Every finding on record at Hampden Hills Post Acute

Based on observations, record review and interviews the facility failed to provide necessary services to maintain personal hygiene for two (#10 and #11) of four residents out of 13 sample residents.Specifically, the facility failed to:-Ensure Resident #11 received timely incontinence care in accordance with professional standards and per the resident's preference; and,-Ensure Resident #10 received oral care as needed and per the resident's preference. Findings include: I. Failed to ensure Resident #11 received timely incontinence care in accordance with professional standards and per the resident's preference A. Facility policy and procedure: The Urinary Continence and Incontinence Assessment and Management policy and procedure, revised 2022, was provided by the nursing home administrator (NHA) on 7/9/26 at 6:06 p.m. It read in pertinent part, The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. For those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. B. Resident #11 1. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included dementia, failure to thrive and basal cell carcinoma with open wound to the right buttock. According to the 6/1/26 minimum data set (MDS) assessment, Resident #11 had severely impaired cognition with a brief interview for mental status (BIMS) score of three out of 15. The resident was dependent on staff for toileting hygiene and the ability to maintain perineal hygiene. The assessment revealed Resident #11 was always incontinent with no episodes of continent voiding. 2. Observation and staff interview Certified nurse aide (CNA) #3 was interviewed on 7/7/26 at 6:30 a.m. CNA #3 said Resident #11 received a bath three times per week and perineal care when the resident was incontinent. CNA #3 said she would perform incontinence care for the resident after breakfast, per Resident #11's preference. At 7:08 a.m. (prior to breakfast) Resident #11 was lying in bed. The resident removed her urine soaked incontinence brief with her bare hands and tossed it onto the floor. Observation of the incontinence brief on the floor revealed the brief was saturated with urine. 3. Record review A review of Resident #11's toileting hygiene task record, from 6/29/26 to 7/9/26, revealed that perineal hygiene was consistently not documented as being completed for a nine to 13 hour period of time throughout the day for 14 out of 14 days. The bowel and bladder incontinence care plan, revised 4/15/23, revealed Resident #11 was incontinent of bowel and bladder related to dementia and weakness. Interventions included checking as required for incontinence, washing, rinsing and drying the resident's perineum and changing the resident's clothing as needed after incontinence episodes. The skin integrity care plan, revised 10/20/25, revealed Resident #11 had actual impairment of her skin integrity related to the chronic area of cancer on her right buttock. Pertinent interventions included keeping the resident's skin clean and dry. C. Additional staff interview The staff development coordinator was interviewed on 7/8/26 at 11:00 a.m. The staff development coordinator said lying in a soiled brief put Resident #11 at risk of infections, including urinary tract and wound infections. The staff development coordinator said she would add a component of the importance of timely incontinence care to the skills education fair for nursing staff. II. Failed to ensure Resident #10 received oral care as needed and per the resident's preference A. Professional referenc According to Terech-Skóra S, [NAME]-[NAME] J, Leyk-Kola czak M, [NAME] A, Piotrkowska R, M drzycka-D browska W, Ksi ek J. Assessment of Oral Health in Long-Term Enteral and Parenteral Nutrition Patients: Significant Aspects of Nursing Care. International Journal of Environmental Resources Public Health, (February 2023), retrieved on 7/14/26 from https://pmc.ncbi.nlm.nih.gov/articles/PMC9967838,/ Oral health is an underestimated factor affecting overall human health and quality of life. Long-term enteral or parenteral nutritional treatment requires not only regular assessment of access routes, the patient's nutritional status, and tolerance to the selected method of nutrition but also of oral health. Patients receiving long-term enteral and parenteral nutrition have an increased risk of developing oral diseases. Increasing knowledge about the factors affecting oral health among nurses is crucial to provide appropriate care for patients requiring long-term nutritional treatment with omission of the natural route of food intake. Oral health is an important part of a person's physical and mental health. It has been shown to have a significant relationship with many chronic diseases and can affect dietary choices, ability to communicate, and functioning in society. Oral health status is closely related to the functioning of swallowing. The longer enteral or parenteral nutrition is used, the greater the risk of deteriorating oral health status, thus resulting in an impaired swallowing mechanism. Chronic dry mouth has an important psychological aspect, as it significantly affects the quality of life of patients. B. Facility policy and procedure: The Oral Care procedure, revised 2025, was provided by the NHA on 7/9/26 at 6:06 p.m. It read in pertinent part, Mouth care: The purpose of this procedure is to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. Preparation: Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Notify the supervisor if the resident refuses the mouth care. B. Resident #10 A. Resident status Resident #10 age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included aphasia (language disorder), dysphagia ( difficulty swallowing), contractures of the upper arms, and functional quadriplegia. According to the 7/13/26 MDS assessment, the resident had the absence of speech and was sometimes understood due to a limited ability to make concrete requests; and sometimes understood simple and direct communication. The resident was unable to participate in the BIMS assessment . The staff' assessment of the resident's mental status revealed the resident's short and long term memory was okay as the resident was normally able to recall after five minutes of time. The resident presented no evidence of an acute change in mental status from baseline and no evidence of disorganized thinking. The resident did not reject care assistance. The resident had functional limitations in range of motion in both upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). The resident was dependent on staff with bed, transfer mobility and when completing all activities of daily living (ADL), including oral care. The resident had an abdominal feeding tube and received more than 51% of his total calories through a tube feeding. B. Resident interview and observation Resident #10 was interviewed on 7/6/26 at 11:22 a.m. Resident #10 shook his head no to respond that staff had not yet assisted him to brush or swab his teeth today (7/6/26). He shook his head yes that he wanted staff to clean and freshen his mouth. Resident #10's teeth were stained deep yellow with brown and white plaque in between his teeth. Resident #10 was interviewed a second time on 7/7/26 at 12:45 p.m. Resident #10 shook his head no to respond that staff had still not assisted him to brush or swab his teeth. Resident #10 opened his mouth and showed his teeth. Resident #10's teeth were stained deep yellow with brown and white plaque in between his front teeth. The resident had a heavy build up of white tartar on his back teeth on the left upper side of his mouth. Resident #10 made a grimacing face with a wrinkled nose and a curled upper lip after exposing his teeth. He shook his head that he wanted his teeth brushed regularly. C. Staff interview The director of nursing (DON) was interviewed on 7/7/26 at 11:00 a.m. The DON said she expected staff to assist all dependent residents with oral care on a daily basis. The DON said it was important to clean a resident's mouth even when they did not take food or drinks by mouth because they did not swallow as much and their saliva could easily dry in their mouth if their mouth was not cleaned regularly.

Based on observations, record review and interviews, the facility failed to ensure residents rooms were free from hazardous conditions for two (#2 and #13) of six residents out of 13 sample residents. Specifically, the facility failed to:-Ensure Resident #2's care planned fall interventions were implemented; and, -Ensure Resident #13 had a clear pathway from his bed to the bathroom and the exit doorway to the hallway that was free of his personal items so he could safely walk around.Findings include:I. Facility policy and procedure:The Incidents and Accidents policy, dated 2024, was provided by the nursing home administrator (NHA) on 7/9/26 at 6:06 p.m. It read, It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. -However, the policy did not include methods to ensure an environment free of accidents and hazards or appropriate preventative interventions.II. Resident #2A. Resident statusResident #2 age [AGE], was admitted on [DATE]. According to the computerized physicians orders (CPO), diagnoses included history of a past fracture of the fourth lumbar vertebra (spine),chronic pain and other low back pain.According to the 5/16/26 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score 13 out of 15. The resident had limited movement in the lower extremities (feet, hip and knees) that interfered with her daily functional abilities and put her at risk of injury. The resident was assessed to need supervision or touch assistance with verbal skills during transfers from surface to surface. The resident could walk. The assessment documented the resident used a wheelchair. The assessment indicated the resident had had two or more falls since admission with a minor injury and one major injury. B. Resident observation and interviewOn 7/6/26 at 2:20 p.m. Resident #2 was sitting in her recliner in her room. The resident stood up from the recliner. As she stood up from the recliner, she hunched over leaning forward as she stood and started to walk. The resident declined to use her walker and continued to walk in a hunched and leaning forward position heading towards the bathroom. There were no grip strips on the floor in front of her recliner (see care plan below). Resident #2 said the reason for her hunched position was due to a painful condition related to a previous surgery where hardware was placed on her spine. Said the last time she fell was three months ago. The resident said she was waiting for staff to come back to help her off the toilet but nobody came so she reached out for the grab bar and missed and fell on the bathroom floor. The resident said she hit her head in the fall and was confused for about a day after the fall. On 7/8/26 7:25 a.m. Resident #2 was asleep in bed. There was no fall mat at the bedside and the bed was not in its lowest position, as was care planned (see care plan below). There were no grip strips on the floor at the resident's bedside. There were two cloth incontinence pads placed on the floor at the bedside. Neither of the incontinence pads securely affixed to the floor and did not have any gripping type surface on the side on the floor.Resident #2 was interviewed a second time on 7/9/26 at 12:05 p.m. Resident #2 said she did not like the fall mat because it was slippery and she placed the cloth incontinence pads on the floor because the floor was cold on her bare feet. Resident #2 said no one told her the incontinence pads were unsafe or could lead to potential falls. The resident said she thought the incontinence pads were non-slip. Resident #2 said staff did not check on her very often because they thought she was independent. She said they came into her room to check on her roommate often because she was in a wheelchair, but she said she had to wait for staff when she needed assistance and that was why she fell in the bathroom a few months ago.C. Resident's representative interview Resident #2's representative was interviewed on 7/7/26 at 1:30 p.m. The resident's representative said she was worried about Resident #2 because the resident had fallen in the facility. She said the resident told her she laid on the floor for 30 minutes after she fell. The resident's representative said Resident #2 was disabled and could not do a lot of things for herself. She said the resident could not use her hands fully due to arthritis and could not stand up straight. She said the staff did not communicate well with Resident #2. D. Record review The fall prevention care plan, revised 7/8/26 (during the survey), revealed Resident #2 was at risk for falls related to pain, muscle weakness and reduced mobility. Interventions included avoiding rearranging furniture, ensuring the call light was within reach and encouraging the resident to call for assistance as needed, ensuring the floors were free from spills and/or clutter, making sure the bed was in a low position at night and making sure the resident's personal items were within her reach. The fall care plan was revised on 7/8/26 (during the survey) to include that Resident #2 was able to transfer independently and tended to put blankets on the floor. Interventions added to the care plan on 7/8/26 included removing fall mats to reduce falls and tripping hazards, educating the resident to not place blankets on the floor due to her risk of falling and applying non-skid strips on the floor where the resident transferred. E. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 7/9/26 at 1:15 p.m. LPN #2 said yesterday (7/8/26) was the first time she had worked with Resident #2. She said it was not safe for the resident to have the incontinence pads on the floor next to her bed because they posed a fall risk, but the resident wanted her room to be like home. LPN #2 said she offered Resident #2 a new fall mat but the resident refused.LPN #3 was interviewed on 7/9/26 at 3:00 p.m. LPN #3 said the incontinence pads were still on the floor at the resident's bedside. LPN #3 said he did not know why the incontinence pads were on the floor at the resident's bedside. He said he would talk to the resident about the pads on the floor.LPN #3 was interviewed a second time on 7/9/26 at 4:30 p.m. LPN #3 said he had talked to Resident #2 and tried to tell her she could not put the incontinence pads on the floor at her bedside because it was a slipping and fall hazard but she got agitated and refused to remove them from the floor. LPN #3 said the resident was non-compliant and there was nothing he could do about it because it was her right to refuse.The director of nursing (DON), the NHA and the corporate nurse consultant were interviewed together on 7/9/26 at approximately 5:10 p.m. The DON, the NHA and the corporate nurse consultant said Resident #2 refused the floor fall mat and they were aware she was placing incontinence pads on the floor. The DON, the NHA and the corporate nurse consultant said they did not know why the resident placed the incontinence pads on the floor. The DON said Resident #2 had just moved into her current room and the staff must have forgotten to apply the grip strips in the resident's new room. The DON said they would get the grip strips installed in the appropriate place. III. Resident #13A. Resident statusResident #13, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included rheumatoid arthritis and age-related cataracts.According to the 6/24/26 MDS assessment, Resident #13 was cognitively intact with a BIMS score of 13 out of 15. The resident was assessed to need supervision or touching assistance with surface to surface transfers and walking. The resident did not have any falls in the facility. B. Resident observationsOn 7/7/26 at 12:45 p.m. Resident #13's room was observed to be full of clutter. The resident was moving out of the facility and the empty boxes he had stacked up had fallen over. There were two empty oxygen portable tanks in the room and several items were randomly lying on the floor in the walk pathway between the resident's bed and the bathroom and the exit door to the hallway. The items on the floor included a drill, hangers, clothing, blankets, boxes and other miscellaneous items. On 7/8/26 at 7:29 a.m. Resident #13's room was observed to be still full of clutter, with the same items (see above) lying on the floor and around the room where they were the previous day. On 7/9/26 at 10:26 a.m. Resident #13's room was observed to be still full of clutter, with the same items (see above) lying on the floor and around the room where they were the previous day. C. Record review The fall risk care plan, revised 3/20/26, revealed Resident #13 was at risk for falls due to physical deterioration and oxygen equipment in his room. Interventions included maintaining a clear pathway, free of obstacles, avoiding rearranging furniture, educating the resident/family/caregivers about safety reminders and what to do if a fall occurred and ensuring a safe environment by keeping the floors free from spills and/or clutter. D. Staff interviewsLPN #3 was interviewed on 7/9/26 at 4:00 p.m. LPN #3 said he offered and suggested to help Resident #13 picked up the items cluttering the resident's room on two different occasions, but the resident refused. He said the resident told him that he was not a child anymore, he was an adult and he did not want anyone touching his things. The DON and the NHA were interviewed together on 7/9/26 at approximately 5:15 p.m. The DON and the NHA said Resident #13 was about to move into a community placement and said he did not like staff to touch his things. The NHA said he was not aware Resident #13 had a drill on his floor. He said that was concerning and he would talk to the resident about not leaving it on the floor.

Based on record review, observations and interviews the facility failed to ensure one (#8) of two residents received enteral feedings consistent with professional standards of practice out of 13 sample residents.Specifically, the facility failed to ensure Resident #8's enteral feeding pump was running at the correct rate per physician's orders.Findings include:I. Professional referenceAccording to Fundamentals of Nursing version 11.2 Fundamental Principles of Medication Administration, updated 4/2/26, retrieved on 7/8/26 from www.openstax.org Nurses are responsible for ensuring patient safety during medication administration. The rights of medication administration are a set of guidelines to adhere to when administering medications in an effort to reduce adverse medication events. The five core rights of medication administration include the following: right patient, right drug, right route, right time, and right dose. The five core rights of medication administration should be confirmed at three different checkpoints during the medication administration process. These three checkpoints are when obtaining the medication, when preparing the medication and when administering the medication. At each of the checkpoints, the medication label should be compared to the medication order to confirm the right patient, right drug, right route, right time, and right dose.II. Facility policy and procedure The Enteral Tube Feeding via Continuous Pump policy, revised November 2018, was provided by the nursing home administrator (NHA) on 7/9/26 at 6:06 p.m. It read in pertinent part, Check the enteral nutrition label against the order before administration. Check the following information: resident name, ID and room number; type of formula; date and time formula was prepared; route of delivery; access site; and, method and rate of administrationIII. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO) diagnosis included failure to thrive, muscle wasting, dysphagia, and generalized muscle weakness. According to the 5/13/26 minimum data set (MDS) assessment, Resident #8 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15.The assessment indicated the resident received enteral tube feeding nutrition. The resident received 51% of her nutrition from the enteral feeding to ensure she maintained her daily caloric intake.B. ObservationsOn 7/6/26 at 9:45 a.m. Resident #8's tube feed was infusing at a rate of 82 milliliters per hour. -However, the physician's order revealed the tube feed was ordered to infuse at 45 milliliters per hour (see record review below).At 10:00 a.m. certified nurse aide with medication aide authority (CNA-Med) #1 entered the room and discontinued the infusion.C. Record Review The July 2026 CPO revealed the following physician's order:Enteral feed, administer Isosource 1.5 at 45 milliliters per hour for 19 hours, off at 10:00 a.m. and on at 3:00 p.m., ordered on 5/27/26.The resident's nutrition risk care plan, revised 5/12/26, revealed the resident received enteral feedings. Pertinent interventions included providing the resident's diet as ordered by the physician, encouraging the resident to eat in the dining room, providing enteral tube feedings as ordered, monitoring meal intakes, registered dietitian (RD) to evaluate and make diet change recommendations, as needed, and RD to monitor ongoing nutritional status as needed related to risk of malnutrition per mini nutrition assessment.C. Staff interviewThe RD was interviewed on 7/8/26 at approximately 12:00 p.m. The RD said she had no concerns that the tube feed was running at the incorrect rate of 82 milliliters per hour as it did not have any adverse effect on the resident.The staff development coordinator was interviewed on 7/8/26 at approximately 12:30 p.m. The staff development coordinator said a root cause analysis was completed in response to the enteral tube feeding rate error. She said nursing leadership found a possible cause of the error may have been related to confusion in other residents orders on the unit. The staff development coordinator said the resident in the room next door to Resident #8 had an order for her tube feeding to run 82 milliliters per hour. She said it was possible that the nurse inadvertently set up Resident #8's tube feed at that rate of 82 milliliters instead of the prescribed rate of 45 milliliters per hour in error.The director of nursing (DON) was interviewed on 7/8/26 at approximately 1:00 p.m. The DON said she and the corporate nurse consultant had audited and reviewed all enteral tube feeding on 7/7/26. She said all tube feeding flow rates were assessed to be running at the correct rate.

Based on observations and interviews, the facility failed to ensure reasonable accommodation of needs for residents on one of two floors. Specifically, the facility failed to ensure residents on the second floor received functional utensils for meals to achieve their highest practicable level of well-being. Findings include: I. Observations During a continuous observation of the second floor dining room on 1/14/25, beginning at 4:20 p.m. and ending at 5:45 p.m, the following was observed:. At 4:20 p.m. residents waited in the dining room for dinner service. At 5:00 p.m. the food was brought up to the dining room kitchenette from the first floor kitchen At 5:06 p.m. staff began to serve food onto paper plates for the residents. Residents were provided plastic utensils and styrofoam cups. The meal was chicken fried steak, brown gravy, mashed potatoes, baby carrots and tapioca pudding. Four residents at the first table in the dining room were served dinner. One resident at the table tried to use her plastic knife and fork to cut the chicken fried steak but she was unable to. The resident gave up and instead ate her pudding. A staff member came over to the table and attempted to assist another resident at the table cut up her chicken fried steak with a plastic knife but was unable to. The staff member had to get a regular knife from the kitchenette in order to cut the meat. The staff member had to use the regular knife to cut three other resident's chicken fried steak. Several other staff members attempted to cut the chicken fried steak for three additional residents but were unable to complete the task with the plastic knives. The staff members requested the regular knife that had been used earlier but none of the staff members were able to locate the regular knife and had to use the plastic utensils. At 5:10 p.m. two residents sitting in the corner of the dining room were served their meals, however, no staff members went to the table to offer assistance to the residents with cutting up their chicken fried steak. At 5:33 p.m. a staff member approached the two residents and offered assistance with cutting up their chicken fried steak. The residents told the staff member the chicken fried steak had been too difficult to cut and declined assistance. The residents told the staff member the food was now cold from waiting and both residents declined alternative options. II. Resident interviews Resident #24 was interviewed on 1/15/25 at 1:53 p.m. Resident #24 said she ate her meals in her room and said she was able to cut the chicken fried steak in the center but it was very difficult to cut the meat from the previous night's dinner with the plastic utensils. Resident #22 was interviewed on 1/15/25 at 2:14 p.m. Resident #22 said the chicken fried steak was too hard to cut with the plastic utensils the night before (1/14/25) and by the time the staff came to help her cut up the meat, she was no longer hungry. The resident said the residents on the second floor had been having this problem with the plastic utensils for a while. III. Staff interviews The dietary consultant (DC) was interviewed on 1/13/25 at 11:37 a.m. She said the facility was using disposable silverware on the second floor due to the elevator being temporarily out of service. The DC said it would be unsafe to have the staff carry all the dishes up and down the stairs. The DC was interviewed again on 1/16/25 at 3:09 p.m. The DC said when the facility was aware the elevator was going to be out of service, the management team discussed different concepts of how to bring the food up to the second floor. The DC did not know if the facility discussed with the resident council members the plan to use disposable silverware and dishes. The DC said the facility management team discussed all the areas in which the use of disposable dishes could be problematic, such as temperature and slowing down the delivery of food to the residents. She said the management team did not discuss if the residents would have difficulty using disposable utensils to eat with.

Based on interviews and record reviews the facility failed to maintain a clean and sanitary homelike environment for residents. Specifically, the facility failed to ensure residents were provided clean washcloths and hand towels. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised November 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:22 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The characteristics of the homelike environment are a clean, sanitary, orderly environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. II. Observations On 1/13/25 at 1:41 p.m. room [ROOM NUMBER] had no hand towels or washcloths.Both of the towel holder bars were broken. On 1/13/25 at 3:35 p.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/13/25 at 4:38 p.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/13/25 at 4:02 p.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/14/25 at 10:02 a.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/15/25 beginning at 2:06 p.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -Room # 1001 had no hand towels or washcloths; -room [ROOM NUMBER] had one wash cloth and no hand towels; -room [ROOM NUMBER] had no hand or washcloths and the towel holder bar was broken; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washclothes. The towel holder bar for the resident on side B of the room was broken; -Room # 2007 had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had one dirty washcloth for the resident on side A of the room and no hand towels or wash cloth for the resident on side B; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had one dirty wash cloth for the resident on side A of the room and no hand towels or wash cloth for the resident on side B; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. On 1/16/25 at 9:30 a.m. a tour with the director of nursing (DON) and the assistant director of nursing (ADON) was completed. The Golden Gate unit had a linen closet which had 18 towels for approximately 65 residents residing on the unit. The second floor laundry room had no hand towels in any of the three blue linen carts. III. Resident group interview Six alert and oriented residents (#128, #44, #124, #70, #60, and #167), selected by the facility and deemed to be interviewable through facility assessment, were interviewed on 1/15/25 at 10:00 a.m. The residents said the facility did not have enough towels or wash cloths and they frequently could not get a clean hand towel on the days they requested one. The residents said shower days were the most problematic and the facility often ran out of clean towels, especially on days when 10 or more residents on their units took showers. IV. Additional resident interviews Resident #5 was interviewed on 1/13/25 at 4:38 p.m. Resident #5 said he did not have linen hand towels in his room. He said he had to use paper towels to dry his hands. Resident #23 was interviewed on 1/14/25 at 10:05 a.m. Resident #23 said she had no hand towels in her room. She said she had to beg the staff for towels. She said she had been told the facility was short on towels. She said she had used paper towels on her face many times. Resident #24 was interviewed on 1/13/25 at 1:41 p.m. Resident #24 said she did not get linen hand towels in her room. She said she preferred using linen hand towels versus paper towels. V. Staff interviews The DON was interviewed on 1/16/25 at 9:30 a.m. The DON said the nursing staff were responsible for passing out hand towels and wash cloths to the residents. She said hand towels and wash cloths should be passed out on each shift and replaced as needed. She said she was not aware the hand towels were not being passed out. She said she would correct the issue immediately. The housekeeping supervisor (HKS) was interviewed on 1/16/25 at approximately 11:00 a.m. The HKS said the hand towels were in the laundry room, and the certified nurse aides (CNA) were to bring the hand towels to the linen closets as needed. -However, observations revealed there were no hand towels in the second floor laundry room (see observation above). The maintenance director (MTD) was interviewed on 1/16/25 at 2:10 p.m. The MTD said he was not aware that resident rooms had broken and non-functional towel holder bars. He said he had a handwritten checklist of repairs to be made and showed that towel holder bar repairs were not on the list. The MTD said the nursing staff should have reported the broken towel holder bars so they could have been repaired and made functional to hold residents' towels and washcloths. VI. Facility follow up On 1/16/25 at 2:06 p.m. the DON provided an audit of all the residents' rooms which was conducted on 1/16/25, during the survey. The audit revealed 22 resident rooms had broken towel holder bars. She said all of the broken towel holder bars were getting replaced as soon as possible.

Based on observations, record review and interviews, the facility failed to ensure three (#23, #34 and #21) of four residents reviewed for activities out of 59 sample residents received an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically the facility failed to: -Ensure Resident #23 and Resident #34 were offered more mind stimulating activities; and, -Ensure Resident #21 was provided with a personalized activity program. Findings include: I. Facility policy and procedure The Quality of Life policy, updated December 2024, was received from the nursing home administrator (NHA) on 1/16/25 at 9:26 p.m. The policy read in pertinent part, It is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental and psychosocial well-being of the resident. The Activities policy and procedure, revised December 2024, was provided by the NHA on 1/16/25 at 9:37 p.m. It read in pertinent part, The facility will ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. Activities may be facility sponsored, group or independent. Activities procedures: Residents who wish to meet with or participate in social or religious activities, or other community activities, at or away from the facility are encouraged to do so as they are able. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations. II. Activity calendar The Golden Gate unit's January 2025 activity calendar for the week of 1/12/25 through 1/18/25 revealed there were four to six activities scheduled per day. The activity calendar had mind stimulating activities scheduled on four of seven days for the week (1/12/25, 1/13/25, 1/16/25 and 1/18/25). There were no mind stimulating activities scheduled on the remaining days of the week (1/14/25, 1/15/25 and 1/17/25). The January 2025 Summit Park unit calendar had similar activities scheduled, however, the residents from the Golden Gate unit could not attend those activities, as the elevator had not been working for the past several months. III. Resident #23 A. Resident status Resident #23, age 73, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified protein- calorie malnutrition, diabetes type II. The 11/5/24 minimum data set (MDS) assessment dated revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The 4/9/24 MDS assessment revealed it was very important to Resident #23 to do activities she liked. B. Resident interview Resident #23, who resided on the Golden Gate unit, was interviewed on 1/14/25 at 9:50 a.m. Resident #23 said she enjoyed going to the activities. She said a lot of the activities were geared towards residents who were cognitively impaired. She said she liked trivia and word games. She said she was told by someone in activities that they could not have word games or trivia because everyone needed to be able to participate. She said because of this, many of the activities provided ended up being coloring pictures. Resident #23 was interviewed a second time on 1/16/25 at 4:30 p.m. Resident #23 said the board game activities the facility had were only scheduled three to four times a month. She said it made her sad that she was not able to attend more thought provoking activities. C. Record review The 11/1/24 psychiatric follow up note documented Resident #23 enjoyed watching television (TV), playing bingo, trivia and games. She preferred to participate in activities in a group setting. The note further documented that staff should attempt to tailor the activities to the resident's interests and ability level. The 11/4/24 activity assessment documented Resident #23 was spending more time in her room instead of attending group activities. Resident #23's activity care plan, updated 11/5/24, identified Resident #23 enjoyed watching TV in her room, reading, word puzzles, coloring and listening to music. Pertinent interventions included assisting the resident to the activities, inviting the resident to intergenerational programs, inviting the resident to exercise groups and inviting the resident to creative arts and crafts and music programs. -The care plan did not address the resident's desire to attend thought provoking activities. IV. Resident #34 A. Resident status Resident #34, age 72, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included multiple sclerosis (MS). The 10/1/24 MDS assessment revealed the resident had minimal cognitive impairment with a BIMS score of 13 out of 15. The resident required total assistance with mobility. The 7/1/24 MDS assessment revealed it was very important to the resident to do activities she liked. B. Resident observations On 1/15/25 at 10:29 a.m. Resident #34 was asked if she wanted to go to the activity of coloring. On 1/15/25 at 10:45 a.m., the resident had a coloring sheet she was coloring, there was an activity assistant at the table, with two other residents, however, there was no talking. C. Resident interview Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she attended the activities on a regular basis, however, she said she wished there were more trivia type games. She said she liked the cognitively challenging activities. Resident #34 was interviewed a second time on 1/16/25 at 4:20 p.m. Resident #34 said she did have books in her room, however, she said she had nothing new to read. She said she had not received a book from the activity department for quite some time. She said she continued to enjoy reading. Resident #34 again said she liked the cognitively challenging activities. D. Record review Resident #34's activity care plan, updated 12/26/24, identified the resident enjoyed watching TV in her room, reading, word puzzles, coloring and listening to music. Pertinent interventions included assisting the resident to the activities, inviting the resident to intergenerational programs, inviting the resident to exercise groups, inviting the resident to creative arts and crafts, and music programs, offering the resident the daily chronicle and magazines, inviting the resident to resident council and community meetings and inviting the resident to religious programs. -The care plan did not address the resident's desire to attend cognitively challenging activities. The 9/27/24 activity note documented Resident #34's activity interests included bingo, trivia and crafts. V. Staff interview The activity director (AD) was interviewed on 1/16/25 at 4:00 p.m. The AD said Resident #23 and Resident #34 attended all the activities and never complained about the activities. She said the activity calendar did have trivia type games on the schedule. The AD said Resident #23 could attend the activity planning meetings and voice her requests. The AD said Resident #34 had visits from her family and she liked to read. She said the activity department provided her books. 51711 VI. Resident #21 A. Resident status Resident #21, age 82, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included hypertension (high blood pressure), cognitive communication deficit, heart failure and depression. The 10/31/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. She required maximum assistance with all activities of daily living (ADL). B. Resident interviews and observations Resident #21 was interviewed on 1/13/25 at 11:08 a.m. Resident #21 said she participated in activities approximately one time a month but had not been able to participate with the larger group activities downstairs due to the elevator being disabled. She said she would like to get out of bed more, however, she said she was dependent on staff assistance. She said she had not received assistance from the facility staff for watching movies on her cell phone. On 1/15/25 at 9:43 a.m. activity assistant (AA) #2 was inviting residents to join her in the common area for coffee and reminiscing, which was the 10:00 a.m. scheduled group activity. AA#2 went room to room asking residents on the 2200 hall if they would like to attend the activity. AA#2 approached Resident #21's room, but did not enter. Resident #21 was not invited to participate in the group activity. C. Record review The activities care plan, initiated 1/24/24 and revised 12/26/24, documented Resident #21 enjoyed word searches, reading, watching television, playing bingo and visiting with friends. It indicated the resident structured her own day with self-directed independent activities and attendance of group activity programs of her interest. The interventions included providing an activity calendar to ensure the resident's knowledge of upcoming activities and encouraging participation in expressed individual and/or group activities. The 12/26/24 activity progress note documented Resident #21's religious preference was Catholic and she would have the opportunity to attend in-house services when scheduled. Resident #21 enjoyed reading, playing bingo, knitting/crocheting, arts/crafts, watching television and word searches. Resident #21 attended group activities of her choice. The 11/12/24 and 11/14/24 certified nurse aide (CNA) documentation revealed the resident would only get out of bed to attend the group activity of bingo, however, Resident #21 was unable to attend the group activity because the elevator was not working. -Resident #21 was unable to attend group activities downstairs in the facility due to the elevator being out of service as of 11/7/24. D. Staff interviews The activities director (AD) and the activities consultant (AC) were interviewed together on 1/16/25 at 2:00 p.m. The AD said an initial activity assessment/evaluation was completed for residents upon admission. She said the interventions were determined based on the resident's likes and interests. The AD said all residents received the facility monthly activities calendar. She said currently, there were two different activities calendars issued due to the need to separate the activities based on the elevator being unusable. The AD said all residents received both calendars but the calendar for their specific floor was posted.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow the weekly menu to ensure adequate nutrition was provided to the residents. Findings include: I. Facility policy and procedure The Food and Nutrition Services, Menus policy, dated August 2019, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:28 p.m. It revealed in pertinent part, This facility's menus and extensions shall be prepared in advance. Menus procedures: If any meal served varies from the planned menu, the change and the reason for the change are noted in the kitchen and /or in the record book used solely for recording such changes; these changes are to be reviewed and approved by the dietitian. Menu spreadsheets are utilized to ensure all menu items are served at the correct portion sizes. II. Failure to follow the correct portion sizes to ensure adequate nutrition was provided to the residents. A. Observations and record review During a continuous observation during the lunch meal on 1/15/25, beginning at 11:15 a.m. and ending at 12:08 p.m., the following was observed: An unidentified dietary aide placed one gray #8 scoop of tortellini on each resident's meal trays who received a regular diet. -The menu extensions documented residents who received a regular diet should have received two gray #8 scoops of tortellini. III. Failure to follow the weekly menu to ensure adequate nutrition was provided to the residents A. Observations and record review Review of the menu and the menu extensions for the 1/14/25 dinner meal revealed that 2% (percent) milk was to be served with dinner. During a continuous observation on 1/14/25 of the dinner service, beginning at 4:17 p.m. and ending at 5:43 p.m., in the main and second floor dining rooms, the following was observed: -The dietary aides in the main and second floor dining rooms did not offer or serve residents milk as a beverage during the observation period. They offered coffee and juice instead. The dietary aides did not offer a dairy substitute to the residents. IV. Staff interviews The dietary consultant (DC) and the registered dietitian (RD) were interviewed together on 1/15/25 at 3:36 p.m. The DC said during the lunch meal on 11/15/25 the wrong amount of tortellini was served. She said two scoops, using the gray #8 scoops of tortellini should have been served. The DC and the RD were interviewed again on 1/16/25 at 3:09 p.m. The DC said the calorie count was inclusive of all items noted on the menu for the day. The DC said the milk should be offered, however, if the resident refused the milk, an alternative to the milk should be offered.

Based on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff wore the proper personal protective equipment (EBP) for Resident #25, who was on enhanced barrier precautions (EBP); -Ensure pull cords were free from debris; -Ensure the resident's rooms were cleaned appropriately; and -Ensure Resident #98's nebulizer was cleaned and stored appropriately. Findings include: I. Failure to follow enhanced barrier precautions A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), retrieved on 1/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing. B. Observations On 1/13/25 at 3:15 p.m. there was a sign on Resident #25's door indicating he was on EBP. There was personal protective equipment (PPE) including gloves, gowns, eye protection and masks stocked on the back of Resident #25 door. On 1/13/25 at 3:34 p.m. Resident #25 was in her room when certified nurse aide (CNA) #2 and registered nurse (RN) #2 entered the resident's room with a Hoyer lift (mechanical lift) to assist Resident #25 to bed. Neither staff applied personal protective gowns prior to providing personal care assistance to the resident. On 1/15/25 at 12:50 p.m., two unidentified staff members entered Resident #25's room with gloves on but no gown or mask to transfer the resident to bed. CNA #2 grabbed a blue protective gown. RN #2 told CNA #2 that she did not need to use the blue protective gown. CNA #2 proceeded to empty Resident #25's nephrostomy tube without applying the required PPE. C. Resident interview Resident #25 was interviewed on 1/15/25 at 8:30 a.m. Resident #25 said the staff never used gowns, masks or eye protection when emptying her nephrostomy tube. Resident #25 said the staff did wear gloves. D. Staff interviews CNA #2 was interviewed on 1/15/25 at 12:55 p.m. CNA #2 said she just needed to wear gloves to empty Resident #25's nephrostomy tube because she did not want to get urine on her hands. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 1/16/25 at 2:41 p.m. The ADON said when a resident was placed on EBP, the staff were expected to put on a mask, gown,and wear face shield/goggles when splashing was likely to occur during care where they came into contact with bodily fluids and open areas of the body. The ADON said the staff received education following EBP in October 2024. The DON said they also provided the staff a more recent in-service in December 2024 on infection control measures. 51916 II. Failure to ensure pull cords were clean A. Observations On 1/15/25 between 3:10 p.m. and 3:50 p.m., resident shower rooms and resident in-room bathrooms were observed. -The first shower room on the first floor was observed; the call light string near the toilet was soiled with a brown substance -The second shower room on the first floor was observed; the call light string near the toilet was soiled with a brown substance. -The shower room on the second floor's call light string was brown. -Nine resident's bathrooms (#1007, #1008, #1210, #2007, #2001, #2204, #2109, #2112, and #2311) were observed. All of them had brown call light strings by their toilets. B. Staff interviews The DON and the ADON were interviewed together on 1/16/25 at 2:20 p.m. The ADON said the housekeeping staff was responsible for cleaning the call light strings. The housekeeping supervisor (HKS) and housekeeper (HK) #3 were interviewed together on 1/16/25 at 4:54 p.m. The HKS said the material that the pull cords were made out of were difficult to clean. The HKS said he would work to create a plan to replace all of the call light strings with a plastic material that would be able to be cleaned. III. Failure to ensure resident's rooms were cleaned appropriately A. Professional reference According to the CDC Prevention Guidelines for Environmental Infection Control in Health Care Facilities (2003), last reviewed 1/8/24, retrieved on 1/21/25 from https://www.cdc.gov/infection-control/hcp/environmental-control/environmental-services.html, High-touch housekeeping surfaces in patient-care areas (doorknobs, bedrails, light switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact (since the transferral of microorganisms from environmental surfaces to patients is largely via hand contact with the surface). Infection-control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff. Cleaning solutions should be replaced frequently. B. Facility policy and procedure The Housekeeping policy, revised September 2024, was provided by the HKS on 1/16/25 at 9:26 p.m. It read in pertinent part, The facility requires effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites, including thorough scrubbing for all environmental surfaces in resident care areas taking dwell times for disinfectants into consideration; frequently changing mop heads, cloths and cleaning solutions; cleaning horizontal surfaces in care areas daily or more often if soiled; disinfectants and detergents must be EPA-approved. C. Observations On 1/16/25 from 10:12 a.m. to 10:50 a.m., a continuous housekeeping observation of room [ROOM NUMBER] was conducted. HK #1 started the cleaning by spraying the sink, bathroom floor and toilet. HK #1 began wiping down the bathroom surfaces and then began wiping the resident's table surfaces with the same towel she used to wipe surfaces in the bathroom. HK #1 also used the same wet towel for both resident spaces in the shared room. The call light string in the bathroom had a brown substance on it. HK #1 did not attempt to clean or replace the soiled call light string. -HK #1 failed to clean high touched areas including the light switches, door knobs, sink handles and call lights. D. Staff interviews The HKS was interviewed on 1/16/25 at 4:54 p.m He said the housekeepers should clean either side of the room using different cleaning towels for different surfaces. 42838 IV. Failed to ensure Resident #98's nebulizer was cleaned and stored appropriately A. Professional reference According to the American Lung Association, How to Clean your Nebulizer, last updated 3/27/23, retrieved on 1/22/25 from https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/resource-library/how-to-clean-a-nebulizer#:~:text=Cleaning%20your%20nebulizer%20is%20important,top%20piece%2C%20and%20medicine%20cup. Many people with chronic lung diseases such as COPD or asthma use a nebulizer to take their medication in the form of a mist that is inhaled into the lungs. Cleaning your nebulizer is important to prevent the spread of germs and keep you from getting sick. It will also keep your device working properly. It is recommended to wash the parts of your nebulizer after each use, including the mouthpiece or mask, top piece, and medicine cup. To start, take the nebulizer apart by removing the tubing and setting it aside. (The tubing should never be placed underwater.) Remove the mouthpiece or mask, and medicine cup from the top piece, and wash the medicine cup, top piece, and mouthpiece or mask, in warm soapy water, and rinse. Shake off the excess water and let the pieces air-dry in a cool, dry place until the next use. Your nebulizer will also need a thorough cleaning once a week. Soak the mouthpiece or mask, top piece, and medicine cup in a white vinegar and water solution for 30 minutes, or as recommended by your device manufacturer. After 30 minutes, rinse and air-dry in a cool, dry place. Clean the surface of the compressor and the outside of the tubing with a soapy cloth or disinfectant wipe. (The compressor and the tubing should never be submerged in water.) and, remember, most compressors have an air filter that will need to be replaced every six months, or as recommended by your manufacturer. B. Resident interviews and observations On 1/13/25 at 1:56 p.m., Resident #98's nebulizer was lying on her nightstand on top of her personal care items. The table was cluttered with papers and used drinking cups. The nebulizer was not clean of the moisture built up from the last use. The nebulizer was not stored on a protective sheet or in any type of protective covering. Resident #98 was interviewed on 1/13/25 at 4:54 p.m. She said the nebulizer needed to be cleaned after each use. She said the staff did not clean it, so she cleaned it herself. On 1/14/25 at 9:30 a.m. and 1/15/25 at 9:30 a.m., the nebulizer was observed, it was still lying on the nightstand with dried water stains. It did not have a protective covering. C. Staff interviews CNA #8 was interviewed on 1/16/25 at 10:30 a.m. CNA #8 said Resident #98 used her nebulizer as needed. CNA #8 said when she requested the nebulizer the nurse would go into her room and give her the medication in the nebulizer. CNA #8 said the nebulizer was then cleaned after each use by nursing staff and it was placed next to her bed on her table. RN #3 was interviewed on 1/16/25 at 11:30 a.m. RN #8 said nursing staff were responsible for taking the nebulizer apart for each cleaning and it dried on the medication cart. RN #8 said once dry it was put back together and placed next to her bed on her table until the next use. The DON and the ADON were interviewed on 1/16/25 at 2:00 p.m. The DON said the nebulizer should be washed after each use and placed in a bag after it was washed and air-dried. The DON said the nurses have access to bags at every nurse's station. The DON did not say why they were not following the procedure for Resident # 98.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the dining room tables were stable and in good condition. Findings included: I. Facility policy and procedure The Safe and Homelike Environment policy, revised November 2023, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. A. Observations and resident interviews On 1/15/25 at 12:45 p.m., there were five dining room tables that were found to be unbalanced. When a resident leaned on the table the table top dipped causing the surface to move up and down in an unsteady manner. On 1/16/25 at 4:15 p.m., the evening meal was observed. There were multiple tables that were unbalanced that residents were eating their meals. Resident #189 was interviewed on 1/16/25 at 4:15 p.m. Resident #189 said the tables wobbled so he had to fold up a paper towel and place it under the leg of the table to stabilize it so his food did not spill when he ate his meal. Resident #189 said the paper towels he stuck under the leg helped but they had to keep replacing it when the table was moved around. Resident #60 was interviewed on 1/16/25 at 4:16 p.m. Resident #60 said the tables were unbalanced and it made it difficult to eat and drink. On 1/16/25 at 4:20 p.m., the dining area was observed and there were pieces of paper towels placed under the table leg to keep the tables balanced. Some tables did not have paper under the legs and were unbalanced. B. Staff interviews The maintenance director (MTD) was interviewed on 1/16/25 at 11:11 a.m. The MTD said the maintenance team was dependent on the nursing staff to report any repair needs. The MTD said the facility had an electronic report database but were not putting it to use. The MTD said all of the maintenance needs observed by staff or requests reported by residents were provided to the maintenance department verbally or by passing along a written note. The MTD said he utilized a legal pad to document his repair to do list. The MTD said there was no backup for this system and no historical data was available to show past repairs. He said once as the repairs were completed he tossed out his to do list. The MTD was interviewed again on 1/16/25 at 4:30. The MTD said he checked the tables in the dining area a few times weekly and did not find any problem with the steadiness of the tables. He said he was not aware of the unbalanced tables. The MTD said he would look at the tables, and he and the maintenance staff would fix any broken tables.

Based on record review, observations and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to ensure resident complaints expressed during the resident council meetings were documented on a grievance and resolved to the residents satisfaction. Findings include: I. Facility policy and procedure The Residents Rights, Subject: Grievances policy and procedure, revised January 2025, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:28 p.m. It revealed in pertinent part, The facility will establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their facility stay; and the facility will make prompt efforts to resolve grievances the residents may have. The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking the grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested; and coordinating with state and federal agencies as necessary. Resident and/or resident representatives have the right to file grievances orally or in writing, the right to file grievances anonymously, and obtain a written decision regarding his or her grievance as requested. Copies of the Grievance Resolution Forms are available from the Grievance Official and at each nursing station. The Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. Upon receipt of a grievance and/or complaint, the grievance officer will respond to the individual expressing the concern within (three) working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. The grievance official or designee completes the Grievance Resolution Form, takes appropriate corrective action in accordance with State Law if the alleged violation of resident's rights is confirmed by facility or an outside entity having jurisdiction, such as State Survey Agency, Quality Improvement Organization, or local law enforcement agency within its area of responsibility. The Grievance Official or designee will contact all parties of the outcome. II. Resident interviews Thirteen residents (#5, #23, #25, #29, #39, #55, #69, #98, #118, #158, #163, #174 and #698) were interviewed during the survey process. All 13 residents were determined to be alert, oriented and cognitively intact based on facility assessments. All residents said the food at the facility did not taste good. Resident #39 was interviewed on 1/14/25 at 1:49 p.m. Resident #39 said she had ordered items to be delivered from two different retailers. She said she had proof of the delivery to the front desk at the facility, however, she did not receive the packages and were reported as missing to the management at the facility. Resident #39 said she was reimbursed for the missing packages, but had not received a resolution to her concern of her packages being delivered to the facility but not receiving them. Resident #118 was interviewed on 1/13/25 at 1:38 p.m. Resident #118 said she did not like the food, the taste was bad and the coffee was always cold. Resident #55 was interviewed on 1/14/25 at 10:05 a.m. Resident #55 said the food at the facility was not appetizing. Resident #163 was interviewed on 1/13/25 at 2:28 p.m. Resident #163 said the food was not flavorful and had no taste. Resident #5 was interviewed on 1/13/25 at 4:39 p.m. Resident #5 said she hated the food. She said the food did not have enough flavor, the meat was tough and the food was often not hot enough. Resident #23 was interviewed on 1/14/25 at 10:04 a.m. Resident #23 said the food was terrible and was either too salty or did not have any salt in it. She said a spoonful of gravy was so salty that it pulled all the moisture out of her mouth. Resident #69 was interviewed on 1/14/25 at 9:00 a.m. Resident #69 said food at the facility was not good and was always cold. Resident #158 was interviewed on 1/13/25 at 10:31 a.m. Resident #158 said the food was not always hot enough. Resident #25 was interviewed on 1/13/25 at 3:52 p.m. Resident #25 said the food did not taste good, was not hot enough and did not have enough flavor. Resident #29 was interviewed on 1/13/25 at 1:49 p.m. Resident #29 said the food was not warm when it was served. Resident #98 was interviewed on 1/13/25 at 2:28 p.m. Resident #98 said the portions of food at the facility were too small. Resident #174 was interviewed on 1/15/25 at 9:47 a.m. Resident #174 said he requested condiments and a slice of cheese with his breakfast. He said he was tired of being served the same meal of eggs every morning and wanted to make himself a sandwich. He said he was not served the condiments and the cheese as he requested. Resident #698 was interviewed on 1/13/25 at 1:49 p.m. Resident #698 said there was a lack of food choices at the facility. He said he preferred sausage links but was brought sausage patties. He said the facility often did not serve what he wanted, but only what was on the menu. B. Record review The 10/22/24 food committee meeting notes documented the following food complaints. -The fruit served in fruit bowls was hard, residents did not receive what they ordered, bacon was too hard, soups had too much pepper, the dining rooms needed more staff for the weekend service and snacks would run out before some residents could get them. -No grievance forms were completed to resolve the resident's concerns. The 11/18/24 food committee meeting notes documented the following food complaints. -The bacon was too hard, the food service assistance in the dining rooms on the weekends had not improved, the residents did not like the tortellini, snacks were not being provided in enough quantity, omelets, waffles and rice were served too often. -No grievance forms were completed to resolve the resident's concerns. The 12/16/24 food committee meeting notes documented the following food complaints. -Condiments were not being offered or delivered on room trays as requested. The tortellini would remain on the menu and residents were instructed to order from the always available menu when it was on the menu. -No grievance forms were completed to resolve the resident's concerns. V. Staff interviews Social services assistant (SSA) #2, the social services director (SSD) and the social services consultant (SSC) were interviewed on 1/16/25 at 2:59 p.m. SSA #2 said grievance forms were posted throughout the facility and were able to be filled out by a resident, resident representative or a staff member. She said the grievance form was placed in a box located in the front lobby of the facility. She said the grievances were retrieved every morning, read in the morning staff meeting and then handed over to the appropriate department head. She said grievances should be resolved and the resident provided a resolution within three days of receiving the form. SSA #2 said she was the grievance official and also ran the resident council meetings and took the minutes. The SSD said the facility staff were educated on the facility grievance process during the regularly scheduled monthly all staff meeting. SSA #2 said she did not always fill out a grievance form when a resident expressed a concern. She said she did not have a way to track those concerns she did not document nor their resolve. SSA #2 said she was aware Resident #39's concern of not receiving her packages, which were also documented in the resident council meeting on 1/15/25. She said multiple residents had brought up the concern during the resident council meetings. She said another resident was taking the packages and placing them in her room. She said the other resident had since been discharged from the facility. SSA #2 said she did not complete a formal grievance for Resident #39's concern. SSA #2 and the SSD said they were unaware of any food related grievances filed by the residents at the facility. -However, the resident council minutes documented multiple resident complaints regarding the food at the facility. SSA #2 said she would begin to run resident council meetings differently by asking residents more probing questions and completing grievances for their concerns. She confirmed she did not complete grievances for resident concerns from the resident council meeting. The registered dietitian (RD) and the dietary consultant (DC) were interviewed on 1/16/25 at 3:09 p.m. The RD said she was aware of resident complaints regarding not having enough snacks, but had not been informed of resident complaints regarding not receiving condiments until today (1/16/25). The DC said the dietary department will be implementing a condiment tray for the aides to have when delivering meal trays to the residents. The RD said the dietary manager (DM) received all complaints from residents. -The DM was unavailable for an interview during the entire survey process. The NHA interviewed on 1/16/25 at 5:46 p.m. The NHA said he was unaware of the missing packages delivered to the facility from the front desk area. The NHA said he reimbursed a lot of residents for a variety of things and did not always keep track. He said last week the facility approved the purchase of two electronic devices for residents, but he did not record the occurrence. The NHA said he implemented a new process two to three weeks ago for packages delivered to the facility for residents. He said previously, the packages were left at the front desk, which was not always manned by a staff member, but the new process required the packages be locked up and verified by a staff member before handing them over to a resident.

