Every finding on record at Good Samaritan Society -- Fort Collins Village

Based on record review and interviews, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for one (#43) of three residents reviewed for restorative services out of 29 sample residents.Specifically, the facility failed to ensure Resident #43 was provided with a splint or palm guard in her left hand to prevent potential worsening of her hand contracture (a condition of shortening and hardening of muscles, tendons or other tissue, often leading to deformity and rigidity of joints). Findings include:I. Facility policy and procedureThe Range of Motion (ROM) [NAME] policy, revised 8/5/25 was received from the nursing home administrator (NHA) on 9/26/25 at 12:36 p.m. It read in pertinent part, Based on the resident's comprehensive assessment, the location will ensure that a resident entering without a limited range of motion will not experience reduction of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. In addition, the location will ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion as much as possible and to prevent further decrease in range of motion.II. Resident #43A. Resident statusResident #43, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included type two diabetes, blindness in one eye, fibromyalgia (musculoskeletal pain and fatigue) and chronic congestive heart failure (weakened heart muscle).The 8/6/25 minimum data set (MDS) assessment identified Resident #43 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented Resident #43 was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear, and transferring to/from the bed to chair.B. Resident interview and observationResident #43 was interviewed on 9/25/25 at 9:20 a.m. Resident's left hand was contracted and she was unable to extend all her fingers. The resident said she sometimes had her brace. She said her brace disappeared the other night but therapy was working on finding her a new one. C. Observations On 9/22/25 at 2:30 p.m. Resident #43 was not wearing her palm protector on left hand (a device used to prevent finger contractures).On 9/23/25 at 2:20 p.m. Resident #43 was wearing her palm protector on her left hand.On 9/25/25 at 9:10 a.m. Resident #43 was not wearing her palm protector. It was on her table in her room.D. Record reviewReview of Resident #43's comprehensive care plan did reveal documentation that Resident #43 had a contracture. The care plan did not list any interventions for the management of the contracture. Review of Resident #43's September 2025 CPO did not reveal a physician's order for palm protector to prevent contractures.Review of Resident #43's occupational therapy notes revealed the first palm protector was given to Resident #43 on 7/7/25. Resident #43 complained of left hand pain 8 out of 10 and did not bump it on anything. The nurse compared the right and left hand and the left looked slightly darker than the right. The OT placed a palm guard on Resident #43's left hand to protect it and keep the hand in a better position. The nurse said they would keep an eye on it.-However, her care plan did not indicate how often and for how long the palm protector should be on. Review of Resident #43's Kardex (staff directive tool) did not include information regarding a hand brace or palm protector.D. Staff interviews Registered nurse (RN) #3 was interviewed on 9/25/25 at 9:15 a.m. RN #3 said the RNs or the certified nurse aides (CNA) could put braces or palm protectors on residents. She said information on how and when to apply equipment should be in the treatment administration record (TAR). CNA #1 was interviewed on 9/25/25 at approximately 9:30 a.m. CNA #1 said Resident #43 should have her palm protector put on in the morning and taken off at night when she went to bed. CNA #1 said information on Resident #43's brace and placement could be found on the care plan, physician's orders or the Kardex. CNA #1 said usually there were pop ups (prompts) that the CNAs followed to make sure tasks were completed. CNA #1 said there were currently not pop ups for Resident #43's palm protector.RN #2 was interviewed on 9/25/25 at approximately 9:30 a.m. RN #2 said there was not a physician's order for a brace or palm protector for Resident #43. Occupational Therapist (OT) #1 was interviewed on 9/25/25 at 2:50 p.m. OT #1 said Resident #43 was admitted with a contracted index finger. She said that upon admission, best practice was to take measurements of resident's contractures. She said she was not sure whether or not the therapy department took measurements. OT #1 said when the resident was admitted to the facility, the therapy team offered different things for her to wear to prevent contractures but she did not want them. OT #1 said that should have been documented. The interim director of nursing (DON) was interviewed on 9/25/25 at 4:27 p.m. The interim DON said when a resident was initially admitted to the facility and had contractures a care plan should have been created. The interim DON said the nursing staff should be updating the care plan and there should be a physician's order for the brace or palm protector. The interim DON said if there was a physician's order, a range of motion task would pop up on the CNA tasks and the CNAs would acknowledge it. The interim DON said this information should be on the Kardex sheet to reference. The interim DON said the therapy team should also evaluate the resident. The interim DON said once the therapy team had evaluated the resident, therapy should be educating nursing staff on the brace and then education should be passed on through verbal reports for the nursing staff. The interim DON said communication tools the staff used included white boards in the resident's room, communication tabs in the electronic charting system and communication questions with the nurses or charge nurse. The interim DON said the charge nurse should verify the brace was on. The interim DON said there was not a restorative program at the facility currently. The interim DON did not know why the resident did not have a physician's order for a palm protector and why her care plan was not updated with a palm protector intervention.

