotics (7 days), diuretic (7 days) and opioid (2 days). D. Resident #41 Resident #41, age 68, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 10/26/17, MDS (Medicare Part A, PPS, 14 day) assessment, the resident had clear speech, made self-understood and was able to understand others. Section C, Should Brief Interview for Mental Status be Conducted? Yes. Not assessed was documented. Should the Staff Assessment for Mental Status be conducted? Yes. Not assessed was checked. Long-term memory, Not assessed, cognitive skills for daily decision making, Not assessed. Section E, Behavioral Symptoms, was not completed. Review of the MDS (PPS Medicare part A, 30 day) assessment, dated 11/12/17, Section C was not completed. II. Staff Interviews The social service director (SSD) was interviewed on 1/10/18 at 2:26 p.m. She said she and the social worker (SW #1) missed completing Section C assessments on the above mentioned residents. The MDS coordinator (MDSC) was interviewed on 1/10/18 at 3:00 p.m. She said it was the social service department's responsibility to complete resident MDS assessments, sections C, D and E appropriately. The SSD was interviewed on 1/11/18 at 8:40 a.m. She said the unit's social worker was responsible for completing sections C, D and E of the MDS assessment. She said the social worker did not complete the assessments as required. The skilled rehabilitation unit social worker (SW #1) was interviewed on 1/11/18 at 9:30 a.m. She said she did not complete, as required, sections C, D and E for the above mentioned residents.

Based on observation, record review, and interview, the facility failed to ensure the environment of eight (#2, #77, #17, #38, #119, #60, #48, and #123) of 41 sample residents remained as free from accident hazards as was possible. Specifically: The bed of resident #2, who was identified to be at risk from falls, was not in the lowest position and locked. The resident fell out of bed 10/18/13 and became entrapped between her bed and the heat register. The register cover was knocked off during the fall and the resident's skin came into direct contact with the heat coil resulting in second and third degree burns to her scapula and hip. The wounds from the burns were prolonged in healing and the resident had developed osteo[DIAGNOSES REDACTED] in the location where her hip was burned. Resident #2 again fell from bed after the facility staff failed to apply bolsters to her bed as indicated on the resident's care plan. After resident #2's 10/18/13 fall, the facility had completed an audit and found 25 residents were in beds directly next to heat registers. There was no evidence assessments were completed to ensure their placement next to the registers was appropriate and the heat registers in resident #77, #17, #38, #119, #60, #48, and #123 rooms were not fitted with a protective cover as of 6/2/14. The findings include: 1. Resident #2 a. Resident Status According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to the 3/18/13 significant change in status Minimum Data Set (MDS), the resident's cognition was severely impaired. She required extensive assistance with bed mobility, transfers, dressing, and toilet use. She had a functional limitation in range of motion in her upper and lower extremities. The fall care plan, initiated on 4/29/11 and last revised on 2/20/14, showed the resident was at risk for falls related to poor vision, a history of falls, requiring total assistance with lift for transfers, a history of throwing herself out of bed when angry, and a recent fall that resulted in being found on top of the heating vent with burns. Approaches included: --Specialty wheelchair and egress mattress in place on bed --Placement of body pillows with education provided --Low bed position and impact mat in place on floor when in bed --Air mattress with bolsters (10/18/13) --Place in room without heat register by bed b. Burn Classifications According to the Mark Manual Home Health Handbook for Patients and Caregivers (http://www.merckmanuals.com/home/injuries_and_poisoning/burns/burns.html), in pertinent part: "Burn depth: The depth of injury from a burn is described as first, second, or third degree: Second-degree burns (also called partial-thickness burns) extend into the middle layer of skin (dermis). Second-degree burns are sometimes further described as superficial (involving the more superficial part of the dermis) or deep (involving both the superficial and the deep parts of the dermis). Third-degree burns (also called full-thickness burns) involve all three layers of skin (epidermis, dermis, and fat layer). Usually, the sweat glands, hair follicles, and nerve endings are destroyed as well. Symptoms of a burn wound vary with the burn's depth: Second-degree burns are pink or red, swollen, and extremely painful. Within 24 hours (often shortly after the burn), blisters develop that may ooze a clear fluid. The burned area may blanch when touched. Third-degree burns usually are not painful because the nerves have been destroyed. The skin becomes leathery and may be white, black, or bright red. The burned area does not blanch when touched, and hairs can easily be pulled from their roots without pain. c. 10/18/13, Fall with second and third degree burns (1) Nursing progress notes and physician assessment The nursing progress notes, reviewed back to 10/13/13, revealed the resident fell from bed on 10/18/13. The notes documented, in pertinent part: --10/18/13 at 8:30 a.m., "Went into (resident's) room, heard her talking calmly. Found her on the floor between the bed and the wall. Was laying on her left side. Wrapped in the bed sheet. Notified RN (registered nurse)." --10/18/13 at 8:30 a.m., "Called