Based on observations, record reviews and interviews, the facility failed to ensure proper treatment and assistive device to maintain hearing abilities for one (#138) of three residents reviewed for hearing and vision services out of 59 sample residents. Specifically, the facility failed to provide a hearing exam for Resident #138 when requested Findings include: I. Facility policy and procedure The Hearing policy, revised April 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: obtaining history from medical records, the family, and the resident regarding hearing and vision abilities, MDS (minimum data set) and care area assessments, ongoing monitoring of sensory problems, care plan development and implementation and evaluation. II. Resident # 138 A. Resident status Resident #138, age 68, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses include anxiety disorder, hypothyroidism and dysphagia (difficulty swallowing). The 12/13/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment indicated the resident did not have any hearing concerns. B. Resident interview Resident #138 was interviewed on 1/13/25 at 11:12 a.m. Resident #138 said he needed to see an audiologist (hearing doctor) because his hearing was worsening and he wanted to get hearing aides. Resident #138 said he told staff about his concerns but the facility was not helping him to see the audiologist. Resident #138 was interviewed again on 1/16/25 at 8:42 a.m. Resident #138 said he had not had any hearing appointments since he had been admitted to the facility on [DATE]. Resident #138 said he just wanted his hearing tested and that he had spoken to the staff about trying to make an appointment. C. Record Review A progress note, dated 12/7/24, documented Resident #138 had poor hearing and he did not have hearing aids. -Review of Resident #138's electronic medical record (EMR) did not reveal documentation that the resident had seen the audiologist. -Review of Resident #138's EMR did not revealed documentation indicating the facility provided the resident education regarding the consent form to receive hearing services (see interview below). D. Staff interview Social services assistant (SSA) #2 was interviewed on 1/16/25 at 2:51 p.m. SSA #2 said Resident #138 told her he wanted to see the audiologist but when he refused to sign the consent to get hearing services, she did not proceed. SSA #2 said because the resident would not sign the consent for treatment the audiologist would not have agreed to see the resident. She said she was not sure if the resident understood the nature of the consent but thought it was probably explained to him. SSA #2 said she had not asked the audiologist if the resident could give verbal consent with a witness since he did not want to sign the consent document. SSA #2 said she would follow up with Resident #138 about the consent form and hearing services.

Based on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for one (#99) of one resident out of 59 sample residents. Specifically, the facility failed to ensure the MDS assessments for Resident #99 accurately documented that the resident had a preadmission assessment screening and resident review (PASRR) Level II qualifying diagnosis. Findings include: I. Professional reference According to the American Association of Post-Acute Care Nursing (AAPACN) The Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Process (October 2024), retrieved on 1/29/25 from https://www.aapacn.org/resources/rai-manual/, The RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. The MDS assessment is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which formed the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. II. Facility policy and procedure The MDS Accuracy policy, revised February 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:26 p.m. It read in pertinent part: It is the policy of this facility to code accurately on the MDS assessment. III. Resident #99 A. Resident status Resident #99, age 84, was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included bipolar disorder. The 9/27/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of The assessment documented that the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. B. Record review The Preadmission Screening and Resident Review (PASRR) Level II Notice of Determination (NOD) for Mental Illness (MI) dated 9/20/24 revealed that information gathered during the PASRR Level II evaluation determined that Resident #99 had a PASRR condition and was determined appropriate for nursing facility level of care. Specialized services required/recommended included: psychiatry case consultation and additional one-to-one engagement support. -However, the 9/27/24 MDS assessment failed to document the resident's PASRR Level II diagnosis. IV. Staff interviews The social services director (SSD) and social services assistant (SSA) #2 were interviewed together on 1/16/25 at 11:53 a.m. The SSD said it was the social services department's responsibility to review the PASRRs and provide Level II determination information to the MDS coordinators (MDSC) so that the residents' MDS would be coded correctly. MDSC #1 and MDSC #2 were interviewed together on 1/16/25 MDSC #1 and MDSC #2 said they reviewed the residents' records, including admission records, skilled nursing notes and social services assessments to complete the MDS assessment. They said PASRR information was provided to the MDSCs by social services. They said when the information was not up-to-date due to a missing PASRR screening the MDSCs relied on social services to provide updated information. MDSC #2 said she would correct the MDS assessment as soon as updates were provided. MDSC #2 said she was not aware that Resident #99 had received a PASRR Level II determination and would review the documentation and make updates to the MDS assessment as appropriate.

Based on observations, record review and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality two (#69 and #23) of two residents of 59 sample residents. Specifically, the facility failed to: -Follow manufacturer's directions when administering Trulicity (insulin) for Resident #69; and, -Have accurate medication orders for Resident's #69 and #23 Trulicity injections. Findings include: A. Professional reference According to the [NAME] Lilly Manufacturer's Trulicity Injection, Instructions for Use, last revised November 2024, retrieved on 1/25/25 from https://uspl.lilly.com/trulicity/trulicity.html#ug Administration of Trulicity injection pen should be held flat on the skin, press and hold the green injection button. You will hear a loud click. Continue holding the clear base firmly against your skin until you hear a second click. This happens when the needle starts retracting in about five to 10 seconds. Every dose of Trulicity comes in the easy-to-use pen, so you can continue to have the same experience with once-weekly Trulicity, regardless of the dose you've been prescribed. B. Observations On 1/14/25 at 4:08 p.m. LPN #3 was giving a Trulicity injection to Resident #69 3 milligram (mg) /0.5 milliliter (ml), single-use pen. While administering the medication injection LPN #3 pinched the upper left forearm and injected the medication. LPN #3 failed administer the medication per the manufacturer's directions (see above) by holding the pen flat to the skin and wait until two clicks were heard. -The dose given was verified as correct with the pharmacy consultant )PC); however, the order on the medication administration record was verified by LPN #3 to be inaccurate and not matching the dosage administered. C. Record Review Review of Resident #23's January 2025 medication administration record (MAR) documented a medication order for Trulicity, inject 0.75 milligrams (mg) /0.5 milliliters (ml). The administration instructions read administer 0.5 ml, ordered on 1/3/22. -The physician's order for Trulicity did not indicate the specific mg dose to be administered to the resident. Review of Resident #69's January 2025 MAR documented a physician's order for Trulicity to inject 1.5 mg/0.5 ml. The administration instructions read to administer 3 mg, ordered on 7/14/23. -However, the dosage on the Trulicity pen administered by LPN #3 (see observation above) was 3 mg/0.5 ml, which was verified to be the correct physician ordered dose for the resident (see pharmacy consultant interview below). -The physician's order on Resident #69's January 2025 MAR did not match the correct dose of the medication that was to be administered to the resident. D. Staff interviews The pharmacy consultant (PC) was interviewed on 1/14/25 at 5:00 p.m. The PC said she consulted with Resident #69's physician to verify the resident's Trulicity injection order and received confirmation that the dose administered to the resident was correct, however the order in the resident's MAR was not correctly written. The PC said she would conduct an audit on the orders for all residents on Trulicity and similar medications to ensure the orders are clearly and accurately written. The director of nursing (DON) was interviewed on 1/15/25 at 9:10 a.m. The DON said they completed a review of all residents on diabetic medications for accuracy of orders and found all residents on Trulicity had contradictory orders and administration directions. The DON said the nursing staff consulted with each prescribing physician to ensure accurate orders were entered into each resident's MAR. The DON said all of the orders had been corrected. The DON said the audit revealed that each resident had been administered the correct single-dose injection pens. The DON said the nurse who initially entered the orders was no longer working for the facility. She said the facility was planning to educate all of the current nursing staff on how to enter accurate medication orders.

Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#47) of two residents reviewed for PASRR out of 59 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #47. Findings include: I. Resident status Resident #47, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included Down's syndrome and major depressive disorder. The 12/24/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed the resident had been identified as having a level II PASRR. II. Resident interview Resident #47 was interviewed on 1/15/25 at 1:27 p.m. Resident #47 said she had been interested in leaving the facility to go shopping, becoming involved in community activities and making friends with people her age in the community. However, she said the facility's social services department had not set up any community activities or services for her. III. Record review The PASRR level II, provided by the facility on 1/15/25, included an evaluation which revealed the resident had been evaluated for IDD (intellectual and developmental disability) due to a qualifying diagnosis of Down's syndrome. Specialized services were recommended to include supported community connections (community integration activities). Review of Resident #47's at-risk care plan, initiated 1/13/25 (during survey), revealed the resident had a level II PASRR due to Down's syndrome. The recommendations included case management, psychiatric case consultation, individual therapy, transportation to behavioral management and pastoral care. Interventions, dated 1/13/25 (during the survey), included anticipating and meeting the needs of the resident. -The care plan failed to reveal community integration activities for the resident. -A review of Resident #47's progress notes from 12/18/24 to 1/14/25 failed to reveal any progress notes related to PASRR. -There was no documentation from social services notes regarding Resident #47's PASRR level II or the recommendations. -There were no documentation in Resident #47's electronic medical record (EMR) to indicate the facility had communicated with the State Mental Health Agency regarding a delay or the facility's inability to follow the recommendations. IV. Staff interviews The social services director (SSD) was interviewed on 1/16/25 at 11:53 a.m. The SSD said it was the social services department's responsibility to set up PASRR recommended specialized services for residents with level II PASRRs. She said if recommendations could not be met, the social services department was responsible for documenting the efforts to meet the recommendations and the outcomes in the progress notes and the resident's care plan. The SSD said the PASRR level II recommendations for Resident #47 included case management, transportation and community integration activities. The SSD said she had sent out a few referrals for services but had not been able to secure services for the resident. She said the documentation of the referrals she sent should be in the progress notes and care plan. The social services consultant (SSC) was interviewed on 1/16/25 at 5:51 p.m. The SSC said the social services department had not sent out any referrals for community services for Resident #47 since December 2024 and the SSD had not followed up with the resident regarding services.

Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#72 and #80) of eight out of 59 sample residents. Specifically, the facility failed to -Develop and implement effective dementia management focused interventions to prevent Resident #72 from wandering into other resident's rooms; -Develop person centered interventions to communicate with Resident #72 and #80; and, -Reassess the effectiveness of care-plan intervention and adjust intervention approaches based on behaviors for Resident #72 and #80. Findings include: I. Resident #72 A. Resident status Resident #72, age 85, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with agitation and mood disorder. The 11/7/24 minimum data set (MDS) revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The assessment indicated the resident had behaviors of physical and verbal aggression directed at others and wandering. The behaviors interfered with the care of others, the activities and socialization of others, the privacy of others, and put others at risk for physical harm. The assessment documented the resident required set up and supervision with all activities of daily living (ADLs). The MDS assessment indicated it was very important to the resident to listen to music and have the opportunity to go outside. B. Record review The comprehensive behavior care plan, revised on 1/15/25 (during survey), revealed the resident had impaired cognitive functioning related to dementia. Interventions included communicating with the resident clearly, identifying oneself, providing distractions and using simple, direct sentences during communication and engaging the resident in simple and structured activities. The comprehensive elopement care plan, revised on 1/15/25 (during survey), revealed the resident wandered without purpose and could fluctuate between being easy to redirect to being difficult to redirect. Interventions included offering structured activities, food, and conversation to distract the wandering behavior and documenting wandering behavior and attempted diversional interventions. The comprehensive discharge care plan, revised on 1/6/25, revealed due to increased wandering/elopement attempts, the family wanted the resident to be placed in a secure unit (facility that offered locked doors to prevent elopement). Review of the comprehensive care plan failed to include a target focus for communication deficits related to the resident who was not primarily English speaking. The January 2025 CPO revealed the following physician orders: Behavior monitoring for aggression towards others and delusions with non-pharmological interventions of approach/speak to in calm manner, provide back rub, change position, offer fluids, offer food, redirect, assess for pain and offer a quiet environment, ordered on 11/1/24; Behavior monitoring for low mood and tearfulness with non-pharmological interventions of providing one on one interaction, offer activity, adjust room temperature, provide back rub, change position, offer fluids, offer food, redirect, remove resident from environment and offer toileting, ordered on 11/26/24; and, Behavior monitoring for exit seeking behavior every shift with no indicated non-pharmological interventions, ordered on 12/27/24. Behavior monitoring dated 11/1/24 to 1/16/25 revealed: Behaviors of low mood and tearfulness were observed on 11/26/24, 11/27/24, 11/28/24, 11/29/24 and 11/30/24. No behaviors of low mood or tearfulness were observed in December 2024 (12/1/24 to 12/31/24) or January 2025 (1/1/25 to 1/15/25). Behaviors of aggression towards others were observed on 11/3/24, 11/9/24, 11/21/24, 11/28/24, and 11/29/24. Behaviors of aggression towards others were observed on 12/2/24, 12/15/24, 12/21/24, 12/22/24 and 12/23/24. Behaviors of aggression towards others were observed on 1/1/25, 1/4/25, and 1/15/25. Behaviors of exit seeking were observed on 12/27/24, 12/28/24, 12/29/24, 12/30/24 and 12/31/24. Behaviors of exit seeking were observed on 1/1/25, 1/2/25, 1/3/25, 1/4/25 and 1/5/25. Progress notes reviewed from 11/1/24 to 1/15/25 revealed: Daily skilled note, dated 11/2/24, revealed the resident was taking other residents' property, went into other resident's rooms, collected dishes and piled them, collected items and wrapped them in napkins and plastic bags and only spoke Korean. Nursing note, dated 11/4/24, revealed the resident had been moved to a new room. She had smeared feces all over the floor and bed. She was filling the trashcan and tub with water. The staff moved Resident #72 to a private room. Nursing note, dated 11/21/24, revealed the resident had taken clothing belonging to another resident and when the staff tried to retrieve the clothing, the resident grabbed and punched the staff member. Nurse management was able to calm the resident by using a translation line to communicate and contacting the family. Nursing note, dated 12/3/24, revealed the resident was agitated while staff attempted to change her. The resident was hitting and kicking the staff. Nursing note, dated 12/15/24, revealed the resident was wandering into another resident's room and attempting to drink lotion from a bottle. The staff took the bottle of lotion and the resident began hitting the staff. Redirections were unsuccessful. Nursing note, dated 1/4/25, revealed the resident was following a nurse into another resident's room during colostomy care. Nursing note, dated 1/15/25, revealed the resident was following the nurse, touching things on the medication cart, interfering in other resident's care and hitting the nurse. C. Additional resident interview Resident #47, who was cognitively intact through facility assessment was interviewed on 1/15/25 at 1:27 p.m. She said she was new to the facility and would like to make friends. She said she was fearful to leave her room because the staff were not able to prevent Resident #72 from entering her room and touching or taking her belongings. She said she had heard Resident #72 had hit the staff and this concerned her. Resident 47 said she felt she had to remain in her room to protect her belongings. II. Resident #80 A. Resident status Resident #80, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included unspecified dementia, hallucinations and mood disorder. The 11/13/24 MDS revealed the resident had severe cognitive impairments and was unable to answer assessment questions with a BIMS score of zero out of 15. The MDS assessment indicated the resident did not have any behaviors. The resident required set up and supervision with all ADLs. B. Resident observations Resident #80 was observed on 1/14/25 at 4:40 p.m. The resident was sitting in the hallway between her room and the dining room on the second floor yelling at another resident sitting near her. Resident #80 yelled in Korean and the other resident did not understand. The staff removed the other resident from the hallway. -However, the staff did not provide any person centered interventions to address Resident #80's behaviors. During a continuous observation on 1/15/25 starting at 4:45 p.m. and ending at 5:25 p.m., At 4:45 p.m. Resident #80 was sitting in her wheelchair in the hallway between her room and the dining room on the second floor. She was yelling in Korean. There were several staff nearby that were watching the resident. The staff were shaking their heads but no one approached the resident. At 5:00 p.m., a nurse attempted to coax the resident to go to the nurse's station with the nurse in order to contact the resident's family. The resident did not appear to understand and grabbed the arm railing and continued yelling. At 5:10 p.m., the nurse convinced the resident to go to the nurse's station. The resident continued to yell. -The staff did not attempt to use a translation app, call a translator on a portable phone or any other methods to communicate in a language that the resident would understand. At approximately 5:20 p.m, the nurses were able to reach the grandson, but the call was disconnected. The nurse then called the language line and the resident continued to yell at the translator. The translator told the nurse the resident was repeating, if you are going to kill me, go ahead and kill me. The resident also expressed to the translator that she believed someone was going to get her but could not explain. At this time, there were two nurses, another unidentified staff member, and social services assistant (SSA) #1 surrounding the resident at the nurse's station. The resident continued to persist with the delusion that someone was coming for her and kept asking the staff to leave her alone. SSA #1 offered the resident food and fluids but the resident only made fun of SSA #1 to the translator. C. Record review The January 2025 CPO revealed the following physician orders: -Behavior monitoring for exit seeking behavior every shift with no indicated non-pharmological interventions-,ordered on 11/2/24. -Psychosocial charting on 11/27/24 to 12/12/24, ordered on 11/27/24. Behavior monitoring was from 11/1/24 to 1/15/25. There were no behaviors documented during this timeframe. The comprehensive language care plan, revised on 7/23/24, revealed the resident had communication difficulty related to a language barrier. The resident knew some basic English but spoke Korean. The resident preferred the family to assist with translation. The resident required the use of a language line interpreter due to language barrier. Interventions included anticipating and meeting the residents needs and providing a translator as necessary. The comprehensive psychosocial care plan, revised 2/22/24, revealed the resident had a diagnosis of dementia and major depressive disorder. The resident had a history of hallucinations and delusions with changes in perception with hearing, seeing, or smelling things that were not present. Interventions included anticipating and meeting the residents needs, providing positive interaction, approaching the resident in a calm manner, reassuring the resident she was safe and providing a program of activities that were of interest and accommodated the resident's needs. Progress notes reviewed from 11/1/24 to 1/15/25 revealed: Nursing note, dated 12/8/24, revealed the resident had been screaming at staff in Korean. A call was placed to the family to speak with the resident. The family said the resident was having delusions and believed people at the facility were accusing her of things she did not do. III. Staff interviews Certified nursing aide (CNA) #7 was interviewed on 1/15/25 at 2:38 p.m. CNA #7 said Resident #72 went into other resident's rooms almost daily and the staff put stop signs on the doors but Resident #72 just removed the sign. CNA #7 said when the staff tried to redirect her or remove her from a room, she became aggressive towards the staff. CNA #7 said she did not know what person centered interventions were implemented to help Resident #72's behaviors other than offer food, fluids and trying to redirect. She said she did not know where the information was for the language line. She said, she tried to use gestures when communicating with Resident #72. CNA #7 said Resident #80 yelled out in Korean frequently and the staff did not understand what the resident was yelling out. She said the staff tried to call the family to translate but the family was not always available. She said she did not know the specific person centered behavior interventions for the resident. CNA #11 was interviewed on 1/15/25 at 2:45 p.m. CNA #11 said Resident #80 yelled out in Korean all the time and the staff just left her alone until she stopped yelling. CNA #11 said Resident #72 wandered the unit daily and went into other resident's rooms, which upset them. CNA #11 said the staff tried to redirect her or distract her with food or fluids. Licensed practical nurse (LPN) #1 was interviewed on 1/15/24 at 2:49 p.m. LPN #1 said Resident #80 yelled out in Korean all the time and the staff just left her alone until she stopped yelling. LPN #1 said she did not know what the tracking for psychosocial charting was except to document if the resident became aggressive or displayed behaviors out of the ordinary. The social services director (SSD) and SSA #1 were interviewed together on 1/16/25 at 2:20 p.m. The SSD said the facility provided dementia care training to the staff through the electronic training modules. The SSD said there had not been a dementia care in-service or additional training with the staff on the second floor. The SSD said she had not provided any in-person dementia care training with staff in over a year. The SSD said the psychotropic drug meeting was conducted monthly with the director of nursing (DON), assistant director of nursing (ADON), the nursing home administrator (NHA), the psychologist and the psychiatrist who provide services to the facility, the social services department and the pharmacist. The SSD said behaviors, medications and non-pharmological interventions were discussed. The SSD said resident was having challenging behaviors, the resident was discussed at the psychotropic meeting. The SSD and SSA #1 said they would also reach out to the psychiatrist and psychologist between meetings to discuss challenging behaviors. The SSD said these conversations were not documented. The SSD and SSA#1 said the documented behaviors for Resident #80 were confusing and not clear. The SSD and SSA #1 said they did not know why Resident #72 had not been discussed in the psychotropic drug meeting for her aggressive and disruptive behaviors. SSA #1 said she was aware Resident #47 was declining to leave her room for meals and activities due to being fearful Resident #72 would enter her room and touch her belongings if she was not there. The NHA, the corporate consultant (CC) and the DON were interviewed together on 1/16/25 at 3:49 p.m. The NHA said the facility utilized online training modules for dementia care training but the facility did not follow up with staff on their comprehension of the training material. The NHA said for residents with aggressive behaviors, the facility would increase activities, medication review, behavior health services and psychiatry intervention. The NHA said the facility had been trying to work with Resident #80's family on medication interventions but the family declined and the resident frequently refused medications. The NHA said the facility has tried using velcro stop signs on resident doors to deter Resident #72 from attempting to enter others rooms but this had not been successful. The CC said the facility had not attempted to utilize a phone translation application with Resident #72 or Resident #80. He said the facility did not believe the residents would understand how to use the application. He said using an application would help the staff with day to day interactions to understand what the residents were saying in Korean or to convey some words to the residents in Korean which might deescalate agitation.

Based on observations, record review and interviews, the facility failed to assist residents to obtain routine or emergency dental services, as needed, for two (#60 and #23) of two residents out of 59 sample residents. Specifically, the facility failed to: -Follow up on a social services referral for denture replacements for Resident #60; and, -Place a timely referral for dental services for Resident #23. Findings include: I. Facility policy and procedure The Dental Policy, revised October 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part, It is the policy of this facility, in accordance with residents' needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, taking impressions for dentures and fitting dentures. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Promptly means within 3 (three) business days or less from the time the loss or damage to dentures or need for emergent services is identified unless the facility can provide documentation of extenuating circumstances that resulted in the delay. II. Resident #60 A. Resident status Resident #60 age 78, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, anxiety and depression. The 12/27/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively intact with a brief interview for mental health status (BIMS) score of 10 out of 15. The MDS assessment did not document any dental concerns or problems. B. Resident interviews Resident #60 was interviewed on 1/15/25 at 10:30 a.m. Resident #60 said she had been waiting for her new dentures for the past seven months. She said the facility was supposed to be assisting her through the process and she had not heard anything since her admission to the facility regarding the status of her dentures. Resident #60 said not having dentures was problematic and bothered her because she was having a hard time chewing. Resident #60 was interviewed a second time on 1/16/25 at 12:10 p.m. Resident #60 said she required both upper and lower dentures and could only eat soft foods at this time. Resident #60 said she needed to eat slowly in order to chew her food due to needing dentures. She said she wanted dentures. C. Record review The comprehensive care plan, initiated on 2/27/24, documented a care focus for activities of daily living (ADL) self-care performance deficit. The goal was the resident would safely perform ADLs with appropriate assistance. Interventions included oral hygiene and indicated the resident was waiting for dentures (initiated on 3/11/24). The nutrition note dated 3/4/24 documented Resident #60 told the nurse that her appetite had been good and she had been eating her meals. The resident reported she had no teeth but she was supposed to be getting dentures soon. -However, the note did not document who was helping the resident obtain her dentures or when they would be arriving. The social services note dated 3/4/24 documented the resident wore dentures but did not have dentures at that time. The note documented that the social worker sent a referral for new dentures and the new dentures would be coming in about two months (May 2024). The social services note dated 6/3/24 documented Resident #60 used dentures. -However, Resident #60 did not have dentures during the interviews on 1/15/25 and 1/16/25 (see resident interviews above). -Review of Resident #60's progress notes revealed there was no documentation to indicate the facility had followed up when the resident's dentures did not arrive at the facility. D. Staff interviews Social services assistant (SSA) #2 was interviewed on 1/16/25 at 12:29 p.m. SSA#2 said she was not aware of any dental concerns for Resident #60 and she did not know the resident was still waiting for dentures. SSA#2 said she would have to check into the status of the resident's dentures. SSA #2 said, from what she remembered, the social services department initially thought Resident #60 had been fitted for dentures but realized that was not the case, so a denture referral was placed for the resident in March 2024. SSA #2 said she would follow up. 20287 III. Resident #23 A. Resident status Resident #23, age 73, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included unspecified protein-calorie malnutrition and type 2 diabetes. The 11/5/24 MDS assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The 4/9/24 MDS assessment revealed the resident had no natural teeth or tooth fragments (edentulous). B. Resident interview and observation Resident #23 was interviewed on 1/14/25 at 10:06 a.m. Resident #23 was wearing an upper set of dentures, but she was not wearing a lower denture. Resident #23 said her bottom denture was missing. She said she ate in bed and she snacked on cheetos. She said without her bottom denture she had difficulty eating. She said she was told by a social worker that, because she had received dentures within the past two years, she could not get a replacement for her bottom denture due to cost. C. Record review The nutrition assessment dated [DATE] documented Resident #23 used to have a full set of dentures, however, she now only had the upper dentures. The resident denied having difficulty with eating. The care plan, updated 6/4/24, identified that Resident #23 had the potential for oral health problems related to being edentulous (no teeth). Pertinent interventions included assisting the resident with dental appointments. -Review of Resident #23's electronic medical record (EMR) did not reveal any documentation to indicate the resident had been referred to the dentist for follow up regarding her missing lower denture. D. Staff interviews The social services director (SSD) was interviewed on 1/16/25 at 8:00 a.m. The SSD said she was not aware Resident #23 was missing her lower dentures because another social worker maintained the ancillary appointments for residents. She said she would look into the situation. The nursing home administrator (NHA) was interviewed on 1/16/25 at approximately 5:00 p.m. The NHA said if the facility was made aware that a resident had lost their dentures, the facility would pay for new dentures when there was no other funding available to the resident. SSA #1 was interviewed on 1/16/25 at 6:30 p.m. SSA #1 confirmed Resident #23 did not have lower dentures. She said she was told the resident's dentures were lost and found several times. However, she said the facility had been unable to locate Resident #23's lower dentures since November 2024. SSA #1 said the resident was currently on the list to see the dentist. SSA #1 was interviewed a second time on 1/16/25 at 6:52 p.m. SSA #1 said Resident #23 had just been placed on the dentist list earlier today (1/16/25). She said there was no documentation regarding the resident's missing dentures in the resident's EMR.

Based on observations, record review and interviews, the facility failed to provide accessible dining equipment and utensils for residents who need them for one (#172) of one resident reviewed for adaptive equipment out of 59 sample residents. Specifically, the facility failed to provide adaptive drinking equipment for Resident #172. Findings include: I. Facility policy and procedure The Adaptive Equipment policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:22 p.m. It read in pertinent part It is the policy of the facility to evaluate and provide adaptive equipment for residents who have been identified at risk for contractures, skin breakdown, assisting with eating. On admission the resident will be assessed for needs for adaptive devices. Residents needing adaptive equipment will be screened by therapy or nursing and equipment will be supplied for respective residents Residents will be reassessed quarterly for continued needs of the adaptive equipment. II. Resident #172 A. Resident status Resident #172, age less than 65, was admitted to the facility on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dysphagia following cerebral infarction (swallowing difficulties following a stroke), cerebral vascular disease affecting left dominant side, hemiplegia and hemiparesis following other cerebral vascular disease (decreased or no movement on one side of the body following a stroke) and need for assistance with personal care. The 12/20/24 minimum data assessment (MDS) assessment documented the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was dependent on facility staff for most activities of daily living (ADL) and eating. B. Observations On 1/13/25 at 3:57 p.m., Resident #172 was drinking a can of Sunkist soda. Resident #172 was not provided with a straw or a spill-proof cup that is designed to be used with a straw. The resident had visible spills on the front of her shirt. On 1/13/25 at 4:20 p.m., Resident #172 was observed in the small dining room on the second floor Resident #172 was served milk and hot coffee in a styrofoam cup without a lid or a straw. Throughout the entire observation of the dinner meal, Resident #172 was served multiple beverages in styrofoam cups and not in an adaptive cup. On 1/14/25 at 1:18 p.m., Resident #172 was observed in the common area on floor two with a styrofoam cup without handles and a straw or lid. The resident had visible spills on her blue shirt. C. Record review The nutrition care plan, initiated on 1/10/24, revealed Resident #172 had a nutritional problem related to diagnosis of dysphagia, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis, muscle wasting and atrophy. Pertinent interventions included providing adaptive equipment, an adaptive cup. A dietary meal ticket from 1/16/25 revealed Resident #172 required a spill-proof cup that is designed to be used with a straw with all meals. III. Staff interviews The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 1/16/25 at 5:34 p.m. The DON said updates to care plans related to adaptive equipment would be completed by the dietitian and/or the therapy department. The DON said the nursing staff did not update the care plan for adaptive equipment. The DON and the ADON said they were unsure how the dietary department and the therapy department communicated the changes. The dietary consultant (DC) was interviewed on 1/16/25 at 4:48 p.m. The DC said Resident #172's dietary meal ticket documented the resident should receive a spill-proof cup that is designed to be used with a straw for all beverages with every meal. The DC said Resident #172 did not receive a spill-proof cup that is designed to be used with a straw, which was part of the comprehensive plan of care. The DC said she would provide education to the kitchen staff to ensure Resident #172 received the appropriate adaptive equipment.

Based on record review and interviews, the facility failed to ensure specialized rehabilitative services to maintain highest practicable level of functioning for one (#158) of two residents reviewed for specialized rehabilitative services out of 59 sample residents. Specifically, the facility failed to ensure services for Residents #158 were provided to maintain the residents highest practicable levels of functioning. Findings include: I. Resident #158 A. Resident status Resident #158, age 85, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included stroke, polyneuropathy and adult failure to thrive. The 11/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance for bed mobility, repositioning, bathing, dressing, transferring and toilet use. Staff provided only set up assistance for meals. The MDS assessment indicated the resident had no deficits with swallowing or eating and was not receiving speech therapy services. B. Resident observation and interview Resident #158 was interviewed 1/14/25 at 4:30 p.m. Resident #158 said the facility sometimes helped him eat his meals in his room and other times the staff just left his tray on the bedside table for him to feed himself. He was unable to say how long this had been occurring. On 1/15/25 at 6:10 p.m. Resident #158 was in his room. A staff member brought in his meal tray and left it on his bedside table. The staff member did not remain in the resident's room to assist the resident with eating. II. Record review The January 2025 CPO revealed the following physician orders: ST (speech therapist) to evaluate and treat related to pocketing food in the mouth and intermittent cough when swallowing, ordered on 12/15/24. Regular diet, mechanical soft texture, thin liquids consistency, ordered on 12/21/24. Supplement shakes two times a day for weight maintenance, ordered on 1/6/25. Resident #158's nutrition care plan, revised 12/20/24, revealed the resident had nutritional deficits related to a history of throat cancer. Interventions included to provide and serve diet as ordered. -The care plan failed to identify the degree of eating assistance or monitoring the resident required. -Review of Resident #158's comprehensive care plan revealed there was no speech therapy care plan focus related to pocketing food or intermittent coughing when swallowing for the resident. A review of Resident #158's electronic medical record (EMR) from 12/15/24 to 1/16/25 revealed the following progress notes: A nursing note, dated 12/15/24, revealed Resident #158 was noted to have a generalized decline as evidenced by being more lethargic and sleepier. The staff encouraged fluids and assisted the resident with the meal. The resident was observed by nursing to be pocketing food and fell asleep while he was eating. The nurse had to remain with the resident to provide cueing to ensure he swallowed his food. The nurse notified the physician and an order for speech therapy was obtained. A registered dietitian (RD) nutrition note, dated 12/20/24, revealed Resident #158 had triggered for an 8 pound (lb) weight loss since 11/22/24. The note indicated the potential cause of the weight change may have been related to increased confusion, lethargy, difficulty swallowing and decreased intake. A RD nutrition note, dated 1/6/25, revealed the RD had changed Resident #158's diet order on 12/21/24 to mechanical soft texture. -Despite the documentation in the progress notes that Resident #158 was having difficulty with swallowing and had been noted to have an 8 lb weight loss, there was no documentation in the resident's EMR to indicate that a speech therapy evaluation had been completed (see physician's order above). III. Staff interviews The director of rehabilitation (DOR) and the speech therapist (ST) were interviewed together on 1/15/25 at 2:09 p.m. The DOT said Resident #158 had been receiving physical and occupational therapy for balance, transfers and general functional mobility with upper extremities. The DOT said the resident had not received speech therapy. The DOT said orders for therapy services were communicated in the morning management meetings, during the Risk Management meeting or the nurses reached out to the therapy department directly. The DOT said he was unable to explain why the 12/15/24 physician's order for a speech therapy evaluation for Resident #158 had not been completed by the therapy department. The ST said she would complete an evaluation with the resident by the end of the day (1/15/25). Certified nurse aide (CNA) #7 was interviewed on 1/15/25 at 2:38 p.m. CNA #7 said the staff did not provide Resident #158 with eating assistance. CNA #7 said the resident ate in his room and the staff checked on him because he ate slowly but the staff did not assist him with eating. The director of nursing (DON) was interviewed on 1/16/25 at 3:49 p.m. The DON said the nursing department communicated new physician's orders for therapy in the morning management meetings, where the therapy department was in attendance. The DON said the therapy department also reviewed the daily physician order reports. The DON acknowledged the facility did not have an explanation for why the 12/15/24 speech therapy evaluation order for Resident #158 was missed.

Based on observations record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three ( #35, #34 and #25) of 10 residents out of 59 sample residents. Specifically, the facility failed to: -Ensure Resident #35 was provided with assistance for oral care and proper nail care; -Ensure Resident #34 was provided with assistance for oral care and repositioning; and, -Ensure Resident #25 was provided with assistance for repositioning. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised September 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:28 p.m. It read in pertinent part, Residents who are unable to carry out ADLs will receive necessary services or support from staff regarding specific needs including eating, grooming, personal hygiene, communication, oral hygiene, transfers and ambulation. II. Resident #35 A. Resident status Resident #35, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included degeneration of the brain, vascular dementia and need for assistance with personal care. The 10/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS). The resident was assessed to have difficulty focusing attention and had disorganized thinking with an altered level of consciousness. The assessment indicated the resident was dependent on staff to complete most ADLs and needed maximal assistance to complete oral hygiene. B. Resident observation and interview On 1/13/25 at 10:28 a.m. Resident #35 was in bed. Resident #35's teeth had a heavy build-up of whitish matter on the surface of his teeth and in between each visible tooth on the top and bottom jaw. His nails were long, jagged and dirty. Because his fingers were contracted, the tips of his nails were resting directly on his palms. Resident #35 was interviewed on 1/13/25 at 10:29 a.m. Resident #35 said he felt terrible and shook his head yes when asked if he was thirsty and wanted his teeth brushed. Resident #35 tried to extend his finger to move his nails from resting on his palm but he was unable to move his fingers far enough to relieve the pressure on his palms. On 1/14/25 at 8:05 a.m. Resident #35's nails were still long and dirty and his teeth were still covered with a thick layer of white buildup. C. Resident representative interview Resident#35's representative was interviewed on 1/15/25 at 11:30 a.m. The representative said facility staff had been avoiding providing consistent care and had not been brushing the Resident #35's teeth lately. The representative said that hospice care aides came in a couple of times a week and used an oral swab to remove the food buildup on his teeth and other than the oral care she provided, the resident's teeth were not being cleaned. The representative said the nursing staff was not cutting or cleaning the resident's nails so she brought in nail clippers and cut his nails for him. D. Record review Resident #35's comprehensive care plan, revised 3/7/24, documented a care focus that the resident had a self-care performance deficit related to peripheral neuropathy and mild cognitive impairment. Interventions documented Resident #35 required substantial to maximal assistance from staff to complete oral care and personal hygiene. -There was no care focus for nail care, cleaning nails or maintaining trimmed nails to protect skin integrity. Resident #35's bedside Kardex (care plan instruction for the certified nurse aides (CNA) documented a skincare focus with interventions that included encouraging the resident to avoid scratching and keeping the resident's hands and body parts from excessive moisture and keeping the resident's fingernails short. E. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 1/14/25 at 1:10 p.m. CNA #8 said Resident #35 was dependent on staff for the completion of all ADLs. CNA #35 observed Resident #35's teeth and acknowledged they needed to be cleaned. CNA #8 said the nurse would cut the resident's nails. Licensed practical nurse (LPN) #5 was interviewed on 1/14/25 at 1:55 p.m. LPN #5 said Resident #35 required total assistance with brushing her teeth and the CNAs would trim the resident's nails on both days. LPN #5 said it was the hospice CNAs responsibility to assist the resident with grooming tasks when they came to the facility to work with the resident. LPN #5 said he would follow up with the resident's care needs and ask the facility CNAs to provide the needed care. 20287 III. Resident #34 A. Resident status Resident #34, age 72, was admitted on [DATE]. According to the January 2025 (CPO), diagnoses included multiple sclerosis (MS). The 10/1/24 MDS assessment revealed the resident had minimal cognitive impairment with a BIMS score of 13 out of 15. The resident required partial assistance with oral hygiene and total assistance with repositioning. B. Failed to provide oral care 1. Resident interview and observation Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she had not had her teeth brushed for some time. She said she needed to tell the staff to brush her teeth because they did not help her. The resident had foul smelling breath and a white substance visible on her upper teeth. Resident #34 was interviewed a second time on 1/15/25 at 10:08 a.m. Resident #34 said she had not had her teeth brushed. She continued to have foul smelling breath and the white substance was still visible on her upper teeth. On 1/15/25 at 10:24 a.m. CNA #3 brushed Resident #34's teeth. The resident did not participate in the teeth brushing task. After her teeth were brushed, Resident #34 said she felt so much better. 2. Record review Resident #34's care plan, revised 12/30/24, identified the resident had a self-care performance deficit related to MS, muscle spasms and glaucoma. Pertinent interventions included providing the resident with partial to moderate assistance with teeth brushing. Review of the CNA task documentation for Resident #34's oral care revealed the resident was set up to brush her teeth on 1/13/25, 1/14/25 and 1/15/25. -There was no other documentation to indicate the CNAs had provided assistance with Resident #34's oral care. 3. Staff interviews CNA #1 was interviewed on 1/15/25 at 10:19 a.m. CNA #1 observed Resident #34's mouth and teeth. CNA #1 said the resident had foul smelling breath and she had a white substance on her teeth which indicated her teeth had not been brushed. Registered nurse (RN) #2, who was the unit manager for the Golden Gate unit, was interviewed on 1/15/25 at 12:35 p.m. RN #2 said Resident #34 required full staff assistance with brushing her teeth. She said residents' teeth should be brushed in the morning and the evening. She said she would talk with the staff in regards to the importance of brushing residents' teeth. The director of nursing (DON) was interviewed on 1/15/25 at 6:00 p.m. The DON said residents' teeth should be brushed twice a day, once in the morning and again before bed. C. Failed to provide repositioning 1. Resident interview Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she was assisted by staff to get out of bed in the morning, sometimes as early as 6:00 a.m. The resident said she stayed up in her wheelchair until the staff laid her back down in the afternoon. She said a mechanical lift was used for her transfers and the staff did not reposition her during the time she was up in her wheelchair. Resident #34 said she had been a registered nurse and she knew she needed to be repositioned more frequently. She said her bottom got sore from not being repositioned but she said she did not have any open areas on her bottom. Resident #34 was interviewed a second time on 1/15/25 at 10:08 a.m. Resident #34 said staff got her out of bed at approximately 7:00 a.m. that morning (1/15/25). 2. Resident observations On 1/15/25 at 7:55 a.m. Resident #34 was sitting up in her wheelchair in the common area. During a continuous observation on 1/15/25, beginning at 8:44 a.m. and ending at 12:35 p.m., the following was observed: At 8:44 a.m. Resident #34 was sitting in the common area in her wheelchair. The reclining wheelchair was slightly tilted backward. At 9:01 a.m. the resident was visiting with her husband. The resident was assisted to another common area for visiting in private. At 10:00 a.m. Resident #34 was assisted back to the common area after her visit with her husband. At 10:05 a.m. CNA #1 assisted Resident #34 to her room so he could administer an injection. CNA #1 did not offer to reposition the resident. At 10:24 a.m. CNA #3 assisted Resident #34 with brushing her teeth. CNA #3 did not offer to reposition the resident. At 10:36 a.m. Resident #34 was assisted to an activity. At 11:00 a.m. CNA #4 assisted the resident from the activity and transported her to the dining room in her wheelchair. CNA #4 did not offer to reposition the resident. At 12:18 p.m. Resident #34 was assisted away from the dining room and transported back to her room. The resident asked to lay down and the unidentified CNA told the resident that CNA #3 would be back later. At 12:42 p.m. Resident #34 was laid down in bed with the use of the mechanical hoyer lift. -Resident #34 was in her wheelchair for three hours and 58 minutes during the continuous observation without being provided or offered repositioning assistance from the staff. 3. Record review Resident #34's care plan, revised 12/30/24, identified the resident had a potential for pressure ulcer development related to MS and weakness. The resident had a history of pressure injuries. Pertinent interventions included repositioning the resident throughout the night as the resident would tolerate. -The care plan did not include how often to offer the resident assistance with repositioning while she was in her wheelchair. 4. Staff interview Registered nurse (RN) #2 was interviewed on 1/15/25 at 12:35 p.m. RN #2 said the resident required full staff assistance with a mechanical lift for transfers. She said the resident was unable to reposition herself. She said Resident #34 was at risk for pressure injuries and the resident should be repositioned at least every two hours. RN #2 said staff had been trained to offer the every two hour repositioning to the resident. -However, observations revealed staff did not offer to reposition Resident #34 for almost four hours when she was sitting up in her wheelchair (see observations above). 52045 IV. Resident #25 A. Resident status Resident #25, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included history of urinary tract infections, pressure ulcer of the right buttock (stage 4), multiple sclerosis, Parkinson's disease and quadriplegia. The 1/10/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required maximum staff assistance with transfers, toileting and showering. B. Resident observation and interview On 1/13/25 at 10:30 a.m. Resident #25 was in her room sitting in her wheelchair and leaning to her left side. On 1/13/25 at 2:00 p.m. Resident #25 was in her room sitting in her wheelchair and leaning to her left side. Resident #25 was interviewed on 1/13/25 at 2:30 p.m. Resident #25 said she was left in her wheelchair all day even though she asked staff to put her back to bed after breakfast. Resident #25 said staff had not repositioned her since getting into her wheelchair at 6:00 a.m. this morning (1/13/25). On 1/13/25 at 3:34 p.m. Resident #25 was in her room still sitting in her wheelchair, in the same position, leaning to the left side. CNA #2 and RN #2 entered the resident's room with a mechanical lift to put Resident #25 to bed. Resident #25 was interviewed on 1/15/25 at 8:30 a.m. Resident #25 said CNA #2 got her up at 6:00 a.m. this morning (1/15/25). Resident #25 said she requested to stay in bed until 9:00 a.m. but she was told by CNA #2 that she had to get out of bed. Resident #25 said she was uncomfortable in her wheelchair because it was too small but staff did not give her any other option. On 1/15/25 during a continuous observation, beginning at 8:30 a.m. and ending at 12:30 p.m., the following was observed: At 8:30 a.m. Resident #25 was in her room sitting in her wheelchair and leaning to the left side. At 9:57 a.m., director of rehabiliation (DOR) entered Resident #25's room and asked Resident #25 if she wore her pressure-relieving boots all the time. At 11:35 a.m., a CNA #1 entered Resident #25's room and escorted the resident to the dining room for lunch. CNA #1 did not assist or offer to reposition the resident before taking the resident to the dining room. At 12:15 p.m. a CNA #1 assisted Resident #25 back to her room. CNA #1 did not reposition the resident. The resident was left sitting up in her wheelchair in her room. At 12:21 p.m., Resident #25 put her call bell on requesting to go to bed. CNA #1 entered the resident's room and told Resident #25 she had to wait for CNA #2 to return from break. Resident #25 was interviewed on 1/15/25 at 12:30 p.m. Resident #25 said she asked to go back to bed and was told that she had to wait until CNA #2 returned because CNA #2 went to lunch. At 12:50 p.m. CNA #1 and CNA #2 entered Resident #25's room and transferred her to bed. -Resident #25 sat up in her wheelchair in the same position without repositioning for four hours and 20 minutes. D. Record Review Review of the comprehensive care plan, revised on 11/4/24, revealed Resident #25 had a pressure ulcer on her buttock. The care focus goal was for the resident's pressure ulcer to show signs of healing. Interventions included frequent repositioning with staff assistance. The bedside Kardex, dated 1/14/25, revealed staff should offer and encourage Resident #25 to accept turning and repositioning assistance, as necessary. Review of the resident's electronic medical record (EMR) ADL task response history revealed Resident #25 did not refuse any offers for repositioning from staff. E. Staff interviews RN #2 was interviewed on 1/15/25 at 12:35 p.m. RN #2 said offloading, turning and repositioning for residents who were unable to perform the task on their own should be provided by staff every two hours. The DON and the assistant director of nursing (ADON) were interviewed together on 1/16/25 at 5:46 p.m. The DON said physically dependent residents needed to be repositioned every two hours or more frequently if the resident had a pressure wound. The DON said the CNAs were trained on the importance of repositioning dependent residents to relieve pressure points. -Documentation of the last resident positioning training for staff was requested but was not provided by the facility as of the conclusion of the survey on 1/16/25.