Based on observations, record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for two (#70 and #10) of five residents out of 29 sample residents. Specifically, the facility failed to: -Identify Resident #70 had a history of suicidal ideation in order to monitor for worsening signs and symptoms of depression or suicidal ideation; -Identify and implement effective interventions for Resident #10's yelling behavior;-Ensure hours of sleep were monitored for Resident #10 while she was on antidepressant medications known to cause drowsiness; and, -Ensure Resident #70 and Resident #10 were offered mental health services.Findings include: I. Resident #70 A. Resident statusResident #70, age greater than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia, chronic myeloid leukemia (cancer of the blood and bone), depression and insomnia. The 9/17/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. He used a wheelchair and had an impairment on both the upper and lower extremities. He required supervision with eating and he required substantial assistance with showering, oral hygiene and personal hygiene. The MDS assessment revealed Resident #70 had little interest or pleasure in doing things, felt down, depressed or hopeless, and felt tired or had little energy on seven to 11 days during the assessment look-back period. The MDS assessment revealed the resident had thoughts he would be better off dead or hurt himself on two to six days during the assessment look-back period. The MDS assessment indicated the resident's patient health questionnaire (PHQ-9 - a multi-purpose tool used for screening, diagnosing, monitoring and measuring the severity of depression) was seven out of 27, which indicated mild depression. B. Resident interview Resident #70 was interviewed on 9/25/25 at 10:28 a.m. Resident #70 said he was not happy at the facility. He said none of his relatives visited him. He said he would talk to a professional about how he felt about living at the new facility if he was given the chance. C. Record review Resident #70's suicide statement care plan, initiated and revised on 9/25/25 (during the survey), revealed the resident made statements he was ready to die and felt he would be better off if he was gone. He denied suicidal ideation, intent and plan. Interventions included giving the resident adequate rest periods per the resident's requests, discussing with the family and resident any concerns, fears and issues, attempting non-pharmacological interventions for depression, enjoying one-on-one conversations, going outside, watching history and nature television programs. -However, despite the resident's expressions of not wanting to be here anymore and feeling bad about himself from the 9/17/25 MDS assessment the facility failed to assess and monitor the resident for signs and symptoms of depression and suicidal ideation. The 9/2/25 physician's progress note revealed Resident #70 was seen for worsening depression. The resident expressed feeling not worthy and wanting to get out of here. He reported feeling sad and stating he was in a nursing home and nobody visited him except for his wife and she could only come so often. He reported difficulty finding enjoyment in activities at the nursing home. He reported he had fleeting suicidal thoughts including thinking about jumping in front of traffic or cutting his artery with a hacksaw. He mentioned sleep saved him and he fell asleep before he was able to act on any of these thoughts. The depression and suicidal ideation plan was discussion of antidepressant medication therapy. The medical power of attorney (MPOA) declined medication initiation at the visit. The physician encouraged frequent mood reassessment once the resident moved to a new facility. The physician recommended implementing increased safety precautions and added orders for more frequent safety checks by staff every two hours and staff removed sharp objects and potential self harm tools from the resident's room and coordinating with facility staff to encourage resident engagement in daily activities. The 9/9/25 referral discharge physician orders revealed Resident #70v may benefit from behavioral health consultation if his mood did not improve following the move. Send last progress notes so the future provider was aware. The 9/13/25 PHQ-9 score revealed a score of nine out of 27 which indicated mild depression. He had little interest or pleasure in doing things on seven to 11 days, felt down, depressed or hopeless on two to six days, felt tired or had little energy on 12 to 14 days, trouble concentrating on things seven to 11 days and moving or speaking so slowly that other people could have noticed occurred on two to six days during the assessment look back period. -Review of Resident #70's electronic medical record (EMR) failed to identify that a suicide lethality assessment was completed after the 9/17/25 PHQ-9 assessment revealed the resident had thoughts he would be better off dead and the facility failed to document that the resident was scheduled to be seen for his depression and suicidal ideation. II. Resident #10 A. Facility policy and procedure The Psychotropic Medications policy and procedure, revised 5/12/25, was provided by the nursing home administrator (NHA) on 9/26/25 at 12:36 p.m. It read in pertinent part, Based on a comprehensive assessment of a resident, the location must ensure that residents who use psychotropic drugs receive behavioral interventions, unless clinically contraindicated, in aneffort to discontinue these drugs. Throughout the administration of the psychotropic medications, the following must be completed: mood and behavior documentation must continue in order to monitor the effect the medication has on the behavior. Monitor for effectiveness and potential adverse consequences. The reduction committee will review the need for psychotropicmedications at least every three months and document the rationale for continuing the medication. The committee also will need to evaluate the resident's target symptoms and the effect of the medication on the severity, frequency and other characteristics; any changes in the resident's function during the last quarter; this can be done by reviewing the minimum data set (MDS) and whether the resident experienced any medication-related adverse consequences during the previous quarter.B. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included dementia, chronic obstructive pulmonary disease, aortic stenosis, morbid obesity, lymphedema, disorder with mixed anxiety and depressed mood, insomnia and major depressive disorder. The 9/24/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of 12 out of 15. She had one impairment on her upper extremity and used a wheelchair. She required supervision with eating. She required substantial assistance with oral hygiene and personal hygiene. She was dependent on staff for toileting and showering. The assessment revealed the resident received an antipsychotic medication and an antidepressant medication. The assessment revealed the resident did not exhibit any behaviors and did not reject care. C. Resident interview Resident #10 was interviewed on 9/23/25 at 9:39 a.m. Resident #10 said the staff said she asked for help too much. She said staff said she needed too much personal care. She said staff did not always say that when she asked for help. She said staff said she asked for help too much off and on. Resident #10 was observed in her wheelchair next to her bed in her room.D. Resident observations During a continuous observation on 9/23/25, beginning at 1:00 p.m. and ending at 1:49 p.m, Resident #10 was observed in her wheelchair next to her bed in her room. From 1:09 p.m. to 1:21 p.m. Resident #10 said please help three times, help me three times and help over ten times.-However, no staff members went into the resident's room to see what the resident needed. At 1:24 p.m. an unknown certified nurse aide (CNA) walked in and walked out at 1:25 p.m. At 1:26 p.m. Resident #10 said help two times. At 1:29 p.m. the same unknown CNA went into Resident #10's room with CNA #2. At 1:32 p.m. Resident #10 was observed in her bed. At 1:44 p.m. Resident #10 had two visitors enter her room. At 1:49 p.m. Resident #10's visitor asked an unknown CNA who was in the hallway outside of Resident #10's room if the resident could get up in her wheelchair. The CNA got the resident.During a continuous observation on 9/24/25, beginning at 3:00 p.m. and ending at 4:00 p.m. Resident #10 was observed in her bed with both of her eyes open. At 3:12 p.m. Resident #10 said hello two times. -However, no staff members went into the resident's room to see what the resident needed. At 3:22 p.m. Resident #10 said help me three times. -However, no staff members went into the resident's room to see what the resident needed. From 3:28 p.m. to 3:34 p.m. Resident #10 said help eight times. -However, no staff members went into the resident's room to see what the resident needed. At 3:36 p.m. CNA #3 went into Resident #10's room. At 3:46 p.m. Resident #10 was observed being escorted by CNA #3 to the common area. E. Record review Resident #10's psychopharmacological medication care plan, initiated 8/26/21 and revised 6/13/25, revealed the resident used psychopharmacological medication related to major depressive disorder, dementia with behavior episodes and adjustment disorder with mixed anxiety. Interventions included consulting with pharmacy and healthcare providers to consider dosage reduction, discussing with healthcare providers and family the ongoing need for the use of the medication and monitoring the resident's condition based on clinical practice guidelines or clinical standards of practice related to the use of psychotropic medications. Resident #10's behavior symptom care plan, initiated 1/17/25 and revised 3/4/25, revealed the resident's behavior included yelling out, banging on the wall, inappropriate comments to the staff during care. She denied care was given and stated nobody ever helped her when staff was recently in her room. Interventions included intervening as necessary to protect the rights and safety of others, approaching in a calm manner, diverting attention, removing the resident from the situation and taking her to alternate locations as needed, providing opportunities for positive interaction and attention, offering a warm blanket for comfort as needed, offering a weighted blanket for comfort as needed, repositioning as needed, assessing for pain, thirst, hunger and constipation and offering one on one reassurance and emotional support as needed. Resident #10's cognitive deficit care plan, initiated 4/7/21 and revised 9/12/25, revealed Resident #10 exhibited forgetfulness and became upset and agitated with reminders. She had difficulty with timelines, she was repetitive with her concerns, and brought up past concerns after they had been resolved. She was unaware of current reality at times, such as saying she needed to be changed when staff just assisted her. She called out for help and then did not know what she needed help with. Interventions included enjoying one on one conversation especially about astrology, enjoying the presence of others, understanding consistent, simple and direct sentences, providing her with necessary cues, communicating with the resident regarding her capabilities and needs, asking yes or no questions, presenting just one thought, idea, question or command at a time and break tasks into one step at a time. Review of Resident #10's September 2025 CPO revealed the following physician's orders: Zoloft (antidepressant medication) 50 milligram (mg) tablet. Take one tablet by mouth one time a day for depression, ordered 3/1/25. Zyprexa (antipsychotic medication) 7.5 mg tablet. Take one tablet by mouth at bedtime for dementia with behaviors, ordered 6/13/24. Depakote 250 mg delayed release tablet. Take two tablets by mouth two times a day for dementia with behaviors, ordered 4/9/25. Mood monitoring: tearful, change in sleep habits, refusing medication, decrease in appetite, easily irritated with staff. Complete every shift for mood monitoring, ordered 6/9/24. Mood and behavior monitoring: calling out, tearful, accusations she is not being assisted, refusing medications or meals, irritable with staff, demanding behaviors, change in sleeping habits or self isolation. Complete every shift for mood and behavior monitoring, ordered 7/17/23. -A review of Resident #10's EMR failed to reveal the resident's hours of sleep were monitored. The 8/31/25 nurse progress note revealed Resident #10 had minimal yelling out. The 9/1/25 nurse progress note revealed the resident yelled out help throughout the night. The staff were attentive and responded quickly. The resident was forgetful what time it was during the day and thought it was daytime. Staff reassured the resident and she went back to sleep. The 9/2/25 nurse progress note revealed Resident #10 was in the family room with other residents calling out to go to bed after dinner and at shift change. The nurse told the resident many residents were requesting assistance to go to bed and everyone would have to wait until the CNAs were available to assist her. The resident acknowledged the information and she stopped calling out. The 9/10/25 nurse progress note revealed the resident was in the family room calling out for help. When asked how the nurse could help, the resident said she did not know. The resident was given a snack and a drink with a positive effect for 15 minutes. She continued to call out for help after the snack was consumed. The resident went to her room per her request. The resident was provided an additional blanket per her request. The resident had an illogical flow of ideas, changing subject, per baseline. Reassurance and emotional support were provided. The 9/16/25 care conference note revealed Resident #10 continued to call out, was unable to make needs known when approached and sometimes did not know why she was calling out. The 9/17/25 nurse progress note revealed the resident had minimal yelling during the shift. -There was no consistent documentation in Resident #10's EMR regarding what interventions were attempted when the resident exhibited the identified behaviors and if the interventions were effective. -A review of Resident #10's EMR failed to reveal the interdisciplinary (IDT) team met to review the resident's psychotropic medications, what behaviors were being monitored, what non-pharmacological interventions were used to help manage the resident's psychiatric behavior symptoms and the resident's response to the interventions attempted. IV. Staff interviews CNA #2 was interviewed on 9/25/25 at 5:36 p.m. CNA #2 said she was familiar with Resident #70. CNA #2 said Resident #70 did not have any behaviors. CNA #2 said she was not aware of any signs or symptoms of depression or a history of suicidal ideation or attempts for the resident. Licensed practical nurse (LPN) #1 was interviewed on 9/25/25 at 4:21p.m. LPN #1 said Resident #70 did not have any behaviors. LPN #1 said he was not aware of any signs or symptoms of depression or a history of suicidal ideation or attempts for the resident. The social services director (SSD) was interviewed on 9/25/25 at 3:52 p.m. The SSD said she started working at the facility in February 2025 and this was her first nursing facility social worker position. She said she had a consultant she collaborated with as needed. The SSD said she was responsible for completing the social services section of the MDS assessment. She said she recently hired a part-time social services assistant. The SSD said if the assistant completed the assessment, the SSD reviewed the section with her assistant. The SSD said if a resident answered yes to feeling better off dead or had little interest or pleasure in doing things, felt down, depressed or hopeless, she talked to the resident further to learn more about why the resident had those feelings. She said she would document the conversation as a progress note. The SSD said during the conversation she would complete a suicide ideation assessment to determine if the resident had a suicide plan. The SSD said after she talked to the resident, she would implement interventions to help the resident and it was documented in the resident's care plan. She said mental health services were one intervention. The SSD said she would have a physician's order for mental health services. The SSD was familiar with Resident #70. She said she completed the MDS social services assessment for Resident #70. She said when the resident answered yes to feeling better off dead, she talked to him for an hour to learn why he answered yes. The SSD said he did not feel better off dead, he said he hated being in a new facility, he missed his wife and he talked about how he missed his independence. The SSD said she thought she documented the conversation as a progress note. The SSD reviewed Resident #70's progress notes during the interview and she said did not see a progress note that documented her conversation with the resident about his suicidal statements. The SSD said based on her conversation with Resident #70 and reviewing his chart, the resident had depression. The SSD said she should arrange for Resident #70 to see mental health services and she should collaborate with nursing staff so the nursing staff could monitor his depression. The SSD said nursing staff monitored depression through a physician's order and documented the depression monitoring on the resident's treatment administration record (TAR). The SSD said she collaborated with the IDT regarding what resident behaviors needed to be monitored. The SSD said the IDT reviewed residents who were on psychotropic medications during the psychotropic pharmacy meeting. The SSD said she was responsible for the psychotropic pharmacy meetings. She said residents were reviewed prior to the residents starting a psychotropic medication, quarterly and as needed. She said she took handwritten notes at the meetings and she did not document the meeting notes in the individual resident's EMR. The SSD said typical interventions were resident specific and personalized based on what interventions were effective for the resident. The SSD said sitting with the resident, holding the resident's hand, talking with the resident, repositioning, music, changing the music, a stress ball, a teddy bear, aromatherapy, a warm blanket and sitting in the sunshine were examples of interventions for residents. The SSD said interventions should be offered whenever the resident wanted and needed interventions. The SSD said she was familiar with Resident #10. The SSD said Resident #10 called out for help repetitively and if staff did not respond, she called out louder. The SSD said she had not determined effective interventions to reduce Resident #10's behavior of calling out for help. She said saw the physician's orders for Resident #10 to be seen for individual counseling and mental health services. The SSD said she was unable to determine when Resident #10 was seen for individual counseling and mental health services.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#16 and #48) of the five residents reviewed for antibiotic use out of 29 sample residents. Specifically, the facility failed to track and monitor the use of long-term antibiotics for Resident #16 and Resident #48. Findings include:I. Professional reference According to The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes (2025), retrieved on 9/29/25 fromhttps://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html?CDC_AAref_Val=https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.htmlTo track how and why antibiotics are prescribed, providers perform reviews on resident medical records for new antibiotics started to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.II. Facility policy and procedureThe Antibiotic Stewardship policy, dated 7/8/25, was received from the nursing home administrator (NHA) on 9/25/25 at 11:04 am. It read in pertinent part, To guide Good Samaritan Society-Fort [NAME] Village locations for antibiotic stewardship plans. To decrease the incidence of multidrug-resistant organisms (MDRO). Promote appropriate use while optimizing the treatment of infections and reducing the possible adverse events associated with antibiotic use. To provide standard definitions to be used as guidelines when initiating antibiotics.III. Resident #16A. Resident status Resident #16, age greater than 65, was admitted on [DATE]. According to the September 2025 computerized physician order (CPO), diagnoses included congestive heart failure, atrial flutter, long-term anticoagulant use, chronic kidney disease, hyponatremia, urgency of urination and overactive bladder. The 9/3/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of ten out of 15. The assessment revealed the resident was on an antibiotic. B. Resident interview Resident #16 was interviewed on 9/24/25 at 10:03 a.m. She said she did not currently have a urinary tract infection (UTI). The resident said she was not sure the last time she had a UTI. She said when she had a UTI in the past, it made her feel uncomfortable. She said she was not on any antibiotics currently.C. Record review Review of Resident #16's September 2025 CPO revealed the following physician's order:Cephalexin (antibiotic) tablet 250 milligram (mg). Give 1 tablet by mouth one time a day for UTI prophylaxis (to prevent an infection from occuring), ordered 12/9/22.The physician's order for the Cephalexin failed to indicate a stop date for the use of the antibiotic. The antibiotic therapy care plan, revised 12/7/23, revealed the resident was on antibiotic therapy related to UTI prevention. Pertinent interventions included monitoring/documenting signs or symptoms of UTI.Review of Resident's #16 EMR did not reveal documentation regarding the physician's justification for the long-term use of an antibiotic. Review of Resident #16's EMR did not reveal documentation to indicate the facility's infection preventionist (IP) completed an antibiotic use assessment or documented the McGeer's criteria met to justify the physician's order for Cephalexin. Review of the IP infection surveillance documents from 6/25/25 to 8/25/25 revealed that the facility identified residents with active infections. -However, Resident #16 was not included on the infection surveillance documents.The 6/20/25 pharmacist note documented Resident #16 had received an antimicrobial agent, Cephalexin 250 mg once a day, since December 2022 for the prevention of UTI. The note documented prolonged use of antibiotics for infection prophylaxis increased the risk of resistance and the development of C. difficile infection.-However, review of the resident's EMR did not reveal documentation that the facility took action to clarify the antibiotic use for Resident #16. IV. Resident #48A. Resident status Resident #48, age greater than 65, was admitted on [DATE]. According to the September 2025 CPO, diagnoses included vascular dementia, atrial fibrillation, prediabetes, muscle weakness and lack of coordination.The 9/10/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of one out of 15. The assessment revealed the resident was on an antibiotic. B. Record reviewReview of Resident #48's September 2025 CPO revealed the following physician's order;Cipro Oral Tablet 250 MG (Ciprofloxacin HCl): Give 250 mg by mouth in the evening for UTI prophylaxis, ordered 2/18/24.-The physician's order for the Cipro failed to indicate the duration for the use of the antibiotic., The antibiotic therapy care plan, revised 8/6/23, revealed the resident was on antibiotic therapy related to UTI prevention. Pertinent interventions included encouraging fluid intake and monitoring/documenting/reporting signs or symptoms of UTI. Review of the Resident #48's EMR did not reveal documentation regarding the physician's justification for the long-term use of an antibiotic. Review of Resident #48's EMR did not reveal documentation to indicate the facility's IP completed an antibiotic use assessment or documented that McGeer's criteria were met to justify the physician's order for Cipro. The 6/21/25 pharmacist note documented that Cipro was started in February 2024 and was a long-term antibiotic. The note documented the evidence supporting prophylactic antibiotic use for recurrent UTI in older adults was lacking and the harms of long-term use may outweigh the benefits in older adults.-However, there was documentation that the facility reviewed the use of the long-term use of Cipro for Resident #48.V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/25/25 at 10:40 a.m. LPN #1 said Resident #16 had been on an antibiotic since she started working at the facility. LPN #1 said there was a question as to why the antibiotic was prescribed prophylactically for UTI, without an end date. LPN #1 said Resident #16 had not experienced a UTI while at the facility. LPN #1 said she was not aware of Resident #16 ever having a UTI. The IP and the NHA were interviewed together on 9/25/25 at 4:42 p.m. The IP said the facility's process for monitoring and tracking infections and antibiotic use included mapping of current infections and outbreaks. The IP said the medical director reviewed antibiotic use as needed. The IP said if the resident's family refused to stop antibiotic use, it would continue prophylactically per family request. The IP said the process for prophylactic antibiotic use was continued by the family of the resident, even though the facility had an antibiotic stewardship program.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#8) of three residents reviewed for hospice services out of 29 sample residents.Specifically, the facility failed to:-Establish an effective communication process, including how the communication would be documented between the facility and the hospice services provider for Resident #8; and,-Ensure the hospice agency's care notes were easily accessible to the facility staff and included consistent documentation of the hospice care visits in Resident #8's electronic medical record (EMR). Findings include:I. Facility policy and procedureThe Hospice Care policy and procedure, revised 11/1/24, was received from the nursing home administrator (NHA) on 9/26/25 at 12:36 p.m. It read in pertinent part, Hospice care addresses symptom management, coordination of care, communication and decision making, clarification of goals of care, and quality of life for the dying resident and their family. Hospice care is provided by an interdisciplinary team (IDT) approach to address the physical, psychosocial, spiritual, and medical care to help someone with a terminal illness live as well as possible for as long as possible, increasing quality of life.II. Facility-Hospice contractReview of Resident #8's EMR revealed a contract between the facility and the hospice services company, which was signed by the resident's representative on 2/21/25. It read in pertinent part, A coordinated comprehensive plan of care shall be jointly developed by the facility and hospice. Hospice participation in the care plan conference and input from the hospice representative are required.III. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia, Parkinson's disease, cerebral ischemia (not enough blood flow to the brain leading to brain cell damage), cervical disc degeneration, osteoporosis, anxiety, anemia and hypertension.The 8/13/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required maximum assistance with activities of daily living (ADL) and had a performance deficit related to incontinence, activity intolerance, aggressive behavior, confusion, dementia, and limited mobility.The assessment documented that the resident was receiving hospice services.B. Record reviewThe September 2025 CPO revealed a physician's order for Resident #8 to be admitted to hospice care services on 2/7/25 due to cerebral ischemia (not enough blood flow to the brain, causing brain cell damage). Review of Resident #8's end-of-life care plan, initiated 9/5/25, revealed the resident was receiving hospice services for end-of-life comfort care. The hospice agency's phone number was included in the care plan.-However, the care plan did not include interventions related to the coordination of the resident's specific needs with hospice staff. -The care plan did not include documentation related to the specific care needs the hospice services company would be providing to the resident.Review of Resident #8's EMR failed to reveal documentation of the hospice service company's visits with the resident and what care was provided to the resident during the visits. IV. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 9/24/25 at 3:45 pm. CNA #3 said the hospice provider would perform some ADL care with Resident #8. CNA #3 said he did not know when hospice would come to the facility and provide care to the resident. CNA #3 said he did not keep track of the hospice care provided to the resident. He said if it was a bath day and the resident had not had a bath, the hospice agency's bath team would give Resident #8 a bath. Licensed practical nurse (LPN) #2 was interviewed on 9/23/24 at 10:20 a.m. LPN #2 said the Resident #8 was receiving hospice services. LPN #2 said Resident #8 would sometimes get music therapy from the hospice provider. LPN #2 said she would need to call the hospice agency's phone number if she had questions or concerns regarding the resident. LPN #2 said she would call the hospice agency for a change in the condition of the resident. LPN #2 said she when she called the hospice agency she could request that the hospice nurse come and see Resident #8 to evaluate the resident due to a change in condition. She said she did not know how often the hospice nurses or hospice CNAs came to see the resident. LPN #2 said she did not have a reference form to refer to for information on who and when hospice provided care for the resident. LPN #2 said she did not have access to the hospice agency's notes in order to see what hospice services were provided during each hospice visit. The hospice registered nurse (RN) was interviewed on 9/24/25 at 3:10 p.m. The hospice RN said she documented her notes in her iPad, and then the notes were sent to the hospice services agency. The hospice RN said the facility would contact the hospice nurse for medication refills. The hospice RN said she did not share her visit notes with the facility; the notes were only documented in the hospice agency's EMR. The hospice RN said she would get a call from the facility for falls, comfort care questions or if the resident was combative with personal care. The hospice RN said Resident #8 had impulsive behavior at times. The interim director of nursing (DON) was interviewed on 9/25/25 at 4:45 p.m. The interim DON said Resident #8 was receiving hospice services. The interim DON said the hospice contract indicated what services the hospice company provided to residents. The interim DON did not know the exact services that were provided by the hospice agency, what discipline within the hospice agency provided them or how often specific services were provided to Resident #8. The interim DON said in order for the facility staff to communicate with the hospice agency, a phone call would be made to the agency. The interim DON said when the hospice agency had a question or concern with a resident, they would call the facility.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated in the nourishment rooms; and, -Ensure timely inspection of the ice machine and ice machine water filter. Findings include: I. Ensure food was labeled and dated A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved [DATE]). B. Facility policy and procedure The Food and Supply Storage policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:49 p.m. It revealed in pertinent part, Cover, label and date unused portions and open packages. Date and rotate items; first in, first out (FIF). Discard food past the use-by or expiration date. The Safe Handling of Personal Food (Outside Food) policy, dated [DATE], was provided by the NHA on [DATE] at approximately 11:30 a.m. It revealed in pertinent part, All food items must be covered, dated and labeled with common name of the items. Most refrigerated foods must be labeled with the date they are to be discarded. A general rule would be three days from the time it was prepared. C. Observation On [DATE] at 1:45 p.m. the following was observed in the rehabilitation unit nourishment room: -In the refrigerator, there was a container of clam chowder with a manufacturer expiration date of [DATE], a peanut butter and jelly sandwich that was dated [DATE], a loaf of bread with no label or date. -In the dry-storage, there were seven cartons of orange juice with a manufacturer expiration date of [DATE]. -In the freezer, there was a package of frozen cheeseburger with no label or date. At 1:56 p.m. the following was observed in the long term care unit nourishment room: -In the refrigerator, there was an opened jar of mayonnaise with a manufacturer expiration date of [DATE], an opened container of coffee creamer with a manufacturer date of [DATE], a container of an unknown food item that had a one-fourth inch layer of black on the top of it with no label or date, a container of blueberries with white fluffy substance on it with no label or date, a container of blackberries with white fluffy substance on it with no label or date, an opened container of prune juice with a manufacturer expiration date of [DATE] and a ham and cheese sandwich dated ,d+[DATE]. -In the freezer, there were two containers of unknown food items with no label or date, a box of frozen yogurt sticks that expired on [DATE] and three frozen milkshake beverages with no label or date on them. On [DATE] at 10:35 a.m. the following was observed in the long term care unit nourishment room: -In the refrigerator, there was a ham and cheese sandwich that was labeled ,d+[DATE], a container of blueberries with a white fluffy substance on it with no label or date, an opened container of coffee creamer with a manufacturer date of [DATE], a container of blackberries with a white fluffy substance on it with no label or date, a carton of prune juice with a manufacturer expiration date of [DATE], a container of an unknown food time with a layer of black substance on it and an opened jar of mayonnaise with a manufacturer expiration date of [DATE]. The DM was interviewed during the observation and said the sandwich was labeled incorrectly and needed to be disposed of. The DM said the prune juice, coffee creamer, blueberries, blackberries, mayonnaise and unknown food item needed to be disposed of. -In the freezer, there were two containers of unknown food items with no label or date, a box of frozen yogurt sticks that expired on [DATE] and three frozen milkshake beverages with no label or date on them. The DM said the yogurt sticks and milkshakes needed to be disposed of. On [DATE] at 10:40 a.m. the following was observed in the rehabilitation unit nourishment room: -In the refrigerator, there was a container of clam chowder with a manufacturer expiration date of [DATE] and a loaf of bread with no label or date. The DM said the clam chowder and the loaf of bread needed to be disposed of. -In the dry storage, there were seven cartons of orange juice with a manufacturer expiration date of [DATE]. The DM said the orange juice needed to be disposed of. D. Staff interviews The DM was interviewed on [DATE] at 10:35 a.m. The DM said the dietary department was responsible for ensuring the nourishment rooms were clean, food was labeled and dated and expired foods were disposed of timely. The DM said the nourishment room on the long term care unit needed attention. The DM said whoever put the food item into the refrigerator or freezer was responsible for ensuring the food was labeled and dated. The DM was interviewed again on [DATE] at 10:30 a.m. He said he spoke with the infection preventionist (IP) and the night shift nursing staff were going to begin double checking the nourishment rooms to ensure all food was properly labeled and dated. The IP was interviewed on [DATE] at 3:11 p.m. The IP said all food should be labeled and dated. The IP said expired foods should be disposed of timely. II. Ensure timely inspection of the ice machine and ice machine water filter 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_6CCR10102_RFFC_EffJan2019.pdf. It revealed, in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved [DATE]) B. Facility policy and procedure The Ice Machine Cleaning procedure, dated [DATE], was provided by the NHA on [DATE] at 8:40 a.m. It revealed in pertinent part, Ice machines are cleaned and sanitized on a regular basis and checked by the Supervisor or Manager. Ice scoop is sanitized daily through the dishmachine. C. Observation and interviews On [DATE] at 1:41 p.m. the ice machine scoop holder had brown particles floating in the bottom of the holder. On [DATE] at 10:35 a.m. the ice machine scoop holder had brown particles floating in the bottom of the holder. The water filter was changed on [DATE]. The water filter read to change the filter every 12 months. The DM was interviewed during the observation and said he would remove the ice machine scoop and ensure the ice scoop and the ice scoop holder were cleaned. The DM said an outside company came every six months to clean the filter. The DM said the filter needed to change annually and had not been changed since [DATE]. The DM was interviewed again on [DATE] at 10:30 a.m. The DM said he implemented a new system to clean the ice machine scoop and the ice machine holder every night. The DM said the ice scoop and the ice scoop holder should be clean and free of debris. The DM said he had the outside company service the ice machine and change the filter.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease. Specifically, the facility failed to: -Ensure professional standards of infection control were followed when cleaning resident rooms and bathrooms; and, -Ensure the facility followed the infection control program when Resident #17 had gastrointestinal symptoms. Findings include: I. Ensure professional standards of infection control were followed when cleaning resident rooms and bathrooms A. Facility policy and procedure The Housekeeping and Custodial Overview policy, dated 4/14/23, was provided by the nursing home administrator (NHA) on 1/3/23 at 2:07 p.m. It revealed in pertinent part, Housekeeping and custodial staff members are critical participants in infection control programs. Without solid cleaning practices, the ability to break the cycle of infection in any building becomes unobtainable. The Hand Hygiene policy, dated 3/29/22, was provided by the NHA on 1/9/23 at 2:49 p.m. It revealed in pertinent part, Health care workers will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: before entering patient room or before donning sterile gloves B. Observations During a continuous observation on 1/8/24 beginning at 12:34 p.m. and ended at 12:55 p.m. the following was observed: -At 12:38 p.m. maintenance assistant (MA) #1 entered the room with gloves on. MA #1 began vacuuming the resident room. MA #1 got down on his hands and knees to vacuum underneath the resident bed, chair and other furniture items. MA #1 stood up and returned to the housekeeping cart to get a clean towel and entered the resident room again without performing changing his gloves. MA #1 began wiping down the bathroom sink. MA #1 returned to the cart, disposed of the towel, got a clean towel and returned to the bathroom to wipe off the toilet riser. -With the same dirty gloves, MA #1 gathered the trash bag from the bathroom and placed the bag in another trash can in the room. MA #1 returned to the housekeeping cart, disposed of the dirty towel, got a new clean towel and returned to the bathroom to wipe off the toilet. MA #1 flushed the toilet. -MA #1 returned to the housekeeping cart, disposed of the dirty towel and took off his gloves. MA #1 put on new gloves without performing hand hygiene. MA #1 returned to the resident bathroom and returned the toilet riser to the correct position. -MA #1 went back to the housekeeping cart and got the mop. MA #1 moped the bathroom. MA #1 returned to the cart. MA #1 got a clean towel and began dusting the resident's room without performing hand hygiene. -MA #1 removed three drinks and some personal items from the resident's bedside table. MA #1 placed the items onto the ground. MA #1 wiped off the resident's bedside table. MA #1 used the same gloved hands and picked the resident's hot chocolate up by the rim of the mug where the resident's mouth would touch and placed it back on the bedside table. MA #1 placed the other items back on the resident's bedside table. C. Staff interviews The infection preventionist (IP) was interviewed on 1/8/24 at 2:00 p.m. The IP said the housekeeping staff were responsible for cleaning the resident rooms daily. The IP said all staff including housekeeping staff should always conduct hand hygiene prior to putting on gloves and after taking off gloves. The IP said the housekeeping staff needed to perform a glove change and hand hygiene every time they returned to the housekeeping cart. The IP said MA #1 should have changed his gloves and performed hand hygiene after crawling on the floor to vacuum. The IP said personal items including drinks should never be placed on the floor. The IP said cups should not be handled with dirty gloves or handled from the part of the glass that the resident's mouth would touch. The maintenance supervisor (MS) was interviewed on 1/9/24 at 9:59 a.m. The MS said he was in charge of the housekeeping department. The MS said MA #1 worked as a maintenance assistant and a housekeeper. The MS said hand hygiene should be performed before and after glove usage. He said gloves should be changed when moving from a clean surface to a dirty surface or anytime they returned to the housekeeping cart. The MS said MA #1 needed to change his gloves and perform hand hygiene after crawling on the floor. The MS said the floor was a dirty surface. The MS said MA #1 should have wiped around the resident's items, instead of putting them onto the floor and cleaning. The MS said he would provide education to MA #1 and the other housekeeping staff. D. Facility follow-up The MS provided a copy of the education that was provided to MA #1 on 1/9/24 at 11:14 a.m. It revealed in pertinent part, Gloves are not to be worn in hallways with the exception of cleaning or sanitizing surfaces with chemical cleaners, the use of carpet extraction equipment, transport of dirty laundry carts. II. Ensure gastrointestinal symptoms were reported to the IP and the physician timely to prevent the spread of the norovirus A. Facility policy and procedure The Identification and Reporting of Suspected Infections policy, dated 12/15/22, was provided by the NHA on 1/3/24 at 3:39 p.m. It revealed in pertinent part, Purpose:to provide guidance in order to identify and contain, as rapidly as possible, any infection that is suspected in any client to prevent spread of infection to others. Any of the following occurrences signals potential infection and will be reported Nurse and Infection Preventionist (Rehab/skilled): nausea or vomiting lasting more than 24 hours and diarrhea lasting more than 24 hours. B. Record review documented in Resident #17's medical record The 11/25/23 progress note documented Resident #17 complained of nausea today and had emesis three times. Resident #17 had refused her meals, but had accepted ginger ale, Sprite and water. The resident did not have a fever and was negative for COVID-19. The 11/26/23 progress note documented Resident #17 was in the bathroom and said she was nauseated. The resident was spitting up large amounts of mucous. The resident denied a sore throat, refused an oral nutritional supplement and refused all medications. The 11/27/23 progress note documented at 3:48 p.m. revealed the resident reported she was nauseous and did not feel good. The progress note documented the physician was called and an anti-nausea medication was requested. The progress note documented the facility was waiting for a response. The 11/27/23 progress note documented at 10:41 p.m. revealed the resident did not feel well today and was vomiting and nauseous. The 11/28/23 communication with physician progress note documented at 2:39 p.m. revealed the physician ordered Imodium as needed for Norovirus. -The facility failed to notify the physician and the IP when the resident first had gastrointestinal symptoms. C. Staff interviews The IP was interviewed on 1/8/24 at 3:11 p.m. The IP said Resident #17 had gastrointestinal symptoms on 11/25 and 11/26/23. The IP said the licensed nurses failed to inform her or the physician that Resident #17 had nausea and vomiting until 11/27/23. The IP said Resident #17 typically was very active throughout the entire facility. The IP said when she returned to work on 11/27/23 after the weekend, she was notified that Resident #17 had nausea and vomiting. The IP said the licensed nurses should have notified her sooner. The IP said when she found out about Resident #17 having nausea and vomiting on 11/27/23, two other residents had already developed symptoms and tested positive for norovirus on 11/27/23. The IP said norovirus spread through the facility and 31 residents contracted the virus. The IP said the nurses should have notified her of Resident #17's symptoms sooner, so the resident could have been placed on isolation to prevent the spread of the disease and she could have consulted with the medical director sooner to get further direction. The IP was interviewed again on 1/9/24 at 10:12 a.m. She conducted education regarding personal protective equipment (PPE) and the importance of reporting signs and symptoms of norovirus to the IP and the physician timely. The IP said the education was given verbally and she did not document the education she provided to the staff. Registered nurse (RN) #3 was interviewed on 1/9/24 at 1:07 p.m. RN #3 said if a resident had nausea, vomiting or diarrhea more than once she would report it to the IP and the physician to get further guidance. RN #3 said the nurse stations had an infection control surveillance form to fill out that would prompt the nurse to notify the IP and the physician.