to resident's room by LPN (licensed practical nurse). States she found resident on the floor. Resident lying on her L(eft) side wrapped in a sheet, talking calmly. States, "I don't hurt", "I'm ok". Resident lying next to wall and heater vent. Initial assessment completed - good (range of motion). No (complaint of) pain ...Assisted with staff to Hoyer lift. Resident back to bed. Noticed wet area to Hoyer sling. Upon assessment, found 19 cm (centimeter) by 9 cm area to L scapula - skin red with some fluid filled areas still intact. Also noted area to L hip 11.5 x 7.5 with 1 cm red edge and white center, noted several small fluid filled blisters. L shoulder with slight redness. (Telephone call to the physician). Will come see resident to assess. Resident continues to have no complaint of pain. Will monitor and assess till healed. Applied silvadene (a topical antibiotic) and covered with moist ABD pad." --10/18/13 at 8:55 p.m., "Area noted on L ulna. Area is swollen, tender, and pink - Res(ident) states it "hurts like a (expletive)" upon palpation. She is able to move wrist. Bone does not appear to be displaced but with pain and swelling and fall ...x-ray ordered to rule out (fracture)." --10/19/13 at 2:15 p.m., " ...Continues to deny pain to burn areas. (Complains of) pain to L wrist. X-ray result negative for (fractures). Some swelling to L wrist. Burns cleansed and redressed. Continue to rotate her from back to R(ight) side, keeping off of burns as much as possible." A 10/18/13 physician progress notes [REDACTED]. The assessment and plan showed the resident had sustained second and third degree burns. (2) Facility Investigation According to the facility's investigation into the resident's fall initiated on 10/18/13, in pertinent part: "Resident found on floor of her room between the bed and wall (found by LPN). Resident wrapped in sheet on her L side - against heater vent. Interventions put in place to prevent further incident: Resident assisted back to bed via Hoyer lift and three assist. Moved away from heater - another room, vent cover." The 10/22/13 Plan of Action for the incident revealed in pertinent part: "6:30: a.m. approximately (on 10/18/13) - Resident was checked on and in her bed 8:30 a.m. Resident found wedged between bed and wall lying on heat register Resident received a burn to her left scapula. The burned area measured (blank). The area had blistered and when placed in the lift sling to get her off the floor and into bed, the blister popped. The second burn area to the left hip measuring 11.5 cm by 7.5 cm. The area is covered with tissue. 9:00 a.m. Resident had been assessed by nursing after being placed back into bed. The MD was notified of the incident. Orders were given to keep areas moist and apply Silvadine. The MD is planning on coming to evaluate the resident during her lunch hours ... 10:00 a.m. Resident's son notified of incident and follow up plan. Son wanted resident treated here at the facility 12:30 p.m. MD here to see resident, wound team to follow resident Causes: Bed not locked Resident is able to throw/thrust self out of bed Resident is top heavy with very little to no trunk control Resident's primary diagnosis (multiple sclerosis). Resident spastic movements Plan of Action (Immediate): Resident moved to room where heat register not next to her bed (unable to keep her in her room and position her bed away from a heat register) In-service held with staff addressing need to be sure safety measures in place prior to leaving a resident's room, to include: call lights within reach, beds locked, beds in lowest position, alarms turned on, impact to mats to floor, body pillows in bed (what is applicable). Will be coming up with a form and implementing on each neighborhood, but start room rounds now. Room rounds to be completed on each neighborhood at change of shift." The investigation did not contain staff interviews regarding when the resident was last rounded on, nor when she had last received toileting assistance. (3) Prolonged healing of wounds and osteo[DIAGNOSES REDACTED] The nursing progress notes revealed, in pertinent part: --10/23/13 at 3:00 p.m., "Res in poor spirits, "I'm ready to die." ...On specialty mattress, denies pain to burns ..." --11/5/13 at 8:45 a.m., " ...(Dressing) change to L scapular area. (Complains of) pain with dressing removal but didn't want pain pill. (Wound) measures 15.8 x 7.0 ... --11/11/13 at 11:50 a.m., " ...L scapula (dressing) removed. Area measured 15.0 x 6.3 ...L hip 11.0 x 7.5 ..." --2/4/14: "(Dressing changed) to all areas. Son updated on status and okay with (treatment). L hip (dressing) removed and heavy (amount) of foul drainage, peri wound pink, wound bed granular/slough cleansed and redressed. L lateral back (dressing) removed. 2 small areas remain granular and minimal serosang (serosanguineous fluid) drainage. Peri-wound pink ...will recommend to increase (dressing) changes to L hip to twice daily ...Continue with air mattress ..." --2/6/14: "Wound rounds with (wound physician) ...L hip debrided by MD - necrotic tissue removed from tunnel area, wound bed granular, pink periwound ..." --2/12/14: "Wound care to L hip - removed old (dressing) - large amount of drainage ...L scapula - old (dressing) removed - scant drainage noted ..." --2/18/14: " ...Pain noted with L hip assessment. Wound care stopped and resident agreed to 10 mg Roxanol (a pain medication) sublingual ...lidocaine spray (a topical pain medication) applied. Wound bed primarily beefy red granular tissue with area of undermining/tunneling. Heavy (amount) of foul drainage. Sample taken for culture ... --2/20/14: " ...L hip - large foul s/s (serosanguineous) drainage noted ..." --2/23/14: "Resident consistently refusing meals at supper. Very difficult to get resident to drink fluids (even "beer"). Resident stated to this nurse, "I know I'm dying, there's no sense in taking that (expletive) (medications); then did take them a ? hour later with her "beer". She did take Roxanol prior to dressing changes as she said, "It hurts, don't touch me." States "Ouch it hurts" every time she is turned ..." --2/25/14 (5:30 p.m.): "Medicated with Roxanol prior to assessment. (Dressing) removed L hip heavy (amount) foul drainage. L hip superior 6.7 x 6.1 x 1.8 and tunneling at 6 = 4.5 (cm). Wound bed granular. Area of tunneling necrotic tissue ...left another message with (physician regarding) recommendations for surgery and osteo. Notified primary care (physician) also this AM (morning) with increased pain ..." --2/25/14 (6:30 p.m.): " ...Resident very angry. Refused to eat eve(ning) meal. Took very little fluids. Resident pale. Knees cool to touch ..." --2/25/14 (7:30 p.m.): "Resident continues to be very angry. Moaning while being repositioned." --2/26/14 (11:40 a.m.): "(Resident) placed on gurney and left facility." The 2/26/14 hospital notes showed the resident was diagnosed with [REDACTED]. The notes revealed, in pertinent part: " ...Finally, she does have a history of bilateral decubitus in the hips. These are very deep, grade 4 on the left ...Apparently she had a recent bone biopsy on the left side that was consistent with osteo[DIAGNOSES REDACTED]. The patient as yet has not been started on antibiotics ...I feel that the patient needs to be admitted , not only for IV access but to start antibiotics ...In the meantime, I did CT (computed tomography) the hip on the left side as this was the area that was diagnosed with [REDACTED]. There was loss of cortical definition, but no evidence of bone degradation ... ...Stage 4 decubitus ulcer present on admission with osteo[DIAGNOSES REDACTED] of left in the greater trochanter with deep phlegmon (a spreading diffuse inflammatory process with formation of suppurative/purulent exudate or pus)... Patient has history of multiple previous debridements and surgeries for her decubitis ulceration. She is confused but states repetitively she would like to be left alone to die. She is screaming out during wound care dressing changes ... ...Upon arrival the patient couldn't give history ...a chronic left hip wound was unpacked that tunneled to bone. CT scan showed osteo[DIAGNOSES REDACTED] of trochanter. The patient to me expresses desire to die. She swears and screams at staff during turns ..." The resident was admitted to the hospital, treated, and returned to the facility on [DATE] per the nursing progress notes. The nursing progress notes continued, in pertinent part: --3/2/14: "Entered room. Resident laying in bed on R side. Opened eyes and looked at nurse and closed them again ... (Dressing) removed L hip heavy (amount) found, purulent drainage. Wound bed granular with area of tunneling with small amount of necrotic tissue, periwound pink. Cleansed with wound cleanser and resident attempted to hit this nurse and stated leave me the (expletive) alone. I'm dying just leave me alone ..." --3/9/14: "Dressing (changed) to wounds. Resident smiling and in good mood during this assessment...L hip (dressing) removed. Heavy (amount) non-foul purulent drainage. Wound bed now visible beefy, red granular tissue, periwound pink ...wounds improved. Hospice changed to low air loss mattress ..." --3/11/14: " ...MD assessment done. Cont(inues) to recommend (antibiotics) and wound vac and no surgical intervention needed at this time. Primary MD notified at this time POA wants comfort measures and hospice." --5/26/14: "Denied request to be pre-medicated. (Dressings changed) ...Left hip granular, mod(erate amount) serosang drainage ...8.0 x 5.1 x 1.4 with undermining 3.2 (cm). Left back (dressing) changed and cluster measured 10.5 x 3.9 almost healed ... Resident cont(inues) on hospice with comfort measures only. No hospitalization or (antibiotic treatment) wanted ..." The wound care physician note dated 5/27/14 revealed, in pertinent part: "This is a summary to above patient which is overall followed now for over 6 months by myself. (Resident's) wounds overall deteriorated over last few months. I performed a biopsy on one visit which showed osteo[DIAGNOSES REDACTED] and recommended IV antibiotic and also more radical debridement with ambulatory surgeon ...at one point the decision was made by son in conjunction with primary care physician to not pursue further invasive treatment ..." (4) Resident Observations On 5/27/14 at 2:27 p.m., the resident was observed in her room lying in bed. An attempt was made to interview the resident. The resident smiled but was unable to answer interview questions in an appropriate manner. On 5/29/14 at 9:04 a.m., the resident was observed lying flat on her back in bed. An air mattress was used. The bed was in the low position and a fall mat was in place. On 5/29/14 at 2:05 p.m. the resident was observed lying in bed. She was positioned on her left side and facing the wall. The bed was in the low position and a fall mat was down. On 5/29/14 at approximately 4:00 p.m., the resident's dressing changes to her left hip and left scapula were observed. The left hip wound was pink to red with exposed muscle. The left scapula was red and pink with scar tissue and a small open area at the proximal end. (5) Staff Interviews --On 5/27/14 at 2:15 p.m., a licensed practical nurse (LPN #2) assigned to work with the resident was asked if they currently had one or more pressure ulcers. LPN #2 stated the resident had a stage III pressure ulcer to her right buttocks. LPN #2 was asked