Based on observations, record review and interviews, the facility failed to provide the resident the right to make choices about aspects of his life in the facility that are significant to the resident related to left leg prosthetics for one (#55) of one resident out of 59 sample residents. Specifically, the facility failed to honor Resident #55's requests to be fitted and provided with a left leg prosthetic which he had prior to being admitted to the facility. Findings include: I. Resident #55 A. Resident status Resident #55, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included bipolar disorder (mental illness that causes shifts in a person's behaviors), current episode of depression and acquired absence of left leg above the knee. The 11/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required set up assistance with chair to chair transfer and toileting. B. Observations On 1/13/25 at 2:30 p.m. Resident #55 was observed in his room sitting in his wheelchair and had a left above the knee amputation (AKA) and did not have a prosthetic leg to fit his AKA. C. Resident interview Resident #55 was interviewed on 1/13/25 at 2:33 p.m Resident #55 said that he had asked for a new left leg prosthetic since he arrived at the facility and had not yet received assistance to get the prosthetic. Resident #55 said he was not allowed to bring his prosthetic to the facility due to having bed bugs at his previous home. He believed his prosthetic was thrown away. Resident #55 said he was not given many options and choices regarding his health care and not having the prosthetic leg made him feel bad because he had to depend on other people for things he could do on his own. Resident #55 said he spoke with therapy and the director of nursing (DON) in October 2024 about getting a new prosthetic leg and was still waiting for an answer. D. Record review Record review of the physician's progress note dated 7/5/24 revealed that the resident was able to ambulate (walk) when using a prosthetic leg. The interdisciplinary team (IDT) progress note dated 10/22/24 revealed the resident requested to be fitted with a new prosthetic leg and a physician's order was written to follow up with a prosthetics provider. -However, review of Resident #55's electronic medical record (EMR) did not reveal any documentation regarding follow up on the referral. E. Staff interviews The social services director (SSD) was interviewed on 1/16/25 at 12:12 p.m. The SSD said Resident #55's medical provider was responsible for following up on getting the resident his prosthetic device. The SSD said there should have been documentation in the resident's chart on the status of the prosthetic. She said she was not aware of the status of the referral. The nursing home administrator (NHA) was interviewed on 1/16/25 at 2:00 p.m. The NHA said the therapy department was responsible for assessing Resident #55 for a prosthetic leg and making a referral for the device if needed. The NHA said the resident did not have a referral for a prosthetic fitting but he recently made a referral and the resident had an appointment coming up on 2/5/25, through his physician's office. The director of rehabilitation (DOR) and the physical therapy assistant (PTA) were interviewed on 1/16/25 at 2:19 p.m. The PTA said the facility's process, once a resident was referred for therapy services, was to evaluate the resident's level of functioning and determine their assistive needs. The PTA said Resident #55 was assessed and the therapist did not recommend a new prosthetic leg because the resident did not express a desire to transfer or walk. The PTA said that the only reason that the therapy department would provide a resident with a prosthetic leg was if the resident wanted it for walking or transferring. The PTA said per the physical therapy (PT) initial evaluation note dated 6/23/24, the resident declined to work with PT with a front wheel walker and said that he preferred to use a wheelchair to get around. The PTA said on evaluation, Resident #55 was independent with bed mobility and supervision with transfers from bed to wheelchair. The PTA said Resident #55 was also able to propel himself 150 feet independently.

Based on record review and interviews, the facility failed to ensure residents received treatment and care which met professional standards of practice, and was consistent with comprehensive assessments and comprehensive care plans, for two (#2 and #3) residents out of four sample residents. Specifically, the facility failed to fully assess Resident #2 to find the source of an infection which resulted in the resident being hospitalized on [DATE]; failed to assess the resident after reports of confusion, shortness of breath and distress on [DATE]; and failed to take timely action to treat the resident after rectal bleeding was discovered on [DATE]. The facility failed to timely assess pain and possible injury to Resident #3 after a fall out of bed on [DATE]. The resident suffered a fall out of bed on [DATE] and reported generalized pain. However, an x-ray was not completed until [DATE] (three days later) which revealed a distal femur fracture above the resident's knee. Cross-reference F689, fall/accident with injury. Findings include: I. Facility policy and procedure The Change of Condition policy, revised February 2021, was provided electronically by the assistant administrator (ANHA) on [DATE] at 5:30 p.m. It read, in pertinent part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status. -Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the change of condition assessment form. -The nurse will record in the resident's medical record information relative to changes in the resident's medical and mental condition or status. -If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required. II. Resident #2 A. Resident status Resident #2, age 74, was admitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance of one staff member with mobility and activities of daily living (ADLs). He reported occasional pain and shortness of breath at rest. He experienced falls, a major vascular surgery and had two venous ulcers and surgical wounds. B. Assessment of infection 1. Record review On [DATE] Resident #2 experienced four falls with no injury, he was assessed for injuries and neurological checks were completed. A nursing note at 10:18 p.m. revealed the resident was on monitoring for falls and reported pain and discomfort in his legs. Two skin assessments were documented on [DATE], at 5:15 a.m. and 9:46 a.m., with no skin issues noted for the resident at the time. Laboratory testing was ordered and completed for the resident on [DATE] and results received on [DATE] showed a critically high white blood cell count which indicated an infection. The results of the urinalysis showed no urinary tract infection and the chest x-ray revealed no signs of pneumonia. Repeat laboratory testing was ordered and completed on [DATE] and results received on [DATE] showed the resident's white blood cell count was still high, but not critically. The resident was started on antibiotic medication on [DATE]. Resident #2 experienced three more falls with no injury between [DATE] and [DATE] and assessments read the resident had no bumps or bruises and skin was warm and intact. The resident did not complain of pain or discomfort and his range of motion was within normal limits. On [DATE] the resident was ordered to receive intravenous fluids for weakness. A [DATE] change of condition assessment revealed the nurse was called to the resident's room to assess the color and temperature of his leg. The assessment revealed the resident's leg was warm to the touch and the resident reported pain when touched. The resident's leg was weeping fluid, and was cleansed with normal saline and wrapped. The resident's physician was called and gave orders to send the resident to the emergency department for further evaluation. Hospital records from [DATE] were reviewed and revealed the resident presented with altered mental status and left lower extremity pain, clinically consistent with [CONDITION(S)] from venous stasis ulcers and concern for [CONDITION(S)] due to dark toe. He was diagnosed with [CONDITION(S)] of the left lower leg and diabetic ulcers of his second and third toes. Hospital records revealed family reported changes to the resident's baseline cognition for the past five days and the resident's leg was noted by family to be erythematous (abnormal redness), warm to the touch, and swollen the day before in the facility. The resident endorsed experiencing pain in the affected leg for a few days. His left lower leg distal to the knee was notable for diffuse [CONDITION(S)] palpable warmth, and chronic appearing wounds. The left lower leg [CONDITION(S)] and the ulcers of the second and third left toes were determined to be the cause of the resident's infection. 2. Provider interview The resident's medical provider was interviewed on [DATE] at 10:30 a.m . He stated the facility should have completed full skin assessments on the resident with each fall and should have completed an assessment of his legs when he complained on the evening of [DATE]. He stated it was unlikely that the resident developed leg and toe wounds overnight. He stated a full skin assessment should have been completed to try to determine the cause of the resident's infection which was indicated by the lab work completed on [DATE] and [DATE]. 3. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:27 p.m. She stated if a resident reported pain in an area, the area should be assessed and there should be documentation of the assessment of the area. She stated a full skin assessment should always include legs, feet and toes. LPN #2 was interviewed on [DATE] at 12:49 p.m. She stated resident pain and discomfort should be assessed and documented. She stated if a resident had signs of an infection, staff should try to determine the cause and a skin assessment would be included in the assessment. She stated a full skin assessment should include all skin, head to toes. The director of nursing (DON) was interviewed on [DATE] at 1:15 p.m. She stated the staff should have done a full skin assessment on the resident in an effort to determine the cause of infection. She stated a skin assessment should have been documented in the record. She stated through daily care and fall assessments, the [CONDITION(S)] and toe eschar (dry, dead skin) should have been identified sooner. C. Assessment after reports of distress 1. Record review Resident #2 returned to the facility on [DATE] after a scheduled vascular bypass surgery. A nursing note on [DATE] at 8:42 p.m. revealed the resident's son called the facility and reported he had just been speaking to the resident and he seemed distressed, out of breath and confused. The writing nurse documented she went to check on the resident who was lying in bed with his nasal cannula laying next to him and his legs slightly elevated. She asked the resident if he was in any distress, he stated he was on the phone with his son, though he felt he had lost track of what was going on. The nurse documented she helped him replace his nasal cannula and left the room to report to his son. -There was no documented assessment of the resident's condition or his vital signs at the time of the report that the resident was in distress. A nursing note on [DATE] at 12:32 a.m. revealed the resident was alert and oriented to person and place, though had been anxious and restless throughout the night, had reported he felt he had lost track of what was going on and his life was in shambles. Active listening was provided to the resident and he seemed to calm down. He was medicated with [MEDICATION(S)] 5 mg for a report of pain ,d+[DATE] (seven out of 10, severe pain). He had been incontinent of bowel and bladder and continued to remove his nasal cannula through the night. 2. Staff interviews LPN #3 was interviewed on [DATE] at 12:57 p.m. She stated she was taking care of the resident the night his son called. She stated she went to check on the resident and he did not seem to be in any distress. She stated he was confused but stated he was fine. She stated she did not remember if she had taken his vital signs when she went to check on him, though stated she did take them later on in the night. The DON was interviewed on [DATE] at 1:15 p.m. She stated a full assessment of the resident's condition should have been conducted and documented which would include a full set of vitals. She stated the nurse would be educated. D. Timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Record review A nursing note on [DATE] at 1:15 p.m. revealed the resident was experiencing anal bleeding with bright red blood. No hemorrhoids were visible and the site of the bleeding was not visible from the outside. The resident was receiving [MEDICATION(S)] (anticoagulant) 100 mg post surgery. The nurse called to inform the physician and left a voice message. A nursing note on [DATE] at 3:54 p.m. revealed the nurse attempted to call the resident's physician a second time with no answer. A nursing note on [DATE] at 4:51 p.m. revealed the physician called back and gave the nurse orders to hold the resident's [MEDICATION(S)] that evening and would review the resident's orders to make changes if needed. A nursing note on [DATE] at 11:25 p.m. revealed the resident was yelling for help at 7:30 p.m. and stating he could not breathe. His oxygen was increased which was ineffective. The nurse obtained a rebreather mask which was also ineffective. The nurse called 911 and started chest compressions and continued CPR (cardiopulmonary resuscitation) until EMTs (emergency medical technicians) arrived. The EMTs took over CPR, though this was unsuccessful and the resident was pronounced dead at 8:20 p.m. 2. Provider interview The resident's medical provider was interviewed on [DATE] at 10:30 a.m. He stated he remembered the situation with the resident's bleeding. He stated the resident's nurse called with a concern of anal/rectal bleeding and concern the resident's [MEDICATION(S)] dose was too high. He stated if the resident was bleeding profusely, then 911 should have been called, though the nurse would have to be the judge of the seriousness of the bleeding. 3. Staff interviews Registered nurse (RN) #1 was interviewed on [DATE] at 12:18 p.m. He stated the resident had bright red blood in his brief and he called the doctor immediately after discovery. He stated it was enough blood for him to be concerned about the resident and his anticoagulant medication, but not enough where he felt he needed to call 911. He stated if he thought the resident was in immediate danger, he would have called the facility medical director, 911, and notified the director of nursing. The DON was interviewed on [DATE] at 1:15 p.m. She stated if a resident was in medical distress or having an emergency and the resident physician could not be reached, the nurse should call the medical director to obtain orders to treat or to send to the emergency room . She did not say the nurse should call 911. III. Resident #3 A. Resident status Resident #3, age 88, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance of two staff members with bed mobility, transfers, and ADLs. B. Record review revealed treatment delays after the resident's [DATE] fall A nursing note dated [DATE] revealed the registered nurse was called to the resident's room to assess the resident after a fall out of bed. The resident was being changed by a certified nurse aide (CNA) and rolled off of the bed onto the floor. The resident was assessed to have small bruises on her left forearm and a scratch to her right buttock. She was able to move all of her extremities with no difficulty and did not complain of pain. A physician assistant note dated [DATE] revealed the resident was prescribed [MEDICATION(S)] 5 mg for one time only for reports of right knee pain. The physician note continued the resident had a fall out of her bed the night before and was complaining of increased pain (full body) and was treated with aspercreme (topical analgesic) and an extra [MEDICATION(S)] tab. The physician saw the resident the day prior with a concern of increased abdominal girth and she had an abdominal and lung x-ray that showed colonic fecal residual but no concerning findings. The resident was on scheduled [MEDICATION(S)] but her pain is worse and will continue to monitor for one time extra [MEDICATION(S)] given that morning and the pain is 'whole body' and 'likely due to the fall.' A nursing note dated [DATE] at 10:00 a.m. revealed the resident received a one time dose of [MEDICATION(S)] due to pain from her fall from the previous night. The resident's skin was assessed for any injury and none were apparent, though the resident stated she was feeling overall general pain. A nursing note dated [DATE] at 2:03 p.m. revealed the CNA who was providing care to the resident the previous night was provided education related to how to properly roll a resident on an air mattress. (See MDS assessment above, the resident required two-person assistance for bed mobility.) A nursing note dated [DATE] at 9:30 p.m. revealed the resident continued on monitoring for the previous fall. She was assisted with scheduled pain medications, frequent repositioning and checking and changing. She refused to get up in her recliner and refused her shower. A nursing note dated [DATE] at 11:03 a.m. revealed a stat x-ray of the resident's right knee was ordered related to pain from her previous fall. The x-ray was taken at 8:15 p.m. on [DATE] and results were received on [DATE] at 7:30 a.m. and revealed osteopenia and an acute non-displaced distal femoral shaft fracture. The facility medical director gave orders to send the resident to the emergency department on [DATE] at 10:25 a.m. and the resident left at 11:15 a.m. The resident returned to the facility on [DATE] with a brace to her right knee as she was determined to not be a surgical candidate to repair the fracture. -The resident reported increased pain and an x-ray was not performed until three days after the fall incident. (Cross-reference F689 Accidents). C. Resident interview Resident #3 was interviewed on [DATE] at 12:09 p.m. She stated the CNAs who were assisting her during the brief change rolled her off of the bed by accident. She stated the nurse came to assess her and they got her back into bed but she did have a lot of pain from the fall. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:27 p.m. She stated if a resident was experiencing pain after a fall, the resident's physician should be called and an x-ray should be done to rule out injury. Certified nurse aide (CNA) #1 was interviewed on [DATE] at 12:46 p.m. He stated if a resident was two-person assist for bed mobility and changing CNAs should be on opposite sides of the bed to ensure proper body mechanics and to prevent the resident from falling out of bed. He stated Resident #3 was a two-person assist for bed mobility and turning, though he was not working the night the resident fell . LPN #2 was interviewed on [DATE] at 12:49 p.m. She stated when a resident falls, a registered nurse needed to be called to assess the resident for injury. She stated if the resident had pain, the nurse needed to identify where the pain was, assess the area and call the physician for additional orders. CNA #2 was interviewed on [DATE] at 12:55 p.m. She stated Resident #3 was a two-person assist for bed mobility and needed two people to turn her. She stated there should be one CNA on each side of the bed to ensure the resident did not fall. She stated the CNA staff had received training after the resident fell related to proper body mechanics and two assists for bed mobility. The director of nursing (DON) was interviewed on [DATE] at 12:47 p.m. She stated the resident's fall was investigated and revealed the resident was being changed by one staff member and the resident assisted in her bed mobility by holding the side of the bed and throwing her leg over her body which gave her momentum and she fell off the bed. She stated, at the time of her fall, she was determined to be a one-person assist for bed mobility, though was now a two-person assist due to this incident. -However, the resident required two staff assistance for bed mobility and transfer according to the [DATE] MDS assessment. She stated the resident did not complain of pain until two days after her fall and also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -However, the physician noted one day after the fall the resident was having increased right knee and full body pain.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#3) out of four sample residents. Specifically, the facility failed to prevent a fall out of bed with injury for Resident #3 on 8/3/22. The resident was accidentally rolled out of bed by staff during a brief change on 8/3/22, the resident reported pain and an x-ray was performed on 8/6/22 where the resident was found to have a distal femur fracture. Findings include: I. Facility policy and procedure The Fall Prevention policy, updated 7/20/21, was provided electronically by the nursing home administrator (NHA) on 8/26/22 at 5:00 p.m. It read, in pertinent part: A fall can be defined as: when a resident is found on the floor; a resident slides to the floor unassisted; a resident rolls off the bed/chair onto the floor, including bedside mat; and a resident falls off any apparatus/equipment used for transfers. If a fall occurs, the following will be done: -The licensed nurse will complete a thorough assessment of the resident to evaluate for injury. -The licensed nurse will notify the physician and the family/responsible party. -Treatment will be initiated per physician orders. -An incident report will be completed. II. Resident #3 A. Resident status Resident #3, age 88, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), the diagnoses included cerebral infarction, chronic [CONDITION(S)], heart failure, primary [CONDITION(S)] of left shoulder, unilateral [CONDITION(S)] of right knee, [CONDITION(S)], chronic pain, and chronic [CONDITION(S)]. The 6/28/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance of two staff members with bed mobility, transfers, and ADLs. B. Record review An activities of daily living (ADL) care plan, initiated on 2/11/22 and updated on 6/29/22, read: Resident has an ADL self-care performance deficit . with pertinent interventions including: Resident requires extensive assistance by two staff physical assist to turn and reposition in bed and as necessary, which was initiated on 2/11/22 and revised on 8/25/22. A toilet use intervention initiated 2/11/22 read: The resident requires extensive assistance of two staff. A fall care plan, initiated on 2/11/22 and updated on 3/14/22, read: Resident is at risk for falls r/t (related to) Hx (history) of falling, Muscle spasm, [CONDITION(S)] and restless leg syndrome, Vitamin D deficiency, acute and chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)] with alveolar hypoventilation. A nursing note dated 8/3/22 revealed the registered nurse was called to the resident's room to assess the resident after a fall out of bed. The resident was being changed by a certified nurse aide (CNA) and rolled off of the bed onto the floor. The resident was assessed to have small bruises on her left forearm and a scratch to her right buttock. She was able to move all of her extremities with no difficulty and did not complain of pain. A physician assistant note dated 8/4/22 revealed the resident was prescribed [MEDICATION(S)] 5 mg for one time only for reports of right knee pain. The physician note continued the resident had a fall out of her bed the night before and was complaining of increased pain (full body) and was treated with aspercreme (topical analgesic) and an extra [MEDICATION(S)] tab. The physician saw the resident the day prior with a concern of increased abdominal girth and she had an abdominal and lung x-ray that showed colonic fecal residual but no concerning findings. The resident was on scheduled [MEDICATION(S)] but her pain is worse and will continue to monitor for one time extra [MEDICATION(S)] given that morning and the pain is 'whole body' and 'likely due to the fall.' A nursing note dated 8/4/22 at 10:00 a.m. revealed the resident received a one time dose of [MEDICATION(S)] due to pain from her fall from the previous night. The resident's skin was assessed for any injuries and none were apparent, though the resident stated she was feeling overall general pain. A nursing note dated 8/4/22 at 2:03 p.m. revealed the CNA who was providing care to the resident the previous night was provided education related to how to properly roll a resident on an air mattress. A nursing note dated 8/5/22 at 9:30 p.m. revealed the resident continued on monitoring for the previous fall. She was assisted with scheduled pain medications, frequent repositioning and checking and changing. She refused to get up in her recliner and refused her shower. A nursing note dated 8/6/22 at 11:03 a.m. revealed a stat (immediate) x-ray of the resident's right knee was ordered related to pain from her previous fall. The x-ray was taken at 8:15 p.m. on 8/6/22 and results were received on 8/7/22 at 7:30 a.m. and revealed osteopenia and an acute non-displaced distal femoral shaft fracture. The facility medical director gave orders to send the resident to the emergency department on 8/7/22 at 10:25 a.m. and the resident left at 11:15 a.m. The resident returned to the facility on [DATE] with a brace to her right knee as she was determined to not be a surgical candidate to repair the fracture. -The resident reported increased pain and an x-ray was not performed until three days after the fall incident. (Cross-reference F684 Quality of Care). III. Resident interview Resident #3 was interviewed on 8/23/22 at 12:09 p.m. She stated the CNAs who were assisting her during the brief change rolled her off of the bed by accident. She stated the nurse came to assess her and they got her back into bed but she did have a lot of pain from the fall. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/25/22 at 12:27 p.m. She stated if a resident was experiencing pain after a fall, the resident's physician should be called and an x-ray should be done to rule out injury. Certified nurse aide (CNA) #1 was interviewed on 8/25/22 at 12:46 p.m. He stated if a resident needed two-person assist for bed mobility and changing, CNAs should be on opposite sides of the bed to ensure proper body mechanics and to prevent the resident from falling out of bed. He stated Resident #3 was a two-person assist for bed mobility and turning, though he was not working the night the resident fell . LPN #2 was interviewed on 8/25/22 at 12:49 p.m. She stated when a resident falls, a registered nurse needed to be called to assess the resident for injury. She stated if the resident had pain, the nurse needed to identify where the pain was, assess the area and call the physician for additional orders. CNA #2 was interviewed on 8/25/22 at 12:55 p.m. She stated Resident #3 was a two-person assist for bed mobility and needed two people to turn her. She stated there should be one CNA on each side of the bed to ensure the resident did not fall. She stated the CNA staff had received training after the resident fell related to proper body mechanics and two-person assists for bed mobility. The director of nursing (DON) was interviewed on 8/26/22 at 12:47 p.m. She stated the resident's fall was investigated and revealed the resident was being changed by one staff member and the resident assisted in her bed mobility by holding the side of the bed and throwing her leg over her body, which gave her momentum and she fell off the bed. She stated, at the time of her fall, she was determined to be a one-person assist for bed mobility, though was now a two-person assist due to this incident. She stated the resident did not complain of pain until two days after her fall and also had a history of arthritis in her knees. -However, assessments and staff interviews revealed the resident required two-person assistance for bed mobility before and after her fall with injury. In addition, she complained of pain one day after her fall as noted by the physician.

Based on record review, observations, and interviews, the facility failed to ensure that two (#5 and #6) out of 11 sample residents received care and services to prevent the development and worsening of pressure injuries. Resident #5 was dependent on staff for mobility, transfers and repositioning and was identified at risk for developing pressure injuries. The facility failed to prevent the development and worsening of a pressure injury for Resident #5. On 11/18/21 an unstageable pressure injury was discovered on Resident #5's coccyx. The facility failed to implement wound care orders until 11/20/21, two days after discovery, and failed to implement an air mattress until 11/25/21, seven days after discovery. The resident was noted to be resistant to care with minimal documentation done in response to the resident's resistance including a comprehensive assessment by the interdisciplinary team. Wound care treatment orders were not consistently followed. Due to the facility's failures, the resident developed an avoidable, facility acquired unstageable pressure wound to her coccyx. The resident was transferred to the hospital on 1/7/22 where she was discovered to have sacro-coccygeal (coccyx area) [CONDITION(S)] (bone infection) which required intravenous antibiotics. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Based on the initial MDS assessment 9/29/21, the resident was at risk for developing pressure ulcers but had no unhealed pressure ulcers. A nurse's note dated 9/30/21 indicated the resident had a darkened area to the right heel. The facility failed to consistently monitor the right heel after the 9/30/21 nurse's note that indicated he had a darkened area to his right heel. In addition, he had moisture associated skin damage to his coccyx on 11/21/21. On 1/18/22, it was documented the coccyx wound was resolved per the wound doctor. Due to the inconsistencies in monitoring of his skin to include pressure injuries, he developed an unstageable right heel wound on 12/5/21 and unstageable coccyx wound on 1/25/22 as indicated in the wound doctor's notes. Furthermore, the facility failed to provide wound care treatments consistent with professional standards of practice, to an existing pressure ulcer to promote wound healing, prevent worsening of the wound, and prevent potential cross contamination during wound care services for Resident #6 (Cross-reference F880, infection control practices). Moreover, the facility failed to identify and report a new area to the Resident #6's left hip and failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: I. Professional reference The National Pressure Ulcer Advisory Panel (2016) NPUAP Pressure Injury Stages, retrieved on 2/8/22 from: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed the following pertinent information: 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 [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] 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 [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], 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 [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. II. Facility policy and procedure The Pressure Ulcer Prevention Program policy, revised 10/8/2020, was provided by the assistant nursing home administrator (ANHA) on 2/1/22 at 4:47 p.m. It read, in pertinent part: All residents will be assessed for the risk of pressure ulcer development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to prevent the development of avoidable pressure ulcers, or, to treat existing pressure ulcers. All residents will be screened for risk of pressure ulcer development utilizing the braden scale. This will be done at the time of admission/readmission, for 4 weeks thereafter, then quarterly and upon significant change in condition. Residents identified as being at risk will have interventions identified in their plan of care to prevent the occurrence of pressure ulcers. All residents will have a head to toe assessment completed on a weekly basis by a licensed nurse to identify any skin breakdown. The results of this assessment will be documented in the resident's medical record. If a pressure ulcer or skin breakdown is identified, the following will be done: -The licensed nurse will complete a thorough assessment of the affected area. The assessment must include size, stage, location, drainage, and color. -The licensed nurse will notify the physician and family. -Treatment will be initiated per physician orders. -The resident's plan of care will be updated to reflect interventions. -The interdisciplinary team will be notified so that appropriate referrals may made to the dietician, therapy, etc. -The licensed nurse will assess the area on a weekly basis to determine progress and modify treatment as appropriate. The DON (director of nursing) or designee will track and monitor pressure ulcers weekly. In the event the primary assessing nurse is not by state practice act allowed to stage a pressure ulcer, then the DON/RN (registered nurse) must view and stage the pressure ulcer weekly. The DON/designee will report results to the quality assurance improvement committee on a quarterly basis. The Pressure Ulcer Prevention and Treatment Toolkit, revised July 2018, was provided by the assistant nursing home administrator (ANHA) on 2/1/22 at 4:47 p.m. It read, in pertinent part: This toolkit is intended to assist the resident's care team in assessing, developing the plan of care, monitoring the plan implementation and effectiveness, and revising the plan of care, as indicated, to meet the individual resident's needs. -Skin assessment: Regularly conduct thorough skin assessment on each resident who is at risk of developing pressure ulcers. Such skin assessments allow early detection of developing or existing skin breakdown or to verify the integrity of the skin. The assessments help to identify the ability of the skin and underlying tissue to maintain integrity with reduction or redistribution of pressure (tissue tolerance) and assist in the development of prevention strategies. -When conducting skin assessments evaluate all areas at risk of constant pressure, with consideration of various areas that may be affected during the resident's daily activities related to: positioning in bed; positioning in chair with risks from slouching or sliding; use of medical devices; and presence of contractures or deformities. -Repositioning: Repositioning should occur at least every 2 hours, but more frequent repositioning may be warranted for individuals who are at higher risk for pressure ulcer development or who show evidence that repositioning at 2-hour intervals is inadequate. II. Resident #5 A. Resident status Resident #5, age 77, was admitted on [DATE] and discharged to the hospital 1/7/22. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/1/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of six out of 15. Rejection of care was not coded to be exhibited. She was totally dependent on staff for mobility, transfers, and activities of daily living (ADLs) and required extensive assistance of one staff member for eating and personal hygiene. She had an indwelling catheter, was always incontinent of bowel and did not have constipation. She received 51% or more of her nutrition and hydration through a feeding tube. She had an unstageable pressure injury that was not present on admission. She had a pressure reducing device for her bed and her chair and was on a turning and repositioning program. B. Record review Braden scale assessments completed weekly upon admission on 8/3/21, 8/10/21, 8/17/21, and 8/24/21 revealed the resident was at risk for pressure injuries. A new wheelchair with a gel cushion for wheelchair and recliner was provided by physical therapy on 8/30/21 due to resident's reluctance to transfer and change positions outside of therapy activities. The resident's ADL documentation from 8/3/21 to 1/7/22 when she discharged to the hospital was reviewed and revealed the resident received ADL services multiple times a day including but not limited to turning and repositioning, bowel management, catheter care, transferring, personal hygiene, and bed mobility. Turning and repositioning services were frequently refused by the resident. In September 2021 a bed mobility and active range of motion program was added for the resident twice a day three times a week to increase her movement and independence. These tasks were documented as completed or attempted with multiple resident refusals. A range of motion and bed mobility program care plan dated 8/31/21 read Resident to participate in range of motion and bed mobility program 3 x per week related to muscle weakness. The goal of the care plan read: Resident will be able to roll with assist of mod-max and verbal cueing techniques. Ensure resident can participate in ADL care, pressure redistribution, and proper body alignment. An ADL care plan revised on 12/16/21 read: Resident has an ADL self care performance deficit related to [CONDITION(S)], history of [CONDITION(S)], dementia, [CONDITION(S)], tremors, vitamin D deficiency, heart failure, [CONDITION(S)], diabetes mellitus II, [CONDITION(S)], and [CONDITION(S)]. An actual skin impairment care plan dated 11/19/21 read: The resident has actual impairment to skin integrity of the coccyx related to suspected deep tissue injury. Interventions included: Follow treatment order per physician order; Notify physician of any signs or symptoms of infection; Pressure reducing mattress to protect the skin while in bed; and Resident will be seen by wound doctor in the facility. A skin care plan dated 12/2/21 read: Resident has a pressure ulcer on coccyx, unstageable due to slough. The goal read: The pressure ulcer will show signs of healing and remain free from infection. Interventions included: Administer medications as ordered; Administer treatments as ordered and monitor for effectiveness; Apply lotion to dry skin prn (as needed); Assess/record/monitor wound healing with weekly wound rounds. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor); Barrier cream with incontinence care as needed; Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility; good nutrition and frequent repositioning; Follow facility policies/protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Document alternative methods; Inform the resident, family and caregivers of any new areas of skin breakdown; Instruct and assist to shift weight in wheelchair as tolerated; low air loss mattress for pressure re-distribution; monitor dressing to ensure it is intact and adhering. Report lose dressing to treatment nurse; monitor nutritional status. Serve diet as ordered, monitor intake and record; Teach resident and family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes; The resident needs to turn and reposition as needed per protocol or requested; Treat pain as per orders prior to treatment and turning to ensure resident's comfort. -The care plan did not indicate the resident refused to be repositioned or turned. Review of the resident's wound progress, therapy and nutrition notes revealed the resident was educated to the importance of repositioning, nutrition and participation in therapy for wound healing. The notes revealed the resident's family was informed of her condition and refusals, though there was no specific evidence of educating the family related to the risks or attempts to involve family to motivate the resident. A weekly body check dated 11/13/21 revealed the resident had no skin issues. An incident report dated 11/18/21 revealed the nurse was notified by the certified nurse aide (CNA) while changing the resident an open area on the coccyx was discovered. The wound nurse was notified and came to measure the wound 3 cm (centimeters) x 2 cm x .3 cm. The wound was cleaned with normal saline and covered with a dry protective dressing. The nurse practitioner was notified and a message was left for the resident's power of attorney. The unit manager and director of nursing were notified. The resident was educated to stay in bed and reposition as tolerated. -The incident report did not document whether muscle was exposed, slough was present or drainage noted. In addition, there was no stage of the pressure wound indicated on the incident report. A wound care order was entered onto the resident's treatment administration record (TAR) and read: Wound Care: Clean coccyx wound with normal saline, pat dry and apply skin prep peri-wound. Apply wet-to-dry and cover with foam dressing BID (twice daily) and as needed until the wound team evaluate and change dressing order on Monday, 11/22/2021, two times a day for Wound Care/skin integrity. Ordered on 11/20/21. -The wound care order was not added to the resident's TAR until two days after the wound was discovered on 11/18/21. A nutrition note dated 11/19/21 revealed the resident had a new wound on her coccyx and was encouraged to lie down and offload, however, the resident preferred to stay in her lounge chair versus lie down. (The registered dietitian) Recommended increase in nocturnal enteral nutrition (supplemental nutrition given via a feeding tube) by 180 ml (milliliters) to provide an additional 216 kcals, 10.8 g protein, and 144.9 ml of water and extend the run time to continue volume rate. Glucerna 1.2 (formula) at 60 ml/hour x 12 hours on at 5:00 p.m. and off at 5:00 a.m. via gtube (gastrostomy tube). Provides 720 ml enteral nutrition per day, 864 kcals (calories) per day, 43.2 g (grams) protein per day and 579.6 ml water. The updated estimated needs related to the new wound were approximately 1697-2007 kcal per day and protein 63 to 75 grams per day. The resident was reassessed by physical therapy on 11/20/21 due to the skin breakdown. A new NYOrtho (pressure reducing cushion) wheelchair cushion with gel insert was provided for the resident's wheelchair and recliner. A new tube feeding order was started on 11/22/21 for Glucerna 1.2 at 60 ml/hour for 9 hours (on at 5:00 p.m. and off at 5:00 a.m.) via g-tube. Provides 540 mL EN (enteral nutrition)/day,~ (estimated) 648 kcal/day, ~32.4 g PRO (protein)/day, and ~434.7 mL water/day. -Review of this order revealed the order was incorrectly worded where the run time was 12 hours but the order read nine hours. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was seen by the wound care physician during rounds on 11/22/21. The notes revealed the coccyx wound was an unstageable pressure injury obscured full thickness skin and tissue loss. Initial encounter measurements were 4 cm x 4 cm with no measurable depth. Muscle was exposed and the resident reported no pain. The wound bed was 75% slough and 25% granulation. The skin texture, moisture, and color were normal. A debridement was performed where muscle and subcutaneous tissue were removed along with slough. The resident reported no pain during the procedure. Post debridement measurements were 4 cm x 4 cm x .3 cm. Wound treatment orders were written to apply Dakin's gauze and cover with a foam dressing twice daily. Healing was expected to be delayed due to inevitable effects of aging. -However, the initial measurements obtained 11/18/21 on the incident report the wound measured 3 cm x 2 cm x .3 cm. There was an increase in size from the initial measurements. There was no comprehensive assessment by the IDT with the increase in wound size. A wound care order was entered on 11/22/21 to 12/16/21 which read: Wound Care: Clean coccyx wound with normal saline, pat dry and apply Dakin's Solution 0.25% on gauze then pack the wound with gauze the one soaked in dakin's solution and cover with Foam dressing BID (twice daily) and as needed, two times a day for Wound Care/skin integrity. -Review of the treatment administration record revealed the resident refused the wound treatment on the evening shift on 11/24/21 and the wound treatment was not completed on 11/26/21 or 11/27/21 on the evening shift though it was completed on the morning shift both days (11/26/21 and 11/27/21). an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The order for the low air loss mattress was seven days after the wound was discovered. The resident was dependent on staff for mobility, transfers and repositioning. The resident was seen by the wound care physician during rounds on 11/29/21. The notes revealed the coccyx wound was an unstageable pressure injury obscured full thickness skin and tissue loss. Measurements were 4 cm x 4 cm with no measurable depth. Muscle was exposed and the resident reported no pain. The wound bed was 80% slough and 20% granulation. The skin texture, moisture, and color were normal. No signs or symptoms of infection. The wound was improving. A debridement was performed where muscle and subcutaneous tissue were removed along with slough. The resident reported no pain during the procedure. Post debridement measurements were 4 cm x 4 cm x .3 cm. Wound treatment orders were written to clean the wound with normal saline, apply Dakin's gauze and cover with an ABD (abdominal gauze) pad twice daily. Healing was expected to be delayed due to inevitable effects of aging. A nutrition note dated 12/1/21 revealed the resident was being reviewed for a significant change due to recent unstageable pressure injury. Tube feeding was increased on 11/22/21 to meet increased needs due to continued varied oral intake. Physician assistant ordered a registered dietician consult to review oral intake for desired tube feeding wean. However resident's oral intake remains poor and declines to work with speech therapy for advancement. Decrease in tube feeding is not recommended at this time related to increased demand for wound healing. Spoke to resident, noted was only taking bites of cake. Juice and lunch untouched. Educated regarding increased needs to heal wound. Educated for goal to eat 50% of meals in order to reduce the need for tube feedings. Resident stated she did not want to talk about it. Re-emphasized the importance of intake for healing. Resident still drinking oral glucerna. Clarified with nurse tube feeding was running 12 hours for nocturnal feeding. -The enteral feeding order (see above) was corrected on 11/30/21 to reflect the run time of 12 hours. A nursing note dated 12/3/21 revealed the resident refused to be repositioned. The resident was educated related to the importance of repositioning for wound healing. The resident verbalized understanding but still did not allow staff to reposition her. The resident was seen by the wound care physician during rounds on 12/6/21. The notes revealed the coccyx wound was an unstageable pressure injury obscured full thickness skin and tissue loss. Measurements were 5 cm x 5 cm with no measurable depth. Muscle was exposed and the resident reported no pain. Undermining was noted at 12:00 and ending at 12:00 with a maximum distance of 2 cm. The wound bed was 90% slough and 10% epithelialization. The skin texture, moisture, and color were normal. No signs or symptoms of infection. There was no change noted in the wound progression. A debridement was performed where muscle and subcutaneous tissue were removed along with slough. The resident reported no pain during the procedure. Post debridement measurements were 5 cm x 5 cm x .3 cm. Wound treatment orders remained the same to clean the wound with normal saline, apply Dakin's gauze and cover with an ABD pad twice daily. Healing was expected to be delayed due to inevitable effects of aging. -Despite objective worsening of the wound with a larger measured size, undermining, and greater percentage of slough, the wound treatment orders were not changed. In addition, there was no comprehensive assessment by the IDT. -Review of the resident's December 2021 TAR revealed wound care was not provided on 12/2/21 on the evening shift. A nutrition note dated 12/6/21 revealed the RD spoke to the resident who was in bed with her lunch tray set up. She was noted to eat a few bites of mashed potatoes and meat and took sips of glucerna. The RD encouraged more intake. The resident agreed to try to eat more but did not take another bite during the visit. Discussed may need to try an additional protein supplement for wound healing. Resident continued to decline to eat more. Recommended 30 ml active protein liquid or equivalent twice a day for wound healing. An order was added on 12/6/21 to 12/29/21: Prostat two times a day 30 mL Active Protein Liquid or equivalent BID for wound healing. Attempt PO (oral intake). -Review of the resident's December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was seen by the wound care physician during rounds on 12/16/21. The notes revealed the coccyx wound was an unstageable pressure injury obscured full thickness skin and tissue loss. Measurements were 4.5 cm x 5 cm with no measurable depth. Muscle was exposed and the resident reported no pain. The wound bed was 90% slough and 10% granulation. The skin texture, moisture, and color were normal. No signs or symptoms of infection. There was no change noted in the wound progression. A debridement was performed where muscle and subcutaneous tissue were removed along with slough. The resident reported no pain during the procedure. Post debridement measurements were 4.5 cm x 5 cm x .3 cm. Wound treatment orders remained the same to clean the wound with normal saline, apply Dakin's gauze and cover with an ABD pad twice daily. Healing was expected to be delayed due to inevitable effects of aging. -Review of the resident's December 2021 TAR revealed wound care was not provided on 12/18/21 on the evening shift. -The wound had decreased in size, which showed the wound had the ability to heal. Laboratory testing was ordered and completed on 12/19/21. Results on 12/20/21 revealed a critical lab result of white blood cells 26.4. The physician was notified of the result and would come to facility to assess resident in the facility. Vital signs were at baseline and the resident had no complaints of pain or discomfort. The physician assistant assessed the resident in the facility on 12/20/21 at 10:10 a.m. and ordered a urinalysis and chest x-ray. A physician assistant note dated 12/20/21 read: Today the wound care doctor saw her and her coccyx wound has continued 90% slough. They will continue the Dakin's twice daily. Patient with chronically high WBC (white blood cell) count but now more anemic. History of having IV (intravenous) iron in May 2021 as well as 2 units of packed RBCs (red blood cells). She is not currently on any iron. Patient continues to eat very small amounts of food. She has not been willing to work with speech therapy so that they can clear her for an upgrade in her diet and so mostly she is getting her nutrition through the Glucerna both during the day p.o. and Overnight through G tube. Patient says that she is doing well today. No sign of acute respiratory or abdominal symptoms. A physician assistant note dated 12/22/21 read: 12/20 UA (urinalysis) showed leuk (leukocytes, white blood cells) est, bacteria and wbc (white blood cells) but neg (negative) [MEDICATION(S)]. no dysuria (painful urination) or fever or hematuria (blood in the urine). foley (catheter) working well. CXR (chest x-ray) no acute disease. No new orders were written related to the lab results. A nutrition note dated 12/20/21 revealed the RN reported the resident continued to only eat bites of food and had started to decline supplements and tube feedings. The resident was declining feeding assistance. RD spoke to resident and encouraged PO (by mouth) intake and educated the need for increased intakes for wound healing, resident stated she would eat her food later but declined to eat any during visit. Recommended increased PO glucerna supplement and changes to rate and run time of nocturnal tube feedings to encourage PO intake at meal times. Glucerna 1.2 at 76 ml per hour for 8 hours via gtube. Provides 608 ml enteral nutrition per day, 730 kcals, 36.5 g protein and 489.4 ml water. A new order was written on 12/20/21: Enteral Feed Order every shift Glucerna 1.2 @ 76 mL/hr x 8 hr (on 1900, off 0300) via g-tube. (Provides 608 mL EN/day, ~730 kcal/day). From 12/20/21 to 1/5/22: Glucerna four times a day related to type 2 diabetes mellitus without complications (E11.9) 8 oz Glucerna or equivalent QID (4x/day) for nutrition support. Provide bolus via g-tube for wound healing. Flush with 30 mL water before and after bolus. The resident was seen by the wound care physician during rounds on 12/20/21. The notes revealed the coccyx wound was an unstageable pressure injury obscured full thickness skin and tissue loss. Measurements were 4.5 cm x 5 cm with no measurable depth. Bone was exposed and the resident reported no pain. The wound bed was 90% slough and 10% granulation. The skin texture, moisture, and color were normal. No signs or symptoms of infection. There was no change noted in the wound progression. A debridement was performed where muscle and subcutaneous tissue were removed along with slough. The resident reported no pain during the procedure. Post debridement measurements were 4.5 cm x 5 cm x .3 cm. Wound treatment orders remained the same to clean the wound with normal saline, apply Dakin's gauze and cover with an ABD pad twice daily. Healing was expected to be delayed due to inevitable effects of aging. -Review of the resident's December 2021 TAR revealed wound care was not provided on 12/29/21 on the evening shift. The resident went home with family overnight for 72 hours from 12/25/21 to 12/28/21. All medications, tube feeding supplies, and wound supplies were provided to the family. Resident's daughter is an RN (registered nurse) and was able to complete all ordered care. An order was written on 12/20/21 to confirm the home visit: Pt (patient) may have a 72 hr (hour) pass with family 12/25-12/27/21. MDPOA (medical durable power of attorney) is an RN and willing to do wound care dressing and Gtube feedings. Please send pt with routine meds, dakin's solution and appropriate other wound care dressings, with her [MEDICATION(S)] and with her nebulizer machine and nebulizer meds and insulin (pt has glucometer at home). Also send with 12 cans of glucerna and a syringe that can be used for g tube bolus feeding since will not use a pump at the home. A nursing note dated 12/27/21 revealed the nurse received a phone call from the resident's daughter to remain with the family until 12/28/21. Daughter reported the resident had been doing well at home, all medications were given and wound care treatments twice a day were done well. On 12/28/21 when the resident returned to the facility wound care was provided and the wound measured 5 cm x 5 cm with no measurable depth. No foul odor and no drainage. -However, this was an increase in the size of the wound from 12/20/21 and was not reported to the physician. In addition, there was no comprehensive assessment by the IDT. On 12/29/21 a nutrition note revealed the resident's PO intakes continued to be low between 0-25%, continue on tube feedings as ordered and recommended to increase liquid protein to three times a day. -A new order was written on 12/29/21 to 1/5/22: Prostat three times a day 30 mL Active Protein Liquid or equivalent TID for wound healing. Provide via g-tube. Flush with 30 mL water before and after administration. A nursing note dated 12/31/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The x-ray technician was in the facility, but could not complete the x-ray as the machine was too small for the resident's weight. The resident would need to go out to the hospital for imaging. The wound nurse and physician assistant were notified. A new order was written to schedule an open sided MRI as soon as possible to rule out [CONDITION(S)]. -The MRI was scheduled for 1/12/22, which was 12 days later which was the earliest the