Based on record review and interviews, the facility failed implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for three (#7, #16 and #5) of five residents reviewed for antibiotic use out of 29 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Residents #7, Resident #16 and Resident #5. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on 1/11/24, included the following recommendations: Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections. II. Facility policy and procedure The Antibiotic Stewardship policy, dated 12/7/23, was provided by the nursing home administrator (NHA) on 1/3//24 at 3:39 p.m. It revealed in pertinent part, Purpose: to provide guidance for (facility name) locations for antibiotic stewardship plans, to decrease the incident of multi-drug resistant organisms (MDROs), promote appropriate use while optimizing the treatment of infections and reducing the possible adverse events associated with antibiotic use; and to provide standard definitions to be sued as guidelines when initiating antibiotics. Urinary Tract Infections: Residents without indwelling catheter: acute dysuria or fever and new or worsening in at least one of the following): in the absence of fever, two or more of the following): costovertebral angle tenderness, frequently, gross hematuria, suprapubic pain, urgency and urinary incontinence. III. Resident #7 A. Resident status Resident #7, age 91, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease and heart disease. The 10/25/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with short-term and long-term memory deficits. She was dependent for oral hygiene, toileting, showering, lower body dressing and personal hygiene. The MDS assessment documented the resident was frequently incontinent of bowel and bladder. B. Record review The September 2023 CPO revealed the following physician order: -UA with urine culture one time only for confusion, ordered 9/26/23. The 9/28/23 progress note documented an urinary analysis (UA) was obtained using a sterile technique with a straight catheter. The resident tolerated will. The lab requisition was filled out and the urine was placed in the refrigerator. -A review of the resident's medical record did not reveal the resident had a fever or leukocytosis and did not meet McGeer's criteria. The incontinence care plan, initiated on 3/1/22 and revised on 7/31/23, revealed the resident had incontinence of bowel and bladder with no awareness of elimination patterns. The interventions included: checking and changing the resident per facility protocol, checking the resident at regular intervals and assisting with toileting as needed and providing incontinence products. IV. Resident #16 A. Resident status Resident #16, age 86, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included: heart disease, obesity, depression and chronic pain. The 12/6/23 MDS assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) with a score of 11 out of 15. She required set-up assistance with eating and oral hygiene. She was dependent for toileting, showering and lower body dressing. She required substantial assistance for upper body dressing and personal hygiene. The MDS assessment documented the resident was always incontinent of bowel and bladder. B. Record review The 10/3/23 communication with the physician progress note documented the nurse practitioner ordered a UA to be completed after the resident had a shower. The note documented the resident's urine was positive for mixed flora. The nurse and resident were made aware. -A review of the resident's medical record did not reveal the resident had a fever or leukocytosis and did not meet McGeer's criteria. The 10/8/23 communication note documented the urine culture results were called to the provider and an order was given for cephalexin 500 milligrams (mg) twice a day for 10 days. The incontinence care plan, initiated on 12/27/21, revealed the resident was incontinent of bowel and bladder. The interventions included: checking the resident at regular intervals throughout the day and providing hygiene and providing incontinence products. V. Resident #5 A. Resident status Resident #5, age 80, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included lymphedema (swelling) and mixed irritable bowel syndrome. The 10/25/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of six out of 15. She required set-up assistance for eating and oral hygiene. She required substantial assistance for toileting, showering and lower body dressing. She required parietal assistance for personal hygiene. The MDS assessment documented the resident was frequently incontinent of bladder and occasionally incontinent of bowel. B. Record review The incontinence care plan, initiated on 2/10/22 and revised on 10/26/23, revealed the resident was frequently incontinent of bowel and bladder. The interventions included: encouraging residents to drink more fluids, using incontinence products and offering assistance as needed with toileting. -A review of the resident's medical record did not reveal the resident had symptoms that meet the McGreer's criteria to complete a UA. The medical record did not reveal a culture was completed prior to the start of the Augmentin antibiotic on 12/27/23. VI. Staff interviews The infection preventionist (IP) was interviewed on 1/8/24 at 3:11 p.m. The IP said Resident #7's family requested for the UA to be completed because they felt the resident had increased confusion. The IP said the nurse practitioner ordered the UA and did not ensure the resident met McGreer's criteria prior to ordering it. The IP said Resident #7 was started on Amoxicillin on 9/30/23 and ended the antibiotic on 10/5/23. The IP said the medical director completed training with the licensed nurse staff regarding McGreer's criteria and the signs and symptoms the residents needed to have prior to getting a UA order. The IP said she had noticed the nurse practitioner had ordered UAs for residents who did not meet the criteria. The IP said she was going to request the medical director to do training with the nurse practitioner regarding the McGreer's criteria. The IP said the resident needed to have certain symptoms and a fever or leukocytosis per McGreer's criteria to have an UA and cultures ordered. The IP said Resident #16 had confusion and painful urination prior to the order of the UA. The IP said the resident did not have a fever or leukocytosis, so therefore she did not meet the criteria to have an UA ordered. The IP said the resident was started on Cephalexin for 10 days. The IP said Resident #5 did not have a fever or leukocytosis, therefore she did not meet the criteria to have an UA ordered. The IP said the resident was started on Augmentin for seven days. The IP was interviewed again on 1/9/23 at 10:12 a.m. She said the facility used McGreer's criteria for antibiotic use. The IP said Resident #7, Resident #16 and Resident #5 should have not had a UA conducted as they did not meet the criteria. The IP said Resident #7, Resident #16 and Resident #5 should have not been prescribed antibiotics for a urinary tract infection as they did not meet the McGreer's criteria for antibiotic use. The IP said Resident #7, Resident #16 and Resident #5 were all incontinent. The IP said it would have been beneficial to review the cultures of the residents' UAs to determine if the cultures were related to fecal material. The IP said if she monitored which cultures were found in UAs she would be able to provide education to staff. The IP said for example if a lot of residents had bacteria cultures that were found in fecal matter, she would provide education on incontinence care to the nursing staff.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for eight (#9, #18, #21, #32, #5, #25, #3 and #16) of 10 residents reviewed for immunizations out of 29 sample residents. Specifically, the facility failed to: -Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #9, #18, #21, #5 and #25; -Offer Resident #32 a pneumococcal vaccination upon admission; -Offer Resident #32 an annual influenza vaccination; and, -Document declination forms, document risk versus benefit education and re-offer the pneumococcal vaccination annually for Resident #16 and Resident #3. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2022, retrieved on 12/13/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, Routine vaccination-pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Facility policy and procedure The Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19 policy, dated 9/21/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 11:00 a.m. It revealed in pertinent part, Purpose: to provide residents and clients the opportunity to receive immunizations as they fit into their healthcare goals and to provide guidance for the location's immunization program including recommended vaccinations. Upon admission, each client, resident and/or resident representative will receive the Vaccination Information Statements (VIS) for influenza and pneumococcal vaccines and the VIS or Fact Sheet for Recipients and Caregivers for the COVID-19 vaccine. If the client, resident and/or the resident representative consent to vaccination: ensure physician's order has been obtained for the vaccine(s) to be administered, obtain written consent if required by state regulation, if written consent is not required, obtain and document verbal consent, complete vaccine screening prior to administering vaccination and administer vaccination or refer to Provider or Pharmacy for vaccine administration. Pneumococcal Vaccination: it is recommended that all clients and residents receive pneumococcal vaccination(s) per CDC (Center for Disease Control) guidelines for eligibility and timing. Annual Influenza Vaccination: It is recommended that all clients and residents receive influenza vaccination for the current year based on CDC recommendations. Residents admitted during influenza season should be vaccinated at the time of admission, if not previously vaccinated for the current influenza season. III. Resident #9 A. Resident status Resident #9, age 79, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included epilepsy (seizure disorder) and type two diabetes mellitus. The 11/8/23 minimum data set (MDS) assessment revealed indicated the resident was not up to date on her pneumococcal vaccination but did not specify the reason. B. Record review A review of Resident #9's EMR revealed the resident was administered the Prevnar 13 vaccination on 4/11/17 and 8/15/19. -There was no documentation that indicated the resident had been offered the updated pneumococcal vaccination. IV. Resident #18 A. Resident status Resident #18, age 86, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included heart failure, gastro-esophageal reflux disease (GERD) and lymphoid leukemia (cancer). The 12/6/23 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not indicate a reason. B. Record review A review of Resident #18's EMR revealed Resident #18 received the Prevnar 13 vaccination on 3/21/17. -There was no documentation that indicated the resident had been offered an additional pneumococcal vaccination. V. Resident #21 A. Resident status Resident #21, age 89, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included mild protein-calorie malnutrition and hypertension (high blood pressure). The 12/19/23 MDS assessment indicated the resident was up to date on her pneumococcal vaccination. B. Record review A review of Resident #21's EMR revealed Resident #21 had received the Prevnar 23 on 2/18/13 and the Prevnar 13 on 4/19/17. -There was no documentation that indicated the resident had been offered an additional pneumococcal vaccination. VI. Resident #32 A. Resident status Resident #32, age 89, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included dementia, anxiety and constipation. The 11/23/23 MDS assessment indicated the resident had not been offered the influenza or pneumococcal vaccinations. B. Record review -A review of Resident #32's EMR revealed Resident #32 had not received an annual influenza vaccination or a pneumococcal vaccination. VII. Resident #5 A. Resident status Resident #5, age 80, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included gastro-esophageal reflux disease (GERD), opioid dependence, depression and lymphedema (swelling). The 10/25/23 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not indicate a reason. B. Record review A review of Resident #5's EMR revealed Resident #5 had received the Prevnar 13 vaccination on 12/2/15. -There was no documentation that indicated the resident had been offered an additional pneumococcal vaccination. VIII. Resident #25 A. Resident status Resident #25, age 72, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included heart failure and type two diabetes mellitus. The 11/1/23 MDS assessment indicated Resident #25 was offered the pneumococcal vaccination and declined. B. Record review -A review of Resident #25's EMR revealed no documentation that Resident #25 had received or declined the pneumococcal vaccination. IX. Resident #16 A. Resident status Resident #16, age 89, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included heart disease, lymphedema (swelling) depression and history of COVID-19. The 12/6/23 MDS assessment indicated Resident #16 was offered the pneumococcal vaccination and declined. B. Record review -A review of Resident #16's EMR revealed the resident had refused the pneumococcal vaccination on 3/31/21 (see the director of nursing interview below). -A request for the 3/31/21 declination form and risk versus benefit for Resident #16 was requested on 1/8/24. The declination form and risk versus benefit were not provided during the survey process (1/3/24 to 1/9/24). The facility did not offer the pneumococcal vaccination annually. X. Resident #3 A. Resident status Resident #3, age 67, was admitted on [DATE]. According to the January 2024 CPO the diagnoses included multiple sclerosis (disease of the central nervous system) and history of COVID-19. The 11/8/23 MDS assessment indicated Resident #3 was offered the pneumococcal vaccination and declined. B. Record review -A review of Resident #3's EMR revealed the resident had refused the pneumococcal vaccination on 5/28/19 (see the director of nursing interview below). -A request for the 3/31/21 declination form and risk versus benefit for Resident #3 was requested on 1/8/24. The declination form and risk versus benefit were not provided during the survey process (1/3/24 to 1/9/24). The facility did not offer the pneumococcal vaccination annually. XI. Staff interviews The director of nursing (DON) was interviewed on 1/8/23 at 2:00 p.m. The DON said the admissions coordinator and herself were responsible for determining which vaccinations a resident had received prior to admission. The DON said she was responsible for determining which vaccinations the resident needed, obtaining consent, obtaining physician orders and administering the vaccination. The DON said at times she delegated some of the tasks to the charge nurse. The DON said she utilized the State Immunization System to determine which vaccinations each resident needed to receive. The DON said according to Resident #9's EMR, she had received the Prevnar 13 vaccination on 8/15/19. The DON said the resident should have been offered an additional dose of the pneumococcal vaccination one year after the resident received the Prevnar 13 vaccination. The DON said Resident #18 had received the Prevnar 23 vaccination on 3/21/17. The DON said she was unsure of how often the Prevnar vaccination should be offered and she would consult with the medical director for further guidance. The DON said Resident #21 received the Prevnar 23 vaccination on 2/18/13 and the Prevnar 13 vaccination on 4/19/17. The DON said typically the Prevnar 13 vaccination was given a year prior the Prevnar 23 vaccination. The DON said she would need to consult with the medical director to see if the resident should be offered an additional dose of the pneumococcal vaccination. The DON said Resident #32 admitted to the facility in November 2023. The DON said Resident #32 had not been offered an annual influenza vaccination since admission. The DON said she would reach out to the resident's representative to offer the annual influenza vaccination. The DON said she was unsure if Resident #32 had received any pneumococcal vaccinations. The DON said she would utilize the State Immunization System and the resident's family to determine if Resident #32 had received any pneumococcal vaccination and then offer the pneumococcal vaccination if needed. The DON said Resident #32 should have been offered the influenza vaccination upon admission. The DON said Resident #5 received the Prevnar 13 vaccination on 12/2/15. The DON said the resident should have been offered the Prevnar 23 a year after receiving the Prevnar 13. The DON said Resident #5 needed to be offered the Prevnar 23 vaccination. The DON said she was unsure if Resident #25 had received any pneumococcal vaccinations. She said she would look up the resident in the State Immunization System to determine if the resident needed to be offered a pneumococcal vaccination. The DON said according to the immunization tab in Resident #16's EMR she refused the pneumococcal vaccination on 3/31/21. The DON said according to the immunization tab in Resident #3's EMR she refused the pneumococcal vaccination on 5/28/19. The DON said the residents should be offered the pneumococcal vaccination yearly after refusing it initially. The DON said the declination form and the risk versus benefit education should be documented in the resident's EMR annually. The DON said she needed to review all of the residents' pneumococcal vaccinations to ensure the pneumococcal vaccinations were up to date. The DON said going forward she would review all of the residents' EMR annually at the start of the influenza season to determine if they needed additional doses of the pneumococcal vaccination.

Based on observations, interviews, record review, and review of facility policy, the facility failed to maintain a medication error rate of 5% or less. There were two errors out of 34 opportunities, which resulted in a 5.88% medication error rate for two (Resident #19 and Resident #21) of three residents observed for medication administration. Findings included: A review of the policy titled, Medication: Administration including Scheduling and Medication Aides last reviewed/revised 08/24/2022, indicated Purpose: To administer medications correctly and in a timely manner. The policy further indicated, Medications are administered to the resident according to the Six Rights. Furthermore, the policy revealed, Follow the Six Rights: Right medication, right dose, right resident, right route, right time and right documentation. 1. A review of Resident #21's Order Summary Report (physician orders) revealed an order dated 02/03/2022 that directed staff to administer 5 milligrams (mg) of [MEDICATION(S)] to the resident by mouth one time a day for allergic rhinitis. During an observation of medication administration on 09/20/2022 at 6:59 AM, Registered Nurse (RN) #1 prepared and administered 10 mg (twice the ordered dose) of [MEDICATION(S)] to Resident #21. During an interview on 09/20/2022 at 1:20 PM, RN #1 reviewed Resident #21's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During an observation of medication administration on 09/20/2022 at 7:29 AM, RN #1 applied Biofreeze to Resident #19's lower back. A review of Resident #19's Order Summary Report revealed the resident did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an order dated 10/20/2020 for Icy Hot Cream to be applied to the right thigh/hip every 12 hours as needed for pain and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 09/20/2022 at 1:24 PM, RN #1 stated Resident #19 was ordered Icy Hot Cream; however, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per RN #1, the facility had not had Icy Hot Cream in stock for a couple of months. RN #1 stated orders should be followed as written by the physician. During an interview on 09/21/2022 at 9:17 AM, the Director of Nursing indicated staff were expected to follow the rights of medication administration and to verify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 09/21/2022 at 9:18 AM, the Administrator revealed it was expected for staff to follow the rights of medication administration to avoid errors and to look at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE (personal protective equipment) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. A review of the facility vaccination policy and procedure revealed the facility did not require proof of vaccination for all contracted providers, but instead, required a generalized provider company attestation agreement which indicated the provider agreed to comply with the facility's vaccination policy. Cross-reference F880 (Infection control), and F886 (COVID-19 testing) Findings include: I. Facility policy and procedure The COVID-19 Immunization, Employee-Enterprise policy and procedure, revised 6/13/22, was provided by the nursing home administrator (NHA) via email on 6/29/22 at 11:50 a.m. It read in pertinent part: COVID-19 vaccination shall be required for all employees, medical residents, students, volunteers, contingent workers, and vendors unless exempted for medical or religious purposes. Any person who is exempt from the COVID-19 vaccination for a medical or religious exemption ( 'Exempt Person' ) shall be required to wear source control covering the nose and mouth at all times, submit to mandatory surveillance testing, or other agreed upon reasonable accommodation(s) (such as periodic testing) as determined on a case-by-case basis. Any employee who has an approved exemption from the COVID-19 vaccination and who fails to comply with the masking or other required mitigation strategies at any time following the Enforcement Date shall be subject to the progressive corrective action process. If the employee continues to not comply after receiving a verbal reminder, a written reminder and a final written reminder, the employee will be subject to termination of employment. Outright, intentional refusal to mask may result in immediate termination of employment without prior corrective action. II. Observations 6/29/22 -At 9:00 a.m., certified nurse aide (CNA) #2 entered the building. He told the receptionist (RCP) that he was from a hospice agency and that he had never been to the building. The RCP directed the CNA to fill out the screening form. The RCP assisted the CNA as he was having difficulty with the iPad. The CNA was then directed to the skilled nursing facility unit. -At approximately 9:30 a.m., the NHA was observed to ask an unidentified staff who CNA #2 was. -At 2:15 p.m. four individuals identified as volunteers assisted with resident nail painting in the activities room. 6/30/22 -The facility did not have proof of the volunteers and CNA #2's vaccination status (see record review below). III. Failure to monitor each contracted staff member's vaccination status to ensure proper advanced PPE strategies (as indicated in the facility's policy and procedure) were used in the prevention of the spread of COVID-19. The vaccination matrix, provided by the NHA on 6/29/22 at 4:08p.m., documented a list of facility staff members. It indicated each staff member's vaccination status, including if any exemptions had been approved. It included 64 skilled nursing staff members in the nursing, housekeeping, dietary and administration departments. -The vaccination matrix did not include all providers, such as physician's, agency staff, nurse practitioners, or hospice staff. The document showed there was one medical exemption and seven religious exemptions. Without knowing the vaccination status of these providers and outside agency staff, the facility failed to implement their policy and procedures to ensure those who were not vaccinated wore the proper PPE and/or testing procedures when in contact with residents. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 6/30/22 at 10:50 a.m. CNA #2 said he worked for a contracted hospice provider and stated that he had never been to the facility before, there was usually a different person that came to the facility. The activities assistant (AA) was interviewed on 6/30/22 at 11:00 a.m. The AA confirmed volunteers were assigned to assist residents with nail painting in a group activity on 6/29/22. She stated that the volunteers had been there before but came infrequently and on 6/29/22, they came unannounced and asked to assist with activities. The AA said volunteers had to go through a health insurance portability and accountability act (HIPPA) training and provide COVID-19 vaccine status. The AA did not know the names of the volunteers, or if the facility had received the proper documentation in regards to their vaccination status. The receptionist (RCP) was interviewed on 6/30/22 at 11:10 a.m. She stated that volunteers and contracted providers did not need to do rapid testing or show their vaccination status when they came into the facility, they only needed to complete the screening questions on the kiosk. The documentation for volunteers ' vaccination status and HIPPA training, would be with the activities director (AD) according to the RCP, but the AD was out of the office. The RCP said she would contact the AD and request the volunteer information. The nursing home administrator (NHA) was interviewed on 6/30/22 at 11:20 a.m. The NHA produced a binder from the front office with copies of COVID-19 vaccine cards for contracted providers and volunteers, however it was not up to date. He stated that they had stopped that system of collecting photocopies of vaccination cards in January 2022 due to a change in verbiage in their contracts. This change advised providers that they were responsible to ensure that the staff they were sending to the facility were fully vaccinated. Regarding verifying if contracted staff have been fully vaccinated or did not have a medical exemption needing additional precautions, the NHA acknowledged that they did not confirm and trusted that the provider was following the contract. The binder showed copies of vaccination cards, although it documented the first dose of the vaccination on both staff and contractors but not the 2nd vaccination or the booster information. The AA was interviewed a second time on 6/30/22 at 2:25 p.m. She stated that she was still looking for the names of the volunteers from 6/29/22 that had been requested. The NHA was interviewed a second time on 6/30/22 at 4:45 p.m. The NHA confirmed that he was able to reach the AD via phone and she stated to him that the volunteers who had come in for nail painting 6/29/22 had not been there before and she did not have a process for verifying vaccination status for volunteers. The NHA was also unaware that there needed to be a verification process for volunteers that come in to assist with activity functions. The NHA confirmed the facility did not have any verification of the CNA #2's vaccination status, other than the self screen he answered. He confirmed not all providers, such as physicians, nurse practitioners, or hospice staff, were not included on the staff vaccination matrix. He said the facility's contract with the policy was to get an attestation from the provider's agency to ensure vaccination status. V. Facility COVID-19 status The facility COVID-19 line listing as of 6/5/22 showed the facility had confirmed positive cases of COVID-19 in six staff members as of 6/5/22. The first staff member was symptomatic and tested on [DATE] and found to be positive. The local health department was contacted on 6/5/22.

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 disease and infection, including COVID-19. Specifically, the facility failed to: -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; and, -Ensure an iPad computer and thermometer were properly sanitized between uses during a current COVID-19 outbreak in the facility. Findings include: I. Failure to clean the iPads and thermometer used for screening between uses A. Professional reference The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 2/2/22), retrieved on 7/12/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part, HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene,limiting surfaces touched, and use of PPE (personal protective equipment) according to current facility policy. B. Facility policy and procedure The Computer Cleaning-Rehab Skilled, Child Day and Senior Living policy, revised on 5/25/21 was provided on 7/5/22 via email from the nursing home administrator (NHA). It read in pertinent part: The purpose is to provide guidance with cleaning all computer devices (desktops, laptops, tablets and kiosks) and accessories such as a keyboard, mouse, and stylus to prevent the spread of infection. Non-critical items-Surfaces and items that come in contact with intact skin, but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms; therefore, the sterility of items coming in contact with intact skin is 'non-critical.' Examples of non-critical items include computers, kiosks, floors, walls, tabletops and medical equipment surfaces such as blood pressure cuffs, adjustment knobs, lift equipment, etc. Generally, low-level disinfectant is adequate for cleaning. 1. Perform hand hygiene prior to computer use. Do not wear gloves when using the computer 2. Always follow the manufacturer's instructions if available. (See below for Lenovo computers.) 3. Wipe touch screen (kiosks or tablets) only with (facility name)-approved wipes on a daily basis. Never spray any disinfectant directly on the surface. Specific cleaning instructions for kiosks can be found in the Kiosk User Guide. 5. Clean mobile computers prior to going to another resident's room. 6. Clean accessories of the computer as needed. 7. Perform hand hygiene after computer use. C. Observation On 6/29/22 at 10:50 a.m., visitors were observed to use the iPad to screen themselves for the COVID-19 questions. The iPads were not cleaned between uses and a handheld infrared forehead thermometer was used with each visitor, however, not cleaned prior to the next use. At 3:52 p.m., four visitors entered the facility and were asked to complete COVID-19 screening using the iPad. Hand sanitizer was placed by the iPad however, none of the visitors used it before or after touching the iPad. The third visitor needed help with using the iPad, the receptionist came around and completed the screening questions for the visitor. The receptionist did not use hand sanitizer before or after nor did the receptionist clean the iPad after the four visitors had completed their screenings. The four visitors also were observed to use the hand held thermometer to take their temperature. The thermometer was not cleaned after use. On 6/30/22 between 8:25 a.m. and 8:35 a.m. seven visitors came into the facility and completed the COVID-19 screening questions on the iPad. They also were observed to take their temperatures with the thermometer. The RCP did not ask visitors to use hand sanitizer and did not disinfect the thermometer or iPad between visitors. At 9:27 a.m., a visitor checked in and he was not asked to do proper hand sanitation nor did he do it on his own. The iPad and thermometer were not cleaned after use. D. Interview The receptionist (RCP) was interviewed on 6/30/22 at 3:45 p.m. She said the iPads used to screen visitors and staff should be completed after each use, however she only did it when she could . She said she received training and the importance of cleaning the iPads after each use from the information technology department. The director of nurses (DON) was interviewed on 6/30/22 at 3:50 p.m. The DON said that frequently used equipment such as the iPads and the thermometer, needed to be cleaned in between each use. She said a disinfectant wipe was effective. II. Failure to ensure residents were offered hand hygiene before meals A. Professional reference The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes (updated 2/2/22), retrieved on 7/11/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, Educate residents and families through educational sessions and written materials on topics, including information about [CONDITION(S)]-CoV-2, actions the facility is taking to protect them and their loved ones from [CONDITION(S)]-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene.Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. B. Facility policy The Dignity in Dining-Food and Nutrition Services policy, revised 2/22/22, was received via email on 7/1/22. It read in pertinent part, Encouraging residents to wash their hands before dining. Encouraging residents to wash their hands/face after dining. C. Observations 6/29/22 Noon meal in the dining room -At 11:00 a.m., four residents were assisted by staff members into the dining room. The staff assisted the residents past the hand sanitizer station. The residents were not offered or assisted with hand hygiene prior to arriving at the table. One resident was observed to blow their nose on a towel an unidentified staff member served their meal without offering hand hygiene. Evening meal in the main dining room -Beginning at 4:21 p.m.and ending at 5:40 p.m., eleven residents were assisted by staff members into the dining room past the hand sanitizer station in the front of the dining room, were not asked if they wanted to use the hand sanitizer nor were washcloths and sanitizing wipes offered before the meal. The evening meal's main entree was a grilled turkey sandwich (considered a ready-to-eat food). Room tray observations -At 5:18 p.m., the meal was delivered to room [ROOM NUMBER] by certified nurse aide (CNA) #1. She was served a turkey sandwich,CNA #1 did not offer the resident to wash her hands or provide any type of hand hygiene. -At 5:21 p.m., a meal was delivered to room [ROOM NUMBER] by CNA #1. She served a grilled turkey sandwich. No hand hygiene was offered. D. Record review Staff training was done on 3/14/22 and 3/15/22 retrieved on 7/1/22 at 3:12 p.m. via email; it included 17 out of 64 staff members received training on hand hygiene competency and PPE. E. Interview The director of nurses (DON) was interviewed on 6/30/22 at 3:50 p.m. The DON said resident handwashing was performed prior to each meal either whether they ate in the dining room or the room. She said resident hand hygiene was performed using a cloth for handwashing or hand sanitizer. She said the dining room had a hand sanitizer canister set up at the entrance. She said the staff were to assist the residents and encourage them to perform hand hygiene prior to the meal. III. Facility COVID-19 status The NHA was interviewed on 6/29/22 at 11:00 a.m. The NHA said the facility was in a current outbreak with COVID-19. The facility currently had six staff with COVID-19 positive cases, which began on 6/5/22.

