Every finding on record at Haven of Saguaro Valley

Based on clinical record review, staff interviews, and review of the facility policy and procedure, the facility failed to ensure that blood pressure medication was administered in accordance with physician ordered parameters for 1 out of 3 sampled residents (Resident # 1). The deficient practice could result in uncontrolled blood pressure. Findings include: Resident #1 was admitted on [DATE], with diagnoses that include fractures of T11-12, encounter for surgical aftercare following surgery on the nervous system, acute respiratory failure with hypoxia, acute pulmonary edema, other heart failure, and cardiomegaly. A review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Further review of the MDS revealed an active diagnosis of Orthostatic Hypotension and Hypertension.An order initiated on November 13, 2025, for Midodrine HCL 5 milligrams (MG) 2 tablets by mouth every 8 hours for orthostatic hypotension, hold for systolic blood pressure greater than 140. Review of the December 2025 Medical Administration Record (MAR) revealed that the Midodrine was marked administered on:December 5, 2025, at 2:00 p.m., with a blood pressure of 141/83December 10, 2025, at 2:00 p.m., with a blood pressure of 150/89December 12, 2025, at 10:00 p.m., with a blood pressure of 145/70December 15, 2025, at 2:00 p.m., with a blood pressure of 142/60 December 21, 2025, at 2:00 p.m., with a blood pressure of 146/64Review of the Medication Administration Note dated December 10, 2025, at 4:14 p.m. revealed that Midodrine was above parameters.Review of the Medication Administration Note dated December 21, 2025, at 1:39 p.m. revealed that the systolic blood pressure was greater than 140 by Licensed Practical Nurse (LPN/Staff #116)Further review of the Medication Administration notes revealed no notes for the December 5, December 12, and December 15th administrations of the Midodrine.An interview was conducted with LPN (Staff #116) on December 23, 2025 at 2:55 p.m., who revealed that the physician's order of the Midodrine has a parameter that if the systolic blood pressure is above 140, the medication is not to be given. Staff #116 reviewed the December 2025 MAR and stated that a checkmark on the MAR indicates that the medication was administered, and a number 5 means it was outside of parameters and was not given. Staff # 116 reviewed the December 21, 2025, 2:00 p.m. administration of the Midodrine and revealed that the medication was marked as administered and was outside of parameters with a systolic blood pressure of 146. Staff #116 revealed that she made a mistake, and the medication should not have been given. Staff # 116 stated that the concern with giving this medication outside of parameters is that it will cause the blood pressure to go too high. An interview conducted on December 23, 2025, at 3:33 p.m., with the Director of Nursing (DON/Staff #103), revealed that the Midodrine order included a parameter that the medication was not to be administered with a systolic blood pressure above 140. The DON explained that in the MAR, if a medication was administered, there is a checkmark in the box, and if the medication was not administered outside of parameters, then the number 5 is marked meaning hold and see the nurses' medication administration notes for further explanation. The DON reviewed the December 2025 MAR administration of the Midodrine on December 10, 2025, and stated that it was marked administered at 2:00 pm with a systolic blood pressure of 150; however, in reviewing the progress notes, she revealed that it was noted this was above parameters and held. The DON further reviewed the December 21, 2025, 2:00 p.m. administration of Midodrine and stated it was marked as administered, but review of the progress notes showed that the nurse had indicated it was held due to the systolic blood pressure being above 140. The DON goes on to reveal that possibly the nurses had removed the medication from its packaging in preparation for administering and realized the blood pressure was too high, and withheld the medication, and that is why they added the supplementary progress note then disposed of the medication but never changed the administration of the medication in the MAR. The DON then reviewed the December 12, 2025, administration of the Midodrine at 10:00 p.m. and revealed that it was marked administered, and further review could not find a follow-up medication administration note in the progress notes. The DON stated that this indicates the medication was given, and the nurse was not following the physician's order and giving the medication outside of parameters. The DON stated the concern with giving this medication outside of parameters is that it causes the blood pressure to be uncontrolled. A policy and procedure titled, Medications: Administering Medications, dated January 1, 2024, revealed that it is the policy of the facility that medications are administered in accordance with prescriber orders, including any required time frames. The policy also revealed that the individual administering the medication documents in the electronic medical administration record after giving each medication and before administering the next one.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure bowel and bladder care was provided for one resident (#3) out of 3 sampled. The deficient practice could result in skin breakdown and possible formation of pressure ulcers. Findings include: Resident #3 was admitted on [DATE] and discharged on [DATE] with diagnosis including essential hypertension, major depressive disorder-recurrent, peripheral vascular disease, paroxysmal atrial fibrillation, occlusion and stenosis of the left carotid artery, benign prostatic hyperplasia without urinary tract symptoms, pressure induced deep tissue damage of the sacral region and anxiety disorder. A review of the 5-day MDS (minimum data set) dated September 15, 2024 revealed a BIMS (brief interview of mental status) score of 10, indicating moderate cognitive impairment. A review of the care plan revealed a focus area of bladder incontinence due to impaired mobility. The interventions included use of disposable briefs and that these were to be checked and changed as needed, as