Based on observations, record review and interviews, the facility failed to ensure one of six residents reviewed for pressure injuries (#127) out of 68 sample residents received care consistent with professional standards of practice. The facility failed to take steps to promote the prevention of pressure injury development, to promote the healing of existing pressure injuries, and necessary steps to prevent the development of additional pressure injuries for Resident #127. Resident #127 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the facility was informed he entered the facility with a left lateral foot deep tissue injury (DTI) and a day later (2/4/21), knew he had a pressure area on his left gluteal fold. Record review, observation and interview revealed the facility failed to timely and adequately respond to his known risks in order to heal pressure injuries and to prevent additional skin breakdown. In the first two weeks of his admission, Resident #127's pressure injuries were not assessed, monitored or treated and pressure reduction measures were not implemented until 2/23/21. Further, while aware of the resident's poor intake as of 2/5/21, nutritional measures to promote healing were not implemented until 2/25/21. By this time, 22 days after admission, the resident had new pressure injuries - an unstageable left lateral foot injury and DTI right heel, both acquired 2/18/21, and an unstageable pressure injury to his sacrococcyx area (14 cm x 10 cm), extending bilaterally to both buttocks. Record review, interview and observation also revealed the facility failed to comprehensively and consistently address barriers to heal the resident's multiple pressure injuries and to prevent infection and new injuries from developing. As of 4/12/21, the facility had not developed a patient-centered care plan for skin integrity/pressure areas that identified and addressed the resident's resistance to repositioning (known as early as 3/2/21). Further, a nutritional intervention acceptable to the resident was not found until mid-April. Finally, observations during survey revealed the resident's heels were not consistently protected and his sacrococcyx injury was not treated as ordered. The resident's skin condition continued to decline; as of 4/20/21, the resident had six pressure injuries, including a sacrococcyx injury, classified as a stage 4, and a right buttock pressure injury and left lateral foot injury, both classified as unstageable. The facility's failure to recognize and promptly respond to Resident #127's pressure injuries and known risks for further injuries from 2/3/21 to 2/18/21, and failure to comprehensively address known barriers to healing thereafter, created the likelihood of serious harm if not immediately corrected. Cross reference: F656 (the facility failed to ensure care plans were implemented and updated as needed regarding skin conditions), F677 (the facility failed to ensure timely meal assistance) and F880 (the facility failed to ensure proper infection control procedures for wound treatments) I. Immediate jeopardy A. Findings of immediate jeopardy On 4/19/21 at 12:20 p.m., it was identified that the facility failed to prevent pressure injury development for Resident #127. In the first two weeks of his admission, Resident #127's pressure injuries were not assessed, monitored or treated and pressure reduction measures were not implemented until 2/23/21. Further, while the resident's poor intake was identified 2/5/21, nutritional measures to promote healing were not implemented until 2/25/21. By this time, 22 days after admission, the resident had new pressure injuries - an unstageable left lateral foot injury and a DTI right heel, both acquired 2/18/21, and an unstageable pressure injury to his sacrococcyx area (14 cm x 10 cm), extending bilaterally to both buttocks that worsened to a stage 4 wound. Record review, interview and observation also revealed the facility failed to comprehensively and consistently address barriers to heal the resident's multiple pressure injuries. As of 4/12/21, the facility had not developed a patient-centered care plan for skin integrity/pressure areas that identified and addressed the resident's resistance to repositioning (known as early as 3/2/21). Further, a nutritional intervention acceptable to the resident was not found until mid-April. Finally, observations during the survey revealed the resident's heels were not consistently protected and his sacrococcyx injury was not treated as ordered. The resident's skin condition continued to decline; as of 4/20/21, the resident had six pressure injuries, including a sacrococcyx injury, classified as a stage 4, and a right buttock pressure injury and left lateral foot injury, both classified as unstageable. B. Facility plan to remove immediate jeopardy On 4/19/21 at 6:26 p.m., the facility submitted a letter to remove the immediate jeopardy. The plan read: Issue: Wound concerns identified on resident (#127) Resident specific immediate actions: 1. Resident (#127) wound was reassessed by the wound doctor on 4/12/21 and 4/19/21 to ensure appropriate treatment and care plan is in place. 2. Registered dietitian (RD) met with resident on 4/19/21 and reviewed his nutritional plan, discussing options to enhance nutritional interventions for wound healing. 3. Resident (#127) has positioning devices in place for bed and wheelchair (w/c) and is noted to frequently refuse use of devices to offload heels. The interdisciplinary team (IDT) will continue to encourage resident on need for proper positioning. 4. Facility IDT conducted a care plan meeting with resident (#127) on 4/19/21 and explained the risk and consequences of his non-compliance with nutrition and positioning. Systemic actions: 1. On 4/17/21 and 4/18/21 a facility wide sweep was completed by nursing administration to evaluate skin integrity of residents and implement corrective actions as needed. The nursing admin team completed an audit of the skin system on 4/17/21 and 4/18/21 to ensure that weekly skin checks are current. The nursing admin team completed an audit of the Braden Scores on 4/17/21 and 4/18/21 to ensure that Bradens are up to date and interventions implemented accordingly. Braden risk assessments are performed on admission, weekly for 4 weeks, upon change of condition and weekly thereafter. A score of 10-12 is considered high risk and interventions are implemented accordingly. 2. Weekly skin checks will be monitored on an ongoing basis via review of the electronic medical record (EMR) during the stand up meeting. The accuracy of skin checks will be monitored by the director of nurses (DON) or designee via random weekly audits. 3. The nursing admin team ensured that all residents with wounds have appropriate interventions in place (such as pressure reducing mattress, cushions, RD consult) and their plan of care reflects those interventions. Audit initiated on 4/16/21 and completed 4/18/21 by licensed practical nurse (LPN) #13 and registered nurse (RN) #7. 4. Licensed nurses were inserviced by RN #2, RN #8, RN #9, LPN#13 beginning on 4/16/21 on: skin and wound care policy to include the importance of assessment and management of wounds and skin conditions; Braden risk assessments, identifying changes in integrity of skin and reporting those to medical doctor (MD)/DON/representative (RP), turning and positioning, notifications, pressure relieving surfaces and interventions, as well as how to add them if needed. The inservices were completed on 4/18/21, after which no nurse will be able to work without receiving the inservice above. 5. Inservices for certified nurse aides (CNAs) were done on 4/16/21 by RN#2, RN#8, RN#9 on turning and positioning, notification of nurse about new skin areas/dislodgement and soilage of dressing, change of condition, meal intake, notification of refusals, offloading, positioning and hydration. The inservices were completed on 4/18/21, after which no CNA will be allowed to work without receiving the inservice above. 6. Treatment nurse was inserviced by LPN#13 and RN #8 on assessment and staging, notification, implementing orders, interventions, admission assessment review, Braden scale risk assessment and completing wound reports. 7. A skin IDT meeting was held on 4/19/21 to review all current wounds and ensure plan of care is implemented. (IDT members: (names)). Monitoring: 1. DON or designee will monitor evaluations in point click care (PCC) to ensure wounds are evaluated and treatment implemented in a timely manner. Any issues identified will be corrected immediately. 2. DON or designee will complete random checks of wounds twice a week to verify that treatments are being performed as ordered. 3. Wounds will be reviewed with the wound physician during the weekly wound rounds to monitor worsening, improvements, or infections for the wounds. Wound MD is notified of all wounds upon admission, when a new wound is noted, upon worsening and weekly during rounds. 4. All findings will be reviewed during weekly skin and wound meetings and compliance with this system will be reported to quality assurance and performance improvement (QAPI) committee monthly. Resident refusals of wound care, nutritional resources or pressure devices will be tracked during the skin and wound meeting via review of the medication administration records (MARs) and the IDT will identify alternative methods of addressing refusals such as educating the resident/representative on risk/consequence of refusal, offering alternatives and consulting with MD/extender for additional recommendations. Other: Attending physician for (resident #127), wound MD and medical director were notified of the imposition of immediate jeopardy findings as well as this plan of correction. C. Removal of immediate jeopardy On 4/19/21 at 7:00 p.m., the nursing home administrator (NHA) was informed the immediate jeopardy had been lifted at 6:26 p.m., based on the facility's implementation of the above plan. However, deficient practice remained at a G level, actual harm for Resident #127. II. Professional reference A. The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (undated) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Pressure injury prevention points, updated 2016, revealed in part Consider bedfast and chairfast individuals to be at risk for development of pressure injury; Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within eight hours after admission); Use heel offloading devices .on individuals at high risk for heel ulcers. III. Facility policy and procedure Review of the Pressure Ulcer Prevention Program policy, reviewed 10/8/2020, provided by the NHA on 4/21/21 at 2:52 p.m. read in part All residents will be assessed for the risk of pressure ulcer development at the time of admission .Based on the results of this assessment, specific interventions will be implemented to prevent the development of avoidable pressure ulcers, or to treat existing pressure ulcers .All residents will be screened for risk of pressure ulcer development utilizing the Braden Scale/Norton Scale. This will be done at the time of admission .If a pressure ulcer/skin breakdown is identified, the following will be done: the licensed nurse will complete a thorough assessment of the affected area; .the licensed nurse will notify physician and the family; treatment will be initiated per physician orders; the resident's care plan will be updated to reflect interventions; the interdisciplinary team will be notified so that appropriate referrals may be made .the licensed nurse will assess the area on a weekly basis .the DON will report results to the quality assurance/improvement committee on a quarterly basis. IV. Resident #127 A. Resident status Resident #127, age under 50, was admitted on [DATE]. According to the April 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission physician documentation, dated 2/11/21, revealed in part, Skin: warm and dry, no suspicious [CONDITION(S)] .C4-5 spinal cord injury - patient wheelchair bound at this time .[CONDITION(S)]- as per above .Depression-severe at this time. Patient with severe trauma and change in overall status. Is now a new quadriplegic. Review of Resident #127's record (set forth below) revealed the resident entered the facility on 2/3/21 with one deep tissue injury (DTI). As of 4/20/21, the resident had six pressure injuries: a left heel blister (acquired 4/12/21); an unstageable pressure injury to the right buttock (acquired 4/5/21); an unstageable pressure injury to the left lateral foot (acquired 2/18/21); a DTI to the right heel (acquired 2/18/21); a stage 4 pressure injury sacrococcyx extending to bilateral buttocks (2/23/21); and a DTI to the right plantar foot (acquired 4/20/21). B. Resident observations and interview indicated the facility failed to timely, adequately and consistently respond to the resident's pressure injury risk. The resident was observed and interviewed in his room on 4/12/21 at 2:19 p.m., 4/14/21 at 1:55 p.m., and 4/15/21 at 10:16 a.m. and at 11:23 a.m. On 4/12/21 at 2:19 p.m., the resident said he had a new pressure area, a bruise on his buttocks that he did not have when he arrived at the facility. On 4/14/21 at 1:55 p.m., the resident was seated in his wheelchair. His feet were in socks and his heels were pressed up against the wheelchair pedals. No pillow was underneath or behind his feet. On 4/15/21 at 10:16 a.m., the resident was seated in his wheelchair, again without a pillow underneath or behind his feet or any type of heel protection. He said the staff never offered a pillow for his heels. He said he had a big blister. When asked about nutrition (see diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he had tried previous supplements but did not like the taste. He said he had not tried any homemade milkshakes or fortified foods. He said his meal intake depended on the meal. He said he felt like the staff was upset about feeding him because he required assistance. He said the food arrived at 11:30- 12:00 p.m. and they did not feed him until around 1:30 p.m. He said the food was always cold. On 4/15/21 at 11:23 a.m., he was seated in his wheelchair. A pillow was underneath his heels. When interviewed at noon, he said he had to ask for a pillow and this was the first time they had placed a pillow underneath his heels. He also said he had a different mattress when he first arrived at the facility, but now had a special mattress. The resident was observed with a pillow underneath his heels throughout the remainder of the survey, indicating compliance. C. Record review 2/3/21 to 2/25/21, 3/1/21 to 4/12/21 and 4/12 to 4/20/21 confirmed the facility failed to timely and adequately identify and respond to known risks in order to heal pressure injuries and to prevent additional skin breakdown and failed to comprehensively and consistently address barriers to heal the resident's multiple pressure injuries to promote healing. prevent infection and prevent new injuries from developing. 1. 2/3/21 - 2/25/21 a. The facility failed to address a left lateral foot deep tissue injury (DTI) known on admission, failed to ensure appropriate follow up was completed for the pressure area identified on the left gluteal fold the day after admission, and failed to timely complete a comprehensive pressure injury risk assessment (Braden Scale). Review of the hospital history and physical (H&P), dated 2/3/21, revealed in part, physical exam revealed C4/5 spinal cord injury .wounds present on admission: right shin-abrasion, left lateral foot - DTI, left clavicle-surgical, right shoulder friction, right chest tube and PEG tube. Review of the general nurse progress notes, dated 2/3/21, revealed in part Skin warm and dry. Dressing noted to right shoulder 2cm x 1.5cm superficial abrasion noted .Dressing noted to right shin 1cm wound scab noted without drainage .Resident able to move arms but hands are flaccid (soft and hanging loosely) . There was no documentation of the resident's DTI. Review of the admission nursing screener assessment, dated 2/4/21, revealed in part, the resident had an abrasion on left antecubital and the left lower leg. The resident was documented to have had a pressure area on the left gluteal fold. This assessment was signed off on 2/4/21. Yet, review of the weekly body check, dated 2/10/21, revealed the resident did not have any skin issues and the baseline care plan, signed 2/10/21, revealed skin risk was not marked for current skin integrity issues or history of skin integrity issues. Review of the weekly body check, dated 2/17/21, also revealed the resident did not have any skin issues. Review of the Braden Scale for predicting pressure injury risk, dated 2/17/21, revealed the resident was at high risk of developing pressure injuries with a score of 12 out of 23. This assessment was signed off on 2/25/21, 22 days after admission. Per facility policy, the Braden Scale was to be completed on admission (see above). b. Record review revealed new pressure injuries and the progression of moisture associated skin damage/stage 2 pressure areas (identified 2/17- 2/18/21) to an unstageable sarcococcyx injury, extending to bilateral buttocks as of 2/25/21. Review of the weekly wound observation tool, dated 2/17/21, revealed the resident had an acquired stage 2 pressure injury on right/left gluteal folds with a measurement 2 centimeters (cm) x 1cm x 0cm. This was documented as the first observation. The resident was documented as educated for repositioning while in bed. However, the resident was totally dependent and there was no care plan directing staff to assist in repositioning the resident. Review of the skin/wound progress note, dated 2/18/21, revealed in part Resident referred to wound care per nurse. Resident with scab to right [MEDICATION(S)] and right calf area. Right heel with non-blanchable area. Left lateral foot with eschar. Small open area to right buttock and open area to left buttock .Dr (name) updated on wound status. Air mattress ordered. Heels offloaded. Resident complained of pain to shoulders and wound to left buttock . Review of the weekly wound observation tool, dated 2/18/21, revealed the resident had: -An acquired unstageable pressure injury to the left lateral foot (acquired 2/18/21) with a measurement of length (L) 2.4cm x Width (W) 2.0cm. No infection suspected. Treatment updated to include; heel off-loading, positioning and incontinence management. An air mattress was documented as ordered. -An acquired deep tissue pressure injury right heel (acquired 2/18/21) with a measurement of L-2.0cm x W-2.5cm. No infection suspected. -An admitted right calf wound- unknown, with measurement L-7.0cm x W-1.4cm. No infection suspected. -An admitted moisture associated skin damage to the left buttock with a measurement of L-1.0cm x W-1.0cm x depth (D) 0.1cm. No infection suspected. -An acquired moisture associated skin damage to the right buttock (acquired 2/18/21) with a measurement of L-4.0cm x W-1.7cm x D-0.2cm. Small serous drainage. No infection suspected. Pain associated with treatment. Notwithstanding the information above, review of the weekly body check, dated 2/19/21, revealed, in pertinent part, the resident had a small blister on the left index and middle finger. No other skin issues were documented. And, review of the nurse practitioner (NP) documentation, dated 2/19/21, revealed no mention of any pressure injuries. Further, there was no documentation the NP had been informed of the resident's pressure injuries. Review of the skin/wound progress note, dated 2/23/21, revealed in part Resident wound check noted left and right buttock combined with involvement to gluteal fold. Area measures L-8cm x W-4.0cm x D-0.2cm . Small bloody drainage to edges. No complaint of pain to the wound site .Right heel continued with maroon discoloration . Review of the weekly wound observation tool, dated 2/25/21 revealed the resident had: -An unstageable pressure injury to the left lateral foot (acquired 2/18/21) with a measurement of L-2.0cm x W-4.0cm. No infection suspected. Treatments updated to include: air mattress, heel off-loading, positioning, incontinence management and nutritional support. -A deep tissue pressure injury right heel (acquired 2/18/21) with a measurement of L-2.0cm x W-3.3cm. No infection suspected. -A right calf wound- trauma with measurement L-7cm x W-3cm. No infection suspected. -An unstageable pressure injury sacrococcyx extended to bilateral buttocks with measurement L-14cm x W-10cm. Small serous drainage. No infection suspected. Review of the PA (physician assistant) surgical notes, dated 2/25/21, revealed in part, Reason for visit: consultation and evaluation of wounds found on the sacrococcyx extending to the bilateral buttocks, right heel, right shin and left lateral foot .We are analyzing this patient for wounds located at the sacrococcyx extending to the bilateral buttocks, right heel, right shin and left lateral mid foot. -Patient has a wound on the right foot and buttock upon admission. This buttock wound has worsened. Wound #1: Sacrococcyx extending to the bilateral buttocks: unstageable .Muscle tissue debridement performed by surgical excision .Pre-op wound L-14cm x W-10cm x undetermined (UTD). The post op wound area was L-14.1cm x W-10.1cm D-0.4cm. First visit. Wound #2: right heel: rule out vascular/arterial .pre-op wound area was estimated to be L-2cm x W-3.3cm x UTD. First visit. Wound #3: right shin: trauma .pre-op wound area was L-7cm x W-3cm x UTD .wound edge necrotic. First visit. Wound #4: left lateral mid foot: Unstageable pressure injury .Pre-op wound area was measured at L-2cm x W-4cm x UTD .Calloused and necrotic wound edge. -First visit .The wound debrided today was at the sacrococcyx extending to the bilateral buttocks. For this wound, there was an indication of tissue decline which will entail continued management and will probably need future debridement. Healing of these wounds can not (sic) be guaranteed given the patient's diagnoses/risk factors that affect the healing progress of these wounds .Prognosis: feel the prognosis for this patient's sacrococcyx extending to the bilateral buttocks to be fair .Follow up: aggressive, weekly, follow up care is needed with debridement. c. Record review revealed the facility failed to timely implement an air mattress, off-loading interventions and nutritional interventions to promote wound healing prior to the progression of the left and right buttock wound (see above). Review of the April 2021 CPO revealed the resident was ordered for the following: -Air mattress, dated 2/23/21. -Encourage resident to off load buttocks with frequent position changes side to side with pillows or wedge every shift for wound care. Dated 2/23/21. -Encourage resident to off load heels by floating on pillows or booties when in bed every shift for wound care. Dated 2/23/21. Review of the nutrition/dietary note, dated 2/25/21 revealed in part (Resident) is agreeable to multivitamin (MVI) and prostat 30 milliliters (ml) BID between meals . Review of the April CPO revealed the resident was ordered to receive a regular diet with regular liquids and regular texture, dated 3/3/21. The resident was ordered to receive prostat supplement for wound care twice a day, dated 2/26/21 with a discontinued date of 3/5/21. 2. 3/1 to 4/12/21 Record review 3/1 to 4/12/21 revealed the facility failed to comprehensively and consistently address barriers to heal the resident's multiple pressure injuries and prevent infection and new injuries from developing. a. Record review revealed: Resident resistance to measures to relieve pressure and to improve nutrition; presence of infection and debridement of injuries; progression of sacrococcyx pressure injury to stage 4 wound; and the presence of new wounds. Review of the skin/wound note, dated 3/1/21, revealed in part, Resident on bariatric air flow mattress, booties in room and offered. Resident prefers heels floated on pillows at present. Review of the nurses' note, dated 3/2/21, revealed in part, Resident decline(d) to reposition. Resident stated he was on his side for two days and he is going to stay on his back. Resident was educated . Review of the nurses' note, dated 3/3/21, revealed in part, Resident wound is draining and has a bad smell and different color. The wound was treated as ordered. Resident is on IV (intravenous) antibiotics with no adverse reaction noted at this time. The PA surgical notes, dated 3/4/21, revealed the resident's pressure injuries had decreased in size, Change in patient health: patient was started on IV antibiotics .He had a venous doppler done which revealed normal lower extremities. The arterial doppler is pending .Wound #1: Sacrococcyx extending to the bilateral buttocks .Muscle tissue debridement performed by surgical excision .pre-op wound area was L-13.8cm x W-9.8cm x UTD. The post-op wound area was L-13.9cm x W-9.9cm x D-2cm 100% slough .Wound has decreased in size .Wound #2: right heel .pre-op wound was L-1.6cm x W-3cm x UTD .Wound has decreased in size .Wound #3: right shin: trauma .pre-op wound area was L-7cm x W-2.6cm x UTD .wound has decreased in size .Wound #4: left lateral mid foot .unstageable .pre-op wound area was measured at L-1.8cm x W-3.5cm x UTD . wound has decreased in size .we consider the prognosis for the patients sacrococcyx extending to the bilateral buttocks to be poor: patient is noncompliant with offloading and is not eating well. Review of the skin/wound note, dated 3/4/21, revealed in part Encouraged resident to allow staff to turn frequently and off load heels. Resident stated that sometimes he doesn't want to turn. Resident requested to be in semi fowlers at 90 degrees. Educated that position is increasing pressure on wound. States that unable to operate phone .in this position. Review of the infection note, dated 3/6/21, revealed in part Resident continue(s) on IV antibiotics. Review of the skin/wound note, dated 3/9/21, revealed in part Spoke to resident to encourage frequent position changes when in bed, turning from side to side. States that he is doing that. Spoke with physical therapy (PT) concerning possible adaptive devices for phone, bed desk and TV. Discussed positioning challenges. Review of the NP documentation, dated 3/10/21, revealed in part, Patient being seen today for wound to coccyx area. Patient has required frequent change(s) to coccyx area due to increased drainage, patient being followed by wound nurse in the facility .Patient has multiple other wounds to his right shin right heel. Patient also has wound to left lateral foot that is healing. Patient with a history of bilateral shoulder pain, making it difficult for patient to reposition due to pain in bilateral shoulders .Assessment .chronic pain due to trauma .coccyx pain . Review of the weekly wound observation tool, dated 3/11/21, revealed the resident had: -An unstageable pressure injury to the left lateral foot (acquired 2/18/21) with a measurement of L-1.7cm x W-3.2cm. No infection suspected. -An admitted right calf wound- trauma with measurement L-6.6cm x W-1.5cm. No infection suspected. -An unstageable pressure injury sacrococcyx extended to bilateral buttocks with measurement L-13cm x W-9.5cm. Moderate drainage. Undermining present with 80% slough. Infection suspected - Yes. New swelling and undermining present. Added [MEDICATION(S)]. Review of the PA surgical notes, dated 3/11/21, revealed in part, Location: sacrococcyx to the bilateral buttocks, stage IV (4) pressure injury .pre-op wound area was L-13cm x W-9.5cm x UTD. The post-op wound area was L-13cm x W-9.6cm x D-6cm . wound has decreased in size .Location: right heel: pre op wound area was found to be L-1.5cm x W-3.0 cm x UTD .wound has decreased in size .Location: right shin ., pre-op wound area was evaluated to be L- 6.6cm x W-1.5cm x UTD .wound has decreased in size .Location: left lateral mid foot: unstageable .pre-op wound area was evaluated to be L-1.7cm x W-3.2cm x UTD .wound has decreased in size. Review of the nutrition/dietary note, dated 3/12/21, revealed in part (Resident) declines all supplements: med pass, Ensure, Magic cup, Juven, prostat .likes a grilled cheese sandwich at times and plans to order with a meal at times during the week . Review of the weekly wound observation tool, dated 3/18/21 revealed the resident had: -An unstageable pressure injury to the left lateral foot (acquired 2/18/21) with a measurement of L-1.7cm x W-3.2cm. No infection suspected. -A deep tissue pressure injury right heel (acquired 2/18/21) with a measurement of 0cm x 0cm. gNo infection suspected. Intact. -A right calf wound- trauma with measurement L-6.5cm x W-1.5cm. No infection suspected. -An unstageable pressure injury sacrococcyx extended into buttocks with measurement L-12.0cm x W-9.2cm. Moderate drainage. Undermining present with 40% slough. Infection suspected - Yes. Odor - Yes. Fever and foul odor were marked. -A second assessment was completed for the same day (3/18/21) for the sacrococcyx extended to bilateral buttocks with measurement L-13cm x W-9cm with no undermining and labeled as a deep tissue injury with 80% slough. Review of the physician documentation, dated 3/18/21, revealed in part, Reason for appointment: acute visit-fever; wound infection .Di[TRUNCATED]

Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for residents to include two (#13 and #114 ) residents out of 68 sample residents and the facility. Specifically the facility failed to: -Ensure proper infection control practices were followed during [CONDITION(S)] care for Resident #13; -Ensure urinals are cleaned and stored in a sanitary manner for multiple residents; and, -Staff practiced hand hygiene after providing incontinence care for Resident #114. I. Professional reference The Center for Disease Control and Prevention (last updated on January 30, 2020) Hand Hygiene in Healthcare Settings, When and How to Perform Hand Hygiene, https://www.cdc.gov/hai/pdfs/ppe/ppeslides6-29-04.pdf, retrieved on 4/28/21. It read in pertinent part to, clinical indications when to perform hand hygiene include before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient, after contact with blood, body fluids or contaminated surfaces. II. Facility policies and procedures The Infection Prevention and Control Program policy and procedure, dated January 2020, revised November 2020, provided by the NHA on 4/19/21 at 5:47 p.m. read in pertinent part: -An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -Important facets of infection prevention include identifying possible infections or potential complications of existing infections; educating staff and ensuring that they adhere to proper techniques and procedures; and, implementing appropriate isolation precautions when necessary. -Training and education to include disease transmission prevention; standard and transmission-based precautions; procedures to follow when personal protective equipment is used. The [CONDITION(S)] Care policy and procedure, dated 2001, revised august 2013, provided by the NHA on 4/21/21 at 2:52 p.m., read in pertinent part: -[CONDITION(S)] care should be provided as often as needed. -Put exam gloves on both hands. -Remove old dressings, wash hands. -Open [CONDITION(S)] cleaning kit, set up supplies on sterile field. -Maintaining sterile field, pour equal parts [MEDICATION(S)] and normal saline in one compartment of opened kit. Pour normal saline in another compartment. -Put on sterile gloves, gently remove the inner cannula. -Soak the cannula in [MEDICATION(S)]/saline mixture. -Clean with brush, rinse with saline and dry with pipe cleaners. -Remove gloves, wash hands, put on fresh gloves and replace the cannula and lock in place. Site and stoma care: -Apply clean gloves. -Clean the stoma with two peroxide-soaked gauze pads (using a single sweep for each side). -Rinse the stoma with saline-soaked gauze pads (using a single sweep for each side). -Wipe with dry gauze (using a single sweep for each side). -Allow to air dry or wipe with clean dry gauze. -Remove neck ties and replace with clean ones. -Apply a split gauze pad around the insertion site. The PPE policy, last revised March 2020, was received by the Nursing home administrator (ANHA) on 4/20/21 at 10:00 a.m. It read in pertinent part to, staff needed to wear gloves when they were performing a procedure that was in contact or could be in contact with resident bodily fluids to protect themselves from contamination. The hand hygiene policy, last revised on 3/1/2020 was received by the assistant nursing home administrator (ANHA) on 4/20/21 at 10:00 a.m. It read in pertinent part to, hand hygiene needed to be performed after contact with a resident and or bodily fluids as well as when removing gloves. III. Observations of breaks in infection control On 4/12/21 at 1:00 p.m. there were two unknown residents seated in the common area on Golden Gate unit, one had her mask below her nose and the other resident had his mask below his chin. They were talking with a staff member and he did not ask them to reapply their masks correctly. -At 5:11 p.m. room [ROOM NUMBER] had a stop sign on the door that said stop isolation precautions. There was no signage indicating what type of isolation. On 4/13/21 at 8:30 a.m. a nurse was seen preparing to enter isolation room [ROOM NUMBER]. She did not sanitize her hands and applied a gown and gloves then entered the room. -At 8:38 a.m. there was a urinal, containing urine, on the overbed table next to the resident ' s bed in room [ROOM NUMBER]. There was a glass containing ice water next to the urinal on the table. -At 8:40 a.m. LPN #1 was observed during [CONDITION(S)] ([CONDITION(S)]) care for Resident #13. She sanitized her hands and applied a gown and gloves. She then typed on her computer keyboard and used the computer mouse then swiped and typed on a tablet screen. The resident had thick yellow sputum coming from the [CONDITION(S)] and pooled on his chest below his [CONDITION(S)]. She entered the resident ' s room, picked up his urinal and emptied it. She donned new gloves and removed items he had on his overbed table. She used Versa Sure bleach wipes, with a dwell time of two minutes, to clean the top of the overbed table. She did not allow the surface to dry and placed the package of [CONDITION(S)] suctioning supplies on top of the table, as well as the tubing connected to the suction machine, she then turned the machine on. She placed a bottle of sterile water on the table that she obtained from on top of a nearby cabinet. She then retrieved the package of sterile gloves from the tray and placed it on the wet surface of the overbed table and donned the gloves. Wearing the sterile gloves, she opened the bottle of sterile water, picked up the sterile suction catheter and connected it to the suction tubing. She then entered the [CONDITION(S)] with the suction catheter but could not suction any sputum. She removed the plastic inner cannula of the [CONDITION(S)]. She suctioned the [CONDITION(S)] then curled the sterile catheter into her left unclean gloved hand. She then took the yellow sputum covered inner cannula to the handwashing sink in the room, rinsed it, and shook it a couple times in the air. She then went to the suction tray, held the inner cannula over the tray and poured sterile water through the middle of it and replaced it in his [CONDITION(S)]. With the same sterile gloves on she moved the overbed table, opened the night stand drawer and touched items in the drawer looking for gauze pads. She then went to a cabinet at the foot of the bed, that had [CONDITION(S)] supplies on top of it, and moved several of those items. The resident asked the nurse are you sure it's in there, I don't think it snapped. She then obtained a hard plastic ([NAME]) suction piece, attached it to the suction tubing and suctioned the thick yellow sputum off his chest. She wiped the area with dry gauze, and replaced the oxygen humidification mask over his [CONDITION(S)]. She placed the soiled [NAME] on the unprotected surface of the overbed table. She then removed the soiled drain sponge surrounding the [CONDITION(S)] stoma (opening in the skin). She wiped the skin below the [CONDITION(S)] with a dry gauze, she did not clean the area with peroxide-soaked gauze or rinse it with saline-soaked gauze. She loosened the straps of the [CONDITION(S)] collar and replaced the drain sponge then retied the collar straps, she did not change the collar. When she was done she disconnected the [NAME] from the suction tubing and disposed of it in the trash can. She did not clean the overbed table surface and replaced his water pitcher, beverage glasses, and his urinal on top of the table. Review of the nursing skills validation checklist for [CONDITION(S)] care dated 6/6/2020 revealed LPN #1 was checked off on her skills with a return demonstration along with 15 other nursing staff members. There was no skills checked off for LPN #1 after 6/6/2020. -At 11:30 a.m. Resident #13 had his urinal on the overbed table next to a drinking glass. -At 11:58 a.m. a resident was seen exiting her room in the 2300 hall. She did not have her mask on. She approached a cart sitting in the hallway that had beverages in pitchers for the lunch meal. She picked up two different pitchers and poured the drinks into her personal cup touching the spouts of the pitchers to the edge of her cup. -At 1:45 p.m. Resident #13 had his lunch tray on his overbed table. He had coughed several times and there was thick yellow sputum coming from his [CONDITION(S)] and lying on his chest below the [CONDITION(S)]. The nurse came into the room to raise the head of his bed further so he could eat and did not remove the sputum from his chest or suction his [CONDITION(S)]. On 4/13/21 at 4:17 p.m. certified nurse assistant (CNA) #9 and CNA #21 entered Resident #114 ' s room and donned gloves and stood on each side of the resident ' s bed and provided incontinence care. When the CNA ' s completed the task the resident asked to transfer to her wheelchair. CNA #9 and CNA #21 continued to wear the gloves that were used to provide the resident ' s incontinence care. CNA #9 moved the mechanical lift from the resident ' s bathroom to the side of the bed where the resident was sitting and used the control of the lift to position it. CNA #21 moved the resident ' s wheelchair using the control the resident used. CNA #9 opened the resident ' s room door to the hallways. On 4/14/21 at 11:10 a.m. Resident #13 was seen lying in bed with the head of the bed elevated, there was thick yellow sputum coming from his [CONDITION(S)] and it had gathered on his chest below the [CONDITION(S)]. He said he was not necessarily comfortable with the nursing staff taking care of his [CONDITION(S)] but he did not elaborate. -At 4:36 p.m. Resident #13 was seen lying in bed, with his eyes closed. There was thick yellow sputum coming from his [CONDITION(S)] with a streak of red down the middle of it. His urinal, containing urine, was lying on his overbed table next to an ice cream cup, and a glass with water in it. When the nurse saw the surveyor exit the room she went in and cleaned the sputum from his [CONDITION(S)]. On 4/15/21 at 9:03 a.m. Resident #13 was seen in bed, there was thick yellow sputum coming from his [CONDITION(S)] and was on the gauze below it. His urinal was on the overbed table positioned next to a glass of juice he was drinking. -At 10:30 a.m. an observation of [CONDITION(S)] care was done with LPN #2 and the staff development coordinator (SDC) in attendance as well. LPN #2 used alcohol based hand rub (ABHR) and applied gloves. She used a bleach wipe on the overbed table and did not allow it to dry and placed the tray of [CONDITION(S)] cleaning supplies on it. She removed the gloves, applied a gown, and used ABHR then opened the tray of supplies. She obtained a bottle of Peroxide and sterile water from on top of the cabinet at the foot of the bed and placed them on the table next to the tray. She opened the tray and applied the sterile gloves from inside the tray then spread the sterile barrier pad on the table. She then picked up the gauze, the cleaning brush, and the suction tubing from the tray and placed them on the sterile barrier. With the sterile gloves on she picked up the bottle of Peroxide and poured the solution into a section of the tray and repeated the same with the sterile water. While still wearing the sterile gloves she then turned to the resident and grasped the oxygen humidification mask to remove it, then removed the soiled inner cannula of the [CONDITION(S)] and placed it into the peroxide solution. She used the brush supplied in the tray to clean down the middle of the cannula then placed the cannula in the sterile water to rinse it, shook it, dried it with a gauze pad and placed it back into the [CONDITION(S)]. With the sterile gloves still on she opened a container of normal saline and soaked gauze pads with the saline to clean under his [CONDITION(S)]. She then attached the suction tubing and suctioned the [CONDITION(S)]. At this point she removed the sterile gloves and applied a pair of regular gloves. She used bleach wipes and cleaned the overbed table and placed two paper towels on top of the wet surface of the table then placed his urinal on top of the towels next to a juice container, a drinking glass, and a water pitcher. -At 12:09 p.m. a urinal was seen on an overbed table in room [ROOM NUMBER]. On 4/19/21 at 10:05 a.m. social services (SS) #2 was seen entering quarantine room [ROOM NUMBER] without sanitizing her hands or donning a gown or gloves. She leaned on the resident ' s overbed table, with her bare arms, talking to him and documenting on a piece of paper. She then leaned on the handles of his walker with her bare arms touching both handles. His urinal was hanging on his walker below the seat and her pant leg was touching it. She exited the room and did not sanitize her hands and walked down the hall. She said she did not apply a gown and gloves because the resident was her roommate that lived with she and her husband. She said she was around him all the time so she did not feel the need to don the gown and gloves even though he was admitted after a hospital stay and was in quarantine. On 4/19/21 at 12:58 p.m. Resident #13 had his urinal on his overbed table next to a juice glass, a water glass, and an ice pitcher. On 4/20/21 at 11:00 a.m. the wound registered nurse (WRN) was observed during pressure ulcer wound care for Resident #127, Cross-reference F686.There was an individual who said she works for the company that observed the wound care as well. The wound care orders read: 1) Coccyx/sacrum-clean wound with Dakins soaked gauze, clean the peri-wound with Dakins soaked gauze and pat dry, apply skin prep to the surrounding skin, soak Kerlix with Dakins and pack the wound, cover the wound with an abdominal (ABD) pad and tape twice daily. 2) Right buttock-clean with normal saline, pat dry, apply skin prep to the surrounding skin, apply Santyl (a medication that removes dead tissue from wounds) to the wound and cover with foam dressing twice daily. The WRN gathered supplies from the treatment cart outside the room. She placed a pair of stainless steel scissors on the surface of the treatment cart without placing a clean barrier in between the cart surface and scissors . She cleaned the top of an overbed table with a bleach wipe with her bare hands and placed wax paper on the table to place the supplies on. She used the scissors to cut pieces of wide tape and placed them on the table. She placed a bottle of Dakin's solution, an opened roll of Kerlix gauze, 4x4 gauze pads, plastic cups, packages of [MEDICATION(S)] soaked swabs, an ABD pad, skin prep pads, cotton tipped applicators, normal saline ampoules, and a foam dressing on the table. She then cleaned the scissors with an alcohol pad with her bare hands and placed them on the table as well. She entered the room with the table, washed her hands, turned the faucet off with the paper towel she dried her hands with. She applied gloves and removed the two dressings on the resident ' s bottom. The coccyx/sacral soiled dressing had clear/reddish (serosanguinous) and brownish drainage on it. The right buttock wound dressing had a scant amount of serosanguinous drainage on it. The coccyx/sacral wound was large and deep. The wound bed was beefy red with an area of brownish tissue at its deepest point in the center. There was a whitish piece of tissue hanging from the left edge of the wound and the tissue to the right upper corner, just next to the edge, was brownish in color. The nurse removed her gloves and washed her hands and again shut the faucet off with the paper towel she dried her hands with. She applied clean gloves and moistened the old packing inside the wound with normal saline to remove it, as it had dried out. The old packing had serosanguinous and brownish drainage on it and had an unpleasant odor. The nurse removed her gloves and washed her hands and repeated the same process when she turned the faucet off. She donned clean gloves, poured Dakin's solution into a plastic cup and used 4x4 gauze pads soaked with the solution to clean inside the wound. With each wipe the gauze came out with reddish brown drainage. The nurse then used cleansing wipes to remove brown bowel movement (BM) from below the wound. She removed her gloves, washed her hands in the same manner and donned clean gloves. She then cleaned the skin around the wound with gauze soaked in Dakin's solution, then cleaned the wound bed again after cleaning outside the wound, potentially contaminating the wound bed. She then picked up the bottle of Dakin's solution wearing the same gloves to pour the solution into a plastic cup. She patted the skin dry around the wound, removed her gloves, washed her hands again in the same manner and donned clean gloves. The right buttock wound was circular and covered in black tissue. She cleaned the wound with normal saline and patted it dry. She applied skin prep to the surrounding skin. She then wiped more BM from below the coccyx/sacral wound and next to the right buttock wound. She removed the gloves and washed her hands again in the same manner and donned new gloves. She again applied skin prep to the surrounding skin and to the skin surrounding the large wound as well. Wearing the same gloves she reached into the pocket of her uniform top searching for more packets of skin prep. She opened the package containing the foam dressing and used her gloved finger instead of an applicator to apply a small amount of Santyl to the center of the foam pad then placed the dressing onto the right buttock wound. She did not apply the medication to the wound surface. She reached into her pocket to obtain a black marker to date the foam dressing and placed the marker on the chux pad on the bed. She washed her hands in the same manner and donned clean gloves. She applied the large tape strips to the edges of the ABD pad, covered the coccyx/sacral wound and dated the pad. She did not pack the wound with the Dakin's soaked Kerlix as the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The WRN placed the marker on the table and gathered up the supplies, folded them into the wax paper, and discarded them into a red bag. She placed the bottle of Dakin's solution and the pair of scissors onto the bare table top. The unknown company employee who observed the wound care wiped off the bottle of Dakin's solution with a bleach wipe and placed it in a drawer of the treatment cart then used the same bleach wipe to clean the scissors and the overbed table that was used in the room. She placed the scissors on the unprotected surface of the treatment cart. IV. Interviews CNA #21 was interviewed on 4/13/21 at 4:45 p.m. She stated she wore the gloves until she was done providing all the cares for the resident before she left the room and then used hand sanitizer as required when she removed her gloves. LPN #2 was interviewed on 4/15/21 at 11:00 a.m. She said she had received skills training regarding [CONDITION(S)] care but she could not remember when the last time was. She said when she worked on a different hall and was unfamiliar with a resident that had a [CONDITION(S)] she would contact the SDC to receive instruction on that particular resident. She was unaware of the breaks in infection control during the [CONDITION(S)] care provided to Resident #13. The SDC was interviewed on 4/15/21 at 11:10 a.m. She said she was responsible for providing training to the nursing staff on [CONDITION(S)] care. She said she did yearly check offs where the nurses had to do a return demonstration of competencies in those areas. She said she also conducted spot checks periodically especially when new admissions arrive. The facility uses a respiratory company to help with [CONDITION(S)] management and they educate staff as well. She said the nurses were supposed to provide [CONDITION(S)] care every shift and as needed. She said she told them to allow the resident to cough out secretions if they are able because frequent suctioning can cause trauma. She said she observed the breaks in infection control when LPN #2 provided [CONDITION(S)] care to Resident #13. She said the type of inner cannula Resident #13 had was a Shiley and she thought those were disposable and it was printed on the cannula itself that it was not to be cleaned. She said the nurse should not have cleaned the inner cannula but should have thrown it away and inserted a new one. She was made aware of the observation LPN #1s [CONDITION(S)] care procedure on 4/13/21. She said she had not watched LPN #1 lately but when she came back to work she would talk with her. She said it was evident that she needed to re-educate with both LPNs. She later said the respiratory therapist told her the inner cannula is one that only needs to be changed every three days and she said she was unaware of that and no order had been put in for the nurses to change it routinely. She said an order would be put in so the nurses knew to change it every three days because they had not been doing that and there was no way to tell when it had been changed last. The WRN was interviewed on 4/20/21 at 12:00 p.m. She said she used the scissors that were in the treatment cart for all wound dressing changes. She said well, I disinfect them when I use them by wiping them with an alcohol pad. She said the facility had disposable scissors she could use but she had not considered using a separate pair for each resident. She was unaware she did not pack the resident's coccyx/sacral wound per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unaware of the breaks in infection control during the wound care. The DON was interviewed on 4/21/21 at 11:30 a.m. She said she was made aware of the breaks in infection control during [CONDITION(S)] care for Resident #13. She said LPN #2 had reached out to the respiratory therapist and asked him to provide her more training on [CONDITION(S)] care because she wanted to be sure she was doing it right. The DON said they would provide education to both nurses that were observed during [CONDITION(S)] care. She said they would also set up re-trainings for the nursing staff with the respiratory therapist. She said when she was made aware of the observation of wound care with the WRN, that nurse was removed from the floor and a corporate nurse took over wound care. The DON was interviewed again on 4/21/21 at 4:40 p.m. She stated gloves used to provide resident incontinent by CNA ' s or nurses, needed to be discarded properly and then the staff needed to perform hand hygiene before other surfaces were touched. The DON was interviewed a third time on 4/22/21 at 8:30 a.m. She said male resident urinals should not be placed on the overbed tables next to food or drinking items. She said some residents prefer it to be on the table but she said it was an infection control issue and she would provide education to staff and residents to place the urinals in a different location to eliminate the potential for cross contamination. She said the drink cart that was brought up to the second floor before the meal carts arrived should not be left in the hallways and available to the residents to help themselves to drinks. She said she would figure out an area on the second floor to store the drink carts until staff were ready to pass the beverages to the residents. She said there were areas not being used where the carts could be kept. She said SS#2 who entered quarantine room [ROOM NUMBER] should have donned the appropriate PPE regardless whether he was in the same household as she. The DON said she will provide education to the staff member regarding proper PPE to be donned prior to entering the resident room. V. Facility follow up Mandatory education for Peri-Care and Incontinent Care for CNAs and Nurses, was received on 4/22/21 at 8:05 a.m. for eight staff members that were taking care of the resident ' s in the 1200 ' s hall of Golden Gate. Eight pieces of paper were signed by the staff that received the education, that explained staff will change their gloves and perform hand hygiene after peri-care before other surfaces are touched. As well as they completed an online course with a competency check off with the Staff development Coordinator (SCD). On 4/22/21 at 9:00 a.m. the SDC provided a copy of the eLearning educational activity for [CONDITION(S)] tube care and cleaning completed by LPN #2 on 4/19/21. She also provided a copy of the same training completed by LPN #1 on 4/20/21. -At 9:08 a.m. the DON provided documentation of education to SS #2 per phone, as she was not in the facility at this time, related to donning the appropriate PPE prior to entering a quarantine room regardless whether it was a family member. She said SS #2 was off today and when she returned she would be required to perform a return demonstration of appropriate donning and doffing of PPE. She also said at this time the unit managers were making rounds to all male residents who use urinals providing education and updating care plans. -At 9:17 a.m. the DON said all care plans on the Eldorado unit had been updated for the male residents that used urinals. VI. Facility Covid-19 status At the beginning of the survey on 4/12/21 the facility did not have any Covid-19 positive residents or staff members. At the end of the survey on 4/22/21 the facility notified the survey team of a positive staff member after being notified of a vendor that had tested positive.