Based on interviews and record review, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers for COVID-19 which had the potential to affect all 38 residents residing in the facility at the time of the survey. Specifically, the facility failed to: -Complete weekly lab based PCR (polymerase chain reaction) testing for COVID-19, and rapid molecular or antigen test consistently twice a week when a positive COVID-19 was detected; -Ensure all non-vaccinated staff performed point of care (POC) testing prior to work schedule; and, -Ensure all staff were tested during the outbreak, and when staff refused to be tested they were allowed to continue to work. Findings Include: I. Professional reference The Centers for Disease Control and Prevention (updated 2/2/22), Interim Infection Prevention and Control Recommendations to prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes COVID-19 Nursing Homes, retrieved on 7/10/22 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, documented the following, Expanded screening testing of asymptomatic HCP (healthcare personnel) should be as follows: Fully vaccinated HCP may be exempt from expanded screening testing. In nursing homes, unvaccinated HCP should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a [CONDITION(S)] test twice a week. If unvaccinated HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). In nursing homes located in counties with moderate community transmission, unvaccinated HCP should have a [CONDITION(S)] test once a week.In nursing homes located in counties with low community transmission, expanded screening testing for asymptomatic HCP, regardless of vaccination status, is not recommended. Per recommendations above, these facilities should prioritize resources to test vaccinated and unvaccinated symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents or HCP. II. Facility policy and procedure The COVID-19 Employee Testing Enterprise policy, last revised on 8/31/21, was received from the nursing home administrator (NHA) on 6/29/22. The policy documented in pertinent part, All employees, providers, contingent workers, students and volunteers are required to submit to COVID-19 testing where job-related and consistent with business necessity, as well as consistent with applicable federal, state or municipal order or department of health guidance. Unless working on approved 100% remote work arrangement or otherwise exempt for medical or religious purposes, any person who failed to comply with current COVID-19 testing requirements for their location by or before the Enforcement date shall be suspended for 30 days and removed from the work schedule. Any person who is exempt from the COVID-19 vaccination for a medical or religious exemption ( 'Exempt Person') shall be required to wear source control covering the nose and mouth at all times, submit to mandatory surveillance testing, or other agreed upon reasonable accommodation(s) (such as periodic testing) as determined on a case-by-case basis. III. Failure to ensure non vaccinated staff completed POC testing prior to working The facility had seven staff members who had religious exemptions and one staff member who had a medical exemption. On 6/29/22 the facility provided a list with eight unvaccinated staff working in the facility. The POC daily rapid test records were reviewed from 6/1/22 to 6/29/22. The record was compared to the staff schedule and found that the unvaccinated staff did not have a POC test prior to their shift. Dietary worker #1 and dietary worker #2 both had religious exemptions. The schedule was reviewed with the head cook of the facility had no evidence the POC test was completed prior to their shift. The head cook was interviewed on 6/30/22 at 10:35 a.m. The head cook confirmed the DW #1 and DW#2 worked full time and was responsible for the meal distribution for the long term care residents which included, preparing food, and delivery of meals. The head cook spoke with the dietary manager and was told there was no evidence to show the POC test was completed prior to their shifts. The director of nurses (DON) was interviewed on 6/30/22 at 11:55 a.m. The DON said that each department was responsible to maintain and ensure that the POC tests were being completed prior to working their shift. She had no information in regards to the DW #1 and DW#2. The DON confirmed that not all of the non-vaccinated staff were completing the POC testing prior to the shift. She said she realized that not all of the departments were tracking and enforcing the POC testing. The DON spoke with the dietary manager and confirmed they had no evidence which showed the DW #1 and DW #2 had completed the POC testing prior to shift. IV. Testing A. Professional reference The Centers for Disease Control and Prevention, How to Collect an Anterior Nasal Swab Specimen for COVID-19 Testingmonre https://www.cdc.gov/coronavirus/2019-ncov/testing/How-To-Collect-Anterior-Nasal-Specimen-for-COVID-19.pdf was retrieved on 6/30/22. It documented the following in part: 1.Disinfect the surface where you will open the collection kit. Remove and lay out contents of kit. Read instructions before starting specimen collection. 2.Wash hands with soap and water. If soap and water are not available, use hand sanitizer. 3.Remove the swab from the package. Do not touch the soft end with your hands or anything else. 4.Insert the entire soft end of the swab into your nostril no more than three fourth of an inch (1.5 cm) into your nose. 5.Slowly rotate the swab, gently pressing against the inside of your nostril at least 4 times for a total of 15 seconds. Get as much nasal discharge as possible on the soft end of the swab. 6.Gently remove the swab. 7.Using the same swab, repeat steps 4-6 in your other nostril with the same end of the swab. 8.Place the swab in the sterile tube and snap off the end of the swab at the break line, so that it fits comfortably in the tube. Place the cap on the tube and screw down tightly to prevent leakage. 9.Wash hands or re-apply hand sanitizer. 10.Place the tube containing the swab in the biohazard bag provided and seal the bag. 11.Give the bag with the swab to testing personnel or follow the instructions for returning the specimen for testing. 12.Throw away the remaining specimen collection kit items. 13.Wash hands or re-apply hand sanitizer. B. Observations On 6/30/22 at 8:30 a.m., the PCR COVID-19 testing with all of the supplies (swabs, test tubes, and plastic bags) was laid out on the counter. There were no disinfectant wipes on the counter. The counter was positioned directly behind the receptionist desk. At 8:32 a.m, the hair salon worker was observed to perform her own PCR test. She removed her face mask, and proceeded to put the swab in her nose. She rapidly twilled the swab in each nostril for eight seconds. She then placed the swabs into the tube and the bag. She did not sanitize her hands after she finished the test. She also did not disinfect the area. The clean supplies were directly in front of her when she completed the test. At 9:11 a.m., an unidentified certified nurse aide was observed to perform her own PCR test. She lifted her face mask, and proceeded to put the swab in her nose. She turned the swab in each nostril appropriately for 15 seconds. She then placed the swabs into the tube and the bag. She did not sanitize her hands after she finished the test. She also did not disinfect the area. The clean supplies were directly in front of her when she completed the test. At 9:18 a.m., the RCP was observed to handle the individual PCR plastic bags with the completed test in the bag without gloved hands. She was observed to spread the bags across the receptionist desk and then scanned the barcode. She failed to disinfect the desk after. At 9:55 a.m., the rehabilitation director (RD) was observed to perform his own PCR test. He lifted his face mask, and proceeded to put the swab in his nose. He rapidly swabbed his left nostril for six seconds and his right for five seconds. He then placed the swabs into the tube and the bag. He failed to sanitize his hands before the test and after he finished the test. He also did not disinfect the area. At 11:05 a.m., the RCP had another set of PCR tests in plastic bags spread out onto the desk and she did not have gloved hands. She did not disinfect the desk. C. Record review The PCR checklist dated 6/6/22 to 6/30/22 showed 64 names on the tracking. Twelve of the staff were exempt from the PCR test as they were in the 120 day window of having COVID-19. The checklist had 41 staff members who had not completed the eight PCR tests as mandated. Each staff member should have had eight PCR tests completed. D. Interview The RCP was interviewed on 6/29/22 at 2:45 p.m. The RCP said that the PCR testing was completed twice a week (Monday and Thursday). She said the testing was completed in the receptionist area. She said then she was responsible for scanning the specimens into the computer prior to the pick up. She said all staff were required regardless of their vaccination status. She said when the staff completed the PCR test, and she scanned it into the computer she then placed a check mark under the date on the check sheet. The check mark was her way of tracking who had been tested . The NHA was interviewed on 6/30/22 at 8:30 a.m. The NHA said that the staff performed testing in the front as he pointed to the set up that was located behind the receptionist desk. He said that there were some staff who were more private and they did not want to test here at the front. He said those who did not perform their test in the front would complete their test at his desk and bring it to the receptionist in the front. The hair salon worker was interviewed on 6/30/22 at 8:34 a.m. She said that she had been trained to rotate the swab 10 times in each nostril. She said she did not know she had to do it in each nostril for 15 seconds. She said she had been told to perform hand hygiene prior to the test. The director of nurses (DON) was interviewed on 6/30/22 at 3:51 p.m. The DON said due to the county's high positivity rate, plus the building was in a current outbreak of the COVID-19 with six employees, the facility was mandated to test every employee twice a week. She said the staff perform their own tests and the RCP then scans the tests and gets them ready for pick up from the laboratory. She said the staff were trained on how to complete the test. She acknowledged that no staff supervised how the test was completed to ensure it was done correctly. She was not aware the testing area needed to be ventilated by a window or door. She confirmed that she had observed the RCP touching the specimens without gloved hands and not disinfecting the area where the specimen bags laid. She said when the specimen bags were touched it should always be with gloved hands. She said that each department head was supposed to track who has come in to get the COVID-19 PCR test twice a week. She said then text messages were to be sent out, or they need to test elsewhere. -However, they were allowed to work without having the PCR test or POC test. She said the policy was that the employee was to be pulled off schedule but this had not happened. The DON reviewed the COVID-19 testing checklist which was from 6/6/22 to 6/30/22. She confirmed that several employees had not been tested twice a week and also had no evidence that they had completed a POC test prior to the work schedule. The DON acknowledged that no staff had been responsible for monitoring the check sheet to ensure every staff member had been tested for the PCR twice a week. The RCP was interviewed again on 6/30/22 at 4:15 p.m. The RCP said she did not know she was required to wear gloves when handling the specimen bags. V. Facility COVID-19 status The facility COVID-19 line listing as of 6/5/22 showed there were six staff members who tested positive for COVID-19.

Based on staff interviews, and record review, the facility failed to ensure that the residents rights to visitor access was fully available. Specifically, the facility restricted visitors according for convenience and provide residents the facility policy and guideline for limiting visitation. Findings include: A. Observation On 6/29/22 at 6:15 p.m., the front door was locked. The receptionist (RCP) was no longer at the desk. There was no access for visitors to enter the building. B. Record review The visitation policy was requested, however, the nursing home administrator (NHA) responded via email on 7/5/22 that there were no visitation guidelines. C. Interviews The receptionist (RCP) was interviewed 6/29/22 at 2:45 p.m. The RCP confirmed visitation hours were from 8:00 a.m. to 5:00 p.m. Monday thru Friday. She said the hours for visitation were the same as the reception hours. The RCP said visitation was allowed between 9:30 a.m. and 2:30 p.m. on weekends. She said when the visiting hours ended, the front doors were locked. Unless there was a family visiting for hospice or end of life visits, there was no visitation allowed. The director of nursing (DON) was interviewed 6/30/22 at 3:50 p.m. The DON confirmed visitation hours were limited. The hours for visitation ended at 5:00 p.m. on the weekdays and 3:00 p.m. on the weekends. Visitation started at 8:00 a.m. If a visitor came to see a resident outside of those hours, the licensed nurse was trained to deny them entry to visit and instruct them to return during visiting hours. The nursing home administrator (NHA) was interviewed 6/30/22 at 4:18 p.m. The NHA confirmed visitation hours were 8:00 a.m. to 5:00 p.m. on the weekdays and 8:00 a.m. to 3:00 p.m. on weekends. He acknowledged hours were limited. If the family needed to visit outside of those hours, they could make an appointment with social services. If the resident was receiving a visitor due to end of life, then they would be welcome outside of regular visiting hours. The NHA explained the limited visitation hours were due to limited staff to screen and escort visitors. D. Facility follow-up An email received from NHA on 7/1/22. The facility had begun to reach out to the residents and their families regarding visitation. They had made changes by including visitor access through the south entrance of the building. The south entrance allowed for direct access to licensed nursing staff for screening and could be better accommodating for visitation outside of business hours.