about the two other wounds as documented in the 5/26/14 nursing progress note. She referred the surveyor to the wound nurse to answer this question. --On 5/27/14 at approximately 2:30 p.m., the facility's wound nurse who was a registered nurse (RN #3) stated the wounds on the resident's hip and scapula were from a burn. RN #3 was asked how the resident was burned and she responded the resident had fallen onto the heat register in her room. --On 5/27/14 at approximately 4:30 p.m., the director of nursing (DON) was asked to provide the facility's investigation to the resident's fall and burns. --On 5/28/14 at approximately 9:30 a.m., the DON provided the facility's investigation into the resident's fall. The incident report had been completed by RN #1 who had assessed the resident after the fall. --On 5/28/14 at approximately 10:15 a.m., RN #1 was interviewed. RN #1 stated she was informed the resident had fallen by a LPN. She said, "When I found her she was up against the heater. She was not yelling and made no sound. When we moved her I noticed she had been burned." RN #1 stated she was surprised the resident was not in pain. She said the resident usually expressed pain by lashing out and cussing. RN #1 was asked if she had felt the heat register after tending to the resident. She said she had and, "It was warm and it wasn't scalding when I touched it." --On 5/28/14 at 3:14 pm. the environmental director (ED) was interviewed. He said he was aware of the incident involving the resident. He said, "In her room where she was at, there was an incoming line and a return line (for the hot water heating system). When she fell , she knocked off the heat cover and the coils were exposed." The ED said the resident's skin came into direct contact with the hot water coil. The ED was asked how hot the coil got. He said, " We have it set downstairs and at that time it was set to around 130 - 140 degrees." --On 5/28/14 at 3:38 p.m., the director of nursing (DON) was interviewed. She said as part of the investigation into the resident's fall, she did complete staff interviews; however, she could not find the paper she recorded the staff interviews down on. She said the resident was moved to a room without a heat register next to the bed that day. --On 6/2/14 at approximately 2:00 p.m. a certified nurse aide (CNA) #4 was interviewed. CNA #4 stated she was the one who had found the resident on the floor. She said, "We do our rounds when we get here (at 6:00 a.m.) and she was fine. During another round, I didn't see her and she was just laying against the heater vent. She didn't say anything. I called (the nurse) and she came right away. We moved the bed out of the way and lowered her down on the floor. She was wearing a hospital gown and we could already see a blister. We lifted her up in the Hoyer and the blister had popped." CNA #4 stated the resident seemed calm and was talking at the time. d. 3/30/14, fall from bed (1) Record Review A 3/30/14 nursing progress note revealed the resident had again fallen from bed. The note documented, in pertinent part: "Resident found on the floor of her room beside her bed at 1400 (2:00 p.m.). Assessment completed...no injuries found. Resident's bed was in the lowest position and crash mat was in place. This nurse noted that bolsters were not on resident ' s bed. Found bolsters in residents w/c. Advised CNAs to put bolsters back in place on bed ..." The facility's post fall assessment, dated 3/30/14, revealed in pertinent part: "Resident found on floor of her room at bedside, landed on crash mat. Rolled out of bed. No injuries noted, good range of motion. Neuro checks started. Action Plan: Educate/reorient resident to call light and staff education Potential causes of fall: Resident in bed without bolsters or body pillow on side of bed near the wall What can be put into place to prevent further incident: Will have bolsters put back on bed and educate staff on bed and bolsters." (2) Staff Interview On 5/29/14 at 2:00 p.m., the director or nursing (DON) stated she expected the resident's bed bolsters to have been applied. e. No assessment of residents near heat registers --On 5/28/14 at approximately 9:30 a.m., the DON provided the facility's investigation into the resident's fall. Alleged in the investigation was an ongoing plan of action in response to the fall. The plan included: "Community wide checks of each resident's bed in relation to heat register and position of the bed (25 residents found to have bed positioned next to heat register). IDT (interdisciplinary team) to work together to help residents rearrange rooms to ensure safety with heat register as well as fire door to room closes and help to rearrange room with both residents in the room being satisfied. Maintenance assessed each heat register. Nine registers were determined to need to have the enclosed cover at this time. The registers have been ordered and will be installed upon arrival. Maintenance to contact a vendor to have brackets fabricated to fix remaining heat registers. The brackets will be installed when available. Room rounds to continue at change of shift with oncoming and off going CNAs. Room rounds to be done throughout each shift every 2 to 3 hours. Room rounds are to include call lights within reach, bed brakes locked, beds in lowest position, alarms turned on, body pillows in place, and impact mats on floor if applicable." --On 5/28/14 at 10:40 a.m., the DON was asked to show a room where a cover had been installed over the heat register. The DON went to room 129, opened the door, and entered the room. The room was hot and the heater was on. A cover was observed on the heat register. The cover was felt and was hot to touch but not scalding. The DON stated residents were only placed next to the heat registers if they were stable and not at risk for falls. She said they were in the process of ordering covers for every heat register, but the covers were about $500 each so they were ordering them slowly. The DON was asked for a map of the rooms that had the register covers in place. --On 5/28/14 at 10:58 a.m., the DON provided a facility map which showed 14 register covers had been installed with one on order. --On 5/28/14 at approximately 11:00 a.m. the building was swept and 21 residents were seen with beds directly next to heat registers. Of these 21 residents, eight residents were found to have severe cognitive impairments. 