Based on interviews and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for one (#161) of three residents reviewed for falls out of 68 sample residents. The facility failed to ensure for Resident #161 who had Alzheimer's disease and staff were to anticipate his needs was provided with frequent checks to prevent multiple falls. The facility failed to have a care plan in place to prevent Resident #161 from sustaining multiple falls (cross reference F656). Resident #161 had increased pain (cross reference F697) after his first fall and continued to have difficulty with increased pain and the lack of supervision from staff. Furthermore, the facility failed to order an x-ray for Resident #161 who could not express his needs but pointed and rubbed his left knee. This caused a delay in treatment for Resident #161, including pain management, cross reference F697, who sustained major injuries. These failures led to Resident #161 needing hospital treatment and surgery. Resident #161 presented to the emergency room with slight shortening of the left lower extremity with limited range of motion of the left hip due to pain and was in moderate distress. The findings from the computerized tomography (CT) scan were: Acute lumbar (L) 4 and L5 vertebral body superior endplate fractures with associated height loss that is mild to moderate involving the L5 vertebral body, and acute left femoral neck fracture with angulation and impaction. Findings include: I. Facility policy and procedure The Fall Prevention Program policy and procedure, dated 10/8/2020, provided by the nursing home administrator (NHA) on 4/20/21 at 8:30 a.m. read in pertinent part: -All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. -Residents identified at being at risk will have interventions identified in their plan of care to minimize falls. -The resident's plan of care will be updated to reflect risk for falls, and appropriate interventions. -When a fall occurs, the following will be done: -The licensed nurse will complete a thorough assessment of the resident to evaluate for injury. -The licensed nurse will notify the physician and the family/responsible party. -Treatment will be initiated per physician orders. -An incident report will be completed. -The resident's plan of care will be updated to reflect interventions. II. Resident #161 A. Resident status Resident #161, age 79, was admitted [DATE] and readmitted [DATE] and discharged on [DATE]. According to the November 2020 computerized physician orders (CPO) diagnoses included Alzheimer's disease, closed fracture with routine healing, pain in left hip, acute pain due to trauma, aftercare following explantation (removal of tissue) of hip joint prosthesis, unspecified fracture of unspecified lumbar vertebrae. -The fractures were added to the orders from the falls sustained in the facility. The 11/27/2020 minimum data set (MDS) assessment revealed he was negative for mood and behavior symptoms. He required extensive assistance of two staff members for bed mobility, transfers, and was dependent on one staff member for toilet use and personal hygiene. He was not steady and only able to stabilize with staff assistance during transitions of moving from seated to standing and surface to surface transfers. He had impairment of one side of the lower extremity and used a wheelchair for mobility. He was positive for hip replacement for hip fracture and other fractures. No falls since readmission. He had a surgical incision to his left hip. He received scheduled and as needed (PRN) pain medications for facial expressions of pain three to four days of the last five days. He received four out of seven days of anticoagulant injections and two out of seven days of opioid pain medication. Refer to the 11/15/2020 MDS assessment in the progress notes. B. Record review The 9/9/2020 fall scale evaluation indicated the resident was a low risk for falls as he did not require ambulatory aids and his gait was steady. The 9/9/2020 pain evaluation indicated he had no verbal or non-verbal indicators of pain. The 9/9/2020 nursing admission screening indicated he was independent with transfers and walking but needed extensive assistance with toilet use. He was alert and oriented only to self. He did not have pain. The 9/9/2020 baseline admission care plan indicated he did not require assistance from staff with transfers or walking and he did not use any mobility devices. The care plan, initiated 9/10/2020 revealed Resident #161 had impaired cognitive function and or thought processes related to Alzheimer's disease. Interventions included to cue, reorient, and supervise as needed. Anticipate and meet needs. -There was no care plan for falls. The 9/11/2020 physician admission history and physical indicated Resident #161 was admitted from home with progressive dementia as he was in need of more assistance with activities of daily living (ADLs). He was to be comfort measures only status and followed by palliative care. The 11/14/2020 pain evaluation after two falls indicated he was having pain to his left knee and thigh. The 11/15/2020 discharge-return anticipated MDS revealed he was positive for behavior symptoms of physical and verbal behaviors directed towards others, wandering, and rejection of care. He was always incontinent of bowel and bladder. He received PRN non-narcotic pain medications. He was positive for two or more falls with major injury and received an opioid pain medication one out of seven days. The 11/23/2020 nursing readmission screening indicated he returned to the facility after a hospital stay for a closed displaced fracture of the left femoral neck and closed fractures of lumbar vertebral bodies. He was dependent on staff for ADLs. The 11/30/2020 physician progress note, following readmission from the hospital for left hip hemiarthroplasty, indicated the resident grimaced with movement and required narcotic pain medication for uncontrolled pain. III. Sequence of events Fall #1 The nursing note on 11/13/2020 at 8:00 a.m., documented by licensed practical nurse (LPN) #10 read: This nurse called to resident's room by certified nurse aid. Resident found on floor, lying on his left side next to bed. Registered nurse/wound nurse called in and assessed resident. Resident able to move all extremities without difficulty. Small abrasion noted to left side of upper lip, with small amount of blood and area cleansed and no further drainage. Small abrasion noted to left elbow and cleansed and non draining. No other bruising found. This fall was unwitnessed. Resident assisted by 2 staff to stand and to lay in bed. Brief changed for small amount of urine. Assisted resident to bathroom and no further output. Assisted resident to lay in bed and bed in low position, Call light placed in resident's hand and reminded to call if wants to get up. Will make frequent room checks for needs per staff D/T (due to) resident's forgetfulness. (vital signs)VS=97.9-71-16-128/60-95%RA (room air). Neuros (neurological assessment WNL (within normal limits). PERL (pupils equal and reactive to light). Director of nursing (DON) informed, son called and left message on voice mail, physician and clinic/service called and gave information. The nursing note on 11/13/2020 at 8:04 a.m., documented by the wound registered nurse (WRN) read: Called to room - Resident found lying on back on floor beside bed. Small abrasion to Upper L (left) lip noted with drying blood . Small bruising with abrasion to L elbow measure 2.5x2 no bleeding. No rotation noted to hips or legs. Able to have full mobility to upper and lower ext. no pain to palpation. Assisted up to bed. Noted brief was wet. Resident with no verbal response when asked if was heading to bathroom. Resident assisted to bathroom and dry brief placed. Neuro checks initiated. According to the investigation after this fall, frequent checks were to be initiated. The director of nursing (DON) did not provide documentation that frequent checks were initiated or completed. Interdisciplinary team (IDT) note dated 11/16/2020 read in part: Resident denies pain and discomfort. Vital signs every shift for 72 hours. Neuros per facility protocol, treatments as ordered, observe for signs and symptoms of infection, therapy screen, observe for increased pain, injury and bruising, nurse education regarding treatment orders, offer frequent toileting. Fall #2 The incident note on 11/14/2020 at 12:15 p.m., documented by LPN #10 read: CNA called this nurse to 1100 hall and resident found sitting up and leaning against wall in hallway, this fall was unwitnessed. RN called to hall and assessed resident. Resident able to move extremities x4, no visible bruising. Assisted by 3 staff to stand resident and to sit him in chair and then taken to room and assisted to sit on side of bed. VS=98.4-82-16-110/61-pulse ox=93% RA. Resident unable to verbally communicate D/T dementia. Resident is pointing and rubbing left knee. Resident assisted by 3 staff to stand and then sit in chair and then transferred to his bed and sitting on bedside. VS and neuros initiated. PERL. Resident brief changed for small amount of urine. Call light place in hand and instructed to use to call before getting up from bed. Resident is not able to state understanding. Bed in low position. Frequent room checks initiated. DON called and left message, nursing supervisor aware, Son called and left message on voice mail, physician called and informed. -The resident with Alzheimer's disease was pointing and rubbing left knee. No x-ray was ordered to rule out major injuries. The incident note on 11/14/2020 at 12:31p.m., documented by registered nurse (RN) #3 read: RN called to Golden Gate for assessment. Arriving in 1100 hall way this resident was sitting on the floor against the wall across his room. Resident assessed head-to-toe. Pupils are PERLLA. Resident has severe dementia. He couldn't answer any questions per base line. No nausea and/or vomiting noted. Resident has fall yesterday per nurse verbal report. Vital signs are: 110/61, 82, 16, 98.4 and the pulse Oxymeter (sic) unable to read Oxygen saturation. I asked the nurse to use different Pulse Oxymeter and call DON for any abnormality. Resident normally able to walk without assist device, but this time he is not able to stand straight. Resident assisted to chair and pushed to his room by his nurse. His nurse and me assisted resident to his bed. Resident is moaning while assisted to stand and he is holding his left knee. I told the nurse to call DON and explain the situation and see if she wanted us to perform X-ray on his both knee, ankles and hips just to rule out any dislocation and/or fracture. Cross-reference F697. IDT note dated 11/16/2020 read: Vital signs every shift for 72 hours, neuros per facility protocol, therapy screen, observe for increased pain, injury and bruising, pain medication order received, nurse education on completing UDAs/incident report, investigate bright colored tape on call light as a reminder to call for assistance. The therapy screening was not completed until 11/25/2020, after the resident returned from the hospital on 11/23/2020 and indicated he required assistance with ADls, related to decreased safety awareness, reduced upper/lower extremity functioning or muscle weakness, alterations in mobility, poor positioning/body alignment, pain, and history of falls. Fall #3 The incident note on 11/14/2020 at 2:44 p.m., documented by RN#3 read: RN called to Golden Gate for assessment. Arriving in 1100 hallway this resident was lying on the floor on his right side next to his bed, his head is towards the drawer by the curtain. Resident assessed head-to-toe. Pupils are PERLLA. Resident has severe dementia. He couldn't answer any questions per base line. No nausea and/or vomiting noted. Resident has fall yesterday per nurse verbal report. This is his second incident today. Vital signs are WNL per base line. I asked the nurse to call DON and notify the incident. Resident normally able to walk without assist device. The weekend supervisor notified the incident and she start called the DON. Resident is moaning while he is holding his left knee. I told the nurse to call DON and explain the situation and see if she wanted us to perform X-ray on his both knee, ankles and hips just to rule out any dislocation and/or fracture. I left resident to the nurse who is assigned to provide direct care and the weekend supervisor. They said they will take care of the neruro check and notifying provider and family. The late entry nurses note on 11/14/2020 at 3:45 p.m., documented by LPN #6 read: Called to Golden Gate to find resident on floor laying on right side clutching left leg bent at knee and moaning loudly in pain. Resident unable to straighten left leg during RN assessment. Resident lifted to bed and lowered to lowest position and fall mats placed on floor. No bruising noted at this time. Call placed to on-call MD advised of pain and pt unable to straighten leg. No x-rays ordered at this time. Shortly after, RN from Palliative called and order received for x ray to left hip, Left knee, left femur. RN advised she would notify the on-call MD (medical doctor) of verbal order. Call placed to pt (patient) son no answer detailed message left. LPN #6 documented a late entry note related to fall #3 on 11/15/2020 at 1:32 p.m., it read: Called to Golden Gate for reported fall of resident 2nd one this shift. Upon arrival resident noted to be on floor by bed laying on right side holding left leg bent at knee. Resident moaning very loudly with RN assessment. Call placed to on-call MD to request x rays. Denied. Call then from RN palliative care and order received. Charge nurse advised of order. Resident lifted placed in bed. Bed placed in low position with fall mat on floor by bed. Call light within reach. Call placed to resident son x 5 detailed message left. Staff advised to monitor pain. Injury reported to DON. Fall #4 The nurses note on 11/14/2020 at 4:21p.m., documented by LPN #7 read: This nurse heard bang and resident screaming in room 1103, went to see and found this resident laying on the floor on his right lateral side of the body holding left knee and the head against the bedside commode, appeared to be in pain 8/10, RN came in and assessed resident with no swelling, noted resident continually holding left knee during the whole times, resident unable to describe what happened and how happened due to dementia. 10 minutes prior the fall this nurse saw resident sitting on the bed. After RN assessed resident Physician was called and order was received to start [MEDICATION(S)] 50mg every 6 hrs PRN and also [MEDICATION(S)] 1% 4 gram gel to apply to left knee 4 times per day. Resident was transferred back to bed, PRN Tylenol was given, bed in low position and bedside floor mat in place. will monitor resident as per facility protocol. Stat X Ray for left knee, left hip and left femur ordered received from the palliative nurse and later this order was discontinued. POA was notified via voice mail also DON. The nurses note on 11/14/2020 at 7:24 p.m., documented by LPN #7 read: Resident assessed by this nurse after one hr of Tylenol administration, pain subsided while resident is in bed but noted resident having severe pain when staff tried to positioned him and also during care, continue holding left thigh area. Nurse called physician and order received to have stat X Ray of the lumbar-sacral area, also left knee and left hip. Nurse unable to get [MEDICATION(S)] delivered at this time, spoke to Pharmacy staff and was told that stat delivery will take up to 4 hrs, requested to get from Pyxis (medication dispensing machine) and was told that machine not disponible. IDT note dated 11/16/2020 read: Stat x-ray for left knee, left hip and left femur ordered received from the palliative nurse and later this order was discontinued. Vital signs every shift for 72 hours, neuros per facility protocol, observe for increased pain, injury and bruising, bed placed in low position, floor mat placed next to bed. PRN [MEDICATION(S)] started and [MEDICATION(S)] 1% 4 gram gel. Doctor called related to continued pain, x-ray ordered and resident had noted fracture, resident sent to ER for eval and treat. The nurses note on 11/15/2020 at 4:32 a.m. read: Resident remains on monitoring for fall, resident guards L (left) leg and yells out when leg is touched, pain medication ([MEDICATION(S)]) Administered per order. Awaiting X-ray. Will continue to monitor. The nurses note on 11/15/2020 at 7:30 a.m., documented by LPN #10 read: X-ray company in and taking ordered x-rays. The facility failed to notify the medical director of the inability to obtain an x-ray order resulting in a delay of seven hours after the resident fell three times with apparent injury. The x-ray was not completed until 19 hours after the first fall on 11/14/2020 at 12:15 p.m. with apparent injury and the resident was not sent to the hospital for 26 hours after initial injury. The x-ray report indicated an acute left hip fracture involving the femoral neck with displacement. The nurses note on 11/15/2020 at 2:40 p.m., documented by LPN #6 read: Results of x-ray called to on-call MD. Order received to send pt to the hospital for eval and tx Acute left hip fx. Call placed to the hospital report given to PA. Son called left detailed voicemail. DON notified. Ambulance called waiting arrival. A. Hospital records The resident presented to the emergency department at 4:19 p.m. on 11/15/2020 with the chief complaint of a left hip fracture. Upon examination there was slight shortening of the left lower extremity with limited range of motion of the left hip due to pain. He appeared to be in moderate distress, he was moving and waving his arms. After entry to the emergency department he received a dose of [MEDICATION(S)] 50 micrograms (mcg) for his severe pain. Per the resident's son he was normally ambulatory without assistance. A computed tomography (CT) scan was performed and indicated: -Acute lumbar (L) 4 and L5 vertebral body superior endplate fractures with associated height loss that is mild to moderate involving the L5 vertebral body. -Acute left femoral neck fracture with angulation and impaction. He was scheduled for surgery the next day for repair of the hip fracture. He was discharged back to the facility on [DATE]. IV. Staff interviews LPN #6 was interviewed on 4/19/21at 9:18 a.m. She said on 11/14/2020 at 3:45 p.m. after the resident sustained his third fall of the day, she felt the resident was injured because he was in a lot of pain and he was moaning loudly. She said she notified the physician on-call of his pain and inability to straighten his left leg but he did not order x-rays or pain medication. He was on palliative care so she called that RN and received an order for x-rays. She said she only worked weekends and left shortly after she documented the incident and another nurse took over. She did not offer an explanation as to why the MD was not notified to obtain a pain medication order. LPN #10 was interviewed on 4/19/21 at 12:35 p.m. She said when the resident fell on [DATE] at 12:15 p.m. even though he was pointing to and rubbing his left knee, she did not think anything of it because he would point at different areas at different times. She said she did not consider him injured at that time. She said she had heard that after she left for the day he fell again and when the physician was notified he still would not order any x-rays or pain medication. She said she did not understand why the physician would do that. The minimum data set (MDS) coordinator was interviewed on 4/19/21 at 2:16 p.m. She said she would enter a fall care plan if she happened to catch one that was missing. She said there was a team of staff that were responsible for putting in fall care plans and it was not normally her job. RN #3 was interviewed on 4/19/21 at 4:53 p.m. He said he was called to the 1100 hall to assess the Resident #161 when he fell at 12:15 p.m. on 11/14/2020. He said the resident was normally up walking around but when he fell and they tried to assist him to stand he was moaning loudly and holding his left knee. He said it was clear the resident was in quite a bit of pain and he was afraid he may have dislocated or fractured his hip. He said once he did his assessment and told the resident's nurse to notify the physician and the DON, he went back to his hall. The DON and unit manager (UM) #1 were interviewed on 4/20/21at 9:11 a.m. UM #1 said at the time of Resident #161's falls on 11/14/2020 he was in training for unit manager. The DON was not completely certain that she was notified of the resident's falls each time. She said the expectation was for the nurses to notify the physician to get an order for an x-ray and an order to be sent to the hospital for evaluation especially since the resident was in pain. She said according to the nursing documentation of the fall events it was obvious the resident had suffered an injury and needed treatment. She said even if residents were on hospice or palliative care, the nursing staff was required to seek treatment for any apparent injury and the facility would pay for x-rays if they were not covered. She said she would call the physician to see why the palliative nurse's x-ray order was discontinued, and why there was no pain medication ordered when advised of the fall, his pain, and inability to straighten his leg at 3:45 p.m. on 11/14/2020. She said she would call the pharmacy to see why, on 11/14/2020 at 7:24 p.m., the nurse was told the [MEDICATION(S)] could not be obtained from the medication dispensing machine (Pyxis). LPN #7 was interviewed on 4/20/21 at 3:13 p.m. He said when Resident #161 fell at 4:21 p.m. on 11/14/2020 he felt he had suffered a fracture because he was screaming in pain and holding his left knee. LPN #7 called the physician on-call and received an order for the [MEDICATION(S)] and [MEDICATION(S)] Gel but he refused to order an x-ray because he said he did not have any swelling to the leg. The physician told the nurse to cancel the x-ray order that the palliative nurse had given him. LPN #7 said he became so frustrated with the physician because he was not listening to him. He said he spoke to the physician again three hours later when the resident was having severe pain when the staff tried to position him during care and the physician finally agreed to do x-rays. LPN #7 said he was told by the pharmacy that the [MEDICATION(S)] order would take at least four hours to get to the facility. LPN #7 called the pharmacy again to get authorization to obtain the medication out of the Pyxis and was told the machine was not working correctly and the medication could not be dispensed from it, even though the medication was in the machine. He said he did not think to ask the physician for an alternate pain medication because the physician already knew the situation and the physician did not offer to order the resident anything else. He did not think to notify the MD of the situation to obtain an x-ray order or have the MD call the pharmacy to obtain authorization to remove the pain medication from the Pyxis. The DON was again interviewed on 4/21/21 at 8:21 a.m. She said the pharmacy director told her when the order for [MEDICATION(S)] came to them it was put in as a STAT order and when the nurse called the pharmacy to be able to get a dose out of the Pyxis he was told he could not pull it from the machine because the medication was already with the courier on its way to the facility and the amount prescribed was in that order. They could not pull more from the machine because it would be over the tablet amount ordered by the physician. The DON said she was unaware of this particular procedure with the pharmacy. She acknowledged it was a problem that needed to be fixed because of the delay with the resident receiving the ordered pain medication timely. She said she will start a new procedure that will require the nurses to tell the pharmacy they will obtain the first dose of a pain medication from the Pyxis so the resident would not have to wait until the pharmacy delivered the medication, possibly several hours later. The DON was interviewed on 4/21/21 at 8:17 a.m. She said she spoke with Resident #161's physician and she said when the multiple falls occurred on 11/14/2020 a male on-call physician (name unknown) was the one the facility nurse spoke to that had cancelled the x-ray orders from the palliative RN and would not order pain medication. She could not offer an explanation for his actions. She agreed that should not have happened. The facility medical director (FMD) was interviewed on 4/21/21 at 10:17 a.m. He said he was unaware of the circumstances surrounding Resident #161 and in his opinion he felt the facility responded correctly and the resident was treated in a timely manner following the multiple falls. He did not offer any information as to what the facility could have done differently for the resident, although he would have been available to them for consultation. Physician #1 was interviewed on 4/21/21 3:40 p.m. She said she reviewed the communication of the phone calls from the nurses to the on-call physician after each fall the resident had on 11/14/21. She said when the resident had the first fall at 12:15 p.m. and could not stand and was having pain, rubbing his left knee and pointing to it, the physician should have ordered an x-ray and pain medication at that time. Having not intervened timely resulted in the resident having extreme pain and not being sent to the hospital for treatment for 26 hours after the original injury. The DON was interviewed on 4/21/21 at 4:02 p.m. She said when Resident #161 had the multiple falls on 11/14/2020 and the nurses were having difficulty obtaining orders from the on-call physician for an x-ray and pain medication, they should have called the FMD for orders. She said, I'm not sure they would have known to do that, but she would educate them on the need to notify the FMD if they were having difficulty with a physician and they were not ordering what they felt was necessary according to their assessment. V. Facility follow up On 4/22/21 at 11:00 a.m. the DON provided a copy of a sign that will be posted at each nursing station that read: In the event your resident is in need of immediate care your first step is to call the attending physician. If attending does not answer/return call or doesn't agree with your nursing assessment your medical director is available for a second opinion and additional support. The FMD's name and phone number was listed as well.

Based on interviews and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#161) of four residents reviewed for pain management out of 68 sample residents. The facility failed to ensure sufficient pain medication orders were obtained timely after Resident #161 (who had Alzheimer's disease, and staff were to anticipate his needs) had multiple falls (three in a four hour period on 11/14/2020, see record review below) resulting in major injury (cross-reference F689 for falls) and increased pain. In addition, the facility failed to ensure pain medication was available to be administered timely which resulted in the resident having unrelieved pain for over 13 hours of his first documented signs and symptoms of pain (see record review below). Findings include: I. Facility policies and procedures The Pain Management Program Policy, dated 10/8/2020, revised August 2020, provided by the staff development coordinator (SDC) on 4/19/21 at 11:16 a.m. read in pertinent part: -The facility and interdisciplinary team (IDT) will identify individuals who have pain or who are at risk for having pain. -The facility will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. -IDT will make attempts to determine root cause of pain and collaborate with physician to conduct necessary diagnostics and evaluation to identify potential source of pain and determine plan of care. -Create pain care plan-pain in advanced dementia for those residents with a dementia type diagnosis, those non-verbal residents, comatose residents and those not able to verbalize pain. -Obtain orders for pharmaceutical interventions, pain medications,and or non-pharmaceutical interventions. -The nurse will assess the resident every shift for pain on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -If a resident is assessed as experiencing pain during that shift, then pain medication and or alternative therapies should be administered as ordered. -For pain that is not managed through the current care plan the resident should be assessed for new causes of the pain and or the need for a change in frequency, dose or a new intervention. -With a new onset of pain, complete a pain evaluation. Determine an appropriate pharmacological intervention under the direction of the physician. The Medication Ordering and Receiving Controlled Medications From Pharmacy Provider policy dated 2007, revised January 2020, provided by the NHA on 4/20/21 at 4:40 p.m. read in pertinent part: -In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order as described by law. The Pharmacy Medication Ordering instruction sheet, dated 9/17/19, provided by the assistant nursing home administrator (ANHA) on 4/20/21 at 4:54 p.m. read in pertinent part: -For new orders please send the original physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Please call and fax any emergency or immediate (STAT) order requests directly to the pharmacy. -Please call the pharmacy for any emergency requests outside of scheduled deliveries. II. Resident #161 A. Resident status Resident #161, age 79, was admitted [DATE] and readmitted [DATE]. The resident discharged on [DATE]. According to the November 2020 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The pain in the left hip was added after the resident had fallen and sustained a left hip fracture (see below). The 11/27/2020 minimum data set (MDS) assessment indicated Resident #161 was rarely/never understood with a brief interview for mental status (BIMS) score of zero out of 15. He was negative for mood and behavior symptoms. He required extensive assistance of two staff members for bed mobility, transfers, and was dependent on one staff member for toilet use and personal hygiene. He had impairment of one side of the lower extremity and used a wheelchair for mobility. He was positive for hip replacement for hip fracture and other fractures. He received scheduled and PRN pain medications for facial expressions of pain three to four days of the last five days. He had a surgical incision to his left hip. He received four out of seven days of anticoagulant injections and two out of seven days of opioid pain medication. Refer to the 11/15/2020 discharge MDS in the record review. B. Record review The 9/9/2020 pain evaluation upon admission indicated he had no verbal or non-verbal indicators of pain and the pain evaluation completed on 11/14/2020 after two falls indicated he was having pain to his left knee and thigh. The 9/9/2020 nursing admission screening indicated he was independent with transfers and walking but needed extensive assistance with toilet use. He was alert and oriented only to self. He did not have pain. The 9/9/2020 MDS assessment revealed Resident #161 was not receiving a scheduled pain medication regimen. He did not receive PRN pain medications and did not receive non-medication intervention. The care plan, initiated 9/10/2020 revealed Resident #161 had impaired cognitive function and or thought processes related to Alzheimer's disease. Interventions included to cue, reorient, and supervise as needed. Anticipate and meet needs. -There was no care plan for pain. The 11/15/2020 discharge-return anticipated MDS revealed he was positive for behavior symptoms of physical and verbal behaviors directed towards others, wandering, and rejection of care. He received as needed (PRN) pain medication. He was positive for two or more falls with major injury and received opioid pain medication one out of seven days. The 11/23/2020 nursing readmission screening indicated he returned to the facility after a hospital stay for a closed displaced fracture of the left femoral neck and closed fractures of lumbar vertebral bodies. He was dependent on staff for ADLs. The 11/30/2020 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Sequence of events (Cross-reference F689 failure to ensure resident safety and obtain x-ray timely after repeated falls with increased pain) Fall #1 Resident #161 had a fall on 11/13/2020 at 8:00 a.m. in his room and received abrasions but did not indicate he had pain. The IDT note dated 11/16/2020 read in part: Resident denies pain and discomfort. Vital signs every shift for 72 hours. Neurological checks per facility protocol, treatments as ordered, observe for signs and symptoms of infection, therapy screen, observe for increased pain, injury and bruising, nurse education regarding treatment orders, offer frequent toileting. Fall #2 The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time he was unable to stand straight and was moaning and holding his left knee. -There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No pain medication order was obtained after this fall. Fall #3 The resident fell again on 11/14/2020 at 2:44 p.m. in his room. He again was clutching his left leg bent at the knee and moaning very loudly in pain. He was unable to straighten his left leg. A call was placed to the on-call physician and he was advised of the pain and the resident's inability to straighten his left leg. -No x-rays or pain medication were ordered at this time. The nursing staff failed to contact the facility medical director (FMD) to notify him of the situation and the need for x-ray and pain medication orders. Fall #4 The resident had another fall on 11/14/2020 at 4:21p.m. in his room. He was found holding his left knee and appeared to be in severe pain rated at an eight out of ten. Only at this time, after the physician was notified of yet another fall, was a narcotic pain medication ([MEDICATION(S)]) ordered. The nurses note dated 11/14/2020 at 7:24 p.m. revealed licensed practical nurse (LPN) #7 went to check on the resident and he was having severe pain and was holding his left thigh area. The [MEDICATION(S)] order that was received three hours earlier still had not arrived from the pharmacy. LPN #7 was unable to get the [MEDICATION(S)] delivered. He spoke to pharmacy staff and was told that an immediate (STAT) delivery would take up to four hours. The LPN requested to get the medication from the medication dispensing machine (Pyxis) and was told that the machine would not dispense it even though the medication was in the machine. -The facility failed to contact the FMD to notify him of the situation resulting in delayed administration of the pain medication. The order administration note on 11/15/2020 at 1:21 a.m. revealed the resident did not receive the first dose of [MEDICATION(S)] until nine hours after the order was received and 13 hours after the first fall with injury on 11/14/2020 at 12:15 p.m. The [MEDICATION(S)] was given again at 7:05 a.m. and 1:23 p.m. on 11/15/2020. He was transferred to the hospital on the afternoon of 11/15/2020. D. Emergency department note The resident presented to the emergency department at 4:19 p.m. on 11/15/2020 with the chief complaint of a left hip fracture. Upon examination there was slight shortening of the left lower extremity with limited range of motion of the left hip due to pain. He appeared to be in moderate distress, he was moving and waving his arms. After entry to the emergency department he received a dose of [MEDICATION(S)] 50 micrograms (mcg) for his severe pain. III. Staff interviews LPN #6 was interviewed on 4/19/21at 9:18 a.m. She said on 11/14/2020 at 3:45 p.m. after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she notified the physician on call of his pain and inability to straighten his left leg but he did not order x-rays or pain medication. He was on palliative care so she called the palliative registered nurse (RN) and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #10 was interviewed on 4/19/21 at 12:35 p.m. She said when the resident fell on [DATE] at 12:15 p.m. even though he was pointing to and rubbing his left knee, she did not think anything of it because he would point at different areas at different times. She said she did not consider him injured at that time. She said she had heard that after she left for the day the resident fell again and when the physician was notified he still did not order any x-rays or pain medication. She said she did not understand why the physician would do that. RN #3 was interviewed on 4/19/21 at 4:53 p.m. He said he was called to the 1100 hall to assess Resident #161 when he fell at 12:15 p.m. on 11/14/2020. He said the resident was normally up walking around, but when he fell the staff tried to assist him to stand he was moaning loudly and holding his left knee. He said it was clear the resident was in quite a bit of pain and he was afraid he may have dislocated or fractured his hip. He said once he completed his assessment (of the resident) and told the resident's nurse to notify the physician and the DON, he went back to his hall. The DON and unit manager (UM) #1 were interviewed on 4/20/21 at 9:11 a.m. UM #1 said at the time of Resident #161's falls on 11/14/2020 he was in training for unit manager. The DON said she was not completely certain that she was notified of the resident's falls each time. She said the expectation was for the nurses to notify the physician to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said according to the nursing documentation of the fall events it was obvious the resident had suffered an injury and needed treatment. -She said even if residents were on hospice or palliative care, the nursing staff were required to seek treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she would call the physician to see why there was no pain medication ordered when advised of the fall, his pain, and inability to straighten his leg at 3:45 p.m. on 11/14/2020. She said she would call the pharmacy to see why, on 11/14/2020 at 7:24 p.m., the nurse was told the [MEDICATION(S)] could not be obtained from the medication dispensing machine (Pyxis). LPN #7 was interviewed on 4/20/21 at 3:13 p.m. He said when Resident #161 fell at 4:21 p.m. on 11/14/2020 he felt he had suffered a fracture because he was screaming in pain and holding his left knee. LPN #7 called the physician on call and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #7 said he was told by the pharmacy that the [MEDICATION(S)] order would take at least four hours to get to the facility. LPN #7 called the pharmacy again to get authorization to obtain the medication out of the Pyxis and was told the machine was not working correctly and the medication could not be dispensed from it, even though the medication was in the machine. He said he did not think to ask the physician for an alternate pain medication because the physician already knew the situation and the physician did not offer to order the resident anything else. The DON was again interviewed on 4/21/21 at 8:21 a.m. She said the pharmacy director told her when the order for [MEDICATION(S)] came to them it was put in as a STAT order and when the nurse called the pharmacy to be able to get a dose out of the Pyxis he was told he could not pull it from the machine because the medication was already with the courier on its way to the facility and the amount prescribed was in that order. They could not pull more from the machine because it would be over the tablet amount ordered by the physician. The DON said she was unaware of this particular procedure with the pharmacy. She acknowledged it was a problem that needed to be fixed because of the delay with the resident receiving the ordered pain medication timely. She said she will start a new procedure that will require the nurses to tell the pharmacy they will obtain the first dose of a pain medication from the Pyxis so the resident would not have to wait until the pharmacy delivered the medication, possibly several hours later. The DON was interviewed on 4/21/21 at 8:17 a.m. She said spoke with Resident #161's physician and she said when the multiple falls occurred on 11/14/2020 a male on-call physician (name unknown) was the one the facility nurse spoke to that had cancelled the x-ray orders from the palliative RN and would not order pain medication. She could not offer an explanation for his actions. She agreed that should not have happened. The facility medical director (FMD) was interviewed on 4/21/21 at 10:17 a.m. He said he was unaware of the circumstances surrounding Resident #161 and in his opinion he felt the facility responded correctly and the resident was treated in a timely manner following the multiple falls. He did not offer any information as to what the facility could have done differently for the resident, although he would have been available to them for consultation. Physician #1 was interviewed on 4/21/21 3:40 p.m. She said she reviewed the communication of the phone calls from the nurses to the on-call physician after each fall the resident had on 11/14/21. She said when the resident had the first fall at 12:15 p.m. and could not stand and was having pain, rubbing his left knee and pointing to it, the physician should have ordered an x-ray and pain medication at that time. Having not intervened timely resulted in the resident having extreme pain and not being sent to the hospital for treatment for 26 hours after the original injury. The DON was interviewed on 4/21/21 at 4:02 p.m. She said when Resident #161 had the multiple falls on 11/14/2020 and the nurses were having difficulty obtaining orders from the on-call physician for an x-ray and pain medication, they should have called the FMD for orders. She said, I'm not sure they would have known to do that, but she would educate them on the need to notify the FMD if they were having difficulty with a physician and they were not ordering what they felt was necessary according to their assessment. IV. Facility follow up On 4/22/21 at 11:00 a.m. the DON provided a copy of a sign that would be posted at each nursing station that read: In the event your resident is in need of immediate care your first step is to call the attending physician. If attending does not answer/return call or doesn't agree with your nursing assessment your medical director is available for a second opinion and additional support. The FMD's name and phone number was listed as well.

Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for three (#166, #118 and #146) of seven residents out of 68 sample residents. Resident #166 who was admitted on [DATE], with a known history and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #166 complaint of tarry stools and stools with bright red blood to RN#6 and was concerned regarding another GI hemorrhage given his history. The facilities failures to monitor and identify timely the signs and symptoms of internal bleeding to provide necessary treatment, lead to Resident #166 calling the ambulance himself and was transferred to the hospital. Resident #166 was pale upon admission to the hospital, had blood in his stool was diagnosed with gastrointestinal hemorrhage, his hemoglobin level was 7.1 and he transfused with one unit of PRBC (packed red blood cells) (see record review below). Furthermore, when RN#6 was informed of complaints of bleeding by Resident #166, her intervention was to give the resident a container so the stool could be visualized when he had another bowel movement. RN#6 failed to fully assess the resident at the time of his complaint or notify other staff for assistance as she was attending to another emergency situation with another resident. No vitals were taken, the physician was not notified of the status change for the resident, during shift report this information was not passed on to the oncoming staff, and Resident #6 never went back to check on Resident #6 before leaving. Moreover, the facility failed to have a person centered care plan or orders to effectively monitor for bleeding when Resident #166 and #146 were on anticoagulant medications. Additionally, the facility failed to: -Assess and document Resident#118's bowel condition following complaints of having constipation for several days; -Document a complete physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Document the administration of a suppository given to Resident #118 on the resident's medication administration record; and, -Follow up on the results/effects of a suppository administered to Resident #118. Findings include: I. Professional references [NAME] A. M.; [NAME], H. from the National Center for Biotechnology Information (last update August 24, 2020) Gastrointestinal bleeding, Enhancing Healthcare Team Outcomes retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK 1/. It read, [NAME] (stool with blood) is dark, black, and tarry feces that typically has a strong characteristic odor caused by the digestive enzyme activity and intestinal bacteria on hemoglobin Care of patients with gastrointestinal bleeding requires coordinated and efficient interprofessional cooperation. Nurses manage the frequent monitoring of vital signs and more short-term interaction with and observation of patients. They must communicate their findings with the physicians, who use their own and nursing observations to make decisions for treatment. Multiple physicians may be necessary for treatment. General internists are typically responsible for the routine care of patients with GI bleeds A coordinated effort by all of these healthcare professionals functioning as an interprofessional team is necessary for early recognition and intervention in gastrointestinal bleeds to prevent further morbidity or mortalities. The measures to monitor a patient on blood thinning medications for abnormal GI bleeding include symptoms like change in bowel habits like diarrhea or [NAME], abdominal pain, retching or vomiting. Also to consider their history of prior GI bleeds, medications that can cause abnormal bleeding in the GI system. Laboratory values can be used to monitor a resident on these types of medications are, complete blood count hemoglobin and hematocrit, INR/PT/PTT if appropriate, [MEDICATION(S)] or liver function tests. II. Facility policy The Change in Condition and Physician and Family Notification policy was received by the assistant nursing home administrator (ANHA) on 4/20/21 at 10:00 a.m. It read in pertinent part, when a resident has a significant change in their physical status with an example of bleeding, the licensed nurse was required to contact the physician or designated on-call provider. Each attempt required to be charted in the resident's record with information about the provider, what they said and what information was given to that provider. III. Resident #166 A. Resident status Resident #166, age 64, was admitted on [DATE]. According to the April 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/15/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. He required supervision with setup for transfers, walking, eating and personal hygiene and one person assistance with bed mobility, dressing and toilet use. The MDS further documented a health condition for internal bleeding, he received anticoagulant medications. B. Resident interview Resident #166 was interviewed on 4/12/21 at 4:09 p.m. He said he alerted registered nurse (RN) #6 on 4/4/21 about 5:30 p.m. that he had blood in his stool. He said his stools were black and tarry for the past three days before his last bowel movement that day (4/4/21) which had red blood in it and he was concerned. He said RN #6 asked him to use a hat in the toilet to collect his stool so she could assess it because he had flushed the one he reported to her. He said he did not hear from the nurse for almost an hour. He said he felt worried and angry about the bleeding as if the facility staff did not care, so he called an ambulance to go to the hospital. When he arrived at the hospital, he was given a blood transfusion and admitted for four days for monitoring. C. Record review On admission to the facility it was documented in the resident's record that he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's electronic medical record (EMR) during his initial stay at the facility (3/31/21 to 4/4/21) did not include laboratory results. -Additionally, there was no care plan in place to monitor for bleeding until 4/12/21 after the resident was transferred to the hospital (see below). The 4/2/21 nurse practitioner admission summary documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It further documented in his history the resident had [CONDITION(S)], cardiovascular surgery and was placed on three medications for blood thinning, [MEDICATION(S)], Aspirin and [MEDICATION(S)] injection. The April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)], 75 mg, give one tablet by mouth one time a day; -[MEDICATION(S)] Solution 40 mg/0.4ml inject 40 mg subcutaneously at bedtime for anticoagulation. These medications were ordered upon his first admission to the facility. The progress note by LPN #4 on 4/4/21 at 9:50 p.m. revealed, Resident #166 was not in his room after he went to the resident's room to administer scheduled medications. He notified the unit manager and a search was initiated. Later that evening the unit manager cancelled the search because the resident's location was known (the resident had transferred himself to the hospital). The progress note by RN #6 on 4/5/21 at 6:21 a.m. as a late entry read, Resident #166 notified her he had black stool so she gave him a hat to put in his toilet to collect stool and he said he knew how to collect the sample. In her assessment he denied other abnormal bleeding and his general appearance was ok. -There was no documentation that the resident's vital signs were taken, the physician was notified, or the resident had been transferred or requested to go to the hospital. The hospital records for his stay from 4/4/21 to 4/9/21, were retrieved from the resident's electronic chart on 4/14/21. It revealed that on 4/4/21 for Resident #166 began to receive treatment at the hospital facility at 6:38 p.m. -At 6:47 p.m. the occult blood stool sample taken at the hospital which was positive. -At 7:10 p.m. the emergency room doctor's progress note read, the resident had a low blood count for hemoglobin of 7.1 and hematocrit of 21.7. He was actively bleeding and ordered to give the resident a transfusion of packed red blood cells (PRBC) with his current condition, as well as [MEDICATION(S)] infusion through his IV (Intravenous) to help stop the stomach bleed. -At 7:27 p.m. in the resident's history given to the emergency room doctor, it read he said he started to feel abdominal pain, felt dizzy and lightheaded with melana for two to three days. The doctor wrote the resident had a pale color to him. The emergency room doctor documented that the resident needed to have a blood transfusion because his hemoglobin was less than eight with a history of coronary artery disease, had a recent stent placed and had received blood [CONDITION(S)] in his past. Review of the medication administration record (MAR) revealed an order to monitor for abnormal bleeding which was originated on 4/12/21 upon return from his hospital stay from 4/4/21 to 4/9/21 (this was 13 days after his original admission on 3/31/21). The history and physical dated of the encounter on 4/12/21 by the Physician read, the resident had a short hospital stay because he had [NAME] for two to three days and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan focus area for anticoagulant and antiplatelet therapy, was initiated on 4/12/21 (after his admission to the hospital see original admitted [DATE] above) related to the resident's history of a GI bleed. Interventions included, to monitor the resident's vital signs and notify the provider of significant changes, monitor for discolored urine, bright red blood or black tarry stools and other signs of abnormal bleeding. -The resident said he wanted to be involved in making his health care decisions. Based on the experience with his medical history, he described what he knew to look for in his stools and other symptoms. D. Staff interview Registered nurse (RN) #11 was interviewed on 4/20/21 at 3:30 p.m. He stated resident's are monitored for signs of abnormal bleeding when they were first admitted or when they began a medication that was a blood thinner. The orders were used to identify resident's medications and what to monitor them for. When a symptom was identified, nurses obtained vital signs and performed an assessment and needed to notify the findings to the unit manager, the DON and the physician or designated provider to receive orders. The provider provided the next steps in the resident's care and documented the interactions and interventions made. Licensed practical nurse (LPN) #12 was interviewed on 4/20/21 at 3:40 p.m. She said, the signs of bleeding to watch for are blood from vomiting like coffee grounds, and from the genital areas and bruising. Then she would notify the doctor and obtain orders for next steps. RN #6 was interviewed on 4/21/21 at 2:00 p.m. She said Resident #166 came to her about having black/tarry blood in his stool on 4/4/21 at about 5:30 to 6:00 p.m. She said she told the resident she needed to collect a stool sample for a visual assessment. She said she gave the resident a hat to place in the toilet which he took to place in the toilet himself. She said she did not receive a report (at the beginning of her shift) that he had blood in his stool or that he had a prior gastrointestinal (GI) bleed that required a procedure in October of 2020. She said she had another emergency she needed to attend to at the time Resident #166 notified her of his concern but he did not look to be in acute distress so she went to care for the resident who had the emergency. She said the certified nurse aide (CNA) reported to her about 5:45 p.m. the resident refused his dinner and was angry. She said she did not follow up with the resident about his concerns before the end of her shift and she did not complete an assessment of the resident to include vital signs or notify the physician. -She said there were two CNA's scheduled for the evening shift 2:00 p.m. until 10:00 p.m., but from about 4:00 p.m. until the end of her shift at 6:30 p.m. one CNA had to cover both (rapid recovery and 100) hallways. cross-reference F725 sufficient nursing staff LPN #4 was interviewed on 4/23/21 at 3:05 p.m. He said one nurse was usually scheduled for the rapid recovery unit and one nurse for the 100's hallway from 6:00 p.m until 10:00 p.m. He said on 4/4/21 he worked both the rapid recovery unit and the 100's hallway from 6:00 p.m. until 6:00 a.m. He said he cared for residents that required [CONDITION(S)] care, IV administered antibiotics and two person care. He said that there was one CNA that worked those two hallways when usually two cna's were scheduled. He said he did not receive any information Resident #166 complained of blood in his stool in a report from the offgoing nurse on 4/4/21. He said he was told by the offgoing nurse that he refused his supper. -He said on 4/4/21 at 9:50 p.m. he went to administer medications to Resident #166 and he was not in the room. He and other staff members searched the inside and outside of the premises for the resident and did not find him. He notified the supervisor who began a rapid search for the resident, and found out at around 10:30 p.m. the resident was at the hospital and needed to be admitted . The director of nursing (DON) was interviewed on 4/22/21 at 8:45 a.m. She said Resident #166 was a high risk for bleeding related to three medications that can cause abnormal bleeding. She acknowledged the resident did not have any orders or care plan to monitor for abnormal bleeding prior to calling an ambulance for himself due to having blood in his stool. She said staff were supposed to monitor residents on anticoagulant therapy and notify the physician for any change in condition. The nursing home administrator (NHA) was interviewed on 4/22/21 at 8:50 a.m. She stated Resident #166 used his rights to leave the facility, find a means of transportation to another facility and to seek treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, based on the resident's interview, the hospital report and the nurse caring for the resident, the resident's vitals were not taken, and the doctor was not notified of the change in status for the resident. The resident was pale in color upon arriving at the hospital and required urgent services. The facility failed to monitor a resident with a history of GI bleeding and respond appropriately as RN #6 who was caring for the resident stated she had another emergency situation she needed to take care of at the time Resident #166 voiced his concerns of bloody stool. III. Resident # 146 A. Resident status Resident #146, aged under the age of 60, was admitted on [DATE]. According to the April 2021 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/23/21 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. He required extensive assistance with one person for bed mobility, dressing, and toilet use. He required supervision with one person to assist in transfer and personal hygiene. He needed supervision while eating and walking in his room, on the unit and locomotion off the unit. He required oxygen therapy, [CONDITION(S)] suctioning and care and used physical and occupational therapy. C. Observations On 4/12/21 at 2:20 p.m. Resident #146 was wheeled out of his room on a stretcher pushed by two emergency personnel. He had blood that was on and around his [CONDITION(S)]. RN #6 stated the resident expelled a large clot from his [CONDITION(S)] and was sent to the hospital to help with thick secretion suctioning and to stop the bleeding from his lungs. On 4/13/21 at 8:40 a.m. the resident laid in bed at a 45 degree angle, with his [CONDITION(S)] open without a speaker valve, or [CONDITION(S)] collar over the opening to administer heated oxygen. He had a nasal cannula in his nostrils that administered oxygen through his nose. On his bedside table, the inner cannula to his [CONDITION(S)] was laid on his bedside table with a moderate amount of dried blood in and outside of it. The respiratory therapist (RT) assisted him to sit on the edge of the bed. His [CONDITION(S)] was suctioned with a blood clot that expelled out along with thick blood tinged [MEDICATION(S)]. The RT educated the resident about the heated humidity. D. Resident interview Resident #146 was interviewed on 4/13/21 at 9:15 a.m. He said after he returned from the hospital, he had a hard time breathing with the inner cannula in place with his [CONDITION(S)] because it was plugged up. -He also stated that the day he started bleeding from his [CONDITION(S)], the nurse was suctioning him and he felt like a pop, and it hurt a lot. E. Record review Review of Resident #146's care plan revealed no monitor for bleeding even though the resident was on anticoagulant therapy. Review of the April 2021 CPO and MAR revealed there were no orders to monitor for abnormal bleeding while the resident was receiving anticoagulant therapy. The April 2021 orders for resident #146 read that he was receiving an anticoagulant medication, Xeralto, once a day for blood clot prevention from when he was admitted on [DATE] until an order on 4/8/21, was placed to stop the anti-coagulation medication in an effort to stop the bleeding from his lungs. -The orders did not include monitoring for abnormal bleeding when he received the anticoagulation medication for 23 days while he was at the facility. The hospital records for his stay from 3/27/21 to 3/31/21, were retrieved from the resident's electronic chart on 4/12/21. It read in pertinent part, the resident was sent to the hospital because he had blood in his [CONDITION(S)] secretions. His discharged diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . F. Staff interviews The RT was interviewed on 4/13/21 at 8:45 a.m. He stated the resident needed aggressive suctioning when he arrived that morning because there was a lot of thick [MEDICATION(S)] and blood clots that were difficult to expel by the resident spontaneously. The resident began to bleed through his [CONDITION(S)] from suctioning about two weeks prior. In an effort to control the bleeding the anticoagulant medication was stopped. The machine for ventilation was replaced two times and would be replaced again because the resident stated it was only put out cold humidity. The RN's provide deep suctioning while RT is not in the building, and RT is available on call as needed. RN #3 was interviewed on 4/15/21 at 1:00 p.m. He stated that when he had suctioned the resident and had a difficult time, he had to suction the resident [CONDITION(S)] deep and vigorously. Physician #3 was interviewed on 4/15/21 at 3:00 p.m. He said the resident was in a difficult situation because he was bleeding from his [CONDITION(S)]. It resulted from deep and vigorous suctioning, and continued because the tissue area of the lungs were sensitive, he was on an anticoagulant medication and he did not use his recommended [CONDITION(S)] collar with heated humidification because the ventilation machine only put out cool humidity, and had been replaced two times. The DON was interviewed on 4/22/21 at 8:45 a.m. She said all residents that had orders to take anticoagulation or antiplatelet medications are required to have an order and care plan to monitor for abnormal bleeding and to notify the doctor of any changes or complications related to those medications. cross-reference F656 develop/implement comprehensive care plan. IV. Failure to assess a Resident #118 for constipation and document physician orders A. Facility policy The Medication Orders policy, dated November 2014, was provided by the assistant nursing home administrator (ANHA), on 4/20/21 at 5:58 p.m. It read in pertinent part: A current list of orders must be maintained in the clinical record of each resident. Orders must be written and maintained in chronological order. -When recording orders for medications, specify the type, route, dosage, frequency, and the strength of the medication ordered. -When recording a PRN (as needed) medication specify the type, route, dosage, frequency, strength and reason for administration. The facility Bowel Management Protocol, undated, was provided by the nursing home administrator (NHA), on 4/20/21 at 8:35 a.m. It read in pertinent part: In the absence of a bowel movement for three consecutive days the following will be implemented, a licensed nurse will assess the resident for: -Bowel sounds (if no bowel sounds - call the doctor); abdominal distension; pain and tenderness; digital exam to check for the presence of stool; vital signs; review meal intake. -A licensed nurse will initiate milk of magnesia, if no response within eight hours - initiate [MEDICATION(S)] suppository. If no response to the suppository within eight hours-initiate fleets enema and call the physician. -The resident will be monitored every shift to monitor effectiveness of treatments B. Resident status Resident #118, age 80, was admitted on [DATE]. According to the April 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/26/21 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) of 11 out of 15. The resident was unable to balance and stead without staff assistance when transferring and walking. The resident was continent of bowel and needed supervision, cuing and encouragement when going to the bathroom with assistance getting on and off the toilet. C. Resident interview Resident #118 was interviewed on 4/13/21 at 2:52 p.m. Resident #67 said I don't feel too good. I've been constipated for seven days and I feel uncomfortable. The resident said she was given medication to facilitate a bowel movement but, nothing was working. Resident #118 was interviewed again on 4/15/21 at 9:42 a.m. Resident #118 said she is feeling better, was no longer constipated and was able to eat breakfast with no stomach discomfort. 3. Record review Progress notes documented the following pertinent information: -Nursing note dated 4/4/21 at 6:52 a.m. Resident requested [MEDICATION(S)] at 5:00 a.m., for bowel movement. The was no order for [MEDICATION(S)] on the April 2021 medication administration record (MAR) and no documentation of a bowel assessment or outcome of the resident's request. -Nursing note dated 4/12/21 at 12:44 p.m. Resident appears [CONDITION(S)] after physical therapy session, oxygen saturation was percent on room air. Called the resident's physician, ordered chest x-ray and lab work STAT, oxygen at two (2) liters per minute via nasal cannula, titrate as needed. -Nursing note dated 4/12/21 at 2:01 p.m. (Written by licensed practical nurse (LPN) #15) Resident was given a suppository by a female nurse, monitor for efficacy. Resident also saw her physician. -Nursing note dated 4/19/21 at 10:11 a.m. Resident denies pain or constipation, stated she had a bowel movement this morning at 7:00 a.m. Resident declined PRN (as needed medication) for constipation and voiced feeling tired. Physicians visit note dated 4/12/21 revealed the facility nurse request the residents physician see Resident #118 for decreased oxygen saturation levels. There was no documentation of concerns for constipation in the physician's note. The note read in pertinent part: -History of present illness: nurse reports oxygen saturation dropped to 88% on room air. Patient denies chest pain or shortness of breath .Examination: Patient alert, calm and cooperative with exam, no acute distress, no respiratory distress, lungs clear to auscultation. Psychiatry: no anxious affect .abdominal active bowel sounds, non-tender. The April 2021 medication administration record (MAR) revealed the resident did not have any prescribed medication to treat constipation. -There was no documentation of a suppository being administered to Resident #118 as documented in the resident's progress note dated 4/12/21 at 2:01 p.m. The MAR documented orders to track side effects for prescribed antidepressant, antipsychotic medications, constipation was one of the listed side effects. -The record did not indicate signs or symptoms of constipation through the month, from 4/1/21 through 4/14/21. The resident's bowel tracking record was reviewed for bowel movement results from 4/4/21 through 4/14/21. The record revealed the resident had one medium bowel movement on 4/4/21 and two bowel movements averaging a medium size every other day from 4/5/21 through 4/14/21. All bowel movements were described as being formed and of normal consistency. The resident's medical record failed to document a full bowel assessment of the resident's gastrointestinal condition or results of the bowel tracking record related to the resident's complaints of constipation. There was no documented order for the administration of the suppository mentioned in a nursing note dated 4/12/21 at 2:01 p.m. and no documentation of what type of suppository was given or the result/effect of the suppository given. Furthermore, the resident's care plan documented the use of [MEDICATION(S)], which the resident was previously prescribed but had since been discontinued months prior to this episode. [MEDICATION(S)] was not indicated as part of the bowel management protocol. The resident comprehensive care plan revealed a care plan focus for constipation last updated 1/28/21. The care focus read in part: -Resident #118 is at risk related to alterations in bowel elimination constipation and diarrhea. Receives [MEDICATION(S)] (polyethylene glycol). Interventions: encourage increased activity; encourage intake of fluids; evaluate bowel sounds as indicated and report significant abnormalities to resident's physician; refer to dietitian for consultation as indicated or dietary interventions and restrictions. -Resident #118 has the potential for constipation related to use and side effects of medication. Goal: Resident will have a normal bowel movement at least every third day. Interventions: follow facility bowel protocol for bowel management; increase fiber and fluid intake to provide more bulk in diet; monitor medications for side effects of constipation. Keep physicians informed of any problems; monitor, document, report signs and symptoms of complications related to constipation; record bowel movement patterns each day. 4. Staff interviews Licensed practical nurse (LPN) #9 was interviewed on 4/15/21 at 2:43 p.m. LPN #9 said if a resident complained of constipation or showed signs and symptoms of constipation the nurse should assess the resident for bowel function and check the daily bowel movement tracking record. If the resident had not had a bowel movement in three days the nurse would administer medication, as ordered. If the resident was not prescribed medications to treat constipation, the nurse would have to contact the physician to report the resident's bowel status and request treatment orders. Registered nurse (RN) #4 was interviewed on 4/10/21 at 10:04 a.m. RN #4 said Resident #118 had not made any complaints of constipation that she was aware of. RN #4 checked the resident bowel tracking record and said according to the bowel tracking the resident was having regular bowel movements. Resident #118 sometimes had delusions and would say she was experiencing constipation when she was not. If Resident #118 made complaints of constipation, the nurse should follow the bowel management protocol and assess the resident bowel status. Unit manager (UM) #2 was interviewed on 4/19/21 at 11:57 a.m. UM #2 said there should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM was not sure why the order and administration of the suppository, documented in Resident #118's progress notes had not been documented on the MAR. The UM was unable to locate a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM said she would contact LPN #15, the nurse who wrote the progress note, dated 4/12/21 at 2:01 p.m., to investigate what happened. The director of nursing (DON) was interviewed on 4/19/21 at 12:07 p.m. The DON said when a resident complained of constipation the nurse was to follow the bowel management protocol procedure to determine necessary treatment needs. There should be a doctor's order for any medication administered to the resident and there should be a record of all prescribed medications to the resident. The nurse was to document administration of medications immediately following the delivery of the medication. The DON did not know why the order and administration of the suppository was not documented. UM #2 was interviewed on 4/19/21 at 5:10 p.m. The UM said she contacted LPN #15, and discovered form LPN #15 that he received a verbal order from the resident's doctor to administer a [MEDICATION(S)] suppository to Resident #118. Due to resident preferences, he requested a female nurse give the suppository. He said he thought that nurse would enter and record the order and administration of the suppository into the resident's medical record. He was educated on correct procedure assessing a resident for constipation and for taking a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A copy of a telephone order or the signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was interviewed on 4/20/21 at 9:26 a.m. The DON acknowledged there was no assessment of Resident #118's bowel status prior to or after administration of a suppository for complaints of constipation and there should have been. The DON said she conducted verbal education with the unit nurses and will continue education until all of the nurses were educated on expectation for bowel management.