well as an unobstructed path to the bathroom. A review of the facility tasks under bowel and bladder revealed that the resident was changed only once during day shift on September 14, 2024 at 3:05 P.M., September 15, 2024 at 5:30 P.M. and September 21, 2024 at 1:13 P.M. An interview was conducted on March 11, 2025 at 5:16 P.M. with CNA (certified nursing assistant, staff #56). The CNA stated that assigned tasks are documented in PCC (point click care) under the heading of POC (plan of care)/ tasks. She further stated that if tasks were not documented by the end of the shift then they did not occur. She stated that CNA's have to document each shift for each care area. The CNA stated that bowel and bladder care had to occur at least once per shift but often times more frequently. She stated that in general this is for almost every resident for changing and repositioning. She stated that her expectation is to respond to each resident's needs immediately and that if residents are soiled they should not have to wait. She stated that the risk for not changing a resident timely could include bed sores. An interview was conducted on March 11, 2025 at 5:21 P.M. with RN (registered nurse, staff #1). The RN stated that CNA's document the assigned tasks in PCC under the POC tab and that this would include bowel and bladder care. The RN stated that if the area was left blank, then this would indicate that the task wasn't done. She stated that the expectation is that assigned tasks are done and documented. The RN stated that the risk to the resident could be skin breakdown. An interview was conducted on March 11, 2025 at 5:31 P.M. with the DON (director of nursing, staff #41). The DON reviewed the POC task entries for bowel and bladder and stated that the documentation for bowel and bladder care was not consistent. The DON was unable to find any evidence in the resident's record supporting that bowel and bladder care had occured for the missing bowel and bladder entries on the POC. She stated that risk would be that the bowel and bladder care did not occur if it was not documented and that there could be a potential for skin breakdown. A review of the facility policy entitled Urinary Continence and Incontinence-Assessment and Management with a revision date of January 1, 2024 revealed that assessments for urinary continence include review of the resident's history, observations, cognitive limitations, and type of physical assistance required. The policy further notates that nursing staff, as part of a resident's assessment, will document details related to continence to include voiding patterns, pain or discomfort and types of incontinence. The policy also notes that incontinence care is individualized at night in order to maintain comfort and skin integrity. A review of the policy entitled Charting and Documentation, revised April 2008 revealed that all observations, medications administered, and services performed must be documented in the resident's clinical record.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident was free from abuse. The deficient practice could result in further resident abuse. Findings include: Resident #2 was admitted on [DATE] with diagnoses of dementia, cardiomegaly, weakness, heart failure and type II diabetes. The admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 12 indicating the resident had intact cognition. Review of the clinical record revealed the resident will require 24/7 supervision upon discharge; and that, the resident will be discharge to an assisted living. The physician's history and physical revealed the resident had an increase need of assistance with activities of daily living such as continence care and medical assistance such as medication administration. The social services progress note dated March 11, 2022 revealed that there had been an ongoing issue between the resident and the family related to resident's placement or going home. Per the documentation, the resident decided to go to an assisted living facility and this had upset the resident's family who came to the facility on [DATE]. Per the documentation, the family was asked to leave and staff attempted to remove the resident from the situation. The documentation also included this escalated the situation and the family ran to the resident's room and grabbed the resident from behind in a choke hold. It also included that the family was subsequently arrested on domestic violence assault and the resident was discharged to the assisted living of her choice. The facility's self-report dated March 11, 2022 included that the resident was in the process of discharge to an assisted living facility on March 11, 2022 at 10:15 a.m. when a staff found the resident in her room and her family had her in a head-lock. Per the documentation, the police were called and the family was escorted out from the facility. The facility's reportable event record/report dated March 14,2022 included that the family came to the facility on the evening of March 10, 2022 to take his mother home against medical advice; and that, the family was asked to leave the facility. Per the report, the following morning (March 11, 2023), the family returned, would not listen to instructions and instead made a bolt for the resident's room. The documentation included that a certified nurse assistant (CNA/staff #60) witnessed the family putting the resident into a head lock type position; and that, the environmental services director (EVS/staff #41) and another staff intervened and removed the family's grip from the resident. The report also included that the family was arrested by the local police. The facility concluded in their report that the incident of physical abuse of the resident by her family was substantiated. In an interview conducted on October 18, 2023 at 4:40 p.m., the CNA (staff #60) stated the same account of events as described in facility's self-report. An interview was conducted with the EVS on October 19, 2023 at 11:00 a.m. The EVS provided the same account of events as described in facility's self-report. The facility policy on Abuse included an objective is to provide a safe haven for their residents through preventative measures that protect every resident's right to freedom from abuse.