Based on observations, record review and interviews, the facility failed to ensure adequate supervision to prevent accident hazards for one (#5) of three out of eight sample residents. Specifically, the facility failed to for Resident #5: -Consistently implement fall interventions; -Document fall interventions on the care plan; -Identify effective fall interventions utilizing a full spectrum of resources; and, -Educate staff on fall interventions. Findings include: I. Facility policy and procedure The Fall Prevention and Management-Rehab/Skilled, Therapy and Rehab policy, last revised 9/17/21, was provided via email by the nursing home administrator (NHA) on 12/16/21 at 10:00 a.m. It read in pertinent part, In order for a fall prevention and management program to be successful, there must be accountability from the leadership and caregivers in the location, as well as National Campus support. The Fall Resource Packet is a resource to assist in creating an effective fall prevention and management program with positive outcomes for the location. Proactive Approach before a Fall Occurs (e.g., New Admit) Procedure: 1. On admission or readmission, review the applicable documents .and any additional admit information documentation for fall risk factors. 2. Complete the Falls Tool UDA (user defined assessment) for fall screening and identifying fall risk factors. 3. Care Plan the appropriate interventions, including personalizing all (SPECIFY) areas. 4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex (desktop file system that gives a brief overview of residents and is updated every shift), daily stand-up meeting, and/or Fall Committee meetings. 5. Communicate any identified environmental changes and/or referral needs (e.g., maintenance, dietary, therapy). II. Resident status Resident #5, age 82, was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO), the diagnoses included [CONDITION(S)] without behavioral disturbance, falls, depression, [CONDITION(S)] without behavioral disturbance, altered mental status, and anxiety. The 12/13/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. She required limited assistance from one person with bed mobility, transfers, toileting, locomotion on and off the unit. She had a history of falls. III. Observations and resident interview On 12/14/21 at 11:15 a.m. the resident ' s door was closed with the resident inside. The room was situated across from the nurses ' station. Resident #5 was interviewed on 12/15/21 at 9:00 a.m. The resident was observed sitting in a recliner with the wheelchair parked in front of her. The call light was not visible. The resident said that she was unable to locate it. She stated the staff placed pillows in her recliner that helped her from falling as she pointed to the pillows located on each side of her hips. Resident #5 stated that she pressed her call light when she needed assistance and sometimes it took up to an hour for staff to assist her. At 12:04 p.m. the resident was observed sitting in a recliner with her legs resting on the wheelchair parked in front of her. On 12/16/21 at 9:55 a.m. the door to the resident ' s room was closed. The resident was sitting in a recliner with the wheelchair facing her. The anti-roll bars were not visible on the wheelchair. IV. Record review The December 2021 CPO included the following relevant physician orders: -Start date: 6/30/21.[MEDICATION(S)] HCl tablet; Give 125 mg by mouth one time a day for depression. Monitor for side effects. -Start date: 7/1/21. [MEDICATION(S)] (HCL) tablet; Give 10 milligram (mg) by mouth three times a day related to anxiety disorder. Monitor for side effects. -Start date: 10/30/21. Lorazepam tablet 0.5 mg; Give 0.5 mg by mouth in the morning related to anxiety disorder. - Start date: 12/15/21 and End date: 12/29/21. Monitor every shift for 14 days the bruising to the right buttock and to right 4th knuckle of the right hand, which resulted from a recent fall. The fall risk care plan, initiated on 8/29/19 and last revised on 9/20/21, read in pertinent part, that the resident was at risk for falls related to a history of falls with injury, left leg weakness, balance problem during non-ambulatory transitions (Not steady but usually able to stabilize self without staff support), impaired cognitive skills for daily decision making, [CONDITION(S)] medication use, elevated anxiety levels which impeded her abilities. Interventions included: Educate resident and family as to causes of fall. Remind resident not to bend over to pick up dropped items. Encourage resident to call for assistance. Encourage resident to participate in therapies/activities that promote exercise, physical activity for strengthening and improved mobility such as: sit and be fit, strength and balance as provided by activities in addition to therapy services. Ensure appropriate footwear when transferring or mobilizing in a wheelchair. Avoid clothing that were too loose, slippery, too long, etc. Environmental: -Date initiated: 12/22/2020. Placed a night light in resident room across from the bed and at the entrance of the room to light up the bathroom. -Date initiated: 9/26/21. Revision: 10/31/21. Adequate lighting used to maximize resident safety. -Date initiated: 8/29/19. Revision: 8/29/19. Review and modify environmental hazards that could cause or contribute to fall. -Date initiated: 8/29/19. Revision: 8/29/19. Review as indicated for significant changes in cognition, safety awareness and decision-making capacity. -Date initiated: 8/29/19. Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs. -Date initiated: 8/29/19. Review new or progressive neurological impairments. -Date initiated: 8/29/19. Review resident's history of recent or recurrent falls. -Date initiated: 8/29/19. Review resident's medical record for medications or combinations of medications that could predispose the resident to falls and/or increase with fall risk. -Date initiated: 8/29/19. Review status of any medical conditions that predisposed the resident to falling and/or that could increase the risk of injury from falls. The fall care plan initiated on 11/3/21 read in part, Observed sitting on the floor next to recliner. Trying to pick up her candy box that was side of reclining chair, didn't want to bother anyone. No inj([NAME]). 12/1/21 Sitting on floor in her rm (room). Trying to get to the toilet but wasn't able to and sat down. No. inj. 12/10/21 Observed sitting. on the floor in her BR (bathroom). Went to the BR, got up from toilet to look for comb, lost balance and fell , had her W/C (wheelchair) in the doorway & walked to the toilet, then to the sink, then fell . Bruise R (right) hand incurred. 12/11/21 Observed sitting on the floor in front of her recliner just prior to lunch. I tried to get into my W/C for lunch, but I just slid to the floor. No inj. Interventions included: Date initiated: 11/11/21. Revision: 12/13/21. Monitor/document/report as needed for 72 hours to health care provider for signs and symptoms: pain, bruising, changes in mental status like new onset: confusion, sleepiness, inability to maintain posture, agitation, etc. Date initiated: 11/11/21. Revision: 12/13/21. Continue to observe for signs and symptoms of injury and check range of motion at the time of the fall and afterwards. -The care plan failed to include using pillows to help resident with seating in chair, use of enabler bed rails to promote bed mobility, anti rollback bars on wheelchair, auto lock wheelchair, bed in lowest position, personal alarm to alert staff of independent mobility, bolsters on bed to aid with identifying bed boundaries, pain management, inquire about hunger, soft touch call light, front wheeled walker, using a gait belt, and keeping the wheelchair out of her sight. The undated Kardex (the certified nurse aide (CNA) care plan) read in part, -Ambulation: When or if resident ambulates use the front wheeled walker, one staff member to assist, using a gait belt. The resident was not always compliant and would ambulate independently to a destination. The resident utilized a wheelchair related to left upper extremity pain. -Bed mobility: Resident could be independent but required limited to occasional assistance with bed mobility for example: to/from lying position, scooting up in bed, once the resident was situated she was able to off load pressure independently. Resident utilized bilateral 1/4 assist bars to assist with her bed mobility and off load pressure. -Adequate lighting used to maximize resident safety. -Avoid clothing that was a fall risk ie: too loose, slippery, too long, etc. -Ensure that Resident was wearing appropriate footwear when transferring or mobilizing in wheelchair. -Environmental: 12/22/2020 Placed a night light in room across from beside and at entrance to room to bathroom. -Maintain room arrangement to promote independence. -Remind resident not to bend over to pick up dropped items. -Encourage to call for assistance. -Report to nurse observations of blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs, etc. -Review and modify environmental hazards that could cause or contribute to fall. The 12/11/21 Falls Tool assessment read in part that the resident risk factors included: Falls: recent falls of one or more in the last three months. Medications: taking more than two. Psychological: appears severely affected by one or more. Cognitive status: moderately impaired. The Risk Factor Checklist and Intervention Plan: mobility/transfers, observed impulsive/risk-taking behavior, cognitive status, reduced insight, poor memory, impulsive. The care plan was updated. The following progress notes read in part: The 5/4/21 Psychopharmacological Med(ication)/Physical Restraint progress note read, On 4/27/21 the med(ication) nurse reported that she looked up in the dining room and saw the resident sitting on the floor. Nurse had been observing the DR (dining room) and had looked down at her cart for a moment. Resident was unclear of exact circumstances when she fell . She thinks she may have been reaching for her mask and lost her balance. Assessment complete and a bruise was incurred L (left) elbow. F/U (follow up) ? (complain of) pain LUE (left upper extremity X-ray neg(ative) for fx (fracture). Care plan updated. IDT (interdisciplinary) met to discuss above incident. TEam noticing that resident has been having increase anxiety prior to incident (recently reduced [MEDICATION(S)]) and was resumed at previous dosage and [MEDICATION(S)] was added to med(ication) regime for pain mgmt. (management) LUE (left upper extremity) Staff continue to provide education regarding safety. No other recommendations at this time. -The facility implemented education regarding safety, however the resident had a diagnosis of dementia. The facility failed to implement an effective fall intervention. The 6/22/21 Psychopharmacological Med(ication)/Physical Restraint progress note read, On 6/19/21 The resident was observed on the bathroom floor sitting straight up looking at the toilet paper holder, legs straight out, arms holding onto her walker, had her slippers on. Per resident Does not know why she fell in the bathroom, but she did hit the L(left) side of her forehead going down to the floor. Assessment complete- no bruising, bleeding or lump noted to L(left) side of head. Redness in the middle of her brows. Care plan updated. IDT met to discuss above incident. -The facility failed to implement an intervention for this fall. The 8/10/21 Psychopharmacological Med(ication)/Physical Restraint progress note read, On 8/8/21 Staff informed the nurse that the resident was observed sitting on the floor in front of her W/C (wheelchair) with her legs in front of her. Per resident was getting clothes out of her closet and then lost her balance and sat on the floor. Assessment complete- no injuries incurred at this time. Care plan updated. 8/7/21 X-ray pelvis lmp: No acute fracture or discoloration of pelvis, L(left shoulder imp (impression): No acute fracture or discoloration L (left) shoulder, L (left) humerus imp (impression); No acute fracture of the L (left) humerus head. IDT (interdisciplinary) met to discuss the above incident. -The facility failed to implement an intervention for this fall. The 8/24/21 Incident progres note read, This nurse called to Res(ident) room. Res(ident) observed sitting on her bottom. Res(ident) stated she was not injured. Denies weakness or tripping on anything. WC (wheelchair) brakes were locked, call light was not on. Res(ident) states that she stood up from her wc (wheelchair) and just fell down. Res(ident) assessed and vitals taken. Res(ident) BP (blood pressure), pulse and temp elevated, Res(ident) asymptomatic, and values not unexpected, Denies pain/injury. PCP (primary care provider), Administrator, DNS (director of nursing services), POA (power of attorney)- Son, (name). Monitoring w/(with) neuros x72 (for 72) hrs (hours). -The facility failed to implement an intervention for this fall. The 9/24/21 Incident progress note read, Resident observed lying on her left side on the bathroom floor. Shoes on bilateral feet and wheelchair brakes were observed to be locked. Resident reports I had to go. Wetness observed to resident's back of resident's gown and pullup. Resident reports the floor was wet and she slipped. Resident assisted to toilet to finish. Total assist for clothing change. Resident assisted to bed, ice packs applied to left elbow area, left wrist, and left knee. CNS (central nervous system) intact and neuros at baseline. Call light placed within reach. Notification to Administrator, DON, PCP, and day shift will notify family. The 9/25/21 Incident progress note read, This Nurse educated Resident to use of call light for fall prevention 3-5x (three to five times) this morning. Prior to lunch, Resident is observed to self transfer to w/c (wheelchair) without supervision. Resident laughs, I know, I know, I know. Explained purpose of fall prevention techniques and use of a personal alarm to prevent potential for injury from fall. Acknowledges that application of alarm has been utilized before and will remind her to use call light. Personal alarm applied. -The facility implemented education for the resident to use call light, however the resident had a diagnosis of dementia. The facility failed to implement an effective fall intervention. The IDT (interdisciplinary team) progress note read, On 9/25/21 Resident's personal alarm alerted nursing to resident's independent mobility. Resident was then observed sitting on the floor in front of recliner, W/C to R (right) side of recliner within reach. I was trying to get into my W/C. Assessment complete--chronic pain ? (complaint of) LUE (left upper extremity) and back. Care plan updated. On both occurrences resident was educated on imptc (importance) of use of call light. Per resident I thought I could do it myself. Resident has <'ed (decreased) awareness of physical limitations and attempt independent activity. Goal for resident is not to incur injury should fall occur. IDT met to discuss above incidents. -The facility implemented education on using the call light, however the resident had a diagnosis of dementia. The facility failed to implement an effective fall intervention. The 9/28/21 Psychopharmacological Med/Physical Restraint progress note read, On 9/24/21 The resident was observed on the bathroom floor lying on her L (left) side, shoes on, pullup observed below level of her nightgown which is below her hips, urine was observed on the back of nightgown and on pullup. W/C brakes locked. Per resident I had to go and fell on to the floor, the floor was wet and she slipped. Assessment complete--abrasion L (left) knee, bruise L elbow/knee. Rx (treatment) provided. Care plan updated. According to the list of the type of falls paperwork, see below, the resident had a fall on 10/14/21, however no documentation was found in the resident ' s medical record. -The facility failed to implement an intervention for this fall. The 10/19/21 Incident progress note read On responding to call light, res(ident) observed sitting on floor in front of walker. Denies pain with movement and palpation, mentation and neuro check at baseline, no injury noted. Phys(ician) and family aware. -The facility failed to implement an intervention for this fall. The 11/10/21 Psychopharmacological Med/Physical Restraint progress note read, IDT met to discuss incident from 11/3/21. Resident has no awareness of physical limitations and will perform independent activities and not wait for staff assist. Resident's cognitive skills for daily decision making impaired. Goal for resident is not to incur injury should fall occur. -However, there was no incident note or IDT note found in the medical record regarding the 11/3/21 fall to describe the factors around the fall. In addition, there was no evidence through documentation that the fall IDT reviewed the fall and implemented fall interventions. Although the medication review was seven days after the fall it did not contain information on the root cause of the fall and/or interventions put in place after the fall. The 12/1/21 Incident progress note read, This nurse called to room with report that Res(ident) was observed sitting on the floor. Res. observed sitting on the floor in the bathroom. Sitting on her bottom holding on to the commode toilet seat. Res. states she was trying to get to the toilet but wasn't able to and sat down. Res. total lifted X2 (by two) from floor. Assisted to the bathroom. Neuros assessment, vitals and ROM (range of motion) WNL (within normal limits), Res. denies acute injury. WC (wheelchair) locks found to be locked and anti-rollbacks appear to be loose. Will request maintenance to adjust. Admin(inistration), DNS (director of nursing services), PCP (primary care physician) and family notified. The 12/7/21 Psychopharmacological Med/Physical Restraint progress note read, On 12/1/21 The resident was observed sitting on the floor in her bathroom holding onto the commode toilet seat. Per resident Was trying to get to the toilet but wasn't able to and sat down. Assessment complete--no injuries incurred. It is noted that resident is unaware of her physical limitations, is very impulsive and does not consistently use her call light. Assessment complete--no injuries incurred. Care plan updated. IDT (interdisciplinary team) met to discuss above incident. Recommended that the auto lock W/C (wheelchair) be checked and ensure that it is function properly. Goal for resident is not to incur injury should a fall occur. The 12/10/21 Health Status progress note read, This nurse called to Res(ident) bathroom. This nurse enters to observe Res. sitting on the floor on her bottom. Somewhat sideways to her right > (more than) left. Res. had pants on all the way facing with feet toward the toilet and back toward the wall. Call light had been pulled and had been on < (greater than) 5 minutes at time of fall. Res. states she went to the bathroom, she got up from the toilet to look for a comb. States she lost her balance and fell . She says she had her wheelchair in the doorway and walked to the toilet, then to the sink, then fell . Vitals, assessment and ROM (range of motion) WNL (within normal limits), Res. lifted with total lift X2 (of two) assist. Res. placed in wheelchair and went to Nsg (nursing) Station to sit for close monitoring. Admin(istration), DNS (director of nursing services), PCP (primary care provider), and family POA (power of attorney) notified. Will monitor with neuro eval. X72 (for 72) hrs (hours). -The facility failed to implement an intervention for this fall. The 12/11/21 Incident progress note read, Res(ident) observed sitting on floor in front of recliner just prior to lunch. No injury noted or reported. Monitoring per protocol, family and phys(ician) made aware. -The facility failed to implement an intervention for this fall. The 12/12/21 Health Status progress note read, Discussed res(ident) frequent falls with her this day, listing possible options for safety. She states, Please, just get my wc (wheelchair) out of my site, then I will remember to call for you. Per her request, WC remains parked out of her site and she used call light through day, stating, This is working well. Reviewed plan with son (name), and he verbalized agreement. -The 12/14/21 Care Plan Review progress note did not mention fall review. The handwritten fall intervention list provided by the MDS Coordinator (MDSC) on 12/16/21 at 10:00 a.m. contained the fall interventions that were tried. The MDSC said that most of the interventions were currently being used with the resident, see interview below. The MDSC said that she conducted an internet search on alternative fall reducing measures, however found no information. The list contained: -Enabler bars to assist with bed mobility, pressure relief and transfers as applicable. -Fall mat at bedside. (See interview below, this was removed for safety). -Bed in lowest position. -Personal alarm to alert staff of independent mobility. -Bolsters on bed to aid with identifying bed boundaries. -Pain management and toileting opportunities. -Inquire about hunger. -Night lights. -Gripper Socks. -Auto lock wheelchair. -Anti-tippers on back of wheelchair. -Physical, Occupational and Speech therapy services as applicable. (Currently receiving therapy services, see interview below). -Soft touch call light and continuing education with the resident about using the call light to request assistance. The list of the type of falls the resident had since admission was provided by the NHA via email on 12/17/21. It read that the resident was ' found on the floor ' from 4/27/21 to 12/11/21, 12 times. ' Slipped or fell ' incidents once on 4/27/21. Review of the Call Light Audit Reports from November to December 2021 revealed the following call light wait times correlated with falls to show the call light was not used effectively by the resident to reduce her falling: On 11/3/21 Resident #5 used her call light four times prior to her fall at 1:30 p.m.; At 3:14 a.m. for 2.32 minutes, at 6:45 a.m. for 8.01 minutes, at 7:19 a.m. for 8.23 minutes and at 11:13 a.m. for 8.33 minutes. On 12/1/21, the resident used her call light one time at 5:52 p.m. with a wait of 5.06 minutes with a fall occurring at 8:30 p.m. On 12/2/21 at 12:32 a.m. Resident #5 fell . She used her call light four times after the fall at 8:42 a.m. for 19.22 minutes, at 1:09 p.m., for 10.57 minutes, at 3:23 p.m. for 9.22 minutes, and at 7:58 p.m. for 14.19 minutes. Resident #5 used her call light eight times on 12/9/21 prior to the subsequent falls; At 8:30 a.m. for 20.58 minutes, at 9:11 a.m. for 8.5 minutes, at 10:33 a.m. for 3.32 minutes, at 11:59 a.m. for 8.22 minutes, at 1:00 p.m. for 42 seconds, at 3:47 p.m. for 3.42 minutes, at 6:09 p.m. for 1.53 minutes, and at 7:38 p.m. for 5.05 minutes. -Resident #5 did not use her call light on 12/10/21 or 12/11/21 prior to falling on those dates. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 12/15/21 at 1:11 p.m. She stated if a resident was found on the floor she would first make sure they were comfortable, then take vitals, take note of their position. She stated she would ask the resident if they knew what had occurred, if the resident was able to speak on it. If fall was not observed, then the resident would have been placed on neurological (neuro) checks every 15 minutes. She did not place immediate interventions in place, but informed the charge nurse of the fall who would place the interventions. She said she was not on the fall committee. She said that she ensured Resident #5 had not gotten out of bed and assisted her in getting up prior to other residents at the start of each shift. She stated the resident was impulsive when getting out of bed by herself. The director of nursing (DON) and social services director were interviewed on 12/15/21 at 4:00 p.m. The DON stated there was a weekly fall committee meeting. Immediately after a resident had a fall, the charge nurse assessed the resident. Then the nurse and CNA assisted the resident back to bed. In the meeting the IDT team discussed resident falls from the previous week. The team looked at items such as when the resident had been toileted and meal times. The DON said that the MDSC looked into the history of the resident, previous falls, and reasons for falls. Interventions were considered in the weekly fall meeting. The DON stated that the team reviewed past interventions and their effectiveness. The DON stated the last resort they would use was an alarm. Fall interventions were reviewed for effectiveness after the resident had another fall. The DON stated the IDT team looked at the reasons and causes of Resident #5 ' s multiple falls. They looked into the physical reason she had fallen and if speech therapy could help with her cognition. The DON stated Resident #5 was aware she should wait for help after she pressed the call light, but did not wait. Resident #5 pushed her call light and then self transferred. The DON said that staff were educated on Resident #5 ' s frequent falls and were educated to help her first. The DON mentioned that Resident #5 needed to be assisted when she propelled her wheelchair and other non nursing staff had pushed the resident back to her room from the dining room. The DON mentioned other interventions that have been tried including: pain interventions, therapy, electrical stimulation (estim), anti-rollback on her wheelchair, and frequent rounding by staff. The DON stated the team trialed interventions and the best intervention found was frequently reminding her to use her call light. The DON said the door should remain open for staff oversight of the resident. She said the wheelchair was kept out of her sight to help remind her to use her call light for assistance. She said the call light was kept within reach and constant reminders so the resident would use the call light. She said they used signs that at times helped remind the resident to wait for assistance. She said the resident should not be left alone in her room without meeting her needs such as putting her in the recliner and/or taking her to the bathroom. The SSD said that the IDT reviewed [CONDITION(S)] medications post-fall. She stated that weekly reviews happened for medications and behavior changes. She said that the pharmacy sent monthly notes regarding medication changes. The SSD stated she spoke to the medical director and discussed a risk benefit form when residents have increased behavior and falls. The SSD stated that Resident #5 had high anxiety related to mobility and pain, which related to the resident ' s increase in behaviors. The SSD stated that when the resident did not have the wheelchair within sight, she was inclined to use the call light. The SSD clarified that when staff removed the wheelchair this did not cause her inability to move as the resident needed assistance when transferring. The DON stated that when staff anticipated Resident #5 ' s needs, the falls decreased. The DON spoke with Resident #5 ' s family and they voiced their biggest concern was preventing injury. The DON stated Resident #5 ' s door was outside the nurses station; therefore, she was in the direct line of sight of staff. The DON stated this was helpful when the facility was short-staffed. When staff saw her attempting to transfer they could help immediately. The DON stated if the resident fell over the weekend there were no new interventions to put in place since most had been tried and not effective. The DON stated the call light, moving wheelchair, and other interventions had not been effective in preventing Resident #5 from falling. The DON said during the Quality Assurance (QA) meetings the IDT discussed the increase in falls throughout the building. They determined the increase to be related to short-staffing. The MDS coordinator (MDSC) was interviewed on 12/15/21 at 4:20 p.m. She stated that every week a pharmacological fall meeting was held. She said that she took notes and documented what was written on the incident report that the charge nurse filled out and transposed on the meeting minutes. She said the IDT team members consisted of the NHA, the SSD, the activities director, and the DON. They met weekly to review current and past fall interventions. The MDSC stated Resident #5 was very impulsive and sometimes remembered to use her call light. Staff were educated to not take the resident back to her room unless they helped her all the way to her reclining chair or bed. The MDSC stated that therapy services were provided several times but she did not progress. Fall interventions were added to the care plan. Resident #5 enjoyed watching television and sitting in her room. Resident #5 did like attending group activities. Certified nurse aide (CNA) #1 was interviewed on 12/16/21 at 9:30 a.m. She said Resident #5 ' s fall interventions included encouraging her to use her call light, move the wheelchair out of the resident ' s line of sight. With the wheelchair moved, the resident was unable to self-transfer. The CNA stated there was a booklet of information in the nurses station that had fall interventions to use to put into place, but often she heard about fall interventions via word of mouth. She stated the resident was able to use her call light and taking the wheelchair away reminded her to use the call light. The MDSC was interviewed on 12/15/21 at 9:39 a.m. She stated Resident #5 ' s biggest barrier to preventing falls was her cognitive impairment. The MDSC stated Resident #5 had very bad short term memory but her long term memory was fairly good. If items were repeated Resident #5 was able to recall them. The MDSC stated the staff had to constantly remind Resident #5 to use her call light. Resident #5 was able to propel herself in her wheelchair, but was very slow. She stated staff tried not to push her back to her room unless they were able to assist her to the bathroom and then to bed. She stated staff kept the resident ' s door open, so staff were able to see her more easily from the nurses ' station window and as staff passed by the room on their way to the dining room and/or other hallways. This increased the number of staff having eyes on the resident. When the IDT reached out to the family, they did not have any suggestions about preventing falls or minimizing injury from falls. The MDSC stated the resident was more tearful with increased anxiety over her friend's decline. V. Facility follow-up On 12/17/21 via email the NHA provided the Safe Resident Handling and Safe Resident Handling Program: Introduction, training that was provided to staff on 12/16/21. Other annual training provided to the staff throughout the year, 2021 included: Fall Prevention: What Nurses Must Know and Do and Fall Prevention: What You Can Do. The training provided did not include a description of the training programs ' content. On 12/17/21 via email the NHA provided documentations of therapies provided to Resident #5 including physical therapy, occupational therapy and speech therapy. Resident #5 received occupational therapy (OT) treatment on 12/3/21, 12/10/21, 12/13/21 and 12/15/21. The most recent OT treatment report on 12/15/21 indicated Resident #5 was able to correct trunk posture in a wheelchair and had appropriat [TRUNCATED]

Based on record review and interviews, the facility failed to report an alleged violation of abuse to the State survey and certification agency for one (#5) of three residents reviewed for abuse out of 21 sample residents. Cross-reference 610, the facility failed to investigate an alleged violation of abuse. Findings include: I. Facility policy The Abuse and Neglect policy and procedure, last revised 10/18, was provided by the director of nursing (DON) on 12/13/18 at 7:56 a.m. read in pertinent parts: If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, than it will be reported not later than two hours after the allegation is made to the administrator, and to other officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long-term care centers) in accordance with state law. II. Failure to report A review of the State Survey Agency abuse allegation reporting database, conducted on 12/5/18, revealed there was no reported allegation of abuse consistent with Resident #5 (see resident's interview below). III. Resident #5 A. Resident status Resident #5, age 84, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 9/7/18 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The resident did not exhibit any signs or symptoms of [MEDICAL CONDITION], did not exhibit any behaviors nor did she reject cares. She required one person physical assistance for bed mobility, dressing, grooming, toilet use and transfers. B. Resident interview The resident was interviewed on 12/10/18 at 12:53 p.m. the resident stated a night nurse who was working with her had been rough when providing her with cares. She said she was on her way to report the issue with the director of nursing (DON). The resident said she had reported a concern about another staff member being rough with her in August. She said that was a different staff member, and the facility handled it to her satisfaction, so she felt confident they would properly handle the most recent staff member being rough with her. C. Record review The 8/27/18 resident concern form, completed by a staff member on behalf of the Resident #5 documented, Resident #5 reports difficulties with some certified nurse aides (CNA) not providing the amount of care she requires. She specifically mentioned a CNA with blond hair pulled back into a ponytail. She reports she will leave her in the bathroom half-dressed and not return. Reports this CNA presents with a negative attitude and reports difficulty with not assisting with tasks in her room, reaching for things for the resident. She needs assistance to meals and activities, staff are having her ambulate which resident is reporting an increase in arm and back pain. The 8/27/18 resident concern form investigation documented the social worker talked with the DON, and a report sheet was made that included assisting Resident #5 to meals and activities. The 8/27/18 resident concern form resolution, completed by the DON on 8/29/18 documented, the management was unable to narrow down who the blond certified nurse aide was. D. Staff interviews The nursing home administrator (NHA) was interviewed on 12/11/18 at 11:33 a.m. The NHA said he recalled the resident concern form regarding Resident #5. The NHA said he did not report the incident to State agency because the facility did not have a blond certified nurse aide. The NHA said Resident #5 had also reported an allegation of abuse on 12/10/18. The NHA said the facility had completed an investigation and had unsubstantiated the allegations and therefore did not report to the State agency. Facility follow-up The NHA stated he reported the allegation of abuse from 12/10/18 to the State agency on 12/11/18 at 12:36 p.m.