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (#3) of four sampled residents. Specifically the facility failed to address the resident's constipation in a timely manner, resulting in worsening of condition and pain, necessitating sending the resident to the hospital on [DATE] where the resident expired, that afternoon. Record Review Resident #3 was admitted to the facility on [DATE] and was discharged to an acute care hospital on [DATE]. According to the facesheet the resident was [AGE] years old, 4' 7 and weighed 98 lbs. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified the resident as having adequate hearing, clear speech, the ability to make him/herself understood and to understand others. Vision was adequate with corrective lenses. The Brief Interview for Mental Status (BIMS) score was nine which indicated the resident as having moderate cognitive impairment. Functionally the resident required the extensive physical assistance of one person for bed mobility, dressing, toileting and personal hygiene. Review of the resident's medical record showed a 'Change of Condition' form (SBAR) dated [DATE] that showed the resident experienced abdominal distension and loss of appetite. Assessment of the GI (gastrointestinal) /Abdomen showed a distended abdomen, diarrhea, decreased appetite and abdominal pain. The other three 'Change of Condition' forms documented issues other than constipation. A final X-ray report dated [DATE] (from the hospital) gave the following impression: Distended, redundant colon and central abdomen, likely redundant [MEDICATION NAME] colon. This could represent ileus (intestinal obstruction), constipation or distal colonic obstruction. The BM (Bowel Movement) Report Roster for resident #3 dated [DATE] through [DATE], documented the following in pertinent part: The resident did not have a documented bowel movement from [DATE]-[DATE]. The resident then had additional bowel movements on [DATE] and [DATE]. The entry on [DATE] was the last documented bowel movement on the Report Roster. The information on the roster was entered by the certified nurse aide (CNA) each time the resident had a bowel movement or the resident was checked for incontinence. The resident was incontinent of bowel. -There were three bowel entrees on [DATE] (3:06 a.m., 11:27 a.m. and 4:13 p.m.) documenting no bowel movement on that date. -On [DATE] there were two entries (11:32 a.m. and 3:03 p.m.) documenting no bowel movement. -On [DATE] there were two entries (2:34 p.m. and 8:37 p.m.) documenting no bowel movement on that date. -On [DATE] there were three entries (3:50 a.m., 11:21a.m., and 3:19 p.m.) documenting no bowel movement on that date. -On [DATE] there were three entries (3:34 a.m., 9:56 a.m. and 2:56 p.m.) documenting no bowel movement on that date. The Facility's Bowel Protocol read as follows; MOM (Milk of Magnesia). Give 30 cc PO (by mouth PRN (as needed) if no BM in 3 days. Give on day shift. [MEDICATION NAME] Suppository 10 mg. Give 1 suppository PR (per rectum) PRN (as needed) if no result from MOM. Give on evening shift. Fleet's Enema. Give 1 enema PR PRN if no result from suppository. Give on night shift. A Care plan for potential for constipation did not show an initiation date but was reviewed by the facility on [DATE]. The stated goal was the resident would have at least one stool every three days for the next 90 days (Through [DATE]). Interventions included in pertinent part: Assess VS (vital signs), resident abdomen for distention, bowel sounds, tenderness or guarding at least every shift. Administer laxatives/stool softeners as ordered by physician. Document effectiveness. A nursing progress note dated [DATE] at 6:35 a.m. read in pertinent part: Resident complained of low back pain. Resident abdomen slightly distended. Bowel sounds x 4. Resident agreed to have rectal vault checked. Moderate amount of firm stool noted in rectum. Resident agreeable to MOM. Oncoming shift aware and to seek order for suppository. (No note of calling the physician for a suppository was found in resident's record.) A nursing progress note dated [DATE] at 6:47 a.m. documented in pertinent part: Resident complained of back pain ,[DATE] (six on scale of ,[DATE]). PRN (as needed) Tylenol administered and resident repositioned as resident allowed. Resident complained of back pain again at 5:30 am. Resident declined VS. Resident states she does not want MD (physician) contacted or stronger pain relief. Resident states she had a large BM yesterday. Oncoming shift made aware and will contact MD. A nursing progress note dated [DATE] at 11:54 a.m. read in pertinent part: Resident's doctor was reached at 9:53 a.m. Doctor was in the building and came to see resident. The resident was sent out to emergency room at approximately 10:15 a.m. on [DATE]. A nursing progress note dated [DATE] at 12:47 p.m. documented: VS T (temperature) 96.4, P (pulse) 114. R (respirations) 28, BP (blood pressure) ,[DATE]. Oxygen saturation 99% on 2 liters of oxygen/minute. Resident was having major respiratory distress signs and symptoms. Per physician's orders [REDACTED]. Resident was transferred this morning to ER (emergency room ). Gave report to ER nurse. On [DATE] at 3:11 p.m. a late entry note was documented for [DATE]. The note read in pertinent part: Resident complained of back pain throughout the night. Resident assessed for back pain approximately at 7:15 a.m. Resident reported pain of 6 (six) but refused pain medication. On assessment resident reported pain of 6 and agreed to Tylenol at this time. Resident reported having a bowel movement the day before which was [DATE]. This was reported to on-coming shift. The Computerized Physician order [REDACTED]. Indication: Constipation. The Medication Administration Record [REDACTED]. These were the only PRN administrations of MOM documented as given to this resident. A telephone order dated [DATE] ordered the resident be sent to the local hospital. The order noted: Cool, clammy, [MEDICAL CONDITION] Firm right side of abdomen. A transfer form dated [DATE] read in pertinent part, Reason for transfer: Clammy, SOB with distended abdomen and right AKA (above knee amputation). Primary Diagnosis: [REDACTED]. VS: ,[DATE], 114, 28 and 96.1. EMT (Emergency Medical Technician) Record The Patient Care and Response Report from the EMT provider was obtained on [DATE]. The report read, in pertinent part: Nurse states respiratory distress onset that morning and abdominal distention onset approximately two days ago. Nurse also states patient did have bowel movement early morning. Skin cool, pale, clammy. Pt Alert and oriented x 1. Confusion with place, time, event. Tachypneic, shallow breathing. Vitals obtained and recorded below and monitored. Severe abdominal distention all four quadrants. Right upper and lower abdomen rigid with slight tenderness. EMT unable to palpate pulse in all 3 extremities. Carotid artery used. Pt placed on O2 (oxygen) at 15 liters/minute via non-rebreather mask. IV (intravenous) access right arm using aseptic technique and 500 cc NS with 400 cc infused enroute. EMT Staff Interview An interview with the EMT who responded to the facility call on [DATE] was conducted on [DATE] at 3:39 p.m. The EMT was also the Field Supervisor for the responding ambulance service. When we got on-scene I started a full body assessment. We were called for respiratory distress and the patient was having a hard time breathing. I was not able to get a pulse from any of her extremities and finally got a carotid pulse. (Pulse: 132). I couldn't get a blood pressure manually or with the electronic device. Her abdomen was rigid. There were no bowel signs x4 (all four quadrants) .She looked pregnant, that's how distended she was. When I questioned staff they said she had been distended for two days. The EMT stated the BP on his report was from the hospital's assessment (BP ,[DATE]). Hospital Record The resident's hospital record was requested and obtained on [DATE]. The initial hospital History and physical read in pertinent part: Patient had reportedly had several days of increasing abdominal distention. - Paramedics were summoned to her skilled nursing facility, where they noted her to have marked abdominal distention. - There was concern about the possibility of aortic dissection, so the patient underwent CT scanning of the chest, abdomen and pelvis immediately upon arrival to the emergency department. She was found to have massive distention of her bowel with extremely severe constipation and huge amounts of fecal material throughout her colon. -Past Medical History, in pertinent part, [MEDICAL CONDITION], chronic constipation with two admissions in October of 2014 for constipation. -The review of systems read in pertinent part, Abdomen: Massively distended. It is extremely hard. There is no clear guarding or rebound tenderness, though the patient does not appear to be responsive to noxious stimuli currently . The patient has the most severe constipation . and it is exceedingly unlikely this can be managed with medical interventions . A CT (computed tomography) scan of the chest, abdomen, and pelvis is personally reviewed. This scan is notable for extremely severe constipation throughout the majority of the colon. Initial chest x-ray is notable for extensive stool visible in the abdomen with left hemidiaphragm elevation. Follow-up chest X-ray after the patient's intubation and [MEDICAL CONDITION] reveals substantial rightward displacement of the trachea with what appears to be a large amount of bowel content in the left hemithorax. Impression: 1. Bowel obstruction that appears to be due to severe constipation and obstipation (intestinal obstruction; severe constipation). 2. Bradycardic arrest likely due to progressive respiratory acidosis (a pathological state characterized by an increase in the concentration of hydrogen ions in the arterial blood, which may be caused by an accumulation of carbon [MEDICATION NAME] or acidic products of metabolism) associated with hypercapnic (abnormally increased arterial carbon [MEDICATION NAME] tension) [MEDICAL CONDITION]. This is likely a result of the patient's exceedingly impaired respiratory mechanics as a result of abdominal distention and what appears to be a massive hiatal hernia. 3. Previous history of chronic constipation with two hospitalization s in October of 2014 with constipation. A re-evaluation/progress note dated [DATE] at 11:10 a.m. read in pertinent part: [AGE] year old female presents with dyspnea (shortness of breath with exertion) since yesterday and a distended abdomen for the past four days . Now having an increased heart rate 120 and blood pressure down to ,[DATE] again. Cannot get a good waveform on pulse ox (pulse oximetry), she does appear to be having some difficulty breathing, but I suspect this is related to the large abdominal distention. We are placing an NG (naso-gastric tube) now to attempt to decompress and reassess. A re-evaluation/progress note dated [DATE] 4:28 p.m. read in pertinent part, Options discussed with family, all with high mortality and low chance to help her recover. Patient is being made comfort care, I will extubate the patient. [MEDICATION NAME] PRN for oxygen hunger. A re-evaluation/Progress note dated [DATE] at 4:54 p.m. read in pertinent part: Confirmed the patient to be pulseless and apneic (no spontaneous breathing) and in asystole (lack of cardiac contractions). Time of death was noted at 4:52 p.m. Diagnosis, Assessment and Plan, in pertinent part: Impression: Bowel obstruction that appears due to severe constipation/obstipation. Additional facility Record Review A SBAR (change of condition) form dated [DATE] at 10:22 a.m. (the day following resident discharge to hospital) in pertinent part: Situation: Respiratory distress, abdominal distention, pain. Request: Monitor VS and observe. Reported to MGR/DR (manager/doctor). Staff Interview An interview with CNA #2 was conducted [DATE] at 2:10 p.m. The CNA stated if a resident was constipated she would tell the nurse as soon as possible. The CNA said that the CNAs input the information for the Bowel Movement Report Roster. On [DATE] at 2:31 p.m. RNs #1 and #2 were interviewed. RN 1 said that the CNAs document each time the resident had or did not have a bowel movement. This documentation would appear on the BM Report Roster. LPN #1 was interviewed on [DATE] at 2:40 p.m. and stated resident #3 had a history of [REDACTED]. I called the resident's physician. The resident was short of breath and distended. She stated the physician came in, assessed the resident, and decided to send the resident out. LPN #1 said the facility bowel protocol had orders for Milk of Magnesia, [MEDICATION NAME] suppositories and Fleet Enema. The Milk of Magnesia was to be given on the third day without a BM on the day shift. If no results by the evening shift, a [MEDICATION NAME] suppository was to be given on that shift. If no results by night shift, the Fleet Enema should be administered on the night shift. When asked if resident #3 could toilet independently, LPN #1 responded: She is a one person assist for toileting. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at approximately 3:00 p.m. After reviewing resident #3's care plan, MARs/TARs (Medication/treatment administration Records) and care plan for constipation, the ADON explained the facility Bowel Protocol. The ADON was asked if the facility Bowel protocol was followed and replied that he only saw the administration of Milk of Magnesia on [DATE]. If the resident said she had a BM on the 9th, it (the bowel protocol) was followed. The ADON could not explain why the BM Report Roster did not include the resident's self-reported BM on [DATE]. An interview with the NHA (Nursing Home Administrator) was conducted on [DATE] at 4:10 p.m. The NHA said it was her expectation that the Bowel protocol be followed from the date the resident said she had her last BM ([DATE]). The NHA was shown the BM Report Roster and said The resident was alert and oriented and said she had a BM on the 9th. The nurse documented the resident had bowel sounds x 4 (bowel sounds in all 4 abdominal quadrants). I am not a nurse but I don't think you can have bowel sounds if you are constipated. Summary From documentation review and interview the facility's lack of following policy and procedure for bowel protocol and failure to provide treatment contributed to the resident's decline including pain, distention, hospitalization and death.

Based on family interview, staff interviews, and record reviews the facility failed to ensure that one (resident #173) of three residents received the care and services necessary to attain the highest practicable level of well-being. Specifically, the facility failed to: -Provide a Registered Nurse (RN) assessment to a change to the skin on the resident's scrotum. -Monitor the changes to the skin on the resident's scrotum after it was identified. The scrotum became infected and required surgical debridement. -Identify changes in resident's vital signs consistent with infection. -Assess the resident's hydration status, although the resident had experienced emesis (vomiting) and had received a physician's orders [REDACTED]." Cross reference F157 the failure to notify the resident's responsible party of a change of condition. The findings include: A. Resident Status Resident #173, age 80, was admitted to the facility on [DATE]. According to the [DATE] Computerized physician's orders [REDACTED]. The [DATE] quarterly Minimum Data Set (MDS) assessment revealed: -The resident had severe cognitive impairment as evidenced by a Brief Interview Mental Status score of ,[DATE]. -The resident did not experience [MEDICAL CONDITIONS], behavioral symptoms, rejection of cares or wandering during the MDS observation period. -The resident required extensive assistance with bed mobility and eating. -The resident was totally dependent on staff for transfers, locomotion on and off the unit, dressing, toilet use, bathing, and personal hygiene. -The resident was always incontinent of bowel and bladder. -The resident had two stage two pressure ulcers that were present upon admission. -The resident had pressure relieving devices to his bed and chair; nutrition or hydration interventions to manage skin problems; pressure ulcer care; and application of ointments/medications. B. Record Review a. Medical Order's Scope of Treatment (MOST) Form According to the [DATE] (last reviewed [DATE]) MOST form completed by the resident's medical durable power of attorney had designated that the resident was to receive full treatment and was to receive cardiopulmonary resuscitation as applicable. b. Care Plans A skin care plan, dated [DATE], read in part, the resident was at risk of impaired skin integrity related to limited mobility and self care ability, incontinence, [MEDICAL CONDITION], dry skin, history of skin graft to bottom of his right foot which is black/tender at times, scar tissue on left hip, and diabetes mellitus. The goal was for the resident to maintain skin integrity. Approaches for maintaining skin integrity included: -Offer supplements as ordered -Bed canes bilaterally at side of bed for mobility -Record percentages of meals eaten daily and assist with eating and drinking as needed -Follow house protocol regimen for treating breaks in skin integrity/pressure ulcers -Provide skin treatments as ordered -Provide check and change; adult briefs; and assist with perineal care as needed -Weekly head to toe skin checks (C=clear A= abnormal see nursing documentation) -Complete Braden quarterly and as needed -Monitor skin for signs and symptoms of breakdown and redness during all direct care -Dietician to follow/evaluate resident nutritional/hydration status during stay and as needed -Have two staff members to move the resident to avoid friction rubs -Place pressure relieving/reducing products on bed/wheelchair A Nutrition and Hydration care plan, dated [DATE], last reviewed on [DATE], indicated the resident had hydration risk. The goal was for the resident's hydration to be maintained and for the resident's skin to be intact. Approaches to maintain hydration included providing 240 ml of fluid three times daily between meals. c. Nutritional Status Review The [DATE] Nutritional Status Review showed the resident's fluid needs were 2000 ml daily. The resident consumed 360 ml of fluids with each meal. d. CPOs The [DATE] CPO showed an order for [REDACTED]. e. Diagnostic Lab Results The resident's most recent Comprehensive Metabolic Panel (CMP) completed on [DATE] showed the resident's kidney function was normal and his hydration status markers were within established standards: -GFR (glomular filtration rate) African American = 104.56 (>59.00) -Sodium = 138.0 (135XXX,[DATE].0) -BUN = 18 (,[DATE]) -Creatinine = 0.9 (0XXX,[DATE].5) f. Vital Sign and Weight Flow Sheet The resident's Vital Sign and Weight Flow Sheet showed the resident's blood pressure and body temperature were: -No monthly result was recorded for [DATE] -[DATE] = ,[DATE] and 96.6° Fahrenheit (F) -[DATE] = ,[DATE] and 98.1° F -[DATE] = ,[DATE] and 97.4° F -[DATE] = ,[DATE] and 97.2° F -[DATE] = ,[DATE] and 97.2° F g. Discharge Summary The [DATE] Discharge Summary stated: -The resident was non-ambulatory and used a wheelchair for mobility. -The resident required assistance with activities of daily living. -The resident was receiving no special treatments or procedures. -The resident was being seen by a dermatology practice for a rash of unknown etiology. -The resident was being discharged to the hospital via ambulance for being unresponsive, scrotum sloughing, and scabs to his upper body, arms, back and trunk. C. Facility Failures 1. Skin Condition(s) and Assessment A [DATE] Nurse's Note completed on the 6:00 a.m., to 2:00 p.m., shift stated that the resident continued to be treated for [REDACTED]. The resident's scrotum was noted to be "intact with moisture barrier applied." A [DATE] Provider Progress Note signed at 11:46 a.m., by the Physician's Assistant (PA) stated: -The resident continued to do well with respect to resolution of the rash. -The resident had a follow-up appointment with the specialist on [DATE]. A [DATE] dermatology visit note revealed the following information: -The resident was being seen for a follow-up visit for the rash on the trunk of his body. -The dermatologist observed the resident's face, neck, chest, abdomen, back, right upper extremity, left upper extremity, right lower extremity, left lower extremity, right hand and left hand. -The resident was itchy and had scabbed [MEDICAL CONDITION] that were "improved" from the previous visit. -There was "no definitive [DIAGNOSES REDACTED]. -The dermatologist directed that the resident begin an increased (from 10 mg to 25 mg) dose of [MEDICATION NAME] at bedtime and should begin use of [MEDICATION NAME] 0.1% ointment twice daily for treatment of [REDACTED]. -The dermatologist was to be contacted if the resident experienced any side effects including, but not limited to rash, fevers, chills, malaise, abdominal pain, weakness, fatigue, headaches, infections, or difficulty breathing. A [DATE] Provider Progress Note signed at 2:03 p.m., by the Physician's Assistant (PA) stated: -The reason for the visit was a follow-up to the dermatology appointment. -"Left and right upper and axilla (armpit) still with some areas of excoriation very Few open areas but continues to heal well This is the best I have seen the skin. (Sic)" The 24 hour report showed the resident had a change to his scrotum on evening shift of [DATE]. The note showed the resident's scrotum was red, peeling and had open areas. Orders were received to treat the open area. A Nurse's Note dated [DATE] at 9:30 p.m., revealed: -The note was written by a Licensed Practical Nurse (LPN). -A Certified Nurse Aide (CNA) identified a change to the resident's scrotum and informed the LPN. -The LPN described the skin of the resident's scrotum as "red and open." -It appeared "that the top layer of skin" was peeling off the penis and scrotum. -The LPN notified the physician's office and new orders were written. An undated and untimed addendum to the Nurse's Note [DATE] at 9:30 p.m. revealed: -The Nurse Practitioner (NP) at the resident's physician's office was informed of the condition of the resident's scrotum and penis. -The CNA reported that the skin to the scrotum and penis were not peeling with open areas earlier in the shift. A telephone order dated [DATE] at 9:30 p.m., written by the LPN stated: -Apply [MEDICATION NAME] (anti-fungal) to scrotal area twice daily for 14 days for fungal infection. -Cleanse area of scrotum, pat dry, and apply ointment twice daily. No Situation Background Assessment Response (SBAR) form used to capture changes of condition was present in the resident's chart related to the new open areas on the resident's scrotum on [DATE]. No Skin Condition Record for Non-Pressure Ulcer Skin Conditions or other similar assessment tool was identified for the open areas to the resident's scrotum on [DATE]. No Acute/Temporary Care Plan was identified for providing cares to the resident's scrotum injury. A [DATE] Nurse's Note at ",[DATE]" overnight shift revealed: -An LPN wrote this note. -The LPN did not review or observe resident's scrotum injury. -The note did not document any reports of additional changes to the scrotum observed by the night shift CNAs who provided the resident's night time toileting/perineal cares. The 24 hour report showed no monitoring of the resident's skin on [DATE] overnight shift. A Nurse's Note dated [DATE] at 7:45 a.m., revealed: -The note did not document the condition of the resident's scrotum wound. An addendum to the [DATE] at 7:45 a.m., nurse's note stated: -Upon assessment noted resident's scrotum to be open with purulent green drainage and a foul odor noted. -A red fluid filled area to scrotal sack was observed. A nurse's note dated [DATE] at 7:50 a.m., revealed: -There was no documentation about the condition of the resident's scrotum. An addendum to the [DATE] at 7:50 a.m., nurse's note stated: -Upon assessment the resident's scrotum was noted to be red with purulent drainage. The [DATE] at 8:26 a.m., Emergency Provider Report from the hospital revealed: -The resident's scrotum was "discolored with dark purple discoloration and foul smelling skin eroding over left testicle." The [DATE] at 9:08 a.m., emergency patient record nurse's note showed: -"Patient noted to have sluffing (sic), pustular (sic) exudates with foul odor from bilateral scrotum sacs." -"Oozing" blood was also noted. The [DATE] at 6:57 p.m., History of Present Illness note revealed: -The resident was found to have an "extensive scrotal infection ...leading to degloving of the scrotum with ...septic shock and severe [MEDICAL CONDITION] (high sodium levels)." -It was determined that the scrotal infection was in need of immediate debridement. The [DATE] hospital Discharge Summary revealed: -The resident had scrotal gangrene. -The resident required "urgent" surgical debridement of the scrotal tissue on [DATE]. -The resident required "intensive wound care for the scrotal region" throughout the hospital course. 2. Assessment of Condition Change and Vital Signs The day shift 24 hour report had no remarks for the day shift on [DATE]. A [DATE] Provider Progress Note signed at 2:03 p.m., by the PA stated: -The resident's temperature was 98.9° Fahrenheit (F) -No other vital signs were noted. -The PA did not note lethargy at the time of this note. The 24 hour report showed the resident had increased lethargy on evening shift of [DATE]. No vital signs were recorded on the 24 hour report. A Nurse's Note dated [DATE] at 9:30 p.m., revealed: -The note was written by an LPN. -The resident had not been assessed for vital signs. -"Informed NP of increased lethargy. " -Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) ordered. -"Resident has significant change going on. Will continue to monitor." An undated and untimed addendum to the Nurse's Note [DATE] at 9:30 p.m., revealed: -The note was written by an LPN. -No vital signs were noted. -The NP was informed the resident was experiencing a decline of condition. -The resident's blood sugar was 249. -The LPN asked if the NP wanted the CBC and BMP as "stat" labs and was informed routine labs were acceptable. A telephone order dated [DATE] at 9:30 p.m., written by the LPN stated: -CBC, BMP for [DIAGNOSES REDACTED]. No SBAR form used to capture changes of condition was present in the resident's chart related to the increased lethargy on [DATE]. A [DATE] Nurse's Note at ",[DATE]" overnight shift stated: -The resident's blood pressure was ,[DATE]. -The resident's temperature was 99.5° F, which was elevated from earlier entry. -The resident's pulse was 93. -The resident was lethargic but cooperative with all cares. -The note did not indicate that an RN or the resident's physician was consulted about the decrease in the resident's blood pressure which was consistently higher or increase in temperature. -The resident did not appear to be in pain or discomfort. The 24 hour report on [DATE] overnight shift stated, "Hospice consult recommended with change in condition." No Acute/Temporary Care Plan was identified for providing cares to the resident's increased lethargy. A Nurse's Note dated [DATE] at 7:45 a.m., stated: -The resident's blood sugar was 240 -The resident's blood pressure was ,[DATE]. -The resident's temperature was 100.2° F and the resident was warm to the touch. -The resident's apical (heart) pulse was rapid, irregular and difficult to count. -The resident was unresponsive to sterna rubs. -The resident was experiencing apnea. -The resident was sent out to the emergency department via 911. A nurse's note dated [DATE] at 7:50 a.m., stated: -A CNA called the nurse to the room when the CNA was unable to rouse the resident for breakfast. -The resident was unresponsive to verbal stimuli. -The resident's breathing was irregular and his skin was warm to the touch. -The resident's vital signs were as listed above in the 7:45 a.m. note written by the Assistant Director of Nursing (ADON). -The resident's pulse oxygenation was 88% on room air. The [DATE] at 9:08 a.m., emergency patient record nurse's note showed: -The resident's pain was an ,[DATE] based on the Wong-Baker faces scale. -The resident's blood pressure was ,[DATE]. -The resident's temperature was 99.6° F. -The resident's pulse was 106. The [DATE] at 12:42 p.m., Emergency Provider Report from the hospital revealed the resident [MEDICAL CONDITION]. The [DATE] hospital Discharge Summary revealed: -The resident had "[MEDICAL CONDITION] with septic shock" due to scrotal gangrene. -The patient was admitted to intensive care and treated with broad spectrum intravenous antibiotics for 14 days. -The resident required [MEDICATION NAME] for blood pressure support. -The resident required a central line be placed. 3. Assessment of Hydration Status A review of the Intake and Output Roster for [DATE] to [DATE] revealed: -Intakes were for breakfast, lunch and dinner only. -The resident regularly consumed 1080 ml across all meals for the day. -Beginning on [DATE] the resident had decreased intakes. -On [DATE] the resident consumed 484 ml of fluids with meals. -On [DATE] the resident consumed 720 ml of fluids with meals. -On [DATE] the resident consumed 700 ml of fluids with meals. -On [DATE] the resident consumed 600 ml of fluids with meals. -On [DATE] the resident consumed 120 ml of fluids with meals. A review of the [DATE] Medication Administration Record [REDACTED] -The resident was offered and generally consumed all of the 240 ml of fluids provided three times daily between meals. -Beginning on [DATE] the resident consumed less of the fluids. -On ,[DATE] the resident consumed ,[DATE]% of the 240 ml of fluids. -Amounts were not recorded on ,[DATE]. -On ,[DATE] the resident consumed 25% of the 10:00 a.m., offering and all of the 2:00 p.m., and 8:00 p.m., fluid offerings. -On [DATE] the resident consumed 25% of the 10:00 a.m., and 2:00 p.m., offerings and an unknown amount of the 8:00 p.m., fluid. A review of the Meal Intake Roster from [DATE] through [DATE] revealed: -The resident typically consumed 75% to 100% of meals with occasional refusals or low (less than 50%) consumption. -Beginning on [DATE] the resident experienced more frequent episodes of decreased meal consumption. -On [DATE] the resident ate 50% of lunch and 25% of dinner. -On [DATE] the resident ate 25% of breakfast and 25% of lunch. -On [DATE] the resident ate 50% of lunch. -On [DATE] the resident ate 25% of dinner. -On [DATE] the resident ate 0% of breakfast and lunch with no dinner consumption recorded. No nurse's notes or dietary notes were identified related to the resident's decreased intake of food or fluids from [DATE] through [DATE]. The day shift 24 hour report had no remarks for the day shift on [DATE]. A telephone order dated [DATE] at 9:20 a.m., written by the PA stated: -[MEDICATION NAME] 4 mg by mouth every eight hours as needed (for) vomiting for five days. -Encourage fluids. The 24 hour report showed the resident had a small emesis on the evening shift of [DATE]. A [DATE] Provider Progress Note signed at 2:03 p.m., by the PA stated: -The resident experienced an episode of vomiting. -The PA prescribed [MEDICATION NAME] (anti-nausea medication) 4 mg by mouth as needed. An undated and untimed addendum to the Nurse's Note [DATE] at 9:30 p.m. revealed: -The NP was informed that the resident had been prescribed [MEDICATION NAME] for nausea earlier in the day. -Informed the NP that the resident had been "off and on having small amount of emesis." -The note did not show the resident was assessed for hydration status by evaluating the resident's oral mucosa, skin turgor or reviewing the resident's fluid intake or urine output. -The note did not show the LPN requested the RN on duty to assess the resident's hydration status. The 24 hour report showed no monitoring of the resident's skin on [DATE] overnight shift. A [DATE] Nurse's Note at ",[DATE]" overnight shift stated: -The resident "continued to refuse fluids after trying all night." -A swab stick with water was used to keep the resident's oral cavity moist. -Will continue to offer water and monitor for changes. -The note did not indicate that the LPN sought counsel from the RN on duty regarding the resident's hydration status. -The note did not indicate that there resident's oral mucosa or skin turgor was evaluated to determine if the resident was experiencing a loss of fluids. -The note did not indicate that the LPN informed the physician that the resident was refusing fluids. No Acute/Temporary Care Plan was identified for providing cares to the resident's decreased fluid intake and vomiting. A Nurse's Note dated [DATE] at 7:45 a.m., revealed: -The note did not document the assessment of the resident's hydration status by reviewing the oral mucosa or skin turgor. A nurse's note dated [DATE] at 7:50 a.m., revealed: -The note did not document the assessment of the resident's hydration status by reviewing the oral mucosa or skin turgor. The [DATE] at 8:26 a.m., Emergency Provider Report from the hospital revealed: -The resident was dehydrated. -The resident's mucous membranes were dry. The [DATE], lab results completed at 9:55 a.m., showed: -The residents GFR African American was 23 (> or = 60), indicating decreased kidney function. -Sodium was 160 (136 - 145) indicating increased concentration of sodium consistent with dehydration. -BUN was 76 (7 - 18) which was consistent with dehydration. -Creatinine 3.4 (0.6 - 1.3) which was consistent with dehydration. The [DATE] at 9:50 a.m., Emergency Provider Report from the hospital revealed: -"Labs consistent with dehydration." -"Ordered two more liters of fluids." The [DATE] at 12:42 p.m., Emergency Provider Report from the hospital revealed the resident was in [MEDICAL CONDITION]. The [DATE] hospital Discharge Summary revealed: -The resident had acute kidney injury. -The resident had experienced fecal impaction at admission. D. Family Interview On [DATE] at 7:50 a.m., an interview with the resident's daughter revealed: -The resident was sent out to the hospital on [DATE] because the facility found the resident unconscious. -The resident was in poor condition when he arrived at the hospital and required a two week hospital stay to treat his infection and wounds. -The resident was discharged to a different nursing facility on [DATE]. -The resident's daughter felt that the facility should have been more attentive to the changes in her father's skin because his skin was compromised requiring specialist visits. -The resident's daughter explained that her father had gangrene to his scrotum, which she felt was due to the care the resident received at the facility. On [DATE] at 7:37 a.m., a second interview with the resident's daughter revealed: -The resident was dehydrated when he arrived at the hospital on [DATE]. -The resident required intravenous fluids to rehydrate him while at the hospital. -The resident required surgery to remove the damaged tissue in his scrotum. -The resident experienced pain and discomfort from the infection, dehydration and skin problems present when the resident arrived at the hospital on [DATE]. E. Staff Interviews On [DATE] at 12:29 p.m., an interview with the Regional Clinical Specialist (RCS) and Assistant Director of Nursing (ADON) #2 revealed: -The RCS stated that when a change of condition occurred in a resident, the nurse identifying the change should complete a SBAR (change of condition form) and should place it in the resident's chart. -The ADON stated the facility had used the SBAR for "at least the past year." -The ADON stated that an SBAR should be completed for major changes of condition. -The ADON stated a major change of condition included increased confusion, lethargy, and pressure ulcer formation. -The ADON stated that all changes of condition should be noted on the 24 hour report. -The ADON stated that when a change of condition occurred, the nurse should document regarding the changes at least once a shift and more often if changes continue or worsen. -The ADON stated residents should have acute/temporary care plans in place related to changes. -The ADON stated she expected an acute care plan for care concerns like skin injury, vomiting, changes to the resident's vital signs and antibiotic use. -The ADON stated that if residents are not drinking, the physician should be notified. On [DATE] at 11:50 a.m., an interview with Unit Manager (UM) #2 revealed: -The resident had [MEDICAL CONDITION] of unknown origin on his body in the weeks prior to his discharge to the hospital. -The resident was receiving care for the [MEDICAL CONDITION] in consultation with a dermatologist. -The UM reviewed the resident's clinical record and then stated that according to the [DATE] Provider Progress Note, the resident had experienced vomiting sometime before 2:03 p.m., when the note from the provider was signed. -The UM reviewed the telephone orders and stated the resident had an order for [REDACTED]. -The UM acknowledged that the nurse's notes from the day shift on [DATE] did not show the resident had experienced vomiting. -The UM acknowledged the 24 hour report also did not show the resident's vomiting on the day shift. -The UM reviewed the resident's clinical record and stated she was not able to find a skin assessment after the [DATE] skin assessment that noted the continued presence of [MEDICAL CONDITION] present for the past several weeks. -The UM reviewed the [DATE] at 9:30 p.m., nurse's note and stated that new open areas were identified on the resident's scrotum. -The UM stated the author of the [DATE] at 9:30 p.m., note was a LPN from the staffing agency. -The UM reviewed the chart and stated that she could not locate an assessment of the resident's scrotum completed by a RN until the next morning at 7:50 a.m. -The UM stated at that time, the resident's scrotum was exuding purulent, odorous drainage. -The UM stated that there were no vital signs documented for either the day or evening shift on [DATE]. -The UM acknowledged assessment of vital signs are useful when a resident was experiencing a change of condition. -The UM stated that a RN is on duty in the building on every shift, but it did not appear the RN was consulted to assess the resident's scrotum because there was no RN assessment in the chart. -The UM stated that a LPN could not assess a resident and should have contacted a RN to conduct an assessment. -The UM stated that the physician's office was contacted about the open area to the scrotum and a telephone order for [MEDICATION NAME] was obtained. -The UM stated she did not know how it was decided that an antifungal medication was the appropriate treatment for [REDACTED]. -The UM reviewed the [DATE] ",[DATE]" nurse's note and stated she did not know if the note was written at the beginning, middle or end of the shift. -The UM stated the vital signs recorded on the note suggested to her that the resident was becoming septic because the resident had an increased temperature, increased pulse when at rest and had a decreased blood pressure. -The UM stated she would have expected the night shift LPN to notice the changes to the resident's vitals and to contact the physician. -The UM stated that the resident's refusing fluids also should have been called to the physician, especially in the presence of an order to encourage fluids. -The UM acknowledged there was no assessment of the resident's hydration status, even though the resident was not taking fluids and had experienced emesis during the day on [DATE]. On [DATE] at 12:36 p.m., a re-interview with ADON #2 revealed: -The ADON stated she was present and assessed the resident prior to discharge to the hospital. -The ADON stated they checked the resident's blood sugar when he was found to be unresponsive because the resident was a brittle diabetic. -The ADON stated the resident did not respond to the pain of the finger stick for blood glucose testing and did not respond to the sternal rub. -The ADON stated because the resident was a "Full Cor" (wanted all treatment and CPR); she wanted him sent out to the hospital right away. -The ADON stated that when she viewed the resident's scrotum before he went out to the hospital, it was swollen, red and had foul smelling drainage. -The ADON acknowledged that the resident's scrotum was not assessed by a RN when the problem was identified on the evening of [DATE]. -The ADON stated that if a RN had assessed the resident, it would be in a nurse's note or a non-pressure ulcer skin sheet, SBAR or incident report. -The ADON stated there would have been a RN in the building at the time the scrotum injury was originally identified because there was a RN on duty every shift. -The ADON stated the facility now had an additional RN house supervisor assigned to each shift. -The ADON stated that the nurse that worked the overnight shift should have contacted her to let her know the labs were not ordered "STAT" for the resident because she would have requested STAT labs for this resident. -The ADON stated that the facility only tracked fluids at meals in their kiosk system. -The ADON stated that residents typically received 90 ml of fluid with each medication pass in addition to fluids consumed at meals. On [DATE] at 1:42 p.m., an interview with the Interim Director of Nursing (IDON) revealed: -The IDON stated that when a resident experienced a change of condition, the nurse should thoroughly document resident's vital signs, blood sugar, intakes, appetite, changes in mentation. -The IDON acknowledged that this was not captured in the nursing notes for the resident on [DATE]. -The IDON stated the resident's scrotal skin change should have been assessed by a RN and that a RN was always present in the building. -The IDON stated she would expect the chart to include wound sheets for the scrotal wound, but that no such documentation was present. -The IDON stated that when the resident was not taking fluids, the nurse should have notified the physician. -The IDON stated that an SBAR should have been completed related to the resident's vomiting but that one was not present. -The IDON reviewed the resident's meal intakes from November and December of 2014 and then stated that the resident was eating less prior to his discharge to the hospital. -The IDON stated she did not see any documentation about the resident's urine output on the day prior to discharge to the hospital. -The IDON stated she would check the former DON's office for additional documentation such as SBARs or incident reports related to the resident as sometimes the former DON kept these items rather than placing them in charts. [DATE] at 2:37 p.m., the IDON stated she did not identify any additional paper work related to the resident's change of condition in the former DON's office. No additional information such as SBAR, incident reports, or RN assessments was submitted prior to survey exit or during the post survey grace period.