1. Resident #77 in room "A" According to the 3/28/14 quarterly MDS, the resident had a short and long term memory impairment. Her cognitive skills for daily decision making were severely impaired. She required extensive assistance with bed mobility and transfers. 2. Resident #17 in room "B" According to the 4/18/14 annual MDS, the resident's cognition was severely impaired scoring three of 15 possible points on the brief interview of mental status (BIMS). She required extensive assistance with bed mobility and transfers. 3. Resident #38 in room "C" According to the 3/19/14 quarterly MDS, the resident had a short and long term memory impairment. Her daily skills for daily decision making were severely impaired. She required extensive assistance with bed mobility and transfers. 4. Resident #119 in room "D" According to the 4/4/14 quarterly MDS, the resident's cognition was severely impaired scoring three of 15 possible points on the BIMS. She required extensive assistance with bed mobility and transfers. 5. Resident #60 in room "F" According to the 2/21/14 quarterly MDS, the resident's cognition was severely impaired, scoring 7 of 15 possible points on the BIMS. He required extensive assistance with bed mobility and transfers. 6. Resident #48 in room "G" According to the 4/11/14 annual MDS, the resident's cognition was severely impaired scoring 4 of 15 possible points on the BIMS. She required extensive assistance with bed mobility and transfers. 7. Resident #123 in room "H" According to the 3/14/14 quarterly MDS, the resident's cognition was severely impaired scoring 3 of 15 possible points on the BIMS. --On 5/28/14 at 3:14 p.m. the environmental director (ED) stated the register covers were being purchased because the current covers were not designed to stop weight and would fall off if a resident fell on to them. He said the covers were $400 each and with that cost, he was limited to ordering three covers a quarter. The ED stated he placed covers over the current covers in the worst shape. The ED said even with the new covers, the registers got hot but, "They won't get burned like (resident #2) did." The ED said he had turned the heat off in the building earlier that day. He stated the heat would remain off through the summer. --On 5/28/14 at 3:38 p.m., the DON was interviewed. She stated the first register covers were ordered on [DATE] due to a delay in finding covers to fit the heaters. When asked what was done to determine whether it was appropriate for the 25 residents identified to be next to the heat register she said, "We looked at their rooms and we talked about what covers were in the worst condition." --On 5/28/14 at 4:52 p.m., the NHA was asked if the residents next to the heat registers were assessed. She said, "We talked about the people who were in those rooms." The NHA said she would be ordering the register covers for the remainder of the building that day. She said, "We didn't replace them as fast as we could have." --On 5/29/14 at 11:18 a.m., the NHA provided an action plan for bed placement/heat register safety. The action plan included plans to, "Conduct an IDT review of assessment information and fall documentation to determine whether residents whose beds remain alongside the heat register to determine their safety and appropriateness for bed placements. Move residents deemed as unsafe to rooms where the bed is not alongside the heat register as needed."

Based on record review and staff interview the facility failed to ensure that one of seven sample residents (#3) received the necessary care and services to attain or maintain their highest practicable physical well being. Specifically: -Staff failed to thoroughly assess the resident's complaints of pain to ensure appropriate follow-up. -Staff failed to assess and monitor the integrity of the resident's skin. The resident was found upon facility discharge and hospital admission to have multiple open areas that included two pressure ulcers under a splint/brace on his right leg (cross-refer F314), an ulcer on his scrotum and a wound on his left great toe. The findings included: 1. Resident #3, [AGE] years old, was admitted to a hospital, on 3/14/11, following a fall at home. The resident was transferred to the facility from the hospital on [DATE]. The hospital physician's orders [REDACTED]. The resident was sent out to a gero-psychiatric unit for evaluation on 4/19/11. 