Based on record review and staff interviews, the facility failed to ensure two (#29, and #47) of six residents reviewed for skin assessments of 21 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to complete skin assessments for resident #29 and #47 to reflect residents current skin condition. Findings include: I. Facility policy Skin assessment, Pressure Ulcer Prevention and Documentation Requirements policy, last revised (MONTH) (YEAR), was provided by the director of nursing (DON) on 12/12/18 at 4:23 p.m. It read, in pertinent part, If a bruise, contusion, abrasion or skin tear is observed on a resident, this should be reported to the nurse immediately. The bruise/contusion/skin tear/abrasion should be monitored weekly and any changes and/or progress toward healing should be documented on the Skin Observation UDA and on the resident ' s care plan. II. Resident #29 A. Resident status Resident #29, age 84, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 10/11/18 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident did not exhibit any signs or symptoms of [MEDICAL CONDITION], did not exhibit any behaviors nor did she reject cares. She required one person physical assistance for bed mobility, dressing, grooming, toilet use and transfers. According to the 9/7/18 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. He required one person physical assistance for bed mobility, dressing, grooming, toilet use and transfers. The resident was at risk for developing pressure ulcers, and currently had two unhealed pressure ulcers. B. Resident interview and observation Resident #29 was observed on 12/10/18 at 10:30 a.m. sitting in a recliner in his room. The resident had a quarter size deep purple bruise on his left forearm. The resident stated he had gotten the bruise a few weeks ago, but could not recall how he had gotten the bruise. C. Record review Review of the resident (MONTH) and (MONTH) (YEAR) skin observation tools, revealed the resident had no skin observation tools completed for the bruising on his forearm. Review of the resident shower log, with skin revealed the following: -11/17/18 whirlpool bath completed: no scratches, red areas, discoloration, skin tears or open areas noted. -11/21/18 sponge bath completed: no scratches, red areas, discoloration, skin tears or open areas noted. -11/24/18 whirlpool bath completed: no scratches, red areas, discoloration, skin tears or open areas noted -11/28/18 whirlpool bath completed: no scratches, red areas, discoloration, skin tears or open areas noted -12/1/18 whirlpool bath completed: no scratches, red areas, discoloration, skin tears or open areas noted -12/5/18 whirlpool bath completed: no scratches, red areas, discoloration, skin tears or open areas noted -12/8/18 whirlpool bath completed: no scratches, red areas, discoloration, skin tears or open areas noted D. Staff interviews The director of nursing (DON) was interviewed on 12/11/18 at 12:55 p.m. She said the certified nurse aides (CNA) are responsible for completing resident skin checks on the day the resident is getting a shower. She said when a CNA notices an irregular issue with the skin, the CNA then notifies the nurse who follows up with the resident. On 12/11/18 at 12:19 p.m. the DON confirmed the bruise on Resident #29 left forearm. The resident told the DON the bruise was about two weeks old, and maybe had happened when he had blood drawn. The DON stated the bruise should have been noted for the resident. The bruise or any skin issue should be followed for one week, or until the skin issue had resolved. A certified nurse aide (CNA) #3 was interviewed on 12/12/18 at 1:34 p.m. She said she was the CNA for Resident #29, and frequently gave the resident his bath. The CNA said she was responsible for providing the resident his their bath. During the residents bath she said she was looking at their skin for any irregularities. She said when something is noted on a resident, she reports it to the nurse. She said she had given Resident #29 a bath this morning, and that was the first time she noticed the bruising on several areas of his body. She said that information was reported to his nurse. A registered nurse (RN) #3 was interviewed on 12/12/18 at 2:06 p.m. She said the bruising on Resident #29 were noted that morning during his skin checks. She said the bruises on the resident were not new, but would now be followed until they resolved. The DON was re-interviewed on 12/13/18 at 11:28 a.m. She said the facility had done an audit of all of the facilities skin checks, and found they were not being thoroughly completed. She said moving forward weekly skin checks would be completed on all the residents on their shower day. She said the skin assessment would be completed by the nurse working with the resident, but the CNAs would still be responsible for reporting any skin irregularities they noted while providing cares. She said a weekly skin assessment would be entered weekly in the resident's electronic medical chart. The DON said the facility would begin an investigation to determine how the resident received the bruise. She said they looked into his record and he had not had a recent blood draw as he reported. III. Resident #47 A. Resident status Resident #47, age 91, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 11/6/18 minimum data set (MDS) assessment revealed the resident had cognitive impairment and was rarely understood. Her brief interview for mental status (BIMS) score was not conducted. She required extensive assistance with all activities of daily living (ADLs). Resident was at risk for pressure ulcers and had healed stage III pressure ulcer on her bottom. C. Wound care observation On 12/12/18 at 10:25 a.m. resident was assessed by the wound care physician in the presence of registered nurse (RN) #4. During the observation Resident #47 was positioned on her left side. Dressing from her coccyx was removed. The resident had a large white irritation area to the left and right of her coccyx. Skin appeared pale with small open areas, both buttocks. The wound care physician said the resident had a moisture associated skin damage due to incontinence. He said none of the wounds were pressure related and said irritation on the left side was new. After the physician completed assessment, the wound nurse applied dressing to the coccyx. Resident also had a small transparent dressing to her left knee. Wound nurse stated she was not in charge of monitoring any other wounds and she did not know why the resident had a dressing on her knee. The dressing did not have a date on it. B. Record review The resident's care plan, last revised 8/28/18, revealed the resident had a potential in skin integrity related to aging process and fragile skin. Interventions included to identify potential causative factors and eliminate/resolve where possible, weekly skin observations by bath aide, and to report any abnormalities to charge nurse. Another care plan initiated on 12/12/18, revealed the resident had a traumatic wound on her right and left buttock. Intervention included to monitor for changes, provide treatment and to notify nurse of other changes. Review of progress notes between 12/1/18 and 12/12/18 revealed no mention of residents dressing on the left knee. No weekly skin assessments were available for the review. Treatment administration record (TAR) for (MONTH) (YEAR) did not mention dressing observations or changes to resident ' s left knee dressing. D. Staff interviews Wound care nurse/RN #4 was interviewed on 12/12/18 at 11:00 a.m. She said she was in charge of monitoring wounds related to pressure and complicated wounds. She said skin scratches, bruises and other small injuries were monitored by staff nurses. Licensed practical nurse (LPN) #1 was interviewed on 12/13/18 at 11:04 a.m. She said the resident had a small abrasion on her knee that was healing. She reviewed the TAR for (MONTH) (YEAR) and was not able to locate monitoring or treatment orders for that abrasion. She said certified nurses aides (CNAs) usually notify her about new skin issues. She did not know how skin abrasion was missed and why it was not on the TAR. DON was interviewed on 12/13/18 at 1:00 p.m. She said staff nurses were expected to monitor residents skin every week and document on weekly skin assessments. She said all skin conditions, abrasions, skin tears and bruises must be marked on skin assessment and monitored every day until healed.

Based on interviews and record review, the facility failed to have evidence all alleged violations of abuse and/or mistreatment were thoroughly investigated and timely for one (#5) out of three residents investigated for abuse out of 21 total sampled residents. Cross reference F609: Specifically, the facility failed to investigate an allegation of abuse after it was reported in a resident concern form. Findings include: I. Facility policy The Abuse and Neglect policy and procedure, last revised 10/18, was provided by the director of nursing (DON) on 12/13/18 at 7:56 a.m. read in pertinent part: The investigation team (social worker, administrator and director of nursing services) will review all incidents no later than the next working day following the incident. -The investigation may include interviewing employees, residents or other witnesses to the incident. Interview all involved (employee, resident and family) individually .consider having each person write his or her memory of the event. II. Resident #5 A. Resident status Resident #5, age 84, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 9/7/18 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The resident did not exhibit any signs or symptoms of [MEDICAL CONDITION], did not exhibit any behaviors nor did she reject cares. She required one person physical assistance for bed mobility, dressing, grooming, toilet use and transfers. B. Resident interview-alleged violation of abuse The resident was interviewed on 12/10/18 at 12:53 p.m. the resident said she had reported a concern about another staff member being rough with her in August. She said that was a different staff member, and the facility handled it to her satisfaction, so she felt confident they would properly handle the most recent staff member being rough with her. C. Record review The 8/27/18 resident concern form, completed by a staff member on behalf of the Resident #5 documented, Resident #5 reports difficulties with some certified nurse aides (CNAs not providing the amount of care she requires. She specifically mentioned a CNA with blond hair pulled back into a ponytail. She reports she will leave her in the bathroom half-dressed and not return. Reports this CNA presents with a negative attitude and reports difficulty with not assisting with tasks in her room, reaching for things for the resident. She needs assistance to meals and activities, staff are having her ambulate which resident is reporting increase in arm and back pain. The 8/27/18 resident concern form investigation documented the social worker talked with the director of nursing, and a report was made to the certified nurse aides to assist Resident #5 to meals and activities. The 8/27/18 resident concern form resolution, completed by the director of nursing on 8/29/18 documented, the management was unable to narrow down who the blond certified nurse aide was. D. Staff interviews The nursing home administrator (NHA), director of nursing (DON) and social service director (SSD) were interviewed on 12/11/18 at 11:33 a.m. The NHA, DON and SSD said they recalled the resident concern form regarding Resident #5. The DON said at the time of the allegation, the facility did not have a certified nurse aide (CNA) who had blond hair or wore their hair in a ponytail. The SSD said an investigation was not completed because there was not a staff member matching Resident #5 description. The SSD said no other residents were interviewed regarding the 8/27/18 concern reported by Resident #5. The NHA confirmed an investigation was not completed regarding Resident #5 allegation on abuse on 8/27/18.

Based on observations, record review and interviews, the facility failed to ensure one (#35) of three residents reviewed for pressure ulcers, out of 25 sampled residents, received care consistent with professional standards of practice, to prevent pressure ulcers from developing and once pressure ulcers developed, failed to ensure the resident received necessary care and treatment to promote healing, prevent infection and prevent new ulcers from developing. Review of resident #35's record - medication and treatment administration records (MARs and TARs), care plan updates, wound registered nurse (WRN) assessments, and wound and nurse practitioner (NP) notes, and lab reports, revealed the resident sustained [REDACTED]. The resident's record revealed and interviews confirmed both the lack of and delays in assessing, monitoring and implementing interventions to prevent the deterioration of his gluteal wound and the development of additional pressure injuries. Cross reference to F325, failure to maintain acceptable parameters of nutritional status. Findings include: A Facility Policy The director of nursing (DON) provided a copy of the facility's Pressure Ulcer Policy on 11/15/17 at 4:30 p.m. Revised 01/2017, the policy, read: Risk factors are factors that increase a resident's susceptibility to develop or impact healing times of pressure ulcers. They include, but are not limited to impaired/decreased mobility and decreased functional ability, exposure of skin to urinary and fecal incontinence, malnutrition, undernutrition and hydration deficits, and history of previous ulcers . A clinical assessment should address those factors that have an impact on the development, treatment and/or healing of pressure ulcers, which may include: pressure points, nutrition, hydration and the impact of moisture on the skin .Residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes on their skin condition. If a pressure ulcer/wound does not show some evidence of progress toward healing within 14 days, the pressure ulcer/wound and the resident's overall clinical condition should be reassessed. Reevaluation of the treatment plan and modification of the current interventions may be indicated . Once the resident has been assessed and is determined to be at risk for development of a pressure ulcer, the interdisciplinary team should evaluate interventions and actions that can be taken to assist in the prevention of pressure ulcer development .Employees should implement resident-specific turning and positioning programs based upon an individualized assessment. This includes a consistent program for changing the resident's position and realigning the body .The interdisciplinary team should perform an analysis of the precipitating events for individual resident's pressure ulcer development. In addition, they should perform a systemic practice review to evaluate effectiveness of the pressure ulcer prevention and management practices used. B. Professional Reference According to the National Pressure Ulcer Advisory Panel (NPUAP), 4/9/2016, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/, the NPUAP redefined the definition of a pressure injury. The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Pressure Injury Prevention Points: Develop a plan of care based on the areas of risk rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Inspect the skin at least daily for signs of pressure injury. Cleanse the skin promptly after episodes of incontinence. Avoid positioning an individual on an area of [DIAGNOSES REDACTED] or pressure injury . Turn the individual into a 30-degree side lying position, and use your hand to determine if the sacrum is off the bed. Avoid positioning the individual on body areas with pressure injury. Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. Continue to reposition an individual when placed on any support surface . When pressure ulcers deteriorate or fail to heal, the clinician should consider replacing the existing support surface with one that will provide a properly matched support surface environment in terms of pressure, shear, and microclimate for the individual. More frequent repositioning, preventive interventions and local wound care should also be intensified as needed. According to the http://www.lowairlossguide.com/low-air-loss-mattress-work/, viewed on 11/20/17, Low Air Loss (LAL) mattresses are designed to prevent and manage pressure ulcers . Every LAL mattress contains a series of holes that allows air to escape the mattress. As mentioned in the previous paragraph, the vapor-permeable mattress cover sits on top of the mattress. When air escapes the mattress, it goes into the small crevice of space between the mattress and the mattress cover. When a resident sweats and vapor permeates through the cover, it comes into contact with the air escaping the mattress, thus helping evaporate the excess moisture. This process of low air loss helps keep the patient cool, reduces moisture build up and minimizes skin maceration. C. Resident #35 Resident #35, age 78, was admitted on [DATE]. According to the admission record, [DIAGNOSES REDACTED]. 1. Assessments revealed the resident had experienced a physical and mental decline since July, 2017, that included the development of a stage IV pressure injury. Braden assessments revealed the facility was aware of the resident's risk for pressure injuries. a. Minimum data set (MDS) assessments According to the 7/1/17, significant change in status MDS assessment, the resident had intact cognition. He had no hallucinations, delusions or rejection of care behavior. He required extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. He was independent with eating. He was frequently incontinent of urine. His weight was 153 pounds. He did not have any unhealed pressure ulcer(s). According to the most recent MDS significant change in status assessment, dated 10/16/17, the resident's cognitive skills for daily decision making were assessed as severely impaired. He was totally dependent on two staff with bed mobility, toilet use and transfers, required one person total assistant with dressing, and extensive assistance with eating and personal hygiene. The range of motion (ROM) of upper and lower extremities was impaired on one side. He had an indwelling urinary catheter. He had one fall with injury, since prior assessment (9/27/17). His weight was 139 pounds. He had one, stage 4 unhealed pressure ulcer (eschar). He received an antidepressant and opioid medications daily. He was on oxygen and received hospice care. b. Braden Scale for Predicting Pressure Sore Risk revealed: 1/7/17 score 16 (score 18 or below indicated the resident was at risk) 4/6/17 score 16 7/3/17 score 16 c. Facility plans to address resident #53's pressure sore risk prior to development of a Stage 4 pressure injury The resident's comprehensive care plan (CP), in part: -The resident has potential impairment to skin integrity (related to) varying transferring abilities, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] med use, aging process, fragile skin. The CP was initiated on 10/26/13. Interventions included: Educate resident/family of causative factors and measures to prevent skin injury. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Weekly skin observation by bath aide. Report alterations in skin integrity to Charge Nurse, initiated on 12/6/13. -The resident has potential for pressure ulcer/skin breakdown development (related to) bowel incontinence and (decreased) mobility. The CP was initiated on 10/8/14. Interventions included: Educate resident/family as to causes of skin breakdown including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Inform resident/family of any new area of skin breakdown. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. Notify Rehab Coordinator for re-evaluation of mobility status. Explain and reinforce to resident the importance of adequate intake, requesting assist with toileting/hygiene needs, initiated on 10/8/14. 2. Review of resident #35's record - medication and treatment administration records (MARs and TARs), care plan updates, wound registered nurse (WRN) assessments, wound physician (WMD) and wound and nurse practitioner (NP) notes, and lab reports revealed the resident sustained [REDACTED]. The resident's record revealed both the lack of and delays in assessing, monitoring and implementing interventions to prevent the deterioration of his gluteal wound and the development of additional pressure injuries. a. July 2017 - Discovery of a shear wound on right gluteal fold - Failures in facility response July 2017 MAR indicated [REDACTED]. Physician order [REDACTED]. July 2017 TAR documented: Sheer (sic) wound on R (right) gluteal fold - clean with wound cleanser, apply skin prep, cover with Ultec Pro, change bath days and prn one time a day every Monday and Thursday. The order date was 7/20/17 and treatments were documented on 7/20/17, 7/24/17, 7/27/17 and 7/31/17. Failures: There was no documentation of the characteristics of the resident's new wound. Although the care plan read to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, the plan was not updated to address the new wound. b. August 2017 - Decline in status of shear wound to a Stage 3 pressure injury - Failures in facility response The August MAR indicated [REDACTED]. The August TAR documented: Sheer (sic) wound on R (right) gluteal fold - clean with wound cleanser, apply skin prep, cover with Ultec Pro, change bath days and prn one time a day every Monday and Thursday. The treatments were documented on 8/7/17, 8/10/17, 8/14/17 and 8/21/17. There was no documentation of treatments on 8/3/17 and 8/17/17. The record revealed a WRN assessment 8/23/17 that read right gluteal cleft - pressure ulcer stage 3. This wound start as a sheer (sic) wound but today was covered with slough, this wound care RN has now stage this wound as stage 3 (as evidenced by) slough covering wound bed. The 8/24/17 TAR documented the physician's orders [REDACTED]. Clean with wound cleanser, apply Santyl ([MEDICATION NAME] ointment), cover [MEDICATION NAME] (foam dressing). Change QD (daily) and PRN, one time a day for wound care treatment. The treatment was documented daily on the TAR. The 8/30/17 WRN assessment revealed the resident's air mattress was ordered. Failures: Although the MAR indicated [REDACTED]. Moreover, the record revealed no wound assessments after discovery of the resident's shear wound in July until 8/23/17, when the WRN assessed the resident's wound. There had been no treatment changes in over two weeks despite the wound's failure to improve. The record also revealed no evidence of a support surface until 8/30/17 when an air mattress was ordered. The WRN assessment and the TAR showed the wound had deteriorated to a Stage 3. Finally, there was no evidence the facility's Pressure Sore Policy for daily monitoring of the resident's wound was implemented or that the care plan was revised to instruct staff on interventions to promote healing based on resident #35's areas of risk (immobility, incontinence, cognitive decline) such as frequent monitoring for incontinence and scheduled repositioning. (See above professional reference; repositioning should be continued when a resident is placed on any support surface,) c. September 2017 - Further decline in wound to Stage 4 with infection - Failures in facility response The September 2017 TAR documented: Stage 3 pressure ulcer - right gluteal cleft. Clean with wound cleanser, apply Santyl, cover [MEDICATION NAME]. Change QD (daily) and PRN, one time a day for wound care treatment. The treatment was documented daily until 9/13/17. The 9/14/17 TAR documented: Stage 4 pressure ulcer - right distal buttock. Flush out wound with wound cleanser, skin prep periwound, apply Santyl to entire wound bed, lightly pack wound with Calcium Alginate Rope (absorbent wound packing material), cover with [MEDICATION NAME], every evening shift. The treatment was documented daily. The WRN assessed the wound weekly in September, documenting deterioration of the wound. -on 9/6/17, the WRN assessment read the wound had developed an odor -on 9/13/17, the WRN assessment read the pressure ulcer increased in size and was unstageable. -on 9/20/17, the WRN assessment read the right gluteal cleft pressure injury was Stage 4. Lab studies revealed the resident's [MEDICATION NAME] (the main protein of human blood plasma) level (normal range 3.5 - 5.0) had declined from 3.4 g/dl to 3.0 g/dl on 9/12/17. His 9/13/17 lab report study revealed a [MEDICATION NAME] level (potential indicator of malnutrition) was 8.4 mg/dl (normal range 20.0 - 40.0) The resident's Braden score revealed an increased pressure ulcer risk with a score of 14, down from a score of 16 on 7/3/17 (see above). The resident was initially evaluated by the wound physician (WMD) on 9/13/17. The physician documented the resident's right distal buttock pressure injury was debrided surgically, was a Stage 4 wound, 3.5 cm long by 6.5 cm wide. The WMD further noted the resident was on a pressure reducing air mattress (group) and pressure reducing wheelchair cushion. The WMD evaluation dated 9/20/17 documented a Stage 4 pressure injury, 4 cm x 3.2 cm. The wound had deteriorated, present with odor and heavy serious (drainage). The physician wrote, The urine is saturating the dressing pretty much all the time due to his incontinence. Recommendations included repositioning, off-loading wound, limit sitting to 60 minute and Foley catheter to prevent soaking the wound. The resident's care plans were updated in September to read: - Resident has stage 4 (four) ulcer D/T necrosis R (right) distal buttock--debrided by Dr. (wound care physician). The CP was initiated on 9/20/17. Utilizes air mattress, ROHO cushion while in w/c (wheelchair). Assist to turn/reposition at regular intervals and prn (as needed) while in bed. (9/20/17). -Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care (9/23/17). -9/28/17 - Turn/reposition at routine intervals when in bed. Failures in facility response: The facility failed to prevent deterioration of the resident's wound and a wound infection which was not treated or addressed until eight days after odor was first noted by the WRN on 9/6/17. Per the MAR, orders were received over a week later, on 9/14/17, for the antibiotic [MEDICATION NAME] Solution Reconstituted, 1 gram intramuscularly, one time a day for six days as well as an order for [REDACTED]. The resident's wound was not evaluated by WMD until it had deteriorated to a Stage 4, and the WMD note on 9/20/17 indicated the facility was not adequately addressing the resident's incontinence. In addition, although the resident's care plans were revised, 9/20, 9/23, 9/27 and 9/28/17, these revisions were not until the resident's wound had progressed to a Stage 4. Moreover, although the care plans now addressed repositioning at regular/routine intervals, there was no definition of regular/routine intervals to guide staff and no documentation that such repositioning occurred. Moreover, the care plan failed to incorporate the WMD's recommendation to limit sitting to 60 minutes. Finally, although the resident continued to receive the protein supplement (see above) ordered three times a day, there was no documentation how much the resident was consuming, even though it his lab studies showed his declining protein levels. d. October and November 2017 - New pressure injury and resident placed on hospice care On 10/9/17, resident #35 was admitted to hospice due to his decline in clinical status. On 10/10/17, an order was received to discontinue the protein supplements. The October and November 2017 TARs revealed the facility continued daily treatment (see September MAR indicated [REDACTED]. The 11/13/17 TAR documented: Stage 2 - Coccyx - clean with wound cleanser, apply skin prep, cover with [MEDICATION NAME] dressing, change bath days and PRN. The WRN assessment documented: -on 11/1/17 the WRN noted the nurse practitioner (NP) states resident is on hospice and can do what he wants and stay up if he wants. This wound care RN and (wound physician name) recommend limiting sit time to 1 hour at a time. -on 11/8/17, the WRN noted: NP states he can sit up as long as he wants. This RN has educated resident that he can stay up if he likes but his wound may get worse from the pressure. (Wound physician) here this day to assess and debride wound. Resident continues on (name) hospice. (Wound physician) recommends that resident only sit up for an hour at a time. Resident states he likes to sit up after breakfast to read his paper. -on 11/13/17, the WRN noted the resident had developed new pressure injury, Stage 2 on his coccyx. The WMD evaluations were documented 10/11/17, 10/18/17, and 11/15/17. -on 10/11/17, the WMD noted the resident was under hospice care, the wound size was 3 cm x 6.3 cm x 3.2 cm and was improving. -on 10/18/17, the WMD noted the wound size was 3 cm x 6.3 cm x 3.4 cm and the resident had a ROHO cushion in his wheelchair. -on 11/15/17, the WMD documented the resident's Stage 4 pressure injury, right distal buttock, wound size 2.5 cm x 4.9 cm x 3.4 cm and there was no change in the healing process. This note further read the resident developed new, Stage 3, pressure injury on coccyx, 1.5 cm x 4.3 cm. The resident developed shear wound on the left medial buttock, 1.2 cm x 0.3 cm. The resident developed shear wound on the right medial buttock, 0.3 cm x 0.5 cm. The WMD recommendations included reposition, off-load and limit sitting to 60 minutes. The resident's skin related care plans were revised 10/12/17 and 11/13/17 (noting the Stage 2 on the resident's coccyx) and a care plan for hospice was initiated per care plan on 9/28/17. Failures in facility response: Although amended, the resident's care plans failed to include the WRN and WMD's recommendation to limit sitting to 60 minutes or reference the new findings of sheering noted in the WMD evaluation on 11/15/17. In addition, the facility failed to appropriately communicate medical decisions related to the resident's wound care between the primary care provider and the WRN and WMD, as reflected in the WRN notes on 11/1/17 and 11/8/17, as well as the WMD's recommendations 9/20/17 and 11/15/17 (see above). 3. Observations The resident was observed throughout the survey between 11/13/17 and 11/16/17, several times a day and different times of the day. The resident was up on his wheelchair for most meals and for a short period of time after meals. The resident was observed in bed on the right side of his body, on the side with the stage 4 on the right distal buttock and stage 3 on his coccyx. Each time the resident was transferred to bed the staff did not repositioned to his left side. 4. Interviews Interviews confirmed both the lack of and delays in assessing, monitoring and implementing interventions to prevent the deterioration of his wound and to promote wound healing. The registered dietician (RD) was interviewed on 11/15/17 at 12:20 p.m. He said the resident's nurse practitioner discontinued the protein supplement on the day the resident was admitted to hospice despite his continued significant weight loss and pressure injuries. The facility medical director/resident's physician (MD) was interviewed on 11/15/17 at 12:30 p.m. He said the resident's pressure injuries would not have progressed so rapidly if the resident had been monitored more frequently and appropriately by the nursing staff. He said the resident's pressure injury was not a Kennedy ulcer that would grow from stage 1 to stage 4 within hours. He said the resident's medical condition began declining after he was treated for [REDACTED]. He said the resident was losing weight at the beginning of the year and that was his choice. He said the resident's weight loss got to the point it was not controlled well and losing over 20% of the body weight in a few months was not appropriate. He said the nurse practitioner should not have discharged the resident's protein supplement as the resident suffered from malnutrition and his [MEDICATION NAME] was low. He said the resident should continue to receive a protein supplementation. The wound nurse (RN#1) was interviewed on 11/15/17 at 2:30 p.m. She said the resident had a history of [REDACTED]. She said the resident received an overlay air mattress on his bed at the beginning of September after he was observed with the stage 3/unstageable pressure injury. She said the resident should be on a better quality air mattress to improve the healing process and she called hospice to order one. She said the resident received the ROHO cushion for his wheelchair after his fall on 10/16/17. The DON was interviewed on 11/16/17 at 10:30 a.m. She said her expectation was the resident continued to receive the protein supplementation to help with the healing process with the pressure injuries. She said the resident had a low grade overlay air mattress on his bed and the facility should have ordered one that was more appropriate to assist with the healing process. The hospice RN (HRN) was interviewed on 11/16/17 at 11:30 a.m. She said each resident with pressure ulcer(s) received an air circulating, low air loss, high quality mattress when they were admitted to the hospice care. She said she did not know why the resident (#35) did not receive this type of mattress right away on the admission day to the hospice care on 10/9/17.