Based on observation, staff interviews, and facility documentation and policy review, the facility failed to ensure transmission-based precautions and proper hand hygiene was implemented during incontinence care. The sample size was one. The deficient practice could result in transmission of infections to residents. Findings include: An observation of incontinence care was conducted with a certified nurse assistant (CNA/staff#60) and a licensed practical nurse (LPN/staff #91) on October 18, 2023 at 4:45 p.m. The LPN performed pericare and brief change while the CNA assisted the resident on her right side. During the observation, the LPN donned a clean pair of disposable gloves and then touched the resident. However, the LPN did not perform hand hygiene prior to donning of gloves. The LPN then removed the wet incontinent brief, placed it in a trash bag and cleaned the resident's perineal area. The LPN then proceeded to apply the new and clean incontinent brief on the resident using the same pair of gloves she used for pericare and handling of the soiled incontinent brief. The LPN continued to wear the same pair of gloves and adjusted the resident's clothing and positioned the resident in bed. The LPN then removed her gloves and disposed them in the trash, exited the resident's room, went to the nurses' station, washed and dried her hands. An interview was conducted on October 19, 2023 at 12:32 p.m. with CNA (staff #50) who stated the procedure of performing pericare included washing of hands and applying gloves before initiating resident care. In an interview with LPN (staff #84) conducted on October 19, 2023 at 12:52 p.m., the LPN said that staff were to wash their hands before and after applying gloves on, discarding soiled gloves or linens or incontinent briefs and resident care. However, that LPN said that he has not received any training from the facility regarding pericare. During an interview with the Director of Nursing (DON/staff #3) on October 19, 2023 at 1:10 p.m., the DON stated that staff were expected to follow the facility policy/procedure when performing pericare. The DON stated that he policy was to wash and dry hands thoroughly, to put on gloves before beginning procedure, to remove gloves after completing pericare prior to putting on clean brief and repositioning the bed covers, and after task was completed to wash and dry hands thoroughly prior to leaving the room. The facility policy on Handwashing/Hand Hygiene dated August 2015 revealed that all persons shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy stated that an alcohol-based hand rub was to be used before moving from a contaminated body site to a clean body site during resident care and after contact with blood or bodily fluids. Review of the facility policy on Perineal Care dated October 2010 included that staff were to wash hands and apply gloves before initiating resident care. Once completed with perineal care, staff were to remove gloves and wash hands prior to repositioning bed covers, making the resident comfortable, placing the call light, and cleaning the wash basin and bedside stand. Staff were to again wash hands prior to leaving resident room.