2. Resident Status on Admission The resident's initial/full Minimum Data Set of 4/7/11, listed the resident to have scored 14 out of 15 correct answers on his Brief Interview of Mental Status (BIMS) which indicated that the resident was cognitively intact. The resident's mood indicated that the resident was feeling down, had trouble sleeping and was tired. The resident was coded with other behavioral symptoms daily which were listed to have no impact on the resident or others or interfere with care. The resident was also listed to reject care on 1 to 3 days of the 7 day review period. The resident was listed as totally dependent for bed mobility, transferring, locomotion on and off the unit, dressing, toilet use and personal hygiene and bathing. The resident was listed not to walk in his room or in the corridor. The resident needed extensive assistance for eating, limited assistance of one with personal hygiene, eating and locomotion on and off the unit, and assistance of two for the rest of the Activities of Daily Living (ADLs). The resident was listed to have limited Range of Motion on one side of his lower extremities. The triggered care areas for additional assessments included: Cognitive, communication, ADLs, urinary status, behavior, falls, pressure ulcers and pain. 3. Fall 4/14/11 - Failure to thoroughly assess complaints of pain A Nurses Note (NN), of 4/14/11 at 8:15 p.m., documented that the resident was found on the floor. The resident had removed the Tab alarm. He was lying on his left side on the crash pad. He complained of pain to his left shoulder and right hip. The nurse received an order for [REDACTED]. However, the following morning, on 4/15/11 at 8:45 a.m., the resident was in the hallway and requested assistance to move his foot off the foot pedal. When the foot was moved the resident yelled out in pain, "My knee." At this time, the right knee was observed to be twice the size of the left knee and it was warm to touch. A second request was sent for an X-ray. On 4/15/11 at 7:30 p.m., the resident was sent to the hospital with a fracture. The Nurses Note and the Unusual Occurrence Report regarding the 4/14/11 fall did not include what assessment was done by the nurse who was on duty when the resident was found lying on the floor, regarding the resident's complaints of pain in the right hip and left shoulder. There was no indication that the nurse asked if the resident was able to move those areas or how painful they were prior to moving the resident back to bed, or how his potential injury with pain was assessed. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of the above omissions, on 5/12/11 at 3:30 p.m. The NHA and DON did not provide any additional information. 3. Re-admission 4/17/11 Record review revealed the resident did not want surgical intervention for the fracture sustained in the 4/14/11 fall. He returned to the facility on [DATE] with a long leg splint/brace in place on his right leg. Upon re-admission to the facility on [DATE] at 2:30 p.m., following a two day stay in the hospital a Registered Nurse (RN) completed the facility "Nursing Data Collection Tool" for initial-annual-change of condition or quarterly documentation of the resident's status with the following: -The resident was documented, on 4/17/11 at 1:00 p.m., with tenderness to his right leg. The resident's skin evaluation stated that the resident's skin was warm, dry and intact, with 2 plus fluid filled [MEDICAL CONDITION], non-pitting to the right foot only. The resident had a small 0.5 x 0.5 centimeter bruise to the right hand. -The resident, on an individual person outline, was listed to have his right leg in a hard splint with his knee bent at approximately 45 degrees. -The same form listed in the resident's foot evaluation that the color and temperature of the extremity was "pale and warm." 4. Status following re-admission A Nurses Note (NN), on 4/17/11 at 9:30 p.m., listed the resident to complain of knee pain and [MEDICATION NAME], an opiate [MEDICATION NAME], was given at 8:00 p.m. A NN, on 4/17/11 at 9:45 p.m., stated that the resident was yelling out he couldn't sleep and he needed to lay flat. The nurse explained that the resident had to lay with his right knee elevated and flexed due to the wrapping. A NN, on 4/18/11 at 4:15 a.m., documented that the resident was given [MEDICATION NAME] for complaint of right leg pain with good effect. A NN, of 4/18/11 at 1:40 p.m., documented that the resident was agitated and yelling most of the shift. The resident required total assistance with all Activities of Daily Living. A NN, of 4/19/11 at 5:00 a.m., listed that the resident was yelling less and had a sitter in his room from 9:00 p.m. to 5:00 a.m. A NN, of 4/19/11 at 2:00 p.m., (the end of the day shift) documented the resident complained of pain in his right knee and discomfort from the brace. The resident was continually asking to have his right leg re-situated, but he never seemed to find a comfortable spot. On 4/19/11 at 4:15 p.m., the resident was transferred from the facility. A late entry, on 4/21/11, by the afternoon nurse (2:00 p.m. to 10:00 p.m.) for 4/19/11 listed that the resident was given Tylenol of 650 mg for general pain on his shift prior to being transferred. 4. Findings upon Transfer and Admission to Another hospital on [DATE] Records at the admitting hospital, on 4/19/11, after transfer from the facility listed the following: a. Cross-reference F314; Pressure Ulcer Documentation in the Interdisciplinary Progress Notes on 4/20/11 by the admitting hospital Wound Consultant noted that the resident had a partial thickness wound of 4 cm x 1 cm on the back of the right calf and another partial thickness wound of 4 cm x 1 cm on the upper inner thigh. According to the nurse on duty, these wounds appeared to be caused by pressure from the brace used to stabilize the fractured femur. b. Non-Pressure Ulcer Under skin integrity was listed: -ulcer on the scrotum, and -left great toenail sore. Further documentation by the Wound Consultant found the nail on the first digit of the left foot was covered in dry blood and easily removed. There was a foul odor of old dry blood and the Wound Consultant suspected a fracture in the joint of the great toe. Documentation by the Wound Consultant also listed a