Based on interview and record review the facility failed to ensure one (#63) of three residents reviewed of 25 sample residents remained free from accidents and received adequate supervision to prevent accidents. Specifically, the facility failed to appropriately assess the resident for fall risk; identify and address the root cause of the resident's repeat falls (attempted self-toileting); appropriately assist the resident with toileting to prevent falls; and implement care planned interventions to prevent falls. The facility's failures of providing adequate supervision and timely and systematically identifying and evaluating hazards and risks consistent with resident's needs, resulted in resident #63 experiencing multiple falls, injury, pain and discomfort. The failures resulted in resident's transfer by ambulance to a hospital emergency room for assessment, hospitalization and surgery to repair fractured right femur. The findings included: 1. Resident Status Resident #63, age 86, was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the 11/1/17 significant change minimum data set (MDS) assessment, the resident had clear speech, was able to be understood by others and was able to understand others. The brief interview for mental status score was five out of 15, and indicated severely impaired cognition. No hallucinations, delusions or rejection of care were present. She required extensive assist of two persons with bed mobility, transfers, dressing, toilet use and personal hygiene, and limited assistance with eating. No functional limitations in range of motion (ROM) were documented. She was frequently incontinent of urine. She received an anticoagulant and diuretic medications daily (Seven of seven days). According to the 9/18/17 MDS assessment, the resident had clear speech, was able to be understood by others and was able to understand others. She had short and long-term memory problems with cognitive skills for daily decision making - moderately impaired. No rejection of care was documented. She required extensive assist of one person with bed mobility, transfers, walking, dressing, toilet use and personal hygiene, and supervision with eating. She had no limitations in ROM, and was able to use a walker and a wheelchair for mobility. The resident was not steady and only able to stabilize with human assistance when moving from a seated to standing position; walking, turning and facing the opposite direction; moving on and off the toilet; and with surface-to-surface transfers. She was frequently incontinent of urine and bowel. She had no falls history or falls since admission. Medications included an anticoagulant, antibiotic and diuretic daily (Seven of seven days). 2. Record Review According to the 09/2017 and 10/2017, medication administration record (MAR), the resident had prescribed by the physician and was administered the following medications: [REDACTED] -Metoprolol Succinate ER (antihypertensive) 200 mg, one tablet, one time a day (morning), start day 8/18/17, discontinued 9/11/17. -Metoprolol Succinate ER (antihypertensive) 50 mg, one tablet, one time a day (morning), start day 9/12/17, discontinued 10/2/17. -Metoprolol Succinate ER (antihypertensive) 25 mg, one tablet, one time a day (morning), start day 10/3/17. -Furosemide (diuretic) 40 mg, one tablet, one time a day (morning), start 9/12/17, discontinued 10/25/17. According to the Mosby's 2017 Nursing Drug Reference: Metoprolol - side effects included dizziness, orthostatic hypotension, urinary frequency, anxiety and confusion. Furosemide - side effects included vertigo, orthostatic hypotension, confusion, increased urine volume. The bowel care plan, initiated on 8/17/17, read the resident has potential for constipation related to medication side effects, decreased mobility. The interventions included encouraging frequent mobility and encouraging the resident to sit on the toilet to evacuate bowels when possible. The care plan did not provide direction to staff on how to keep the resident safe from fall during the bowel toileting process. The osteoporosis care plan, initiated on 8/18/17, documented resident has osteoporosis. Pertinent interventions included monitoring and documenting risk of falls and educating resident/family on safety measures that need to be taken in order to reduce risk of falls. The activity of daily living (ADL) care plan, initiated on 9/24/17, read the resident required more assistance with ADLs due to the dementia disease process, heart failure and chronic kidney failure. The resident required extensive assistance of one with toileting, transfer, cleansing, and brief management. The resident required extensive assistance of one for transfers. The bladder care plan, initiated on 11/2/17, indicated the resident had urinary incontinence. The resident used briefs that were supplied by the family. Pertinent approaches included: -Encourage resident to drink more fluids during morning and afternoon and limit fluids in the evening/night. -Assist with toileting at regular intervals while awake. (Regular intervals was not defined or described to assist staff with meeting the resident's individualized care need.) -Provide perineal care as needed (PRN). The risk for falls care plan, initiated 10/9/17 and revised on 10/25/17, revealed the resident had impaired cardiac status, weakness, poor safety awareness, recent fall with right hip fracture. Interventions included: Educate resident/family/IDT (interdisciplinary team) as to causes of fall. (10/9/17); Remind resident not to bend over to pick up dropped items. Attempt to anticipate needs; Ensure that Resident is wearing appropriate footwear when ambulating/transferring or mobilizing in w/c (wheelchair); Avoid clothing that is falls risk ie: too loose, slippery, too long, etc; Auto-lock W/C; Adequate lighting used to maximize resident safety; Monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function; Monitor visual and auditory impairments; Review and modify environmental hazards supply that could cause or contribute to fall; Review as indicated for significant changes in cognition, safety awareness and decision-making capacity; Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs.; Review new or progressive neurological impairments; Review resident's history of recent or recurrent falls; Review resident's medical record for medications or combinations of medications that could predispose to falls/increase fall risk; Review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls. 3. Falls a. Fall #1 - circumstances of the fall, facility failures prior to the fall and response after the two falls Review of the clinical record documented the resident, who was known by the facility (per the 9/18/17 MDS) to be unsteady with standing, walking and transfers requiring human assistance to stabilize, did not have a formal fall risk assessment. The clinical record did not include a care plan to help staff reduce the resident's fall risks or risk of injury from falls. The record did not evidence an individualized toileting plan. A nursing note, dated 10/2/17, read, Resident slid onto floor from w/c after attempted self-transfer. An additional nursing note, dated 10/3/17, read, Resident was observed on the floor in the family room sitting on her wheelchair pedals. Wheelchair brakes unlocked. The resident said she was trying to go to the bathroom. No injuries. Approaches included auto-lock wheelchair. A nursing note, dated 10/3/17, documented the X-ray results received and documented degenerative changes. The note read, No acute fracture in the Th (thoracic) and L (lumbar) spine. b. Fall #2 - circumstances of the fall and facility response after two falls had occurred Review of the clinical record documented the facility had not initiated a care plan (see above) to help staff reduce the resident's fall risks or risk of injury from falls after the resident's first fall. Documentation related to the second fall showed the resident's fall was also related to toileting. A nursing note, dated 10/7/17 at 2:25 p.m., read Resident found on floor in bathroom after attempted self-transfer and ambulation from the toilet. A fall risk care plan was initiated, two days after the resident's second fall, on 10/9/17. The care plan had approaches that included: -Educate resident/family/interdisciplinary team as to causes of fall. -Attempt to anticipate needs. -Auto-lock wheelchair -Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs -Review resident's history of recent or recurrent falls -Review resident's medical record for medications or combinations of medications that could predispose to falls/increase fall risk An IDT note, dated 10/10/17, documented the resident attempted to self-transfer. No injury was noted. In pertinent part the note read, Continue to monitor adjustments to room change from rehab to skilled nursing room. Resident does not receive any psychotropic medications. The note did not document a plan to or actual review of the resident's toileting assistance needs or potential need for increased supervision. The note did not specify increased risk of falls due to the resident's taking an antihypertensive medication (Metoprolol) and diuretic medication (Furosemide, see side effects above). After IDT review and initiation of a fall risk care plan, the resident continued to attempt ambulation and transfers without staff assistance. A nursing note, dated 10/13/17, read: This nurse took resident's blood pressure in her room while she was laying in bed this AM (morning). Approximately 2 minutes after, this resident was observed standing in the doorway of her room. Resident's w/c (wheelchair) was sideways by her bed with wheels locked. Resident stated she needed someone to tell her what she was supposed to do. Assisted resident to her w/c. CNA assisted resident with cares shortly after. Reminders given throughout the day to use call-light for assistance and not to transfer without staff presence. Resident verbalized understanding. No documentation in the clinical record evidenced additional review of the resident's supervision needs for fall prevention. c. Fall #3 - circumstance of third fall and facility failures to prevent the fall with a fracture of right femur. Review of the clinical record revealed no documentation to evidence the facility had implemented an individualized toileting schedule prior to the third fall. Moreover, the record did not evidence a change in supervision to help prevent accidents. A nursing note, dated 10/21/17, read, (resident) found on floor in room after attempting self-transfer. Severe right hip pain present upon assessment .MD (physician) ordered resident sent out to ER (emergency room ) for evaluation. A nursing note, dated 10/21/17, documented, the resident had a fall in the bathroom at 1410 (2:10 p.m.). Assessed by RN (registered nurse) and noted with severe pain to the right hip with movement. Ambulance transported the resident to ER. The resident fell three times within 20 days. All three falls were right before or right after toilet self-transfers. All three times the resident was found without staff assistance/supervision. The facility failed to provide timely, appropriate approaches and assistance to prevent resident's falls. The result of the facility's failures was the resident's fall with right femur fracture, hospitalization and surgery. 4. Interview The director of nursing (DON) was interviewed on 11/16/17 at 3:45 p.m. The DON, said the resident should be monitored to prevent falls, toileting schedule, frequent checks on the resident, observe patterns for toileting, activities, therapies. The DON acknowledged the facility failed to complete appropriately fall risk assessment and initiate a fall care plan prior to the residents first fall, with the consideration of her medications. The DON acknowledged the resident's falls on 10/2/17, 10/7/17, and 10/21/17 were all related to the resident's toileting needs and the care plan did not address the resident individualized toileting needs.