Based on observations, record review, and interviews the facility failed to ensure two (#1 and #2) of three, out of 16 sampled residents, who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable; and a resident having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically the facility failed to: - Ensure resident #1, who entered the facility without pressure sores, did not develop an avoidable Stage III pressure ulcer causing the resident discomfort. - Ensure resident #2 received necessary treatments and services to promote healing. Facility Policy for Skin Integrity Program read in pertinent part: Braden skin risk assessment and guidelines: a. Completed within 24 hours of admission b. Score of 18 reflects risk of pressure ulcers Skin analysis and interventions: a. Completed with each Braden assessment that reflects a score of 18 or less b. Placed in care plan section of the chart Weekly skin integrity checks: a. Weekly assessment looking for new wounds-completed by a licensed nurse b. Document on treatment record (TAR) c. If new ( pressure ulcers) are found - complete pressure ulcer assessment d. Notify MD e. Notify Family f. Update care plan Pressure Ulcer Prevention form (part of the policy provided-Risk assessment factors contributing to the loss of skin integrity Definition: a risk assessment tool is used to evaluate internal and external factors that may contribute to the development of a pressure ulcer a. Sensory perception-ability to respond meaningfully to pressure related discomfort b. Moisture-degree to which skin is exposed to moisture c. Activity-degree of physical activity d. Mobility-the ability to change and control body position e. Nutrition-unusual food intake patterns f. Friction and shear Adult residents with a score of 18 or below are considered risks and must have a plan of care developed to prevent the development of a pressure ulcer. The findings include: A.Resident #1 a.Resident Status: Resident #1, [AGE] years old, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. According to the minimum data set assessment ((MDS) dated [DATE], the resident was able to be understood and understand others, had a brief interview for mental status (BIMS) score of 13 out of 15, indicating intact cognition. The resident had no delusions or hallucinations and had not rejected care. The MDS further indicated the resident required extensive assistance of two persons for bed mobility, transfers and toileting. The resident required extensive assistance of one person for hygiene. b.Record Review: The admission transfer paper work form dated 6/9/14 indicated the resident was admitted to the facility without a pressure ulcer. On 6/9/14 a skin assessment was completed by the facility. The form was titled, " Resident Summary " and the box for skin condition was marked " Good " . In the additional comment section of the document it was noted " skin intact except for small patch of chronic eczyma (sic) ([MEDICAL CONDITION]) LLE (left lower extremity). On 6/9/14 the facility completed a Braden Scale (a tool for predicting pressure sore risk). The facility determined a score of 12 which indicated the resident was at high risk for the development of a pressure ulcer. On 6/9/14 a Skin Risk Analysis and Intervention form identified the Braden score of 12. The clinical conditions, sensory perception, mobility/activity, nutritional interventions, management of moisture, friction and shear and other sections (which included patient, family and staff education) on this form were blank. On 6/9/14 a nutritional assessment indicated the resident required tube feeding and was able to answer questions but appeared disoriented. On 6/11/14 a transfer form, from the facility to hospital, indicated a Braden score of 12 and no skin issues/treatments were identified. On 6/18/14 a transfer form, from the facility to hospital, indicated a Braden score of 12 and no skin issues /treatments were identified. Review of the daily skilled nurse ' s notes from 6/9/14 (date of admission) through 6/22/14 revealed the resident did not have a pressure ulcer or coccyx skin integrity issues. On 6/23/14 a skilled daily nurse ' s note written at 8:00 a.m. revealed, " Resident has been cleaned and skin tear has been found on coccyx. More specifically Stage II decubitus ulcer. Gentlefoam placed to reduce any more shearing. Dr. notified, order for air mattress with bolsters and turn q (every) 2 hours in place. All week have been wet. Will continue to monitor and turn " . The 6/23/14 24 hour report read, "2.4 x 1 cm decubitus ulcer found. MD notified new order for air mattress with bolsters. DON notified " . This measurement of the ulcer was not documented in the clinical record. On 6/23/14 the medical record did not have orders written to clarify wound treatment or for the initial treatment identified as " Gentlefoam " . On 6/23/14 a physician's order [REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The skilled daily nurse ' s notes dated 6/24/14 did not include documentation of a pressure ulcer. an order for [REDACTED]. A document titled, " Wound Consult Note " , was written on 6/25/14. The document was completed by the NP, and served as the initial wound consultation for the open wound on the coccyx. The form indicated the resident was non ambulatory, incontinent, experienced parasthesia, skin temperature was warm, a pressure relieving mattress was in place and the wound was staged, as Stage II Ulcer. The form further indicated staff education had been provided. In the associated diagram page, two areas on the coccyx were noted. The superior was measured at 2x1x0.2 cm and the inferior was measured at 1x2x0.1 cm. On 6/25/14 a skilled daily nurses note indicated the resident had a pressure ulcer, the length width and depth were checked on day and evening shifts (not on night shift), however, no measurements or wound description were documented. On 6/26/14 the first documented measurement of the wound by facility staff since discovery on 6/23/14 was recorded. The wound measured 3.4 cm x 2 cm (initial measurement was 2.4 cm x 1 cm) and slough was noted. The document identified the wound as a Stage II pressure ulcer. The document remained in the " wound care binder " which was located in the ADON ' s office. On the wound round sheet for 6/27/14 a Stage II pressure ulcer was documented. On 6/27/14 the therapy department documentation indicated this had been their initial date of involvement in wound care. The Medication Administration Record [REDACTED]. On 7/11/14 a wound progress note written and signed by the resident ' s NP indicated the facility had been notified of the wound deepening. The NP clarified the wound as a Stage III coccyx decubitus ulcer. The NP documented the satellite Stage II ulcer had healed (there was no documentation of the second pressure ulcer from the initial wound consult from 6/25/14 through the progress note written 7/11/14). Review of the MARs and TARs for July, August and September of 2014 did not document if the resident had been repositioned every two hours. There was no order found, in the clinical record, to discontinue this approach (see interviews below). Review of the wound care binder (not available to floor staff) revealed: 7/4/14 - 3.1cm x 2.4 cm, slough, Stage II 7/11/14 - 3 cm x 2 cm x 0.3 cm, slough Stage II 7/18/14 - hand written 2 cm x 1.8 cm, slough in wound 7/25/14 - 2.6 cm x 1 cm x 0.4 cm, Stage II (see interview below as date is identified as the first opportunity to stage this wound). 8/1/14 - 2.8 cm x 1.2 cm x 0.4 cm, Stage II 8/7/14 - 2 cm x 1.5 cm x 0.3 cm 8/15/14 - 2 cm x 1 cm x 0.3 cm, change treatment to collagen 8/22/14 - 1.8 cm x 1 cm x 0.3 cm 8/29/14 - 1.6 cm x 0.8 cm x 0.5 cm 9/5/14 - 1 cm x 1 cm x 0.3 cm 9/12/14 - 0.8 cm x 0.8 cm x 0.3 cm Clinical record (available to floor staff) revealed: On 7/11/14 the NP identified the wound as a Stage III full thickness coccyx decubitus ulcer. On 7/19/14 the NP identified wound as a Stage III full thickness coccyx decubitus ulcer. On 8/12/14 the NP identified wound as a Stage III full thickness coccyx decubitus ulcer. A care plan initiated on 9/15/14 indicated the problems, goals and approaches associated with the pressure ulcer. The facility was not able to provide supportive documentation that a care plan had been created or implemented from the date of onset 6/23/14 until 9/15/14. c.Interviews: Resident: On 9/15/14 at 9:50 a.m. the resident stated sometimes s/he had to wait for extended periods of time after using the call light to be taken to the bathroom. The resident stated s/he developed " sores " on his/her " bottom " . The resident further stated the " sores " were getting better but felt they should have never developed in the first place. The resident stated the " sores " caused him/her discomfort when sitting in a wheelchair. On 9/16/14 at 3:09 p.m. the resident stated s/he was not able to recall if the turning schedule had been implemented prior to the development of the pressure ulcers. The resident stated s/he had been very ill, having just come off of life support and being dependent for movement in the bed. The resident further stated it was a confusing time having woken up with a [MEDICAL CONDITION], a [DEVICE], and being dependent on others for care. Family: On 9/16/14 at 11:38 a.m. a family member stated they had visited the resident daily, and the visits had occurred since date of admission. The family member stated the visits typically lasted longer than two hours. The family member stated during visits facility staff were not observed to check on/or reposition the resident. The family member stated they were upset by the development of the pressure sore. The family member stated they understood the resident was supposed to be on a turning schedule prior to, and after the development of the pressure ulcer, however, in their observation this had not been carried out with consistency. Staff: On 9/15/14 at 1:54 p.m. staff #5 stated the resident had developed a pressure ulcer while in the care of the facility. The staff member stated nursing and therapies were both active in the treatment of [REDACTED]. They stated they did not know where or if the CNAs documented this activity. On 9/15/14 at 2:31 p.m. a physical therapist (PT), providing wound care services to the resident, stated nursing was responsible for care planning the wound and ensuring the plan of care was implemented. The PT stated therapies were always involved with wound care treatments. The PT stated prior to the wounds the facility nursing staff was responsible for repositioning the resident every two hours. The PT stated they were not aware of how this was monitored or recorded. On 9/15/14 at 2:45 p.m. the ADON, responsible for the unit where the resident resided, stated documentation for all wounds was kept in a binder locked in the ADON ' s office. The ADON stated the resident ' s physician and NP were involved in the plan of care and visits occurred one or two times per month. The ADON stated prior to the development of the resident ' s pressure ulcer, the facility implemented a standard pressure reducing mattress. Additionally the ADON stated the resident was being turned or repositioned every two hours. The ADON stated the resident was bed bound at that time and unable to be up in a wheelchair. The ADON determined on 6/26/14 the stage of the pressure ulcer to be a Stage II. The ADON further stated the wound had never progressed past a Stage II. The ADON stated the expectation was that a care plan specific to wound care for all residents with a pressure ulcer would be developed and kept in the medical record. The ADON was unable to locate a plan of care specific to the wound (see record review above) in the resident ' s medical record. The ADON reviewed the TAR and stated there was not a care plan. The ADON stated there was a care plan for the resident but did not know where it went or where it was, and was not able to provide evidence this document was in place prior to 9/15/14. On 9/15/14 at 4:07 p.m. the director of nursing (DON) stated the facility expectation was for all MAR/TAR documents to be initialed to indicate if medication or services had been provided. The DON further stated if the MAR/TAR was not initialed it would not be possible to tell if a treatment had been performed. On 9/15/14 at approximately 4:30 p.m. the DON stated the facility expectation would be for the resident to have a care plan specific to the pressure ulcer. On 9/16/14 at 8:26 a.m. the ADON stated during review of the wound care binder, specific to the resident ' s pressure ulcer, that additional measures beyond the facility's protocol could have been put into place prior to the development of a wound, if a resident would have been identified to be a high risk for the development of a pressure ulcer. The ADON stated high risk was determined by the Braden score and medical complexity. The ADON stated the facility expectation was for residents to be repositioned every two hours, however, there was no flow sheet to monitor this activity. On 9/16/14 at 8:53 a.m. staff #9 stated the facility expectation was to turn residents every two hours or more often if they ask. The staff stated this was not a documented process. The staff member stated they would keep (in their head) track of the last time they turned a resident. On 9/16/14 at 8:57 a.m. staff #10 stated they would try to turn residents who needed assistance every two hours. The staff member stated they would try to remember when two hours had gone by, but there was not a formal process to track when residents had last been turned or repositioned. On 9/16/14 at 12:20 p.m. the corporate consultant (CC), DON, ADON and nursing home administrator (NHA) were interviewed. The CC stated the facility had identified through review of the MAR/TAR an issue specific to skin assessments either not being completed or unavailable for clinical floor staff. The CC stated the issue had been identified in the previous week and the resulting full house skin sweep was anticipated to be completed by the end of the day. The DON stated the resident ' s Braden score identified the resident to be at high risk of developing a pressure ulcer. The DON stated the standard mattress used by the facility would accommodate up to a Stage III pressure ulcer and with turning or repositioning every two hours an air mattress would not necessarily have been indicated. The DON stated this formulary was used for all residents. The DON and the CC stated that turning or repositioning the resident every two hours was a standard of care and documentation of this occurring was not an expectation. The DON and CC were asked how the facility was able to monitor or ensure this expectation had been carried out if not documented; they answered it was the expectation. The DON stated the expectation would have been for the facility to obtain a physician's order [REDACTED]. The DON and CC stated they could not account for the discrepancy between the NP (a certified wound nurse) and the facility staff staging of the wound. The DON and CC stated they would have gone with the staging determined by in house staff. The DON explained the skin risk analysis. She stated this analysis would be where the floor nurse would assess to determine why the resident was at risk and any interventions that needed to be in place. The CC stated this form makes sure that they were following protocol and could update interventions. After review the DON and CC stated the form had been signed but had not been filled out. They stated the expectation would have been for the form to have been completed. No explanation was offered for the blank form, or how additional risks could have been identified without this form completed. The DON stated the resident was turned every two hours (there was no documentation to support this prior to acquiring the pressure ulcer), was frequently incontinent of bowel and bladder, and was able to reposition self (see MDS). The ADON stated the facility would have looked at the resident ' s acquired pressure ulcer after being notified (6/23/14), however, would not have taken measurements until the weekly scheduled wound rounds on 6/26/14. The ADON stated the wound rounds needed to all be on the same day to avoid confusion. During an interview on 9/16/14 at 2:29 p.m., the NP stated the wound was a Stage III based on clinical presentation. The NP stated that initially the wound had been staged as a Stage II, however, should have been a Stage III or unstageable. The NP stated this was clarified through documentation and facility staff notification. The NP stated the facility nursing staff had been present for some of the treatments. On 9/16/14 at 3:21 p.m. staff #12 stated the resident was frequently incontinent of bowel and bladder and the decubitus ulcer had been discovered while doing perineal hygiene in bed. The staff member stated the decision to use " Gentlefoam " dressing was to protect the integrity of the wound, however there had not been an order received. The staff stated s/he recalled being told by the NP to just put something on the wound to prevent further tissue damage.S/he stated at a later date (unsure of date) they were made aware by the facility, there should have been a written order for treatment of [REDACTED]. On 9/17/14 at 4:04 p.m. the DON stated if a resident was admitted without any skin issues the expectation was for weekly skin checks to be completed. This was identified as having not been completed by CC on 9/10/14 and an action plan was put into place. The skin sweep audits were reported to be completed on 9/16/14. On 9/17/14 at approximately 4:30 p.m. an interview with the DON, ADON, CC, ANHA, and staff #2 was conducted. The ADON after reviewing the facility ' s wound care guidelines stated the wound should have been documented as unstageable due to the slough and inability of clinical staff to determine depth. The ADON further stated the wound would at present be a Stage III pressure ulcer. The ADON stated the first opportunity to classify the wound as a Stage III pressure ulcer would have been on 7/25/14. During this interview staff #2 stated that the CNAs would not have been turning the resident because the resident had been able to perform weight shifts independently (see MDS above). The DON stated the facility would have utilized the score on the Braden scale and resident medical history to determine the risk of breakdown. The DON stated the facility used its formulary and the standard pressure reducing mattress provided by the facility should have prevented a pressure ulcer. The CC stated the resident was at greater risk due to low [MEDICATION NAME] levels, however after review of the available laboratory results, stated this was not an issue. The DON stated the resident had a coccyx pressure ulcer in past medical history. The DON stated additional risks of moisture, decreased mobility, and extensive assist of two persons for bed mobility had been identified, however, the facility did not consider these risks to warrant additional intervention or monitoring beyond the facility ' s formulary. Summary: The facility identified issues placing the resident at high risk for the development of a pressure ulcer including: Type I diabetes, history of past pressure ulcer, decreased activity, constant moisture secondary to incontinence of bowel and bladder, decreased sensory perception secondary to acute medical condition and extensive assist requiring two persons for bed mobility and transfers. With these issues identified the facility was not able to provide evidence of the implementation of additional measures or monitoring to prevent the development of a pressure ulcer. B. Resident #2 a. Resident Status Resident #2, age 71, was admitted to the facility on [DATE], according to the facility face sheet. His/her pertinent admission [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the resident had severe cognitive (memory) deficits. S/he had clear speech, was able to understand others, and was able to make his/her needs known. S/he was independent for eating after set up and required extensive assistance from one staff member for all other activities of daily living (ADLs). S/he was noted to have a stage two pressure sore. b. Observations On 9/15/14 at 1:43 p.m. the resident was observed lying in bed. There was a Jorens air mattress on the frame of the resident ' s bed. The resident was lying on his/her right side and denied any pain. There were two cloth incontinence pads (one on top of the other) positioned between the resident and the air mattress. The resident was drinking a nutritional supplement. On 9/16/14 at 9:50 a.m. the resident was observed lying on an Jorens air mattress on the frame of his/her bed. There were two incontinence pads (one on top of the other) noted on top of the mattress. At 2:05 p.m. staff was observed lying the resident down in bed, on top of the two cloth incontinence pads. At 3:50 p.m. the resident remained in bed with the two cloth incontinence pads between him/her and the air mattress. On 9/17/14 at 9:31 a.m. there was a disposable paper incontinence pad observed, lying on top of the resident ' s air mattress. c. Record review physician progress notes [REDACTED]. The physician ' s progress note, dated 9/16/14, revealed the resident had a sacral wound that was slightly open, no pain, with a history of the wound opening and closing at times. Computerized Physician order [REDACTED]. The 9/2014 CPOs revealed staff were to apply (name of treatment) to the resident ' s coccyx (sacrum), every shift, as the resident would allow, until the area was healed. Staff was also to apply an exuderm dressing to the open area on the resident's left buttock daily and as needed. Physician Telephone Orders (TOs) According to the physician ' s TOs dated 6/4/14 through 9/16/14, the following pertinent orders were noted: - 6/26/14: apply (name of treatment) to the resident ' s coccyx/buttock every shift until healed. Monitor the resident ' s coccyx, every shift, for 72 hours, then weekly with skin assessments until healed - 7/16/14: apply an exuderm dressing to the open area on the resident ' s left buttock/coccyx area, once a day, and as needed (PRN). After the area healed, continue the treatment daily as a [MEDICATION NAME] (prevention) measure. Care Plan The resident ' s care plan revealed that the resident had potential for skin breakdown, related to bowel and bladder incontinence, limited mobility, and a Braden score of 16 (assessment for predicting pressure sore risk) placing her/him at mild risk for skin breakdown. The care plan failed to reveal that the resident actually had a stage two pressure ulcer. The goal of the care plan was to maintain intact skin integrity The care plan approaches included; weekly skin assessments according to the facility protocol, complete a Braden scale quarterly and as needed, monitor skin for signs and symptoms of breakdown and redness during all direct care, dietician to evaluate resident's nutritional status as needed, have two staff members move the resident to avoid skin friction rubs, place pressure relieving/reducing products on the resident's bed/chair/other, cleanse perineal area with soap and water following each bowel movement. d. Facility ' s QI log (not part of the clinical record) Review of the facility ' s QI logs with the DON on 9/15/14 at 4:50 p.m., which were not a part of the resident ' s clinical record, revealed staff was monitoring the resident ' s wound weekly. The wound measurements were as follows: 6/26/14: 0.25 x 0.25 centimeters (cm), 7/3/14: Wound healed, 7/16/14: wound reopened and measured 0.5 x 0.2 cm, 7/24/14: not documented as being completed, 7/31/14: 1.0 x 0.8 cm, 8/7/14: 0.7 x 0.5 cm, 8/14/14: 0.3 x 0.3 cm, 8/21/14: 1.0 x 0.6 cm, 8/29/14: 0.6 x 0.4 cm, 9/4/14: 0.8 x 0.4 cm, and 9/11/14: 0.2 x 0.3 cm. e. Facility Failures 1. Consistently conduct weekly skin assessments and document abnormal findings Weekly Skin Assessments According to the treatment administration records (TARs) dated 6/2014 through 9/2014, the resident was to have a weekly skin assessment. The TARs failed to reveal that staff conducted a weekly skin assessment on 7/23/14, 8/13/14, and 8/20/14. Further review of the TARs revealed the resident had an abnormal finding during a weekly skin assessment on 7/9/14, 7/16/14, 8/6/14, 8/27/14, 9/3/14, and 9/10/14. There was no documentation on the TARs or in the resident ' s nursing notes to indicate what the abnormal findings were. 2. Document weekly wound measurements and wound descriptions in the resident ' s clinical record Wound/Skin Healing Record Review of the resident ' s clinical record on 9/15/14 at 4:00 p.m. with the unit manager (UM #1) revealed a wound/skin healing record dated 6/26/14. The wound site/location was noted to be on the resident ' s coccyx. The wound measured 0.25 x 0.25 cm. The wound was noted to be a stage one (intact skin with non-blancable redness of a localized area, usually over a bony prominence). The remainder of the wound/skin healing record was blank. The UM reviewed the clinical record and stated that s/he was not sure why the record was blank. The UM stated that weekly measurements and wound descriptions should be documented on the form. The UM took the form and wrote a late entry in for 9/11/14. The UM documented a stage one ulcer, which measured 0.2 x 0.3 cm. There were no exudates or odor noted. There was an additional note in the outer margin of the form that read, " 7/16/14 reopened " . There were no other wound measurements or wound descriptions noted in the resident ' s clinical record. 3. Complete treatments as ordered The TARs dated 7/2014 and 8/2014, revealed that staff initialed the TARs and circled their initials (7/18, 7/22, 7/23, 7/26, 7/27, 8/7, 8/14, 8/17, 8/21, and 8/31) to indicate that the ordered treatment had not been completed. The TARs failed to indicate why the treatments had not been completed. Further review of the resident ' s clinical record failed to reveal why the treatment had not been completed as ordered, or that the resident ' s physician had been notified. f. Interviews The resident was interviewed on 9/15/14 at 1:43 p.m. and reported that the staff did complete the wound treatments to her/his coccyx. The resident stated that s/he had on occasion refused to have the treatment done, however, it was not very often that s/he refused. The UM was interviewed on 9/15/14 at 4:00 p.m. The UM stated that the resident was first noted to have an open area on 6/26/14 which healed on 7/3/14. The area re-opened on 7/16/14, and the wound was noted to be a superficial wound. The UM stated that one week the wound would look like scar tissue and next week the wound looked like it was open. The UM also stated the floor nurses ' were suppose to complete the wound/skin healing report weekly, along with the resident ' s weekly skin assessments. The UM stated that when staff complete the resident ' s skin assessment and noted a concern, staff was to place an " A " on the TARs to indicate an abnormal finding. If the resident ' s skin was clear, staff was to place a " C " on the TARs. The UM stated when nurses documented an abnormal finding, they should also be documenting those findings, either on the back of the TARs or in the nurses ' notes. The UM was not able to find documentation regarding the abnormal findings noted by staff (see above). The Director of Nursing (DON) was interviewed on 9/15/14 at 4:50 p.m. The DON stated that residents who had actual pressure ulcers were placed on a weekly list to be seen by the assistant director of nurses (ADON). The ADON was responsible for monitoring and measuring the resident ' s wounds weekly. The DON stated that on 6/26/14 the resident was noted to have a stage one pressure ulcer. The resident was then placed on weekly rounds and their quality improvement (QI) log. The DON reviewed the QI log (see above) and stated that the resident ' s pressure ulcer healed as of 7/3/14 and reopened on 7/16/14. The DON was not sure why this information was not noted on the resident's wound/skin healing record. S/he stated that when the Admin. Nurse got the wound measurements, the unit manager or the Admin. Nurse were responsible for documenting those findings on the wound/skin healing report. The DON acknowledged that this had not been done for the resident ' s pressure ulcer. The DON stated that she would have expected staff to document the wound measurement in the resident ' s clinical record, document why treatments were not being done, and update the resident ' s care plan to reflect the stage two pressure ulcers. The nursing home administrator (NHA), assistant nursing home administration (ANHA), and corporate consultant (CC) were interviewed on 9/16/14 at 12:15 p.m. The CC stated that the facility had identified that skin assessments were not being done on 9/10/14, and a quality assurance (QA) improvement plan was initiated. The QA plan included daily nursing management tools, which had a skin assessment on it, which was going to be verified by the Admin. Nurse or UM. These tools would then be taken to the daily stand up meeting and be reviewed. The Admin. Nurse would then go back and validate that the weekly skin assessments were done. The DON stated that the facility was only in the beginning phase of the process and were trying to determine why the skin assessments were not being completed. The DON reported that the management team had developed a weekly skin assessment scheduled for the residents, which would be kept in the front of the nurse ' s Medication Administration Record [REDACTED]. The CC stated that the facility had begun a facility skin sweep on 9/16/14 which would continue until the entire facility had been completed.

Based on record review and staff and resident interviews, the facility failed to ensure one of nine sample residents (#8), received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to ensure timely verification of medications upon admission to be able to provide pain medications to resident #8 which contributed to the resident's severe pain level. The findings include: Resident #8, a [AGE] year old male, was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Due to the resident's recent admission the Minimum Data Set (MDS) was not available. On 7/8/14 the Admission Nursing Summary listed the resident as forgetful and with a fluctuating orientation. He was able to self propel his wheelchair. He required two persons assistance with a Hoyer lift transfer. Record Review On 7/8/14 the Pain Evaluation form documented that he had stage four [MEDICAL CONDITION] which caused him pain at 6-8/10 pain level. Medication, frequent position changes, and distraction helped with pain management. On 7/8/14 the Resident Summary form documented the nurse called the physician four times to verify orders from 2:30 p.m. to 6:40 p.m. without a return call from the physician. The resident complained of back pain numerous times while waiting for the physician to call back. The physician did return the call at 7:30 p.m. Once the nurse had verified the medication orders with the physician, the emergency kit was opened and the pain medications were given to the resident. The resident suffered with pain for five hours until medications could be provided to him. On 7/8/14 (initiated) the Pain Care Plan documented to give medications as ordered, monitor for side effects and effectiveness of the medications, and notify physician if treatment needed to change. Resident Observation/Interview On 7/10/14 at 9:43 a.m. the resident reported that it took quite a few hours to get his pain medication when he was admitted . He reported that he hurt while waiting for the medications to arrive from the pharmacy and thought the facility should not let it happen to someone else. He reported that he thought his back was going to explode while he waited for pain medications. Staff Interview On 7/11/14 at 6:09 p.m. the Director of Nursing (DON) reported that she would expect the nurse to call the Assistant Director of Nursing (ADON) to give further instructions since the physician had not called back in a timely manner. She reported that their usual protocol was to call the physician and get orders verified as soon as possible so the nursing staff could get into the emergency kit to provide the pain medications. She reported that she could see the benefit of having a system in place so that the nurses would know what to do in a situation like this in the future.

Based on interviews, observations and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that residents, including two of 56 sample residents (#213, #130), received adequate supervision and assistive devices to prevent accidents. Specifically: -Resident #213, who had a [DIAGNOSES REDACTED]. After the move, his wandering, per record review, was accompanied by verbal aggression as well as physical aggression. The facility failed to implement measures to ensure resident #213's care was individualized and effective and his supervision adequate to protect the remaining 20+ residents on the secured unit, all of whom were elderly (average age 82), memory and cognitively impaired, and some of whom wandered the unit without direction. The findings include: A. Resident Status on Re-admission Resident #213 (age 63, 6 feet tall and 182 pounds) was readmitted to the facility's open unit on 11/25/13 from a behavioral health facility where he had resided for approximately two months. According to the 12/13 Computerized Physician order [REDACTED]. According to a physician progress notes [REDACTED]." Review of the physician orders [REDACTED]. B. Change in Status - Increase in Aggressive Behaviors 1. Record Review Review of the resident's medication orders revealed the following medication changes shortly after re-admission: -Within a week of his re-admission, Ativan (antianxiety medication) 1 mg orally/IM every four hours as needed for severe agitation, was added. -One week later (12/11/13), Depakote ER was increased to 500 mg in the morning, Seroquel was decreased to 50 mg at every hour of sleep (12/12/13), Trazodone (antidepressant) 50 mg every hour of sleep for depression as evidence by not eating, was added (12/12/13). -The next day, 12/13/13, Depakote was increased to 500 mg TID (three times a day) and Klonapin (anti-seizure, anxiety medication) .5 mg twice a day for three days Klonapin .5 mg PO every day for three days, then discontinued was ordered. Aricept was discontinued and one day later, Depakote was changed from 500 mg ER TID to Depakote Sprinkles. -Three days later, Klonapin was decreased to .5 mg PO Q day (last dose to be 12/19/13), Seroquel was decreased to 25 mg PO QHS (last dose to be 12/19/13) with attempt to stabilize resident on one medication (Depakote). Review of the resident's record (assessments, nurses' notes, incident/accident report, physician progress notes [REDACTED]. Assessments: According to the 11/30/13 Minimum Data Set (MDS), specifically the nurses' summary seven day look back dated 12/5/13, the resident did not have any functional limitation in range of motion, mobility devices and was independent in locomotion. The MDS coded the resident as having memory problems and severely impaired decision making. He had disorganized thinking and exhibited physical and verbal behaviors directed toward others that put others at significant risk for physical injury and also significantly disrupted care and living environment (not documented in the previous 8/6/13 MDS). A mini-mental state examination completed by the psychologist on 12/16/13 documented the resident had a score of one out of 30 indicating severe cognitive impairment. The 8/6/13 MDS had documented the resident with a cognition score of 8/15, indicating moderately impaired. physician progress notes [REDACTED]. On 12/2/13, when the physician documented the resident's move to the secured unit (see above), the physician wrote "He is confused, hair is messy ... his (he) is walking ok. Speech is hard to understand and seems to be wandering ...will continue to work with meds." On 12/4/13, the progress note read, "increase in agitation which required Ativan last night and this AM and PM. He still seems to not know what is happening and is very demented..." Nurses' notes and Incident/Accident Report: -On 11/27/13 at 6:15 p.m. nursing documented, "At 3:40 p.m., resident increased wandering in hallways in/out of other residents rooms, yelling, and cursing at staff nonsensical incoherent speech at time; asked if wanted fluids, food, bathroom etc. Nonsensical responses-refuse to let staff places slipper socks or shoes on. 4:00 p.m. (resident's power of attorney/POA) left. At 4:15 p.m. Resident back yelling and cursing at staff and other residents-attempted to redirect meet basic needs, staff closely following resident, redirected as he entered residents rooms ...At 5:00 p.m. resident still continuing to wander-yelling and cursing at staff and other residents...Resident was wandering in hallway followed by staff ...transferred resident to secured unit ..." -On 12/3/13 at 10:50 p.m., nursing documented, "Resident was very aggressive, thinking things are people and try(ing) to hit staff. He came in the nurses' station, he unlocked the little gate, came in and (threw) resident charts ....threatening and hit the nurse ...reported to unit manager re: resident aggressive behavior. She stated to call MD (medical doctor).received order for Ativan PO (oral)/IM 1 mg every four hours PRN (as needed) for extreme agitation ..." -On 12/4/13 at 3:20 a.m., nursing documented, "resident was report by CNA to have hit another resident on the neck in the day room. Resident was taken to room with staff ... " At 7:30 a.m., documentation read the unit manager was notified of above incident. On 12/4/13 (no time), an incident/accident report documented the CNA reported the resident hit another resident in the back of the neck in the day room. The report documented the resident was confused with agitation and crossed paths with resident #130. The recommendations were "Franklin Way' (fall presentation program) and for the physician to assess the resident. Witness statements read that resident #213 walked into the Christmas tree and wall next to resident #130. The CNA was trying to get resident #213 away from resident #130 when he yelled, "shut up" at resident #130 and hit her on the back of the neck. The LPN's statement read that resident #130 was sitting in her wheelchair by the Christmas tree. Resident #213 wandered next to her and hit her head on the back of the neck. Neither resident was injured. Both were placed on 15 minute checks. On 12/4/13, the note further documented, "I tried to talk to him ...But he started curse and makes threats that you are a "mother ****" and get away from me or I am going to hit you in your face." He is very aggressive and I have to keep watch him when around residents. If you ask him to take his medication or to do anything he will (ball) up his fist. I tried to ask resident to go to breakfast several times and each time he would curse, "you get the F away from me." He did take his medication this am and went to sleep most of the day. When awake he was in his room wandering around and had taken off his pants and socks. I went to put his pants and socks on and he stated, "Get the F out of my face." Then he clenched his fist. He was given Ativan this AM due to his aggression ..." -On 12/5/13, nursing documented, "Resident was up and awake wandering around in room and on unit with (unreadable) gait. Unable to redirect fluids offered and accepted with small amount intake with poor appetite both meals. Resident able to take some meds no aggressiveness noted towards others but cursing to staff at times." -On 12/9/13, nursing documented, "resident wandering up and down halls in and out of room throughout the NOC (night). He had approximately 1 hr (hour) of sleep thru the NOC. At times he gets aggressive, cursing and threatening ...He threw things around in his room. He has some rocks, pictures frames in his closet that he (unreadable) use against someone. Will ask social service to see if they could remove them from his room." -On 12/10/13 at 4:10 a.m., nursing documented, "Resident is awake most of NOC (night). He removed everything from his closet and drawers and brought them and scattered them throughout his room. He turned on the faucet in the sink and tried to flood the room. Standing at the bed of roommate with sharp objects in his hand. This nurse removed roommate from room. Resident then came out of room and wandered the halls for a while and then went back to his room. He is very aggressive whenever he is approached for care and very inappropriate with care. Will continue to monitor behavior. " -On 12/10/13 at 10:50 p.m., nursing documented, "Call to unit to "help." Nurse on unit 3 (secured unit) report(ed) resident punched her mid chest and struck both CNA(s) on unit. On call nurse notified of residents aggressive behavior toward staff. DON (director of nurses) notified by on call. 911 call ... " The resident was transported to the hospital 12/11/13 and was monitored 1:1 until 5:06 a.m. when he was transported back to the facility. See medication changes above on 12/11, 12/12, and 12/13/13, which were documented in a social service note 12/13/13. 2. Interviews - Resident's Change in Status A psychologist who had worked with resident #213 prior to his admission to the behavioral health facility was interviewed on 12/16/13 at 3:45 p.m. The psychologist said that today was the first time she had seen the resident in about six months. She stated he was a different person since returning from the behavioral health facility. She said that when she initially assessed the resident, he was not demented. Review of the psychologist's report, dated 12/16/13 documented the resident "stares into space, no eye contact, responds to 20% of questions/comments. Some speech is clear, but most is jibberish..He has been refusing to take his meds inconsistently ...Pt's chart reports that pt has been agitated, confused, and more demented then on first admit. .. Pt is cognitively and psychological(ly) changed since last seen ..." Resident #213's physician was interviewed on 12/19/13 at 5:02 p.m. The physician, too, indicated the resident had changed since his stay at the behavioral health facility. -The physician stated the resident was the "nicest guy" prior to his stay at the behavioral health facility. The physician stated the resident had "no mean streak" and "was wonderful," helping wheel people around in their wheelchairs and walking all over the building, never bothering anyone. He said the resident may have been shaking his fist (at residents and staff), but that did not mean he was being "aggressive." He stated "(Resident #213) is nice and a good person, he just has a bad disease." -The physician stated the resident had voiced wanting to go somewhere else, "that he felt confined," and voiced wanting to live in the mountains. He said the resident started "eloping." The physician stated that no matter where the resident resided in the facility, he kept heading outside the door. The physician stated that was when the staff decided to take him to a psychiatric (behavioral health) facility. -The physician further stated that the resident was frustrated about his placement at the facility and that he was very open about it. The physician said that even though the resident wanted to go to a different facility and the resident was frustrated about his placement in the facility, they had not tried to move him to another facility. C. Facility Failures The facility failed to implement measures to ensure resident #213's care was individualized and effective and his supervision adequate to protect the other residents on the secured unit. Record review (see medication orders above and social service note 12/13/13) and interviews (Unit Manager/UM #1 for the secured unit, interviewed on 12/18/13 at 9:45 a.m., the resident's physician interviewed on 12/19/13 at 5:02 p.m., the DON interviewed on 12/19/13 at 3:54 p.m., and the pharmacist interviewed on 12/26/13 at approximately 10 a.m.) revealed the interdisciplinary team reviewed and adjusted the resident's medications after his readmission to address his wandering, to 'calm him down,' and because the resident was sleeping all day and up all night with behaviors such as "striking/being combative with others." However, other than the medication changes above, the facility failed to take steps prior to 12/17/13, to respond to the resident's aggressive behaviors documented in the record. 1. Training and education to maintain residents' safety in the secured unit. Interview with the Staff Development Coordinator on 12/17/13 at 12:56 p.m. revealed "a lot of staff float" to the secured unit. Interview with the DON on 12/19/13 at 3:54 p.m. revealed there are 27 residents on the secured unit. The DON described the residents on the unit as having impaired mental status and most of them had impaired mobility. The DON stated that some residents roam into other residents' rooms. The DON further stated that the residents can "get into your personal space, like a regular Alzheimer's unit." Interview with the resident's physician on 12/19/13 at 5:02 p.m. revealed he knew the resident 'got aggressive' if someone got into his space. Interview with the DON on 12/16/13 at 4:35 p.m. as well as LPN #1 on 12/16/13 at approximately 3 p.m. revealed the resident was allowed to wander the unit freely. He was not constantly watched by staff. Observations on 12/16/13, revealed 15 secured unit residents were able to walk without assistance and were observed wandering throughout the unit, going in and out of resident rooms. Observations further revealed the residents often approached visitors, staff and other residents and began to talk or touch the other person. Notwithstanding the risks the characteristics of the secured unit population presented and resident #213's known response to 'his space,' staff interviews above, conducted 12/16/13 and 12/17/13, indicated inconsistent levels of training on managing residents with dementia and behaviors, and no specific education on how to address resident #213's documented aggressive behaviors, including information on what triggers these behaviors, what actions by the resident may precede these behaviors, and how staff are to manage the behaviors to ensure safety of residents in the secured unit. In addition, review of the "Special Care Unit Criteria Review" documenting the resident's transfer to the secured unit, did not reference the aggressive behaviors in the nurses' note regarding his transfer. (See 11/27/13 note above). 2. Plan of Care and Resident Supervision Review of the resident's plan of care (prior to updates 12/17/13 during survey) revealed two care plans addressing the resident's behaviors; neither plan included detailed information about the resident's behaviors such as triggers, antecedents, and management, or information about the supervision required to maintain the safety of residents on the secured unit (see interview with DON and LPN #1 above). Interviews after 12/17/13 revealed such information was available to the facility, but not timely incorporated into the resident's plan of care. (1) A plan for psychotropic medication use, dated 11/25/13, identified the resident received psychotropic medications (Seroquel and Depakote) for dementia with behaviors. -The goal was no adverse effects -The approaches included to "monitor and record any displayed behavior or mood problems, encourage appropriate behaviors, discourage inappropriate behavior, monitor effectiveness of psychotropic meds, provide diversional activities, psych services as needed and enforce positive behaviors." This care plan failed to identify the target behaviors for the use of the Seroquel and Depakote. Moreover, the plan lacked any description of the resident's 'displayed' behaviors, 'appropriate' behaviors, or 'inappropriate' behavior. In addition, the plan lacked any directives for staff on how to intervene to address 'inappropriate' behaviors, other than with medication, or any explanation what "triggered" the resident's 'inappropriate behaviors.' (2) A care plan for inappropriate behavior, dated 12/4/13, identified the resident's involvement in an altercation. -The goal was the resident would show a decrease of inappropriate behavior. -The approaches included psych services as needed, administer medications as needed, monitor resident activities, redirect when behavior happens and document, provide diversional activities, firmly approach resident that behaviors are not acceptable. "Franklin Way," (fall monitoring program) and doctor's assessment. This care plan failed to identify the circumstances of the resident's altercation as recorded in the incident report, failed to include what situations to avoid with the resident and which situations to encourage with the resident to minimize the opportunity for altercations. "Diversional activities" were not identified. There were no approaches added regarding resident supervision or how to maintain the safety of other residents on the unit, other than to redirect resident #213 see above; the resident was on 15 minute checks for falls, but these checks would not necessarily include an assessment of the resident's environment (i.e. if residents were in 'his space'). Finally, neither of the care plans revealed an attempt by the facility to gather resident specific information about his behaviors, what they represented, how they might be triggered, and how they could be managed. See physician interview above and social worker interview below; indicating the resident was "frustrated" with his placement; no approaches recognized and addressed this issue. Interview with the social worker (SW #1) and review of social services notes (11/13 - 12/13) revealed no evidence the resident's aggressive behaviors were evaluated to identify what triggered the behaviors, what the behaviors looked like or how staff should manage them. Indeed, review of social service notes failed to show any documentation about the incidents on 12/4/13, 12/9/13 and 12/10/13 (see above). The social worker (SW #1) for the secured unit was interviewed on 12/18/13 at 8:51 a.m. The SW said that when the resident returned from the behavioral health facility, he was admitted to (the open unit) and another social worker had completed the resident's Social Service Assessment. She said she had attempted another assessment, contacting one of the resident's co-proxies when the resident moved to the secured unit, but it was not successful. She said she obtained his past history from the medical record and interviews from staff that took care of him prior to his move to the secured unit. -The SW stated that when the resident first transferred to the secured unit, there was "really no specific discussion about his behaviors at all." The SW stated that after the resident went to the hospital on [DATE] (see record review above; resident #213 hit a nurse and CNAs) there was an interdisciplinary team (IDT) discussion about the incident but she could not remember the discussion. She said there were "things that were put into place when he came back to prevent him from being aggressive again," but she could not remember the specifics. -The SW stated the resident's co-proxy visited "if not every day, (then) every other day;" however, she indicated the co-proxy had not been interviewed until yesterday (during survey on 12/17/13), about the resident's behaviors. The SW said the co-proxy had a number of suggestions, such as leaving the resident alone and approaching him at a later time, offering the resident sweets (cookies, Twinkies, etc), and provide him with country music. Interview with the Activity Director (AD) on 12/17/13 at 10 a.m. revealed that she was familiar with resident #213 and aware he liked country music. However, she stated that not until today they had provided him with a CD player in his room. She also said that today they had determined the resident needed additional support, 1:1 activities. Interview with the NHA on 12/19/13 at 10:20 a.m. revealed the facility had learned that the resident does not do well with male caregivers, stating one CNA, who was a male, had been involved in the altercation 12/10/13 and in an altercation early this morning (12/19/13). There was no indication this factor was considered following the incident 12/10/13, and acted upon prior to 12/19/13. In an interview with the facility Medical Director (MD) on 12/20/13 at 9:25 a.m., the MD said she knew resident #213 and was aware of the incident with staff on 12/10/13. The MD stated she talked a lot with staff about redirection and had gone through the secured unit and asked staff their plan if this happened again. The MD stated she suggested to the staff to take residents for a walk, separate them from others, or ask if they are hungry or cold. See care plans above; these suggestions were not noted on the resident's plan of care. 3. Training and Education - Monitoring effectiveness See SDC interview above; staff was re-educated on resident to resident altercations and behavior management beginning 12/17/13. The NHA was interviewed on 12/19/13 at 10:20 a.m. and said resident #213 "had an incident early this morning." The NHA reported that "around 2:20 a.m.," resident #213 hit a CNA on the secured unit. The NHA stated that there was a female CNA providing 1:1 supervision of resident #213 last night; however, when the CNA took a break, a male CNA took her position. The NHA stated that the male CNA was walking in the hallway with the resident, when the resident struck the CNA. The NHA reported that the CNA was trying to redirect the resident back to his room. The NHA further stated that the male CNA "did not follow four things that (staff was) in-serviced on" about this resident. The NHA stated the male CNA said that the resident was in the hallway and he (male CNA) put a couple of fingers on the resident's hand and the resident struck him. She said this CNA was also involved in the incident on 12/10/13 (see record review above). The DON, interviewed on 12/19/13 at 3:54 p.m. said she was aware of the above incident. She said the CNA had received training "yesterday' (12/18/13) and was re-educated today on how to provide 1:1 supervision with a resident. The DON stated the CNA was under the impression he had to be right next to the resident while providing 1:1 supervision. The DON said the CNA was advised to give the resident space. The NHA did not provide information on how the facility would ensure staff education was understood and being properly implemented by staff.

Based on observation, record review and interview, the facility failed to ensure three (#291, #21, and #261) of 56 sample residents received specialized treatment and services to attain and/or maintain their highest practicable level of well being. Resident #291, who was lying supine in bed, was observed on 12/15/2013, anxious, pale and breathing shallowly and rapidly. She held tightly to the side rails and said she needed to go to the hospital. She was emergently transferred to the hospital over an hour later; upon arrival at the facility, the ambulance service measured the resident's oxygen saturation level at 50% (normal range 90% to 100%) and documented her oxygen was not turned on. Review of hospital records revealed her [DIAGNOSES REDACTED]. Findings include: I. Respiratory Services A. Professional Reference Normal range for oxygen saturation levels is between 90% to 100% with levels below 90% indicating hypoxemia or low oxygen, International [MEDICAL CONDITION] Coalition. B. Facility Policy According to the facility policy, normal oxygen saturation levels are between 90 - 100%. Oxygen saturation levels below 70% are considered life threatening. C. Resident Failures 1. Resident #291 Resident #291, age 83, originally was admitted to the facility on [DATE]. a. Resident status - hospitalization and re-admission 12/4/13 The resident was discharged to the hospital shortly after admission on 11/27/13. She was re-admitted [DATE]. According to her computerized physicians orders (CPO), [DIAGNOSES REDACTED]. The resident's hospital discharge record from her stay between 11/27/13 and 12/4/13 revealed that resident was diagnosed with [REDACTED]. The discharge summary stated that the source of [MEDICAL CONDITION] was considered to be both urinary and respiratory as her chest x-ray showed multilobar infiltrates. According to the re-admission resident summary, dated 12/4/13, the resident was alert with fluctuating orientation, understanding information conveyed but with difficulty. Her emotional state was described as quiet, anxious, easily upset and easily annoyed, short tempered with a staff written comment of "yelling at staff during care." Behavior problems included lack of awareness of own needs with psychoactive medication ([MEDICATION NAME], an antipsychotic). The summary indicated that resident had no pain, a pressure ulcer on her coccyx, and that she was incontinent of bowel and bladder. The summary also indicated that resident was restless and awakens frequently. The resident's physician orders included in pertinent part: -[MEDICATION NAME] 1.2 45 ml/hour continuously via j-tube (jejunostomy tube/feeding tube) - telephone order 12/4/13 -Mouth care every shift-telephone order 12/4/13 -[MEDICATION NAME] 3 ml, give via nebulizer three times a day for shortness of breath. The resident's care plan revealed a plan for tube feeding and cardiac care. (1) The tube feeding care plan, dated 11/21/13, stated a goal of resident will experience no complications. Approaches included: -NPO (nothing by mouth) -Enteral feeding order: [MEDICATION NAME] 1.2 65 ml/hour x 21 hours/day -Monitor tolerance of feedings -Elevate HOB (head of bed) 30 degrees -Input and output every shift -Observe peg tube/[DEVICE] site for signs and symptoms of infection -Oral hygiene every shift. (2) The cardiac care plan 11/21/13 stated a goal of no complications. Approaches included: -assess heart rate, blood pressure and respirations -oxygen therapy/oxygen saturations -elevate HOB 30-45 degrees -monitor [MEDICAL CONDITION] -monitor for signs and symptoms of heart failure and dyspnea The resident did not have a care plan to address her respiratory needs. b. Resident status 12/5/13 Observation: At 11:10 a.m., the resident was observed lying flat in her bed with the head of the bed elevated slightly (less than 10%). She was hooked up to tube feeding. A white/tan thick substance was observed in and around her mouth. The resident spoke in a gurgled/congested voice, as if something was stuck in her throat. She looked distressed, held onto the side rails tightly, was pale and stated she needed to go to the hospital. The resident seemed to be having trouble breathing; her breaths were shallow and rapid. The nurse was immediately alerted to resident's condition and she ran down to the room to check on resident. As the nurse entered the room, the resident was overheard to tell the nurse that she needed to go to the hospital. The nurse asked the resident what she needed to go to the hospital for. The nurse then shut the door. At 12:10 p.m., resident #291 was observed being taken out of her room on a stretcher by the ambulance service with an oxygen mask on. Record review: The resident's skilled daily nursing note from 12/5/13 was reviewed and it revealed: -On night shift, the resident's respiratory status was normal at 94%. The night shift nurse wrote in the note section at 2:00 a.m. that resident had no complaints of pain that shift, her feeding tube was patent, and she was resting quietly. -At 7:00 a.m., revealed the registered nurse (RN) charted the resident had no complaints of pain or discomfort. Crackled lung sounds bilaterally, j-tube (feeding tube) in place patent, continuous [MEDICATION NAME] tube feeding. Head of bed elevated at 30 degrees. Mouth care performed. Heels off loaded. Repositioned for comfort. Meds administered via j-tube, no difficulty. -At 10:00 a.m., the RN charted that she was informed by a state surveyor (but see above; the time of notice was after 11:10 a.m.) to check on resident as she appeared to have aspirated. The RN documented that she immediately went to the resident's room and resident had no complaints of pain or discomfort. She cleaned thick white secretions from resident's mouth and asked a CNA student to help her reposition resident. She documented that after repositioning, she checked that the bed was still at 30 degrees and assessed the resident's her lung sounds, which had crackles bilaterally and checked her oxygen saturation which was at 90%. -At 11:30 a.m., the same RN documented that a CNA informed her the resident was turning blue. She immediately rushed to the resident's room where the resident was showing signs of dyspnea (shortness of breath). She applied oxygen at 2 liters via nasal cannula and checked the resident's oxygen saturation which was at 65%, so the RN wrote she changed the resident to a non-rebreather mask; the resident's oxygen saturation level increased to 71%. She documented that she called the unit manager for assistance, cleared visible secretions from resident's mouth and raised the head of the resident's bed to 45 degrees. She called the resident's physician and the unit manager called 911 for urgent transport. -At 11:55 a.m., the ambulance arrived and resident was transferred to the hospital. -At 1:50 p.m., the unit manager charted that she was called to resident's room around 11:40 a.m. At that time, the resident's blood pressure was 166/98, her pulse was 107, the non-rebreather mask was applied and resident's oxygen level was 67%. She charted that resident's skin was pale and cool to the touch and her lung sounds were diminished with crackles. She called 911 and resident was transported by ambulance. -A second note written by the unit manager timed 1:40 p.m. read, "Bed was placed at 60 (or 90, it is written over with no correction) degree angle after (crossed out) when this writer entered the room." Interview: On 12/5/13 at 1:50 p.m., the RN on the hall was interviewed. -She stated that when she arrived on shift that morning around 6:00 a.m., the resident was alert and oriented x 1-2 and had no complaints. She said she performed oral care on the resident and took her vitals around 7:00 a.m. All vital signs were stable at that time and her oxygen saturation was in the 90s. She stated that resident was on continuous j-tube feedings. -She said there were two different groups of students from a nursing school in the building, a certified nurse aide (CNA) student group and a nursing student group. She said she had sent in both groups of students, one around 8:30 a.m. and one around 9:45 a.m., to do oral care on the resident. -She said at 11:10 a.m., when surveyor alerted her to resident's distress, she entered the room and swabbed resident's mouth with a dry swab to get all of the debris out. She also took the resident's oxygen saturation and it was 90% and resident had no complaints. -She said at around 11:30 a.m., a CNA came to get her, stating the resident appeared to be out of breath. She said she ran down to the resident's room and took her oxygen saturation level which was at 65%. -She said she put oxygen on the resident at 2 liters via nasal cannula, which did not work to bring up resident's oxygen saturation level, so a non-rebreather mask was placed at 2 liters and her oxygen level came up to 75%. She stated the head of the bed was raised as high as it would go. She said the resident's lungs were crackly and she asked the unit manager to assist. -She stated the unit manager called 911 and RN called the resident's physician at the same time. She stated that at 12:00 p.m. the ambulance crew arrived and took over. -She stated the resident had been discharged to the hospital on [DATE] for shortness of breath as well. Hospital record review: The hospital records from the resident's emergent transport and admission on 12/5/13 were obtained on 12/18/13. The hospital records showed: The resident's oxygen saturation was 50% upon the EMS arrival at the nursing facility as her oxygen was not turned on. The resident was intubated and was put on mechanical ventilation and admitted to the intensive care unit (ICU). The impression and plan written by the ICU physician was [DIAGNOSES REDACTED]. c. Facility failures (1) See observations above. The resident was lying flat at 11:00 a.m. while her tube feeding was infusing. According to the American Association of Critical Care Nurses 2011, expected practice for those patients with a tube feeding is to maintain the head of bed elevation at an angle of 30 to 45 degrees to prevent complications which can include aspiration pneumonia. (2) See skilled nurses' notes and interview above. There was no indication the unit manager or physician was notified between 10:00 a.m. (see skilled note above) and/or 11:10 a.m. of the resident's respiratory distress, as evidence by a gurgling/congested voice, the resident's perception that she needed to go to the hospital, rapid, shallow respirations, and the nurse's documentation of crackles bilaterally, as well as an oxygen saturation of 90%, a decrease from earlier that morning. There was no indication the nurse continued to monitor the resident's status after she entered the room following notification of the resident's condition at 11:10 a.m. until she was notified by a CNA that the resident was turning blue. (3) See hospital records above. The hospital records from the resident's emergent transport and admission on 12/5/13 indicated no oxygen was being administered when the ambulance/EMS) arrived at the facility. d. Staff interview On 12/19/13 at 1:23 p.m. the Unit Manager was interviewed. -She stated the resident had a j-tube, was NPO, and had a Foley catheter. She stated the resident had returned to the facility (from her first hospitalization [DATE]) on 12/4/13 at 4:45 p.m. and the nurse on duty for the 2-10 shift did the initial assessment on the resident. -She stated that on 12/5/13, the nurse on the hall, an RN, called for help. The resident's pulse oximetry (used to check oxygen saturation levels) was low, so they placed a non-rebreather mask, called the director of nursing and informed her the resident had respiratory distress and needed to be sent out to the hospital. She said the resident was a full cor (to be resuscitated if she had a respiratory or [MEDICAL CONDITION]). She stated 911 was called before 12:00 p.m. and arrived in five to seven minutes. -She stated CNAs reposition residents every 2 hours, and that during tube feedings, residents need the head of the bed to be at a 30-45 degree angle depending on physician orders. She confirmed that there was no order written, therefore, facility policy that the head of the bed be above 30 degrees, applied. She stated the RN should check to make sure that the head of bed was at 30 degrees or more. She stated that all rooms have a triangle at the side of the bed to show 30 degrees, which all nursing staff, including RNs, licensed practical nurses/LPNs, and CNAs as well as students in the building would be aware of. -She stated that she was told by the resident's physician that resident #291 will always aspirate on her own saliva and he did not believe the resident was appropriate for a nursing home; he was trying to find a long term acute care facility for the resident. -She stated that if a resident was in respiratory distress, the physician would be called right away. She stated she was not aware of the resident's condition until the RN asked her for assistance, which was after the CNA found resident to be in distress. 2. Resident #21, [AGE] years old, was admitted to the facility on [DATE]. According to her computerized physician orders (CPO), [DIAGNOSES REDACTED]. The resident's most recent minimum data set ((MDS) dated [DATE] indicated she exhibited cognitive deficits scoring a 7/15 on her brief interview for mental status (BIMS). She exhibited no behaviors or mood issues. Functionally, she required extensive assistance of one to two staff members for bed mobility, transfers, and toileting. Record Review: Upon review of resident's medical record on 12/30/13 at 10 a.m., there was no order for resident to receive oxygen on her CPO, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's care plan, dated 12/12/12, and last updated on 5/23/13 stated, 'I have shortness of breath upon exertion/activity/lying at rest. O2 2L via NC (oxygen at two liters through nasal cannula). The goals for this care plan stated the resident would be able to complete activities of daily living without shortness of breath; and resident will not exhibit any anxiety related to shortness of breath through the next 90 days. Approaches included:(pertinent) -Administer oxygen therapy as ordered -Obtain and record my oxygen saturation levels -Assess my respiratory status A second care plan related to oxygen, dated 12/12/12, and updated 5/23/13 read: resident required oxygen therapy, SOB (short of breath). O2 2L via NC. The goal for this care plan was that resident will exhibit no shortness of breath through the next 90 days. The approaches included (pertinent): -Administer oxygen as ordered -Ensure that supply is available at all times -Provide with humidification -Monitor changes in my symptoms that may indicate worsening respiratory status and report to physician. The resident's most recent progress note, dated 11/13/13 and written by the nurse practitioner (NP) stated that resident was on 2 liters of oxygen. The resident's nurses' summaries, dated 10/17/13 and 11/7/13, both indicated that resident had normal respiration and had oxygen at 2 liters as needed (prn). Observation: On 12/5/13 at 4:15 p.m., the resident was observed in her room. There was a blue stationary oxygen concentrator in the room; however, the resident was attached to a portable oxygen tank via nasal cannula. The resident said that she could feel oxygen coming out through her nasal cannula and she was not short of breath. However, observation of the portable oxygen tank, by holding the tank by the strap, indicated the tank was empty. Interview: On 12/5/13 at 5:30 p.m., a certified nurse aide (CNA) who was working with the resident was interviewed. She stated that the resident's oxygen tank was full and said she had checked it at the beginning of her shift at 2 p.m. She stated she knew the resident's tank was full because of the weight of the tank. She was observed to hang the tank by the strap and check the gauge needle which did not move. On 12/5/13 at 5:40 p.m., the registered nurse (RN) was interviewed. The RN held the oxygen tank by the strap and looked at the gauge needle. She confirmed the tank was empty. The CNA took the tank and went to fill it. The RN checked resident's oxygen saturation and it was 91%. The nurse stated that the resident's orders were for 2 two liters of oxygen continuously via nasal cannula. The RN stated that when the resident was in her room she should be connected to her stationary concentrator. On 12/12/13 at 9:27 a.m., the resident was interviewed. She stated that they never ask her to go on the stationary concentrator in her room. She stated that she has run out of oxygen a couple of times, but staff filled her tank quickly when this happened. On 12/20/13 at 8:55 a.m., the assistant director of nursing (ADON) was interviewed. She stated that the CNAs should check portable oxygen tanks every two hours on their rounds. She stated that the only time a resident would use the stationary oxygen concentrator would be if they are bed bound, on a higher concentration than a portable could handle or at night. She stated that if a resident was mobile or on a lower concentration, they use the portable oxygen tank at all times. B. Podiatry Services 1. Facility Policy - Ancillary services (requested and provided by the Director of Nursing/DON on 12/17/13) Review of the facility policy regarding ancillary services revealed it read in pertinent part: -Podiatry will be provided to the resident per state and federal guidelines ...as needed ...Any resident needing ...Podiatry (services) will have their needs met timely ...Social Services/Designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner." 2. Resident #261 Resident #261, age 57, was initially admitted to the facility from the hospital on [DATE] and per care plan, placed on hospice care 7/30/13. According to the resident's face sheet, the resident's [DIAGNOSES REDACTED]. Physician assessment notes, dated 12/10/13, indicated a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), dated [DATE], revealed resident #261 was severely impaired in his ability to make daily decisions. The resident rarely/never understood others and others rarely/never understood the resident. The resident had no behavioral symptoms. The resident was totally dependent or needed extensive assistance of one to two staff for all activities of daily living (ADLs). The resident was non-ambulatory and was bedbound. Record Review: Review of the activities of daily living (ADLs) care plan, initiated on 7/17/13, read in pertinent part, "Require(s)assist (assistance) with ADLs related to intracranial injury, hx (history) of [MEDICAL CONDITION] with [MEDICAL CONDITION](tracheotomy)." -The goal for the care plan read in pertinent part, "will be clean, neatly groomed and dressed (through 1/15/13)." -The care plan approaches included showers three times a week and a sponge bath on alternate days and PRN (as needed); nail care weekly and PRN. Nurse to cut nails since diabetic." Review of the resident's record revealed no documentation of podiatry services since admission 7/13. Observations: -On 12/10/13 at 8:30 a.m., observations of the resident's ADL and pressure sore/wound care were conducted with the unit licensed practical nurse (LPN). The resident was in bed in a fetal position and all four extremities were observed to be contracted. The resident's hands here observed clenched into fists. When the resident's covers were removed, the resident was observed without shoes or socks in place. -The resident's right (R) big toe nail was observed to be broken, ragged, rough, hardened and elongated. During the observation of ADLs, the LPN stated, "It's (R big toe nail) long, hardened and ragged ...it needs to be trimmed." -The left (L) big toe nail was observed and the LPN stated, "It's thick and very long." -As the LPN evaluated the resident's toes nails, the resident pulled away and cried out in pain, "owe, owe." As the resident cried out, the LPN stated, "they (toe nails) are painful to touch." The LPN further stated that because the toe nails were hardened, the resident needed to be seen by podiatry for cares for trimming/cutting of his toe nails. On 12/10/13 9:19 a.m., the Social Worker (SW #2) who was responsible for the resident's ancillary needs was interviewed. The SW stated, "Unit Manager/LPN/UMLPN) just asked me to schedule him with Podiatrist ...It's the first I've heard (about) his toe nails." The SW stated that he would obtain Podiatry services for the resident as soon as possible. No further comments were made and no further documentation was provided at exit (12/20/13) or faxed shortly after exit.