wound on the scrotum of 2 and 1/2 cm by 1 and 1/2 cm with a thin yellow slough covering. The Wound Consultant planned further assessment the next day when/if the resident had achieved appropriate pain control. Interdisciplinary Progress Note of 4/21 regarding the resident's condition at admission listed: At admission when taken to bed and undressed the following was found: -the resident had dried food stuck to his skin; -an un-addressed wound was found on the left great toe, which had caked on dried blood and the nail was barely attached; -while doing peri care there was a very strong odor; -there was dried bowel movement on the resident's scrotum and also skin breakdown on the scrotum; -the catheter was listed as rust colored, cloudy and was malodorous; -there was drainage from the penis; and, -when the leg brace on the right leg was removed there were two open sores (listed as partial thickness wounds which was clarified by the nurse manager to be open areas that could also be described as Stage II areas) on the leg from the brace. 5. Failure to thoroughly assess resident's complaints and behaviors Review of the resident's record revealed no documentation that the resident's pain following re-admission was thoroughly assessed. The character, location, and source of pain, as well as the intensity of the pain were not documented in the NNs, on the MAR indicated [REDACTED]. Review of the resident's record revealed there was no documentation of the condition of the resident's skin after the re-admission nursing assessment 4/17/11, stating there were no open areas and there was no information found regarding injury to the resident's left great toenail. The staff was unable to supply a copy of the transfer information to the receiving hospital for the transfer on 4/19/11, so a list of what was faxed to the facility was provided. It stated that the information sent included copies of the following: the face sheet; Guardianship papers; Cardiopulmonary Status; History and Physical; Computerized physician's orders [REDACTED]. There was no assessment of the resident at the time of the planned discharge from the facility, stating what the resident's skin condition was related to the pressure areas, the open area on the scrotum, or the condition of the resident's left great toe. There was also no information regarding the condition of the resident's catheter or urine at discharge. 6. Staff Interview The Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed on 5/4/11 at 2:20 p.m. -The DON was asked to share any skin assessments. She stated skin assessments were documented on the Nursing Data Collection Tool. She provided a skin assessment completed on 4/5/11. -The DON stated at that time that no other documentation was found of a skin assessment; specifically, there was no assessment of the resident's skin prior to the resident's transfer on 4/19/11. The DON stated that the nurse who was on duty when the resident was discharged had not had time to evaluate him prior to his discharge. -The DON stated that they had no orders to remove the brace. The NHA stated he was only in the facility for two days upon his re-admission. The NHA stated that the injury to the resident's left great toenail could have occurred during the transfer on 4/19/11.

Based on record review and interviews, the facility failed to ensure one of seven sample residents (#3) received the care and services necessary to prevent the development of pressure ulcers. Specifically, resident #3 wore a long splint/brace on a contracted leg to address a femur fracture sustained during a fall. Resident #3's skin was not assessed and monitored to prevent the development of two pressure areas under the splint/brace. The findings include: 1. Resident #3, [AGE] years old, was admitted to a hospital, on 3/14/11, following a fall at home. The resident was transferred to the facility from the hospital on [DATE]. The hospital physician's orders [REDACTED]. The resident was sent out to a gero-psychiatric unit for evaluation on 4/19/11. 2. Resident Status on Admission The resident's initial/full Minimum Data Set, of 4/7/11, listed the resident to have scored 14 out of 15 correct answers on his Brief Interview of Mental Status (BIMS) which indicated that the resident was cognitively intact. The resident's mood indicated that the resident was feeling down, had trouble sleeping and was tired. The resident was coded with other behavioral symptoms daily which were listed to have no impact on the resident or others or interfere with care. The resident was also listed to reject care on 1 to 3 days of the 7 day review period. The resident was listed as totally dependent for bed mobility, transferring, locomotion on and off the unit, dressing, toilet use and personal hygiene and bathing. The resident was listed not to walk in his room or in the corridor. The resident needed extensive assistance for eating, limited assistance of one with personal hygiene, eating and locomotion on and off the unit, and assistance of two for the rest of the Activities of Daily Living (ADLs). The resident was listed to have limited Range of Motion on one side of his lower extremities. The triggered care areas for additional assessments included: Cognitive, communication, ADLs, urinary status, behavior, falls, pressure ulcers and pain. A care plan with an original date, of 4/8/11, addressed the resident being at risk to develop pressure ulcers and having frail skin. The resident needed staff to reposition him. He was incontinent at times of bowel. He relied on staff for peri-care as well as catheter care. The resident also had a [DIAGNOSES REDACTED]. He had a rash to his groin area. -The goal was not to have any open areas and/or complications from skin tears or bruises: -Interventions: --adult incontinent products; --apply moisture barrier per facility policy; --monitor for skin breakdown, bruises or skin tears during daily cares; --weekly skin assessment; --pressure reducing mattress and pressure reduction cushion to wheelchair; --monitor skin for bruises or skin tears; --cleanse approximate any dress any skin tears; and, --monitor for infection. 