Based on observations, record review and interviews, the facility failed to ensure two (#35 and #15) out of 25 sample residents maintained acceptable parameters of nutritional status through timely recognition of weight loss, consistent implementation and monitoring of identified interventions to minimize weight loss, and communication of these interventions to staff, medical providers and family. The facility's failures contributed to resident #35 experiencing severe weight loss, associated with Stage 4 and stage 3 pressure injuries. Cross reference F314; pressure ulcers. Findings include: I. Professional Standards According to the Journal of the American Medical Directors Association, September 2013 (www.jamda.com), Body weight, anorexia, and undernutrition in older people, by Stijn Soenen PHD and Ian M. Chapman MD, PHD, in part: Ideal body weight for maximum life expectancy increases with advancing age . When older people lose weight, more of the tissue lost is lean tissue (mainly skeletal muscle) than in younger people. When excessive, the loss of lean muscle tissue results in sarcopenia (an independent predictor of poor gait, falls, fractures, and other disability) which is associated with poor health outcomes . -The optimum BMI (body mass index) for survival in people older than [AGE] years is probably in the range of 25 to 30 kg/m2, and close to the upper end of that range. -Weight loss in older people predisposes to the development of protein-energy malnutrition . In older persons, unintentional weight loss of 5% or more over 6 to 12 months is associated with an increased risk of adverse effects, whereas a loss of 10% or more is associated with a particularly high risk of protein-energy malnutrition and poor outcomes. Protein-energy malnutrition is associated with decreased bone mass, impaired muscle function, decreased muscle mass and muscle strength, decreased functional status and increased incidence of falls, [MEDICAL CONDITION], pneumonia, poor wound healing . -To reduce the risk of harmful weight loss, weight loss diets should be recommended to 'overweight' older people with caution, and probably only if the excess weight is clearly causing functional impairment, rather than because of body weight alone. Weight loss from dieting leads to loss of lean (muscle) as well as fat tissue, and this is particularly so and harmful in older people. Such diets should therefore contain sufficient amount of protein to build up muscle tissue in older people . -A logical and common strategy for undernourished older people is to try to increase their energy intake .Energy-rich, often protein-rich, nutritional supplements are being increasingly recommended to older, undernourished people. There is evidence that they help .protein supplementation has a protective and beneficial effect on muscle mass and strength . II. Resident Failures A. Resident #35 Resident #35, age 78, was admitted on [DATE]. According to the admission record, [DIAGNOSES REDACTED]. The resident was admitted to hospice in October 2017. 1. Documentation of resident #35's physical and mental decline. a. Minimum Data Set (MDS) assessments According to the 7/1/17, significant change in status MDS assessment, the brief interview for mental status (BIMS) score was 14 out of 15 and indicated intact cognition. He had no rejection of care behavior. He required extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. He was frequently incontinent. His weight was 153 pounds. He did not have any unhealed pressure ulcer(s). He received an antidepressant, anticoagulant and antibiotic medication. He was on oxygen. According to the most recent MDS, a significant change assessment dated [DATE], the resident's cognitive skills for daily decision making were assessed as severely impaired. He was totally dependent on two staff with bed mobility, toilet use and transfers. He required one person total assist with dressing and required extensive assistance with eating and personal hygiene. The range of motion (ROM) of upper and lower extremities was impaired on one side. He had an indwelling urinary catheter. He had one fall with injury, since his prior assessment (9/27/17). His weight was 139 pounds. He had one, stage 4 unhealed pressure ulcer (eschar). He received an antidepressant and opioid medications daily. He was on oxygen and received hospice care. b. Care plan updates, wound registered nurse (WRN) assessments, wound physician (WMF) and wound and nurse practitioner (NP) notes, and lab reports. The above documents revealed the resident sustained [REDACTED]. Cross reference F314 for detailed findings of the resident's skin breakdown. c. Weight records Resident's weights as documented in the medical record revealed a severe weight loss. 12/12/16 180 pounds (#). 2/13/17 168 3/13/17 162 10% weight loss in three months 4/17/17 154 5/15/17 153 6/12/17 149.2 17% weight loss in six months 7/10/17 150.1 8/14/17 140.2 6.6% weight loss in one month and 16% weight loss in 6 months 9/18/17 138.6 10/30/17 132.9 14% weight loss in six months and 26% weight loss in 10 months 11/13/17 133.1 d. Lab studies Lab studies revealed the resident's [MEDICATION NAME] (the main protein of human blood plasma) level (normal range 3.5 - 5.0) had declined from 3.4 g/dl to 3.0 g/dl on 9/12/17. His 9/13/17 lab report study revealed a [MEDICATION NAME] level (potential indicator of malnutrition) was 8.4 mg/dl (normal range 20.0 - 40.0) 2. Facility documentation of and response to resident #35's nutritional decline. Observations, record review and interview revealed the facility failed to timely recognize and respond to resident #35's weight loss, failed to consistently implement and monitor identified interventions to minimize weight loss, and failed to communicate these interventions to staff, medical providers, the resident and family. a. Nursing notes A nursing note dated 5/1/17 revealed weight loss 7.5% in one month and documented Resident trying to lose weight. Dietary manager aware. A nursing note 5/22/17 nursing note documented, weights monitored weekly, resident states he is trying to lose weight, all meals in the dining room, making his own choices. A nursing note 7/18/17 read: Reviewed vital signs and current medications. Discussed recent taper of [MEDICATION NAME] (antidepressant) and informed daughter that team is monitoring any change in mood or behavior closely. Discussed recent change with resident which has been noted by various departments such as res(ident) sleeping more, periods of confusion, and weight decline. Daughter encouraged to let staff know of concerns or any changes she notices .Currently receiving OT (occupational therapy) who is working on splint placement as well as ROM (range of motion) .Res averages about 60% intake at meals, most recent weight is 148lbs, down from a recent weight of 153lbs. Daughter suggests that res(ident) may be having more difficulty with eating r/t (related to) more 'shaking' .stable with res(ident) reporting slight decline in energy and mood r/t recent pneumonia . Facility failure: There was no documentation in the above nursing notes that showed the resident was educated about the potential adverse effects of weight loss (see professional reference above). In addition, there was no indication, in nursing notes or on the resident's care plan, that the daughter's suggestion triggered a response by the registered dietitian (RD), the OT, or nursing staff. b. Care plan The resident's comprehensive care plan (CP), initiated on 10/25/13 read in part: -The resident is at risk for nutrition decline related to [DIAGNOSES REDACTED]. Interventions included: Explain and reinforce to resident the importance of maintaining the diet ordered. Please reinforce adequate intake of food and fluids. Resident has regular diet orders. Offer fortified foods. Offer finger foods. Provide certified nurse aide (CNA) assistance at meals. Facility failure: The care plan was not updated until 11/13/17 (during survey). It failed to address resident's severe weight loss, resident-specific appropriate interventions to prevent the weight loss, such as interventions to address the resident's shaking as noted by his daughter and as observed (see below). In addition there was no instruction to staff to educate and communicate with the resident family about the potential effects of weight loss and possible interventions to promote weight gain. c. RD notes -A 6/15/17 note read, The following information was reviewed at the nutrition alert meeting: Resident has over 10% weight loss in the last 180 days. Current weight ~150 lb. Resident initially wanted to lose weight, but recent weight loss may not be intentional. RD will keep working with resident and determine best goal. -A 7/6/17 note documented a Significant Change Nutrition Assessment. It read: Resident on a regular diet, regular diet texture, and thin liquids. No chewing or swallowing difficulty noted. Appetite is fair. Resident expressed satisfaction with meal service. -Resident sits at independent table and is able to make needs known. Current weight is 153 lbs . Recent weight loss may not be intentional as resident has had fluctuations in health. At the moment, resident doesn't want any new interventions . >10% wt loss in 6 months, depression, insidious weight loss, refusal of foods. At risk for dehydration d/t: depression, use of mental health medications. At risk for pressure ulcers d/t: use of mental health medications .Refer care plan for all interventions. Goal 1: weight maintenance between 148 and 157 lb. Goal 2: 75-100% meal completion. Will follow weights, appetite/intake, feeding ability, hydration status, skin integrity. -A note 8/18/17 read, Monitoring weekly for weight change . Resident likely has continued weight loss. After education, resident willing to accept Resource 2.0 supplement and CNA assist. -A note 9/1/17 read, The following information was reviewed at the nutrition alert meeting: Monitoring weekly for weight change. Weight was 144.5 lb, which is up 4 lb in the last week. Resident has orders for fortified foods. Also agreed to receive nutritional supplement TID (three times daily) and CNA (certified nurse aide) assistance recently. Recently developed stage 3 PI (pressure injury) on R (right) gluteal cleft, 2.5 x 1.5 cm. With CNA assistance, needs are being met. Facility failures: Despite severe weight loss prior to 8/18/17 (see weight records above), no nutritional interventions were initiated until 8/16/17 when a physician order [REDACTED]. Although the 7/6/17 Significant Change Nutrition Assessment, that the resident did not want any new interventions, there was no documentation what nutritional interventions were offered and what education was provided about the potential harm from further weight loss. See F314; pressure ulcers. In August, the resident's shear wound progressed to a Stage 3 pressure injury (full-thickness loss of skin). In addition, there was no evidence of a response to the daughter's concern the resident's difficulty eating due to his shaking. And while the August 2017 Medication Administration Record [REDACTED]. The October 2017 MAR indicated [REDACTED]. d. Observations Observations confirmed the resident's difficulty eating due to tremors. Observations further revealed identified interventions - fortified foods, finger foods and CNA assistance - were not communicated to staff or provided to the resident. The resident was observed in the dining room on 11/13/17 between 11:55 a.m. and 12:30 p.m. during the lunch meal. He was seated at an independent table. He did not receive any staff assistance or cueing with the meal. He was not served finger foods or fortified foods. The resident's meal card did not note either finger foods or fortified foods. While neither one of these interventions was documented in the orders, both interventions were identified in the record (see above). The resident was observed in the dining room on 11/14/17 at 4:53 p.m. The resident was transferred from the independent part of the dining room to the assisted table. He was trying to eat a slice of pizza. Severe left upper extremity tremors were observed. There was no nursing staff at the table to assist residents with meal. The resident's meal card did not note either finger foods or fortified foods. The resident was observed in the dining room on 11/15/17 at 4:45 p.m. at an assisted table. The resident's meal card did not note either finger foods or fortified foods. -A plate with taco salad (cooked ground beef, shredded lettuce, shredded cheese, pieces of tomatoes) was in front of him. He was trying to pick up small amount of meat and cheese with the fingers of his left hand. This left arm was shaking. He was not able to put too much food in to his mouth. -The dietary manager watched the resident attempt to eat the taco salad and said the resident needed a finger food. He asked the resident if he would like to have the taco salad made into a burrito, wrapped up in a tortilla. The dietary manager prepared the burrito and served to the resident. The resident ate 100% of the burrito. The dietary manager said the resident should have served finger food to be able to eat independent. 3. Interviews Interviews revealed a failure to communicate identified interventions to address the resident's nutritional decline to staff, medical provider, and family. The facility medical director/resident's physician (MD) was interviewed on 11/15/17 at 12:30 p.m. He said the resident's medical condition begun declining since he was treated for [REDACTED]. He said the resident was losing weight at the beginning of the year and that was his choice. He said the resident's weight loss got to the point it was not controlled well and losing over 20% of the body weight in a few months was not appropriate. He said the nurse practitioner should not have discharged the resident's protein supplement as the resident suffered from malnutrition and his [MEDICATION NAME] was low. He said the resident should continue to receive a protein supplementation. The registered dietician (RD) was interviewed on 11/15/17 at 12:20 p.m. and again on 11/16/17 at 12:05 p.m. -He said the resident's nurse practitioner discontinued the protein supplement the day the resident was admitted to hospice despite his continued significant weight loss and pressure ulcer. - He said the resident wished to lose some weight. He said he did not educate the resident about risks of excessive weight loss. He said he did not communicate the weight loss with resident's family. He said he did not observe the resident during meals. He said he reviewed the resident's meal intake from the CNAs records. He said the resident was seated at the independent part of the dining room until recently. He said the staff did not assist the resident during meals. He said the resident received a distant supervision; he was not physically assisted with eating. The DON was interviewed on 11/16/17 at 10:30 a.m. She said her expectation was the resident continue to receive the protein supplementation to help with the healing process with the pressure injuries. At 12:15 p.m., she said the resident was recently transferred to the assisted table in the dining room. She said the resident was observed by the staff from a distance during meals and encouraged to eat. She said the resident did not receive a physical assistance from staff with food consumption. The occupation therapist (OT) was interviewed on 11/16/17 at 12:30 p.m. She said she was working with the resident in August and September (2017) on feeding assistance during meals and self-feeding tasks with appropriate build-up utensils. She said due to the resident's severe tremors and impaired motor control, the resident was unable to feed himself with fork and spoon. She said the resident was able to feed self with supervision and verbal cueing when he had finger foods to eat. The resident's son was interviewed on 11/20/17 at 9:30 a.m. He said he was not aware his father was not assisted in the dining room, during meals. He said the staff did not communicate to him or his sister (power of attorney) about discontinuing the protein supplement. He said he would like his father to be comfortable but also appropriately treated to help with wounds healing and to prevent any further weight loss. 4. Facility follow-up during survey A physician order [REDACTED]. -On 11/16/17 laboratory result for [MEDICATION NAME] was 22 mg/dl (range 20.0-40.0). -On 11/16/17 at 5:00 p.m., the resident was observed in the dining room eating dinner with a CNA assistance. B. Resident #15 Resident #15, age 78, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the admission record, the resident had [DIAGNOSES REDACTED]. The resident was admitted to hospice care on 7/28/17. 1. Orders, care plans, assessments and notes related to the resident's nutritional status on and shortly after admission. The physician monthly order summary report for November 2017 read the resident was on a level two mechanical texture diet with nectar thickened fluids and offered fortified foods, starting on 7/13/17. The report also noted a house supplement 2.0 (named brand) orally three times a day for weight gain started on 7/13/17. The schedule drop down box noted the specific times the supplement was to be given. In another drop down box, it instructed staff to document the amount of supplement consumed. The resident required assistance with eating during all meals due to generalized weakness, starting on 7/14/17. A care plan, initiated on 7/10/17 for activities of daily living, identified a self-care performance deficit and that the resident required limited to extensive assist with meals. A resident nutrition assessment dated [DATE] documented the resident was on a regular level two diet with nectar thick liquids. The resident did not have any chewing or swallowing difficulty. The resident's appetite was fair and had improved since the resident's last admission. -The nutritional supplement orders were (named) 2.0 house supplement (120 milliliters) orally three times a day. This provided 720 kcals/day (kilocalories/day), 30 gm (grams) of protein/day and 360 mL/day (milliliters/day) of liquids. -The resident sat at an independent table and was able to make her needs known. The CNAs were to monitor for assistance. The resident's current weight was 79 pounds (98% of their usual body weight) with a body mass index (BMI) of underweight. The resident's average meal completion was 47%. The resident was at risk for weight loss due to dementia, a BMI less than 21, depression, and [MEDICAL CONDITION]. The resident was at risk for a pressure ulcer due to malnutrition and use of mental health medications. -The resident was underweight due [MEDICAL CONDITION], dementia, failure to thrive and a BMI less than 18.5. Goal one was to have a weight maintenance of between 77 and 81 pounds. Goal two was to have a meal completion of between 50 and 75%. 2. Record review revealed declining nutritional status with poor intake (0-25%), weight loss, and skin breakdown. a. Summary of meal intake The meal intake records noted from 9/1 to 10/17/17 (all meals) the resident ate 0-25% of their meals 61 times. The resident ate 26-50% of their meals 17 times. The resident ate 51-75% of their meals 15 times. The resident ate 76-100% of their meals 16 times. The resident refused meals 17 times. The record noted, not applicable, 12 times and there was no documentation six times. The meal intake records noted from 10/18 to 11/16/17 (all meals) the resident ate 0-25% of their meals 57 times. The resident ate 26-50% of their meals 13 times. The resident ate 51-75% of their meals one time. The resident ate 76-100% of their meals three times. The resident refused meals four times. b. Summary of weight changes The clinical record documented the resident's admission weight was 70 pounds on 7/11/17. On 8/16/17 the resident weighed 66 pounds, a four pound weight loss. This was a 5.7% weight loss. The record also noted the resident had a weight of 63 pounds on 11/8/17. This was a seven pound or a 10 % weight loss since admission. c. Summary of nutritional status A Nutritional Status (NS) note dated 7/26/17 documented a 14-Day nutrition minimum data set (MDS) note. The note documented, in pertinent part, the resident weighed 75 pounds with a 10:18% weight difference between the resident's highest and lowest weights within a maximum range of 101 days. The resident was at risk for additional weight loss due to dementia, BMI less than 21, depression, [MEDICAL CONDITION], insidious weight loss, needing assistance in feeding, poor appetite, refusal of foods and very slow eating or not providing adequate time for eating. The resident's average meal completion was 36%. New medication nutrition interaction of (named) antidepressant and (named) anabolic steroid for increased appetite and weight. Nutritional goals were not being met. An occupational therapy (OT) note dated 7/26/17 (not timed) documented, in pertinent part, the resident presented as refusing to eat and a dietary report of severe malnourishment with weight loss. The resident demonstrated difficulty feeding with extended amounts of time chewing and coughing as well as severe weakness and fatigue. A NS note dated 8/4/17 at 11:58 a.m., documented a significant change nutrition assessment. The assessment noted the resident's appetite was low but the resident said it was improving. The resident was on hospice services and sometimes preferred puree texture foods. The resident required feeding assistance and was able to make her needs known. The resident had a current weight of 73 pounds (92% of their usual body weight). The resident had a BMI classification of underweight. The resident had a 7.5% weight loss within the last 30 days due [MEDICAL CONDITION] and failure to thrive. The resident had an average meal completion was 55%. The note repeated the resident's multiple risk factors (see 7/26/17 note above). New goals included a weight maintenance between 71 and 75 pounds and a minimum meal completion of 50%. A NS note dated 10/27/17 at 14:53 (2:53 p.m.) read the resident's most recent weight was 66.2 pounds which was down 6.5% in the last week. Comfort nutrition measures were put in place. The resident ate in the dining room occasionally and received certified nurse aide (CNA) assistance. A NS note dated 11/3/17, a quarterly nutrition assessment, read the resident's appetite was fair. The nutritional supplement orders were (named) house supplement 2.0 (120 milliliters) orally three times a day. This provided 720 kcals/day (kilocalories/day), 30 gm (grams) of protein/day and 360 mL/day (milliliters/day) of liquids. The resident required feeding assistance and was able to somewhat make her needs known. The resident's current weight was 67 pounds (97% of her usual body weight). The resident had BMI classification of underweight. The resident's 30 day weight noted a 6.42% weight loss. The resident's 60 day weight noted a 8.47% weight loss. The resident's 90 day weight noted a 16.77% weight loss. Comfort nutrition was to be followed. New goals were to maintain weight between 65 and 69 pounds and to have a minimum of 50% of meal completion. Goal three was to have intact skin. A NS note dated 11/10/17 at 14:56 (2:56 p.m.) read the resident's most recent weight is 66 pounds, which was up 0.2 pounds in the last week and the resident had a Stage 3 pressure injury on her coccyx measuring 3 x 3 centimeters (worsened).(See below) d. Summary of skin breakdown The wound care log (WCL) dated 10/29/17 noted a stage 2 to the resident's coccyx measuring 2 x 1.5 cm (centimeters) with nursing interventions to offload area and update the care plan. Resident was on hospice. A PO dated 10/29/17 at 7:15 a.m., noted a stage 2 on the resident's coccyx. Clean with wound cleanser, apply skin prep and cover with a [MEDICATION NAME] dressing. Change on bath days and as needed. Once a day every Wednesday, Saturday and as needed for a stage 2 coccyx ulcer. The care plan initiated on 10/29/17 noted the resident had a stage 2 pressure ulcer on her coccyx. The pertinent interventions noted assess/monitor wound healing each week. Report improvements and declines to the health care provider. Provide supplemental protein, amino acids, vitamins and minerals as ordered to promote wound healing. Notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration and so on, noted during a bath or during daily cares. Explain and reinforce to the resident the importance of adequate intake. The WCL dated 11/1/17 noted a stage 3 to resident's coccyx measuring 3 x 3 cm with nursing interventions of no back lying and to off load area: update the care plan. The WCL 11/8/17 noted a stage 3 to resident's coccyx measuring 3 x 1.5 x not measureable. The nursing interventions were no back lying and to off load area: no update to care plan. A communication note with the resident's family dated 11/15/17 at 8:18 a.m., noted the daughter asked if the wound physician (named) could see the resident due to a pressure ulcer on the resident's coccyx that was progressing very fast. The resident was on hospice services. The daughter gave oral consent over the phone for wound debridement today if it was necessary. The wound nurse left consent for debridement for the daughter to sign next time she was in with the nurse manager. The wound care specialist evaluation dated 11/15/17 noted a pressure ulcer (unstageable necrosis) measuring 2.8 x 1.9 x 0.2 cm a surface area of 5.32 cm (squared) with light serous exudate. It had 50% thick adherent devitalized necrotic tissue, 30% granulation tissue and 20% skin tissue. The physician performed surgical excisional debridement to the wound. Post Stage of the pressure ulcer was a Stage 3. The note also documented a second wound on the distal coccyx. This unstageable deep tissue injury measuring 0.6 x 0.7 x not measureable was noted to start this date. The recommendations were skin prep three times a week and as needed, [MEDICATION NAME] three times a week and as needed. Reposition resident per facility protocol, off load wound area and limit sitting to 60 minutes. An interview with registered nurse (RN) #1, who also was the facility wound nurse (WN), was conducted on 11/15/17 at 4:00 p.m. The WN said the resident had a wound on her coccyx which started on 10/29/17. She said the resident's bottom was red and the skin was pealing. It was Staged at a 2 because the skin was open. The wound measured 2 x 1.5 cm with no depth. The WN said the wound was noted to be a Stage 3 on 11/1/17 because it was covered with slough. The measurement was 3 x 3 x 0 cm. The WN said that on 11/8/17, the wound on the coccyx was a stage 3 and measured 3 x 1.5 x 0 cm. The WN said on 11/15/17, the coccyx wound was a stage 3 measuring 2.8 x 1.9 x 0.2 cm. The WN said the resident was seen today (11/15/17) by the physician wound specialist for the first time and he debrided the wound. The WN said an air mattress was placed on the resident's bed 7/30/17. She said the resident had a (named) cushion on her wheelchair; however, the resident did not usually get out of bed and use the wheelchair. She said the RD received the wound notes every Sunday to help make nutritional decisions. The WN said she was unsure if staff marked the amount of supplement consumed by the resident. The hospice registered nurse (HRN) was interviewed on 11/16/17 at 11:15 a.m. She said hospice supplied an alternating air mattress on admission which was a high end mattress that circulated air around the resident's body. The resident also had bolsters on the bed. She said she collaborated with the facility wound team and the resident was seen by a physician wound specialist (named). She said the resident did not get up in the wheelchair anymore; the resident did not want to get out of bed. She said because the resident had a lot of sugar in her body, it would be difficult to heal their pressure ulcers. 3. Record review, observations and interviews revealed failure to adequately address the resident's nutritional decline. Although record review revealed frequent NS reports documenting the resident's nutritional status, facility failures in care planning, implementation and monitoring of ordered and planned interventions led to an inadequate response to the resident's nutritional decline. a. Failure to timely develop a nutritional care plan to instruct staff on interventions to address resident #15's known nutritional decline and skin breakdown. Record review revealed a care plan to address the resident's nutritional decline was not initiated until 11/13/17 (during survey), well after nutritional decline was documented. Interventions included monthly weights or as needed, a level two texture diet with thickened liquids, offer fortified foods, offer fluids as needed, monitor/record meal intakes, follow nutritional supplementation orders, and provide certified nurse aide (CNA) assistance during feeding (meals). Interviews (see below) indicated the lack of a timely, comprehensive, resident-specific care plan contributed to conflicting understanding among staff regarding implementation of interventions to address the resident's nutritional decline, as well as an inability to evaluate the effectiveness of interventions and make revisions if necessary. b. Failure to effectively implement and monitor the resident's nutritional supplement intake as ordered and planned. Review of the August through November medication administration records (MARs) revealed the house supplement was to be administered around mealtimes, at 8:00 a.m. 12:00 noon and 5:00 p.m. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. -The MAR indicated [REDACTED]. The facility had 93 opportunities to document the intake of the administered supplement. -The MAR indicated [REDACTED].

Based on record review, observation, and interview, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one (#29) of 30 sample residents. Specifically resident #29 suffered a fall and the resident's fall care plan was not reviewed or updated. Shortly after, the resident had another fall and suffered a rib fracture. The circumstances of the falls were not thoroughly investigated and interventions to prevent further falls were not implemented. The findings include: 1. Facility Policy According to the facility's prevention and management of falls practice guidelines, in pertinent part read: " ...Upon admission each resident will be evaluated to determine his or her risk for falling. Include the following component for review: -Implementation of interventions, including adequate supervision, consistent with resident needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. -Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice ... ...The Interdisciplinary Team should perform an analysis of the precipitating events for individual resident falls and evaluate potential interventions aimed at prevention of future falls. In addition, this team should perform ongoing systemic evaluation to determine the effectiveness of the Falls Prevention Program ..." 2. Resident #29 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 4/29/14 quarterly Minimum Data Set (MDS), the resident's cognition was severely impaired, scoring four of 15 points possible on the brief interview of mental status (BIMS). She required limited assistance with bed mobility, supervision with transfers and walking, and extensive assistance with toilet use. The fall care plan, last revised on 10/29/13, showed the resident was at risk for falls related to deconditioning, gait/balance problems, and vision problems. Approaches included: --Educate resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. --Encourage resident to participate in activities that promote exercise, physical activity for strengthening, and improved mobility. --Review and modify environmental hazards that could cause or contribute to fall. --Review resident's history of recent or recurrent falls On 6/4/14 at 1:31 p.m., the licensed practical nurse (LPN #1) assigned to work with the resident was asked if the resident had had a fall and/or sustained a fracture within the last 30 days. Upon review, LPN #1 stated the resident fell on [DATE]. b. Record Review The resident's nursing progress notes were reviewed back to April 2014 and revealed the resident fell on [DATE] and on 5/23/14. (1) 4/19/14 Fall According to the 4/19/14 fall investigation, in pertinent part, "CNA (certified nurse aide) heard resident calling for help. CNA entered room and observed resident sitting on the floor legs extended back against the wheelchair." Following the fall, the interdisciplinary team (IDT) met on 4/22/14 to review the incident. A 4/22/14 progress note documented, "IDT met and reviewed resident, see signature sheet for attendance. No new recommendations at this time. Continue to monitor." The 4/22/14 Fall Risk Evaluation documented, "Fall occurred on 4/19/14 at 10:30 p.m. CNA heard resident calling for help. CNA entered room and observed resident sitting on floor with legs extended back against the wall/chair. No injury observed ...resident was wearing improper footwear at time of the incident." The review and recommendations sections of the 4/22/14 fall evaluation including the options of identifying and evaluating the effectiveness of the approaches used to prevent falls, recommendations for changes, continuing to monitor the resident, and interventions effective was incomplete and left blank. There was no evidence the nursing staff were interviewed to determine the reason or the root cause of the fall; including the last time the resident had received assistance to use the bathroom. Following the 4/19/14 fall, there was no evidence the resident's fall care plan was reviewed or updated. (2) 5/23/14 Fall The 5/23/14 nursing progress notes revealed the following: --4:33 p.m.: "Resident found on floor in bathroom. (Physician) notified Orders received to transfer to ER for x-ray. C/O (complained of) right rib pain ..." --5:22 p.m.: "Resident transported to ER per ambulance. Alert and oriented to self. C/O right rib pain ..." A 5/24/14 nursing progress note documented, "Resident up and pleasant this (morning). Resident states she had 10/10 pain in r(ight) rib. Resident had a fall 5/23/14 and went to ER. X-ray showed a fracture on R side. Tramadol given this (morning) and was effective for pain. This nurse encouraging resident to deep breathe to keep lungs clear. Resident voices understanding and states she will even though it hurts. Will monitor and report changes." According to the 5/23/14 fall investigation, in pertinent part, "Resident in bathroom across from dining room on floor. Gently assisted per lift into (wheelchair). No injuries apparent. C/O right rib pain." Following the fall, the IDT team met to review the fall on 5/26/14. The 5/26/14 progress note documented, "Resident was found on floor in bathroom across from resident dining room on 5/23 with injury sustained to right rib. Resident has been independent in her mobility throughout facility with (front wheeled walker), current using (wheelchair) for mobility (as needed) ...Resident has good affect with worried/anxious expression at times, engages in conversation and attends activities per her preferences and interests." The 5/27/14 Fall Risk Evaluation documented, "5/23/14 resident in (bathroom) across from (dining room) on floor. Gently assisted via lift into (wheelchair). C/O r(ight) rib pain. To ER and (returned) with ([DIAGNOSES REDACTED]." The review and recommendations sections of the 5/23/14 fall evaluation including the options of identifying and evaluating the effectiveness of the approaches used to prevent falls, recommendations for changes, continuing to monitor the resident, and interventions effective was incomplete and left blank. There was no evidence the resident nursing staff were interviewed to determine the reason or the root cause of the fall; including the last time the resident had received assistance to use the bathroom. There was also no evidence of staff education to provide more supervision to the resident when using the bathroom near the dining room. Following the 5/23/14 fall, there was no evidence the resident's fall care plan was reviewed or updated. c. Resident Observations On 6/4/14 at 1:57 p.m., the resident was observed in her room. She was seated in a recliner. An attempt was made to interview the resident and the resident stated she had only lived at the facility for a couple of days. On 6/9/14 at 9:53 p.m., the resident was observed walking with a walker in the hallway. She stated she was going to get a cup of coffee. The resident's gait was slow but steady. On 6/9/14 at 2:10 p.m., the resident was observed in the dining room eating soup. On 6/10/14 at 2:05 p.m., the resident was observed walking near the restroom across from the dining room. d. Staff Interview --On 6/9/14 at approximately 10:00 a.m., Minimum Data Set Coordinator Registered Nurse (MDSC #2) who participated in the IDT post fall review meetings was interviewed. She stated if any fall recommendations were recommended, they were documented in the IDT progress note following the fall. MDSC #2 was informed no fall recommendations were found in the note following the 5/23/14 fall with injury. She said, "I don't think anything was recommended at that time because she wasn't a frequent faller and we'd made some reductions in her medications. There was no need to do any other interventions." --On 6/9/14 at 11:43 a.m., the director of nursing (DON) was asked about the facility's fall investigation process. She said, "The nurse does an initial investigation that starts at the time of the fall as to why that fall occurred. And then the next morning whenever I come in I review the incident reports and I talk to the (nursing home administrator) and I talk to the charge nurse and the CNAs and I try to understand what happened and what caused the fall. I also talk to the therapy staff and determine if we feel they could benefit from any type of therapy for safety devices and I'd get orders. And then every Tuesday everyone in the (IDT) meeting discusses the falls to come up with the interventions." The DON was asked about the resident's fall in the bathroom across the dining room. She stated the resident used to live in the independent apartments connected to the facility and it was her pattern to use that bathroom. --On 6/9/14 at 1:06 p.m., the DON was again interviewed and stated interventions were not implemented because they felt the resident's falls were isolated events. Regarding the 4/19/14 fall she said, "We heard here calling for help and she said a motorcycle had dragged her onto the floor. We think she was dreaming and there were no unsafe conditions. We didn't feel there were any interventions needed at that time and it was an isolated incident." Regarding the 5/23/14 fall, the DON said, "We felt this was an isolated case because she had used that restroom before and she'd used that restroom for years and years." --On 6/10/14 at 9:46 a.m., the DON stated she did investigate both of the resident's falls including talking to staff and therapy, however, she said she did not document this in the progress notes. --On 6/10/14 at 10:28 a.m., the charge/registered nurse (RN #3) stated the resident would be forgetful of education and reminders to use her call light or to use a certain bathroom. --On 6/10/14 at approximately 2:10 p.m., the DON stated it was discussed to monitor the resident when she used the bathroom near the dining room. She said, "We had discussed that she's going to need more help and to try to get her to go to the bathroom in her room." The DON agreed the resident's care plan and interventions were not updated to reflect this.