Based on observations, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one (#2) of five sample residents. Specifically: -The facility failed to develop a behavioral plan for caring for resident #2, in spite of his many refusals of care. -The facility failed to keep the resident's MPOA and the physician fully informed of the resident's decline. -The facility failed to thoroughly and timely assess and address resident #2's needs after a significant change of condition. Resident #2 was transported to the hospital on [DATE] with an altered mental status, a large draining wound that the facility verified they were unaware of (no evidence of documentation), and severe dehydration. The family was unaware of the resident's continuing refusals for bathing, toileting, receiving his insulin and finally his decline during the first part of May 2013. Moreover, physician was unaware of the resident's change of condition during the first part of May. The facility's multiple failures resulted in the admission of the unresponsive resident to Intensive Care Unit with a blood sugar of 491 and a blood pressure of 52/45. The findings include: I. Resident Status Sample resident #2, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. He resided in the locked unit due to wandering and dementia. 1. a. MDS The 5/2/13 Minimum Data Set (MDS) indicated resident #2 had both short- and long-term memory problems and was moderately impaired in the cognitive skills for daily decision-making (decisions were poor and cues and supervision were required). The MDS coded the resident as having no behavior problems, was understood by others and usually understood others. The resident's vision and hearing were adequate. The MDS indicated the resident had intact skin, was at risk for pressure ulcers, and had no pain or swallowing problems. The resident was coded as needing extensive assistance with bed mobility, transferring, dressing, toilet use and with personal hygiene. The resident weighed 190 pounds and was 67 inches tall. According to the MDS, the resident was always incontinent of bowel and bladder. b. Care Plan The care plan, last updated 5/13/13, after the resident was sent out to the hospital, indicated the resident was a diabetic dependent on insulin. The goal was the resident would not suffer any injury/complications related to elevated blood glucose and the resident would not suffer effects/adverse reactions from the anti-diabetic regime. Added on the care plan, however, not dated, were the handwritten comments that the resident was treated with [MEDICATION NAME] subcutaneously in the a.m. and at bedtime (HS), was on a diabetic diet, and had accuchecks twice a day. Some of the approaches listed were: -Monitor the resident for complications such as decreased circulation, decreased healing, decreased hearing, visual problems, urinary problems, etc... Notify the physician if observed. -Monitor the blood glucose as ordered by the physician. Notify the physician of abnormal values as necessary and perform prescribed treatment. -Give medication as ordered; notify the physician if the resident refused. -Monitor for signs and symptoms of [MEDICAL CONDITION], such as confusion, agitation, restlessness, etc. Check the blood glucose and notify the physician if observed. -Monitor for signs and symptoms of [DIAGNOSES REDACTED] such as decreased cognition, lethargy, agitation, confusion, etc... Check the blood glucose and notify the physician. -Encourage the resident to have less ice cream. -Encourage the resident to allow the administration of insulin to other sites rather than just the stomach. Another problem care planned was that the resident often refused diabetic injections in any site other than the lower abdomen. Handwritten comments, not dated, read the resident often refused insulin injections and required staff to re-approach the resident several times before he would agree to the injection. The goals included that the resident would receive injections without undue harm from repeated injection administration in one site through the next 90 days. Several approaches listed included: -Administer medications as ordered, -Observe for adverse effects of medications and report to the physician, -Monitor for behaviors that warrant intervention. Handwritten undated comments written to the side of this approach were, "Refusing insulin injection, eating a lot of cookies, seeking out cookies to eat, offer diabetic snacks, re-approach resident if he refuses his insulin and tell him you will be back in 5 min. (minutes) to give it to him. Frequently remind him why he needs his insulin injection." -Monitor for uncontrolled pain and report to the physician promptly, -Monitor for the effectiveness of medications and report negative findings to the physician. A third problem addressed the resident's incontinence and less attempts of toileting himself. Handwritten and undated were the comments that the resident benefits from reminders and assistance with toileting due to his advanced dementia. The goals included the resident would be free from skin breakdown problems, would maintain his skin integrity, and would preserve his self image. Some of the approaches included: -Toilet the resident upon arising, before and after meals, at bedtime and as needed. -Encourage fluids, -Monitor for signs and symptoms of infection, and -Report any changes to the physician. A fourth problem was the resident could be socially inappropriate/disruptive/impulsive behavior (although not identified on the MDS), "resident loves to sing and dance, it is an activity for him and residents or staff are not bothered by this, it is not something that should be taken away from him." Added was an undated handwritten comment that the resident benefits from supervised walks outside. Goals for this issue included that the resident will be redirected by staff, to assist him to decrease wandering behavior into others rooms, and to assist the resident to maintain appropriate behavioral functioning. Some of the approaches included: -One to one with staff, -Psychological evaluation as needed, -Diversional activities to decrease impulsive behaviors, -Monitor labs as ordered and report abnormal to the physician, -Encourage family/responsible party to visit with the resident, -Identify the cause and triggers for the impulsive behaviors and eliminate, -Approach the resident warmly and positively, -Elicit family input for the best approach(es) to the resident, -Include the resident in activities as needed, and -Talk with the resident in a calm voice when resident was disruptive. A fifth problem care planned was the resident was at risk for skin breakdown related to incontinence, diabetes, cognitive impairment, and a right sided weakness due to a history of a [MEDICAL CONDITION]. The goal was to keep the resident's skin clean, warm and dry and intact without evidence of breakdown over the next 90 days. Some of the approaches included were: -Monitor for incontinence every two hours and as needed, -Monitor for skin breakdown, report to the physician and the responsible party, -Assess skin weekly and record findings, and -Give medications as ordered, monitor labs and report any abnormal results to the physician. A sixth problem included nutrition and hydration risk with the long term goals of maintaining his weight at 190 pounds with a variance of four to six pounds for the next 90 days. A slow/gradual weight loss was acceptable. The resident would consume 50% or greater of meals for the next 90 days. Hydration will be maintained with no signs or symptoms of dehydration for the next 90 days. The resident would tolerate his diet with no signs or symptoms of chewing or swallowing problems. The resident's skin would remain intact for the next 90 days. Some of the approaches listed were: -Encourage diet adherence, -Encourage and assist resident with meals as needed, -Record food/fluid intake of meals, -Challenging to educate due to memory loss and dementia, and -Makes independent choices. 2. Physician Orders Review of the 5/13 Computerized physician's orders [REDACTED]. Offer 240 cc water three times a day between meals and record the amount consumed (12/27/12). Accuchecks twice a day scheduled at 5:30 a.m. and 4:30 p.m. The physician was to be called if the blood sugar was under 60 or over 450 (8/3/12). If the Fasting Blood Sugar was over 501, eight units of Regular insulin were to be given (3/5/13). Monitor blood pressure every evening shift and call the physician if the systolic blood pressure was greater than 180 or the diastolic blood pressure was greater than 90 (12/10/12). Give [MEDICATION NAME] 45 units every a.m. scheduled at 7 a.m. and [MEDICATION NAME] 38 units every HS scheduled at 8 p.m. (8/3/12). Offer to go outside every day and document (8/22/12). Review of the physician progress notes [REDACTED]." II. Significant Change in Condition Review on 5/22/13 of the nursing notes, Activities of Daily Living (ADL) computer notes, May 2013 Medication Administration Record, [REDACTED] On 4/22/13, the resident refused his shower and the responsible party was notified. On 4/24/13, the resident ate 100% of breakfast, 50% of his lunch and 100% of his dinner. There were no nurses' notes for this day. The resident also received a bath, however, refused his 4/24/13 head to toe weekly skin assessment as he had also done per documentation on 4/3, 4/10 and 4/17/13. On 4/25/13, the resident ate 0% for breakfast, 100% for lunch and dinner. There were no nurses' notes for 4/25/13. On 4/26/13, the resident ate 100% of his breakfast, 50% of his lunch and refused the alternate. He ate 25% of his dinner and refused the alternate. There were no nurses' notes for 4/26/13. On Saturday 4/27/13, the resident ate 25% of breakfast, 75% of his lunch and 50% of his dinner and refused the alternate. There were no nurses' notes for this day. The resident also received a bath. On Sunday 4/28/13, the resident ate 50% of breakfast, 0% of his lunch and 25% of his dinner and refused the alternate. A nurse on the 10 p.m. to 6 a.m. shift documented the resident refused vital signs x 3 and was compliant with his medications. The resident also received a bath. On Monday 4/29/13, the resident ate 0% of breakfast, 0% of his lunch and 25% of his dinner and refused the alternate. A nurse on the 6 a.m. to 2 p.m. shift documented the resident refused all of his medications x 3 including his 7 a.m. [MEDICATION NAME]. There was no evidence that the physician or the responsible party was notified. On Tuesday 4/30/13, the resident ate 0% of breakfast, 75% of his lunch and 50% of his dinner and ate 5 to 25% of the alternate. A nurse documented at 10:30 a.m., the resident's blood sugar was 264 and his gait was unsteady. [MEDICATION NAME] was given and he walked with the nurse. His blood pressure was 142/78 and he had a bloody nose. At 12:15 p.m., a nurse documented the resident stumbled and almost fell . The Nurse Practitioner (NP) wrote orders (no time) for a magnesium level, a hemoglobin A1C, CMP (complete metabolic panel), and a lipid panel for the morning of 5/1/13. Also an RD (registered dietitian) consult was ordered due to a seven pound weight loss in the last month. There was no evidence that the responsible party was notified of the weight loss. On Wednesday 5/1/13, the resident ate 0% of his breakfast, lunch and dinner. A nurse documented at 6:40 a.m., the resident's blood sugar was 468 and the physician was notified. [MEDICATION NAME] 50 units was ordered and given. Another nurse documented (no time) the resident refused supper and "refused to come to the day room because of his unsteady gait, can't stand up by himself... BS 369, took insulin, resident sleeping all the shift in (his) bedroom, refused to eat p.m. snack and drinks too, will continue to monitor." There was no evidence that the physician or the responsible party was notified of these issues. In addition, the resident had refused the lab blood draw and there was no evidence that the physician was notified. Documentation indicated the resident refused the weekly skin assessment. On Thursday 5/2/13 the resident ate 0% of his breakfast, lunch and dinner. There were no nurses' notes for the date. According to the MAR, the resident had refused both his 7 a.m. and his 8 p.m. insulin. The 5:30 a.m. blood sugar was illegible and the 4:30 p.m. blood sugar was documented as 305. On Friday 5/3/13, the resident ate 0% of his breakfast, lunch and dinner. There were no nurses' notes for this date or any evidence the physician had been notified the resident was not eating. Documentation indicated the resident had received a bath, however, had refused the weekly skin assessment. On Saturday 5/4/13, the resident again ate 0% of his breakfast, lunch and dinner; however, he did eat 50% of the alternate that was offered at breakfast. A nurse documented at 8 p.m. that the resident's vital signs were 109/77, pulse of 109-99 (sic), his respirations were 18 and his temperature was 97.2. His pulse ox was 93% on room air. The nurse documented the resident was incontinent, however ate 100% of bed time snack and drank 240 cc of fluid. On Sunday 5/5/13, there was no documentation if or how much the resident ate at breakfast or lunch. Zero % was documented as his intake for dinner with 50% of the alternate taken. The resident received a bath that day; however, there were no nurses' notes regarding the resident this day. There was no evidence that the physician or the responsible party was notified of the resident's condition. On Monday 5/6/13, documentation indicated the resident ate 0% of all three meals. At 2 a.m., a nurse documented the resident refused care. The RD's consult was done and she documented no skin issues. The RD recommended 60 cc of med pass (a supplement) to be given at 10 a.m. and at 3 p.m. and to record the percentage of the amount taken. In addition she recommended weekly weights and to offer snacks of his choice at 10 a.m., 3 p.m., and again at bedtime and to record the amount taken. On 5/7/13 Tuesday at 3:00 a.m., a nurse documented the resident was, "in and out of slumber, noted lips dry c (with) old milk and juice. Tol. (tolerated) mouth care and encourage pt. to drink fluid, but he refused. Will continue to monitor. VS (vital signs) 99.4-22-96-152/56, POX 92% on RA (room air)." At 5:30 a.m., a nurse documented the resident was incontinent of urine only one time during the night shift, water was offered, but the resident refused. The nurse also documented she had called the laboratory several times to find out the results of the lab tests ordered on 4/30, eight days previously, however, noted the resident had refused the lab draw. The laboratory stated they would send someone out either that night or in the a.m. However, there was no evidence the physician was notified that the lab draw had not been completed as ordered. In addition, there was no evidence that the facility staff had previously followed-up on the results of the lab tests ordered eight days prior. At 6:45 a.m., a call was placed to the physician to notify the physician of the resident's condition and to report a blood sugar of 496. The physician stated he would send someone to review the resident's medications. "No new orders written at this time." Review of the 3/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 4/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 5/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The was no evidence the physician was consistently notified of the insulin refusals. On 5/7/13 at 10:30 a.m., the NP visited and ordered ? Normal Saline IV with 250 cc [MEDICATION NAME], remainder of liter at 75 cc per hour, BMP (Basic metabolic Panel), and a CBC (complete blood count). The NP documented if the resident showed no improvement, to send the resident to the emergency room (ER). The resident was sent unresponsive to the emergency roiagnom on [DATE] at approximately 11:30 a.m. after the CNA (certified nurse aide) and the nurse could not get any vital signs. The nurse was also unable to start the ordered IV fluids. At 11:00 a.m. to 11:30 a.m., documentation in the, "Interdisciplinary Discharge Summary" revealed when the paramedics arrived at the facility, they were, "unable to secure vital signs other than erratic via 12-lead. PO2 78%-98%. Pulse 39-220." The paramedics were also unable to access a vein for the ordered fluids. The transfer form indicated the skin was clean, dry and intact. a. Hospital Record Review The hospital record was received and reviewed on 5/22/13. Pertinent information included the resident was admitted with, "[MEDICAL CONDITION] with septic shock, large right gluteal abscess, likely the source of infection, acute toxic metabolic [MEDICAL CONDITION] related [MEDICAL CONDITION], uremia, and [MEDICAL CONDITION], acute on (sic) [MEDICAL CONDITIONS], dehydration..., Diabetes Mellitus with marked [MEDICAL CONDITION]" The blood pressure was documented as 52/45 in the ER and the resident was, "aggressively hydrated." The operative report read, "because of the ongoing purulent drainage of the gluteal abscess, the resident was taken to the operating room for incision, irrigation, and drainage of the gluteal abscess." The hospital record indicated the ulcer on the right gluteal fold was draining a fair amount of purulent drainage and had 5 cm tunneling in the direction of the rectum. Daily wound care had to be completed by physical therapy. The resident only responded to pain and was documented on 10 liters of oxygen per a non-breather mask. The resident was placed on NPO status (nothing by mouth) due to "Mod(erate) to severe oropharyngeal swallowing deficits impacted by confusion and weakness. Pt with absent swallow at times impacted by confusion and weakness." In addition, the resident was placed on antibiotics and pressors to help elevate the blood pressure. Hospital Lab evaluation (on 5/7/13) included: Potassium of 6.2 (normal range is 3.5-5.1), Sodium level of 158 (normal range is 136-145), Blood Glucose was 561 (normal range is 74-106), BUN was 101 (normal range is 7-18), and Creatinine was 11.8 (normal range is 0.6-1.3). Observation of the resident in the intensive care unit on 5/22/13 at approximately 2:00 p.m., revealed the resident lying on his right side, his hands were covered with cloth mitts and his eyes closed. He was attached to monitors. A Foley catheter was connected to dependent drainage and draining amber urine. IVs were running per a [MEDICATION NAME] catheter (per hospital record). The resident did not respond to any verbal stimuli, therefore an interview was not attempted. b. Hospital Staff Interviews Interview with the hospital case worker caring for the resident was conducted, on 5/21/13 at 1:45 p.m., per telephone and again at the hospital on [DATE] at approximately 2:00 p.m. The case worker stated when the resident first arrived at the hospital, he was smelly, not shaven, and could not pass the swallowing evaluation so had to be fed by a [MEDICAL CONDITION] tube. She said she had talked to the DON at the facility to get more information about the resident. She stated the DON stated the resident was a big man and would swing at staff. The DON stated the resident would get angry so they would attempt three times when he refused care or medications and then would give up. The case manager stated the daughter had visited the resident in the hospital and mentioned the resident did not like women, so the son-in-law would come to the facility when they called the family for assistance. The hospital ICU nurse, who admitted the resident to the unit, was interviewed per phone on 5/21/13 at approximately 2:15 p.m. She stated the resident was, "definitely unkempt, smelled, had really, really dry skin and long curled toe and fingernails." She stated there were dreadlocks in the pubic hair and the resident had a "pimple" on his bottom. She continued that with cleaning the resident and wiping over this area, it exploded and per documentation, "a large stream of bloody pus shot out approximately 6 inches." After the hospital staff interviews about the resident's personal hygiene, further review was completed of the resident's facility records. III. Other Failures Review of the 3/13 facility's, "ADL Assistance and Support Sheets" on 5/21/13 revealed, the resident was scheduled for two baths per week. The computer print outs revealed documentation that the resident received 4 baths (of 8 possible) in 3/13; on 3/8, 3/13, 3/16 and on 3/27/13. Review of the 4/13 facility's, "ADL Assistance and Support Sheets," on 5/21/13 revealed documentation on the computer print outs that the resident received 2 baths (of 8 scheduled) in 4/13; on 4/27 and on 4/28/13. There were three days that the DON stated they had computer problems during the month so it, "might have been possible that the resident had a bath on those days." Review of the 5/13 facility's, "ADL Assistance and Support Sheets," on 5/21/13 revealed documentation on the May computer print outs that the resident received 1 bath (on 5/6) before he was transferred to the hospital on [DATE]. However, according to hospital staff interviews and record review, the resident was unkempt with foul odors that were present upon admission to the hospital, one day after the above documented shower. Review of the 3/13, 4/13, and 5/13 Treatment Administration Records (TARs) indicated the resident had refused all the weekly head to toe skin assessments evidenced by the circled initials in the dated squares and/or by the documented word, "refused." In addition, review of a Podiatry examination documentation indicated the resident refused to be seen on 1/31/13, 3/29/13, and again on 4/26/13. According to an incident form that was re-created by the Director of Nursing (DON) on 5/22/13, documentation showed the resident had fallen from a chair and landed directly on his bottom on 4/27/13. There were no injuries reported at that time. However, according to the above reviews, the resident had refused head to toe skin assessments. Moreover, the transfer form indicated the skin was clean, dry and intact when he was sent to the hospital. However, when he was admitted to the hospital the evidence showed a "pimple" was present on his bottom that ultimately exploded and per documentation, "a large stream of bloody pus shot out approximately 6 inches." (Refer to gluteal abscess above). Facility Staff Interviews The physician (who was also the medical director for the facility) was interviewed, on 5/22/13 at approximately 9:30 a.m., in the presence of the nursing home administrator (NHA). The physician stated, "she felt she was doing what the POA wanted and gave the resident a good quality of life." She added that she had really only spoken to the daughter once. She stated it was difficult to contact the family. She commented the NP had tried many times to contact the family. The physician stated the daughter did not want medications to treat the resident for depression. The physician stated she felt she was following the POA's decisions when she thought she had the resident's best interest in mind. The physician also stated that they educated the family on what would happen with his refusals of medications and insulin. The physician went on to say that she was not aware that the resident related better to men and commented that he would refuse medications and care. She felt he was not in any distress because if this. However, she was unaware that the resident was not eating or drinking the week before he was sent out and that the labs the NP had ordered were not done. She stated that the last time she had visited the resident, he had refused her physical exam. She stated the resident had the right to refuse care and treatments. The NP was unavailable for an interview. The NHA was interviewed on 5/22/13 at 9:30 a.m. She stated the resident was difficult to care for and they felt they were doing the best they could. She was aware of the resident's refusals of care and medications. When asked about social service's involvement with the family and the resident, she stated the social worker for the unit was no longer with the facility. She added the other social workers were taking on her residents. When asked about the facility's responsibility in keeping the residents clean and insuring he received his medications as ordered, she stated they tried, however, they could not force the resident to do what he did not want to do. The nightshift Licensed Practical Nurse (LPN) was interviewed on 5/22/13 at 4:45 a.m. She stated the resident refused medications, insulin, and care. She continued that it sometimes took two to three people to change him. The unit manager for the unit was interviewed on 5/22/13 at 8:45 a.m. She stated the resident was a big strong man. She went on to say he would refuse medications, insulin and baths. She stated you could not get into his personal space. She added that they cannot hold a resident down to do his cares. We did try to involve the NP, the physician, and the family many times. The secure unit had two nurses that gave medications, assisted with meals and helped with the care of the residents. The LPN that worked on the side of the unit that the resident had resided upon was interviewed on 5/22/13 at approximately 12:05 p.m. She stated the resident had his days. She went on to explain that the resident had been a boxer and when he said, "No," he meant, "No!" She explained he would swing his arms and when sitting, put his feet up as if to push you away. She continued to say the resident loved to dance, and there was a nurse that spoke his language and she sometimes could get him to do things. The LPN stated sometimes the resident ate and sometimes not, however, he usually always would take fluids. She added she never saw a family member visit, however, had left messages for the daughter (the medical power of attorney). The daughter, who was also the MPOA, was interviewed per phone on 6/1/13 at approximately 5:30 p.m. She stated she used to take care of her father before he went to the facility. She stated the facility would sometimes leave voicemail's when the resident would refuse his baths or his insulin, however, she thought these were only isolated events. She stated her father had Alzheimer's Disease and was demented and she would expect them (facility) to have some kind of plan to take care of someone with dementia. The MPOA stated the resident was a diabetic and needed his insulin. She added the resident has dementia and did not know what he needs and expected the facility to find a way to give him what he needed. She went on to say the hospital had notified her of the resident's admission before she heard from the facility. She stated she was unaware of her father's decline before he went to the ER. She was only aware that he was not eating well. She stated when she later heard from the facility, they had, "a whole list of things to tell me." She stated the only discussion she had with the facility about her father's behavior was about a year ago, when the physician had contacted her about, "starting a medication for depression." She stated the physician had told her, "the medication could cause kidney failure but he would be happy for a month." She stated she refused the addition of the medication because he already had problems with his kidneys. She stated the resident had been a fairly active man and so asked about what activities the resident was involved with. She added that she had requested the staff to take the resident on a daily walk outside whenever possible because he loved that. The MPOA stated she thought there had been a change in the activities person and thus the resident was not as involved in the activities as he had been previously. The daughter stated she had told the facility many times, the resident did not like women and preferred male caregivers. She stated that was why she would send her husband when the facility requested assistance with the resident. She added that she would receive a letter to attend a care conference, however, it was always at 10:00 a.m. and she was at work. She went on to say that she had requested a later time for the conference so she did not have to miss work, however, was told that was "their policy" to have them during those hours. She stated she worked full time, went to school and had small children so wanted to meet after work. The daughter stated she last visited her father in March and he did not recognize her as his daughter. She stated that she would think the health and safety of her father would be the facility's priority. She added the resident does not know what he needs and what is best for him, "He is demented."

Based on record review, family interview, and staff interviews, the facility failed to ensure one (#41) of 53 sample residents received the necessary care and services to attain or maintain the highest practicable physical well-being. -The resident's wound was not addressed in a timely manner. Specifically, there was no documentation to show the facility responded promptly when a wound on the resident's right hip first showed signs and symptoms of infection on 8/6/10. The resident was transferred to the hospital on [DATE], where incision and drainage procedure was conducted. -The resident's ordered fluid restriction was not monitored. The findings include: 1. Sample resident #41, age 77, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of dementia, [MEDICAL CONDITION], and hypopotassemia. According to the facility's hospital transfer form, the resident was discharged on [DATE] to the hospital for a "(right) hip wound/burn (with) copious (amounts) of bloody, purulent, foul-smelling drainage." The 7/21/10 admission minimum data set (MDS) assessment documented the resident had short- and long-term memory problems and moderately impaired decision-making skills. The resident was usually able to make herself understood and usually able to understand others. She did not exhibit any mood or behavioral problems. The resident required limited assistance with bed mobility, walking in her room, dressing, and personal hygiene. She required extensive assistance with transfers, toilet use, and bathing. She was independent with locomotion and eating. The resident had no pressure or stasis ulcers, but she had abrasions or bruises. She used a pressure-relieving device on her bed and wheelchair and received preventative skin care. 2. Record Review A 7/17/10 nurse's note documented during rounds, an abrasion to the resident's right hip measuring 11 centimeters (cm) by 7 cm was found and an incident report was initiated. A 7/18/10 physician's telephone order (TO) documented an order to cleanse the abrasion to the right hip with wound cleanser, apply triple antibiotic ointment, and cover with a sterile combiderm dressing. The order was to change the dressing daily and as needed. A 7/21/10 TO documented an order to apply silvadine to the wound on the right hip for five days and to change the dressing daily and as needed. A 7/22/10 nurse's note documented new orders were received for treatment of [REDACTED]. A 7/26/10 skin condition record documented the resident had a burn to the right hip/lower posterior area first observed on 7/26/10. The burn was 13 cm long, 14 cm wide and, 0.3 cm deep and had jagged edges. A 7/26/10 TO documented an order to cleanse the right hip wound daily with wound cleanser, then apply xenoderm and combiderm. A 7/26/10 nurse's note documented the resident's dressing was changed and there were no signs of infection noted. A temporary care plan addressing the resident's wound/burn to the resident's hip was created on 7/26/10. It documented the approaches: provide treatment as ordered, monitor for signs and symptoms of infection and "notify the physician with any change," provide skin protection as ordered, administer medications as ordered, assess the skin weekly and record findings, and "prevent shearing forces and friction during transfers." The 8/4/10 skin condition record documented the wound was the same size and was scabbing over. An 8/5/10 TO documented an order to apply santyl on the wound daily for five days for debridement. An 8/6/10 nurse's note documented a "strong odor" was noted to the wound bed. Another 8/6/10 nurse's note documented an odor was noted to the dressing on the resident's right hip. There was no documentation that the physician was notified about the change in condition of the resident's wound. An 8/7/10 nurse's note documented the resident's dressing was changed and odor and drainage were noted. There was no documentation that the physician was notified about the change in condition of the resident's wound. An 8/10/10 nurse's note documented the resident's dressing was replaced after a shower. The wound had a foul odor. Another 8/10/10 nurse's note documented the resident had pain, foul odor, and bloody, purulent drainage in the hip wound. A TO 8/10/10 documented the order, "Send resident to the hospital for evaluation and treatment of [REDACTED]. Review of hospital documentation revealed the 8/24/10 hospital discharge summary read that the resident was admitted to the hospital with [REDACTED]. A wound culture showed the wound was infected [MEDICAL CONDITION] and [MEDICATION NAME]. Surgery was consulted on the day of her admission (8/10/10) and an incision and drainage procedure was conducted that same night. The resident received a wound vac and a 10-day course of antibiotics. 3. Failure to Timely Address Wound and Signs/Symptoms of Infection Record Review: Although the wound was first noticed on 7/17/10 (see nurse's note, above), a skin condition record was not implemented until 7/26/10. Moreover, a temporary care plan addressing the resident's wound/burn to the resident's hip was not created until 7/26/10, eight days after discovery of the wound. Although the temporary care plan directed staff to "notify the physician with any change," there was no documentation the resident's physician was notified of the change in condition of the resident's wound (odor and drainage) first noted on 8/6/10 until 8/10/10, when the resident was documented to have "pain, foul odor, and bloody, purulent drainage in the hip wound." Moreover, there were no physician's orders or skin assessments after the signs and symptoms of infection were noted. Family Interview: On 8/23/10 at 3:15 p.m., the resident's family member stated the resident's wound progressively worsened, and ended up requiring debridement and grafting at the hospital. She stated the resident's wound "could be smelled from the unit floor." She also stated she requested a wound care consult when it began to look infected, but the facility did not provide one. The resident was sent to the hospital for surgery on 8/10/10. Staff Interviews: On 9/1/10 at 2:30 p.m., the licensed practical nurse (LPN) who had worked with the resident prior to her hospital discharge stated she was not working the day the hip wound was found, but she was told the patio chair might have burned the resident's hip. The LPN stated the wound was pink and began to form a scab. The odor was noticed after the scab was formed. She stated the wound then started to drain severely, so she notified the director of clinical services (DCS). The LPN stated she had not notified the resident's physician, but believed numerous calls had been made to the physician regarding the new infection. On 9/1/10 at 5:00 p.m., the DCS stated she phoned the resident's physician on 8/7/10 to inform him of the signs and symptoms of infection. She stated she did not document this phone call in the resident's medical record because it was unavailable at the time. The DCS stated the resident had a scheduled appointment with the physician on 8/18/10, but she told the physician the resident "could not wait until then" to be seen; she needed to be seen right away. The DCS stated the resident's physician stated he would send someone out to see the resident immediately. The DCS stated "several days later" she realized the physician had not sent anyone to see the resident. She stated she then spoke to the resident's physician again, who ordered she be sent to the hospital. She stated the facility had spoken to the physician regarding the lack of follow-up, but had not documented any of the information. review of the resident's medical record revealed [REDACTED]. There was no documentation of additional physician contact until 8/10/10, when the resident was experiencing pain and the wound was exhibiting copious amounts of bloody, purulent drainage. 4. Failure to Monitor an Ordered Fluid Restriction Record Review: The 7/8/10 nutritional assessment documented the resident was on a 1,000 cc fluid restriction as recommended by the [MEDICAL TREATMENT] dietician. The 7/19/10 nutrition care plan documented the resident was restricted to 1,000 cc of fluid per day due to her [DIAGNOSES REDACTED]. The care plan documented the resident's fluid restriction was "clarified in the MAR (medication administration record)." An undated fluid restriction allowance chart documented dietary was to provide 240 cc of fluid at breakfast, lunch and dinner, and nursing was to provide 90 cc of fluid three times per day during medication administration. Review of the resident's 7/10 and 8/10 MARs revealed there was no documentation of the resident's fluid restriction. Review of her medical record revealed there was no monitoring of the resident's fluid intake. Family Interview: On 8/23/10 at 3:15 p.m., the resident's family member stated the [MEDICAL TREATMENT] staff informed her the resident frequently had an excess of fluid in her system when she received [MEDICAL TREATMENT]. Staff Interview: On 9/1/10 at 2:30 p.m., the LPN who had worked with the resident prior to her hospital discharge stated the resident was on a physician-ordered fluid restriction. She stated the resident was allowed to have ice chips in her room between meals, received 90 cc of fluid at medication pass, and received the allotted amount of fluids at meals. She stated the resident's fluid intake was not monitored. She stated the facility assumed the fluids passed at medication administration and at meals were served as ordered, but the ice chips between meals were not measured or monitored in any way. On 9/1/10 at 5:00 p.m., the DCS stated if a resident was on a fluid restriction, the facility nursing and dietary staff should monitor the resident's fluid intake, including the ice chips between meals. She stated this should be monitored on an intake and output form. The DCS stated the resident's fluid intake had not been monitored.

Based on observation, record review and staff interview, the facility failed to ensure the environment for residents, including five (#170, #96, #284, #289, and #203) out of 53 sample residents were as free of accident hazards as possible. Specifically: - The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. Resident #203, who was known to stand up from her wheelchair unassisted, stood up from her wheelchair and fell , sustaining a facial laceration. - The facility failed to ensure the resident environment was free of hazards. Findings include: RESIDENT FAILURES 1. Resident #203 Sample resident #203, age 99, was admitted to the facility on [DATE]. According to the 8/10 Computerized Physician order [REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], the resident had cognitive impairments with moderately impaired decision making. The resident was coded as requiring extensive assistance with transfers. The resident was coded as experiencing a fall in the past 31 to 180 days. a. At risk for falls - interventions planned to minimize risk The fall risk assessment, dated 8/9/10, assessed the resident as being a high risk for falls. The assessment documented the resident had experienced one to two falls in the past 3 months. The resident's care plan, dated 5/5/10, documented the resident had a potential for falls. The goal was that falls and injury from falls would be minimized through interventions. Pertinent approaches included: - Use self releasing seatbelt when resident is in wheelchair. - Therapy screen. - Personal alarm in wheelchair and bed. Review of the 8/10 CPO documented an order for [REDACTED]. The assistant director of nurses (ADON) for the fourth and fifth floors (where the resident resided) was interviewed on 9/1/10 at approximately 3:45 p.m. The ADON stated the resident had experienced a fall a few days ago and that she required the personal alarm, as she was at risk for falls. b. Fall 8/29/10 Review of the nurses notes 6:45 a.m. dated 8/29/10 documented, "was standing out in hallway when heard a loud crash noise in room. Opened door and found CNA (certified nurse aide) and resident on floor - wheelchair folded up laying on side. Large amount of blood noted from nose and laceration to right eye. RN (registered nurse) called in to do assessment. No complaint of pain noted from resident. Called 911 to transport to (name of hospital) for eval(uation) and tx (treat)..." 12:18 p.m. note documented, "resident back in facility at this time new orders to cleanse laceration with warm soapy water QD (every day) Apply TAO 2 times a daily. Ice maybe applied up to 20 min. 4-6 hours per day. Sutures to be removed in 7 days..." Review of the nurses notes for 8/30/10 read, "...complained of slight discomfort to nose..." An 8/31/10 physician telephone order documented a personal alarm to be used in both bed and wheelchair at all times. b. Failures (1) Observations - failure to implement safety device On 8/30/10 at approximately 5:45 p.m., the resident was observed sitting in the dining room. The resident was observed to have a black and blue eye and bruising on the right side of her face. The resident was observed to have sutures to her forehead. On 8/31/10 at approximately 4:00 p.m., the resident was observed to attempt to stand up in her wheelchair which was in the common area. No staff were in the immediate vicinity of the resident's wheelchair. The resident did not have a personal alarm on. A staff member was alerted that the resident was attempting to stand up by herself. On 9/1/10 at approximately 3:30 p.m., the resident was observed sitting in the common area on the second floor. The resident was observed to not have a personal alarm. The assistant director of nurses (ADON) was notified. The ADON stated she would ensure an alarm was placed on the resident. - At 5:00 p.m., the resident was observed to have the personal alarm on; however, the cord was too long to timely trigger the alarm to alert staff. The cord measured at approximately 25 inches long. - At 6 :05 p.m., the rehabilitation leader observed the approximately 25 inch long cord on the resident's personal alarm. The rehabilitation leader stated the cord was too long, and she shortened the cord. She stated she would have the staff development coordinator provide training to staff on how to shorten the cord. The medication nurse, who was present during the interview with the rehabilitation leader, stated that she, too, had noticed the cord was too long; however, she was unsure how to shorten the cord. (2) Record review The investigation of the 8/29/10 fall was requested of the clinical health manager; however, the investigation was not provided for viewing prior to end of survey (9/2/10). Therefore, there was no documentation that the resident's seatbelt was on, the personal alarm was attached, the resident was being supervised at the time of the fall, or other evidence to show staff implemented interventions to minimize the resident's risk for falling. Review of the fall care plan revealed no plan to increase resident supervision, notwithstanding her history of standing up from her wheelchair without assistance. Likewise, the care plan included no directives for staff to monitor the placement and status of the resident's personal alarm to ensure it was in place and operational and effective in alerting staff to resident movement. (3) Staff interviews The rehabilitation leader (RL) was interviewed on 9/1/10 at approximately 5:45 p.m. The RL stated that after every fall, the resident was to have a screen completed to evaluate resident risk and to develop recommendations for resident safety. At approximately 6:00 p.m., the RL stated, after reviewing the record, a screen was not completed after the 8/29/10 fall. The director of nurses (DON) for the 4 and 5 station was interviewed on 9/1/10 at approximately 6:15 p.m. The DON stated the resident was at risk for falls. - She stated the resident had experienced a fall on 7/19/10 at the bedside. She stated the personal alarm was added as an intervention. - She stated the resident had experienced a fall from her wheelchair a few days ago. She stated the resident was in the room with the CNA; the CNA was at the sink brushing the resident's dentures when the resident fell from the wheelchair. The DON stated the resident stood up and fell ; the CNA did not see the resident stand up. The DON stated she was not sure if the personal alarm had been attached and sounded. She further stated she was not sure if the alarm had been ordered, although, see above, it had been ordered since 5/7/10 and according to the DON, was "added" after the resident's 7/19/10 fall. 2. Resident #284 Resident #284, [AGE] years old, was admitted on [DATE]. This resident's August 2010 monthly computerized physician's orders [REDACTED]. This resident had orders and was care planned to use sensor alarms whenever in bed or up in his wheelchair to assist in preventing additional falls. The sensor alarm was not consistently observed being used on his wheelchair as ordered. a. Record Review This resident's record was reviewed from 8/23 through 9/2/10. This resident's August 2010 CPO listed orders for devices to help prevent falls, including: - An order, dated 7/01/10, for a sensor alarm on resident at all times while in bed to alert staff if resident attempted to ambulate without assistance and to remind resident to call for assistance prior to ambulation due to resident's decreased safety awareness. - An order, dated 7/01/10, for a sensor alarm on resident at all times while in WC (wheelchair) to alert staff if resident attempted to ambulate without assistance, and to remind resident to call for assistance prior to ambulation due to resident decreased safety awareness. This resident was documented to have had falls on 6/30, two falls on 7/10, a fall on 7/12, and a fall on 8/24/10. Care Plan - The resident's current care plan included a problem of falls. The goal was to have no injury due to a preventable fall. - Approaches included sensor alarm to bed and wheelchair, which was added to the care plan on 6/30/10. b. Observations The following observations were made of this resident in his wheelchair: On 8/30/10 at 4:20 p.m., the resident was in his wheelchair across from the nursing station. A visitor said he was trying to get out of his wheelchair. A nurse for the other hall moved the resident into his room. No alarm device was observed on his wheelchair. On 8/30/10 at 4:45 p.m., the resident was in the TV room, which was entered from their bedroom. The resident was in his wheelchair facing the TV with no visible alarm on the wheelchair. On 9/1/10 at 12:45 p.m. the resident was in his wheelchair at the dining room table. An alarm pad was sticking out of the back of the seat of the wheelchair. Further observations revealed a small alarm in the clear bag with the oxygen tubing. The alarm had areas where it would be attached to the pad, but it was not attached to anything. On 9/1/10 at 2:45 p.m. the resident was seated in his wheelchair across from the nursing station. The resident had his oxygen on and the alarm was still observed in the plastic bag with his oxygen tubing; the alarm was not attached to the alarm pad. On 9/1/10 at at 5:10 p.m., the resident was sitting in his wheelchair across from the nursing station. When staff came, the resident's feet were off the foot rests. The surveyor asked the CNA (certified nurse aide) to assist the resident in putting his feet back on the foot rests. The resident's alarm was still in the clear plastic bag with the oxygen tubing. c. Staff Interview and Facility Record Review The head of the therapy department was interviewed on 9/1/10 at 6:00 p.m. regarding the observations above. She stated therapy was contacted for evaluation for fall/safety devices and that the order for the device should be listed on the care plan, there should be a physician's orders [REDACTED]. Review of the Resident Care (hole punched where the next word is) - Guide for CNAs indicated the resident was a fall risk but there was no documentation the resident was to have a sensor alarm on his bed or wheelchair. An ADL form listed the resident was to have fall prevention equipment of a sensor alarm on his bed and wheelchair. The ADL form for the month of August 2010 showed the sensor was in use on the wheelchair and there was a notation to "check to assure plugged in." The ADL sheet documented the use of the sensor alarm in the wheelchair on all shifts on 8/30/10. Review of the resident's falls with the Director of Nursing (DON) on 8/31/10 at 2:15 p.m. revealed the following: - The fall assessments on 7/10/10 (when the resident fell twice) listed the resident to have fallen at 1300 (1 p.m.), trying to transfer himself from the recliner to the wheelchair. - The second fall assessment on 7/10/10 (12:45 a.m.) documented the resident was found on the floor next to the bed. - The fall assessment on 7/12/10 documented the resident was found next to the wheelchair. The documentation regarding these fall assessments did not include whether the resident's ordered safety devices, including the sensor alarms, were in place and sounding. The DON stated she had instructed staff that they were to include more information about the circumstances when a resident had a fall and staff were completing the assessment of the fall. 3. Resident #289 Resident #289, [AGE] years old, was admitted on [DATE]. The resident's August 2010 monthly computerized physician orders [REDACTED]. This resident had physician orders [REDACTED]. The resident was observed in his wheelchair without the sensor alarm on the wheelchair until staff was notified. a. Record Review This resident's record was reviewed from 8/23 through 9/2/10. The August 2010 CPOs included the following orders: - Sensor alarm on resident at all times while in bed to alert staff if resident attempts to ambulate without assistance prior to ambulation due to resident's decreased safety awareness. This order was dated 5/3/10. - Sensor alarm on resident at all times while in wheelchair to alert staff if resident attempts to ambulate without assistance, and to remind resident to call for assistance prior to ambulation due to resident decreased safety awareness. The order was also dated 5/3/10. Minimum Data Set (MDS) - The resident's full/initial MDS was completed on 5/6/10. The MDS listed the resident to have fallen in the previous 30 days. The Resident Assessment Protocols that were triggered by the MDS for additional assessment included the area of falls. The RAP for ADLs (activities of daily living) documented the resident required assistance of one to two with ADLs for safety. The resident was very impulsive. The MDS documented the resident needed extensive assistance for transferring and locomotion on the unit. - The Quarterly MDS of 8/5/10 did not list additional falls but did document the resident now needed total assistance for locomotion on the unit. Care Plan The care plan had an approach for the problem of falls on 5/3/10. The approach documented that staff would provide a hi-low bed, a fall mat, sensor alarms to the bed and wheelchair, helmet and hip protectors. The helmet was documented as being discontinued on 7/12/10, as the resident refused to wear it. Resident Care (hole punched where the next word is) - Guide for CNAs indicated the resident was a fall risk and was to have a TAB (a different type of alarm) to his wheelchair and bed. Rehab(ilitation) Referrals - A rehab referral of 7/12/10 listed the resident to have fallen on 7/9/10. The resident stated he was trying to get the wheelchair and hit his head. - A rehab referral of 7/21/10 read the resident had a fall on 7/20 and was observed lying on the fall mat next to the bed. No documentation was found indicating the resident was receiving restorative or skilled therapy during the survey or in the last quarter. b. Observations This resident was observed to be up in his wheelchair without a sensor alarm on. - On 8/30/10 at 10:00 a.m., the resident was seated in his wheelchair in the TV lounge, facing the window. The resident did not have an alarm on his wheelchair and one was not found on his bed. - On 8/30/10 at 1:22 p.m., the resident was observed in his wheelchair in the hallway outside his door. There was no alarm on his wheelchair or bed. - On 8/31/10 at 3:10 p.m., the resident was observed in his wheelchair with no alarm. The unit nurse was asked about the resident's alarm. The nurse indicated another unit nurse was the resident's nurse and she located this nurse. When asked about the resident's alarm, this nurse checked and said the resident was supposed to have an alarm on his wheelchair. She also checked and did not find an alarm. The nurse located a new wheelchair sensor pad and took the resident back to his room to put it on his wheelchair. c. Staff Interview See therapy interview above. ENVIRONMENTAL FAILURES 1. Torn Geri Chair Armrests Sample resident #96, age 88, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of subarachnoid hemorrhage, constipation, [DIAGNOSES REDACTED], anemia, and esophageal reflux. The 7/7/10 quarterly MDS assessment documented the resident had short- and long-term memory problems and severely impaired decision-making. She was rarely/never able to make herself understood or understand others. The resident was totally dependent with bed mobility, transfers, locomotion, and all activities of daily living. She had partially limited functional range-of-motion. a. Observations On 8/25/10 at approximately 2:00 p.m. the resident was observed sitting in her geri-chair in the common area. The resident had a short sleeve shirt on. The armrests of the geri chair were ripped. On 8/27/10 at 5:30 a.m., the resident was observed to be sitting in her geri -chair in the common area. There was ripped plastic on the arms of the geri-chair. The resident had short sleeve shirt on. On 8/31/10 at approximately 5:15 p.m., the resident was observed to be transported in her geri-chair by a certified nurse aide. The resident had a short sleeve shirt on. The armrests of the geri chair were ripped. b. Record Review The 5/5/08 interdisciplinary care plan documented the resident was at risk for injury related to her cognitive loss, weakness, and dependence on staff assistance. She was at risk for skin breakdown and had poor mobility. The resident tended to lean to the side while seated in her geri chair. Care-planned approaches included: transfer the resident to her geri chair for meals and socialization and ensure the use of the right armrest of the geri chair for positioning. review of the resident's medical record revealed [REDACTED]. c. Staff Interviews During the environmental tour with the maintenance director (MD) and assistant nursing home administrator (ANHA) on 9/1/10 at 10:00 a.m., the ANHA stated wheelchairs and geri chairs were to be cleaned by certified nurse aides (CNAs) three times per week and any damage was to be reported in the maintenance log. She stated the CNAs should have reported the torn geri chair armrests in the maintenance log to be repaired or replaced. On 9/1/10 at 4:49 p.m., the MD stated he did not have any maintenance log entries regarding the resident's geri chair armrests. He stated new armrests would be applied immediately. 2. Gap at Foot of Bed Sample resident #170, age 90, was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the face sheet, of dementia, depression, psychosis, constipation, pain, and joint stiffness. The 8/20/10 quarterly MDS assessment documented the resident had short- and long-term memory problems and severely impaired decision-making. She was rarely/never able to make herself understood or understand others. The resident was totally dependent with bed mobility, transfers, locomotion, and all activities of daily living. a. Observations On 8/24/10 at 11:00 a.m., 8/25/10 at 3:00 p.m., and 8/31/10 at 11:30 a.m., the resident's bed was observed with a gap at the foot of the bed between the foot board and the mattress. The gap was approximately three to seven inches, depending on the placement of the mattress on the bed frame. The gap exposed the bed frame and the springs. On 9/1/10 at 2:45 p.m., the resident's bed was observed, along with the director of clinical services (DCS), to have approximately a seven-inch gap between the end of the mattress and the footboard. The bed frame and springs were exposed in the gap. b. Record Review The 9/17/09 interdisciplinary care plan documented the resident could fidget at times, was at risk for injury due to osteoporosis, could become combative with staff during care, and was at risk for skin injury/breakdown. review of the resident's medical record revealed [REDACTED]. c. Staff Interviews On 9/1/10 at 2:45 p.m., the resident's CNA stated she was not independently mobile while in bed. On 9/1/10 at 2:47 p.m., the DCS stated the gap between the mattress and the footboard posed a risk for injury due to the resident's mental status, the potential for entrapment, and the exposed springs and bed frame. The DCS stated the gap should be covered with a foam insert for the resident's safety.