3. Fall and re-admission 4/17/11 Record review revealed the resident sustained [REDACTED]. The resident was sent to the hospital on [DATE], after the fall on 4/14/11, for treatment of [REDACTED]. Upon re-admission to the facility 4/17/11 at 2:30 p.m., following a two day stay in the hospital a Registered Nurse (RN) completed the facility "Nursing Data Collection Tool" for initial-annual-change of condition or quarterly documentation of the resident's status with the following: -The resident was documented, on 4/17/11 at 1:00 p.m., with tenderness to his right leg. The resident's skin evaluation stated that the resident's skin was warm, dry and intact, with 2 plus fluid filled [MEDICAL CONDITION], non-pitting to the right foot only. The resident had a small 0.5 x 0.5 centimeter bruise to the right hand. -The resident, on an individual person outline, was listed to have his right leg in a hard splint with his knee bent at approximately 45 degrees. -The same form listed in the resident's foot evaluation that the color and temperature of the extremity was "pale and warm ". -The form listed under the "Head to Toe Comments Section" .....right leg in hard splint & bent at knee. 2 plus [MEDICAL CONDITION] to right foot only, safety alarm in place due to fall risk, bed in lowest position with crash mat in place. Physical Therapy to evaluate and treat. -The form contained no other information related to the resident's skin condition. A "Braden Risk Assessment Scale" was completed on 4/17/11 with a score of "15". According to the scoring note at the bottom of the form any resident with a total score of 16 or less was considered to be at risk of developing pressure ulcers. A score of 15 or 16 would be a low risk. The resident's re-admission, post acute care order form from his hospitalization , on 4/15/11, listed the resident to have a right distal femur fracture. The resident was non weight bearing on the right lower extremity. The other orders listed that the "brace over (the) posterior leg can be re-wrapped if needed." There were no other orders found related to care and treatment of [REDACTED]. 4. Status upon discharge 4/19/11 Review of the resident's record revealed there was no documentation of the condition of the resident's skin after the re-admission nursing assessment 4/17/11, stating there were no open areas. The staff was unable to supply a copy of the transfer information to the receiving hospital for the transfer on 4/19/11, so a list of what was faxed to the facility was provided. It stated that the information sent included copies of the following: the face sheet; Guardianship papers; Cardiopulmonary Status; History and Physical; Computerized physician's orders [REDACTED]. There was no assessment of the resident at the time of the planned discharge from the facility, stating what the resident's skin condition was related to the pressure areas, 5. Findings upon Transfer and Admission to Another hospital on [DATE] Records at the admitting hospital on [DATE] after transfer from the facility listed the following, in pertinent part: Documentation in the Interdisciplinary Progress Notes on 4/20/11 by the admitting hospital Wound Consultant noted that the resident had a partial thickness wound of 4 cm x 1 cm on the back of the right calf and another partial thickness wound of 4 cm x 1 cm on the upper inner thigh. According to the nurse on duty, these wounds appeared to be caused by pressure from the brace used to stabilize the fractured femur. The Wound Consultant planned further assessment the next day when/if the resident had achieved appropriate pain control. Interdisciplinary Progress Note of 4/21 regarding the resident's condition at admission listed: At admission when taken to bed and undressed the following was documented, in pertinent part: When the leg brace on the right leg was removed, there were two open sores (listed as partial thickness wounds which was clarified by the nurse manager to be open areas that could also be described as Stage II areas) on the leg from the brace. 6. Staff Interview The Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed on 5/4/11 at 2:20 p.m. -The DON was asked to share any skin assessments. She stated skin assessments were documented on the Nursing Data Collection Tool. She provided a skin assessment completed on 4/5/11. -The DON stated at that time that no other documentation was found of a skin assessment; specifically, there was no assessment of the resident's skin prior to the resident's transfer on 4/19/11. The DON stated that the nurse who was on duty when the resident was discharged had not had time to evaluate him prior to his discharge. -The DON stated that they had no orders to remove the brace. The NHA stated he was only in the facility for two days upon his re-admission. The NHA stated that the injury to the resident's left great toenail could have occurred during the transfer on 4/19/11. 7. Failure Although the resident complained of pain and discomfort with his leg positioned with the brace/splint, there was no documentation that the staff called to clarify the orders or for additional orders related to caring for the right leg with the brace. When the brace was removed at the receiving hospital (see above) two open areas were discovered.