Based on staff interviews and review of facility documentation and policy, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 66 and the sample was 17. The deficient practice could result in resident not provided with advanced care activities to meet their needs. Findings include: The Facility Assessment with completion dated of February 1, 2023 revealed tan average daily census range of 90-105. Staffing planning included one FT (full time) DON (director of nursing), wound nurse, admission nurse, unit manager; and, two FT MDS (minimum data set) nurses. Per the assessment there should be at least one RN per 24-hour period; individual nursing staff assignments was based on patient care needs and individual staff needs/training; and that, nursing shifts are twelve hours with a goal of consistent assignments. Review of facility punch detail for registered nurses for March and April 2023 revealed no evidence of RN coverage on the following dates: -March 11, 16, 17, 18, 23, 24, 25 and 30; and, -April 6 and 7. An interview was conducted with the DON (staff #32) and staffing Coordinator (staff #111) on April 13, 2023 at 10:24 a.m. The DON stated that if a registered nurse (RN) was not available to provide the RN coverage that the DON would assume the role of an RN floor nurse. She stated that the risk could include simultaneous demands on both roles and not being able to fully fulfill one or the other. A request for the staffing policy was submitted on April 10, 2023, a policy regarding posting direct care daily staffing numbers with a revision date of August 2006 was provided noting the following Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to resident.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that the responsible party was notified of a fall with injury for one resident (#186). The deficient practice could result in required decisions regarding treatment and care not made timely. Findings include: Resident #186 was admitted on [DATE] with diagnoses of malignant neoplasm of the brain, anxiety disorder, schizophrenia and auditory hallucinations. A face sheet included that this resident had a Power of Attorney (POA) for financial and care. A care plan dated September 30, 2022 included that the resident was at risk for falls and injury An incident note dated November 2, 2022 included that the resident was on the floor with small pool of blood from a small cut to the right eyebrow. Per the documentation, pressure was and a small band-aid was applied to injury; and that, the director of nursing (DON) and the unit manager (UM) were notified of fall. Further review of the clinical record revealed no evidence that the resident's family or POA was notified of the fall or injury until November 6, 2022. An interdisciplinary team (IDT) review dated November 6, 2022 included that the responsible party was notified of the resident's fall. An attempt to contact the nurse providing care was made on April 12, 2022 at 9:27 AM and April 13, 2023 at 2:30 PM, however no return call or answer was received. An interview was conducted on April 11, 2023 at 10:06 a.m. with a registered nurse (RN/staff #12) who stated that unless a resident does not have anyone, staff need to inform contact family or a POA of resident's admission, change of condition such as transfer to the hospital or a fall. In an interview with a licensed practical nurse (LPN/staff #80) conducted on April 12, 2023 at 1:03 p.m., the LPN said that when a resident falls she would tell the staff not to move the resident until the she assess the resident. The LPN said that if a resident is not alert and oriented she would do neuro-checks; and, after resident was assessed and neuro-checks had been started, she would inform the doctor, the family, administration and the supervisor and do a fall report. During an interview with the Director of Nursing (DON) conducted on April 13, 2023 at 3:07p.m., the DON said that when a resident had a fall incident, the facility would investigate how the fall happened, assist the patient, notify provider and family and then put the intervention in place. She said that it did not meet her expectations that staff waited days to notify the POA of resident #186. The DON stated that notification should be done right away. A review of the clinical record was conducted with the DON who stated that she was not able to find documentation that resident's family or POA had been notified of the resident's fall on November 2, 2022. The facility policy on Accidents and Incidents - Investigating and Reporting revealed that the date/time the injured person's family was notified and by whom will be included on the report of incident/accident. This document included that the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a report of incident/accident and submit the original to the Director of Nursing Services within 24 hours of the incident or accident.

Based on clinical record review, staff interviews and review of policy, the facility failed to ensure intervention was implemented to prevent a fall for one resident (#29). The sample size was 19. The deficient practice may result in avoidable accidents. Findings include: -Resident #29 admitted on [DATE] with diagnoses of COVID-19, weakness and unspecified lack of coordination. The baseline care plan dated February 17, 2023 included the resident was at risk for falls related to weakness and history of falls; and, was at risk for ADL (activities of daily living) self-care performance. Goal included that the resident will be free of falls and will safely perform ADLs. Interventions included following facility fall protocoal and call light within reach. The history and physical note dated February 20, 2023 included the resident subsequently fell twice, the most recent fall was 3 days ago; and that, the resident reported that he was losing his balance easily and his legs were giving in even though he was using a walker. Review of the Admission 5-day MDS assessment dated [DATE] revealed the resident had a BIMS (brief interview for mental status) score of 14 indicating resident had intact cognition. The assessment included that required extensive assistance with 2-person physical assist bed mobility, toilet use and dressing. The daily skilled evaluation note dated February 23, 2023 included the residnt was alert and oriented to person, place, time and situation, was able to make his needs known and was a 1-2 person assist with ADLs. The daily skilled evaluation dated February 28, 2023 included the resident was alert and oriented x 4. was able to make his needs known and was incontinent of bowel and bladder. The incident note dated March 11, 2023 included that the resident was being changed by a certified nurse assistant (CNA/staff #105) who pulled the chuck from underneath the resident who rolled out off the bed on the other side and hit his head and sustained an abrasion on the left side of the eyebrows. Per the documentation the provider was notified and the resident was sent to the hospital. The fall risk evaluation dated March 11, 2023 included a fall risk score of 10 indicating the resident was moderate risk for fall. The evaluation included that the resident had a history of 1-2 falls within the last 6 months and had a decrease in muscle coordination. A nursing note dated March 12, 2023 revealed the resident returned from the hospital. The documentation included the resident had a band-aid to his forehead; and that, the resident's head CT (computed tomography) was clear. The IDT (interdisciplinary team) fall review and report dated March 12, 2023 included that the resident had a fall with minor injury on March 11, 2023 at 10:45 p.m. Per the documentation, the resident was being changed by a CNA (staff #105) who pulled the chuck from underneath the resident who rolled out off the bed on the other side and hit his head. The documentation included that the resident sustained an abrasion on the left side of the eyebrows; and that, the resident was sent out to the hospital for CT scan. New interventions included use of pool noodle to help identify the bed parameters. An interview with a licensed practical nurse (LPN/staff #73) was conducted on April 12, 2023 at 12:54 p.m. The LPN stated that the CNA (staff #105) called her into the resident's room around 10:00 p.m. and told her that resident #29 had a fall. The LPN stated that resident #29 told her that while he was being changed by staff #105, he fell off the bed and hit his head. The LPN said that resident #29 normally lay over on his side because he has a pressure ulcer; and, staff #105 reported that she was rolling the chux from under the resident who got too close to the edge and fell off the bed. The Lpn said that she assessed the resident and called the doctor who recommended for the resident to sent out for a CT scan. An interview was conducted on April 12, 2023 at 2:10 p.m. with a CNA (staff #50) who stated that end of shift report will tell her whether a resident requires 1 or 2 two person assist in report; and, she may also ask therapy staff, if needed. She stated that for a resident who requires extensive assistance, she would anticipate having 2 or more CNAs fto assist that resident. Staff #50 also said that for a larger resident with an air mattress, she would think that the resident would require a 2-person assist at all times. Regarding resident #29, she stated that the resident was always a 2-person assist. Staff #50 stated that there are usually 2 CNAs and a nurse on on each hall, so there is always someone around to help if she needs it. In an interview with the alleged CNA (staff #105) conducted on April 13, 2023 at 8:06 a.m., staff #105 stated that she was only 4'8 tall; and that, she should have gotten some help when she assisted resident #29 on the day of the incident. Staff #105 said that on the evening of March 11, 2023, she turned resident #29 on his side to provide incontinence care, and the resident rolled out of the bed. She stated she was standing on the opposite side of the bed, with the resident's back facing her. She stated that she had rolled all of the chux up underneath him, then pulled the draw sheet back towards her body but, the resident continued to roll out of the bed. Staff #105 said that she was able to grab his arm to keep him from falling, but that there was no restraining him after that; and that, the resident bumped his head and got a little scratch. Further, staff #105 said that she did not mean for it to happen and she was really sorry. During an interview conducted with the director of rehabilitation (DOR/staff #98) on April 13, 2023 at 9:15 a.m., the DOR stated that, functionally, resident #29 still needed a lot of assistance. She stated that resident #29 was able to roll from left to right with moderate assistance and that meant someone needed to hold onto him. She stated that resident #29 was able to do about 25% of the rolling on his own, but that he definitely needed help. Further, the DOR said that the resident definitely needed two persons to assist with incontinence care. In addition, the DOR stated that the air mattress the resident had could also make the surface less stable for him. In an interview conducted with the director of nursing (DON/staff #32) on April 13, 2023 at 1:15 p.m., the DON stated that if a resident had been assessed to require 2-person assistance, then the expectation was that 2 staff would provide care to the resident. The DON said that on November 16, 2022, staff were in-serviced on falls; however, staff #105 was not able to attend the in-service because staff #105 worked the night shift and had a day off the following day. The facilty policy on Activities of Daily Living (ADLs), Supporting revised March 2018 included that residents will be provided with care, treatment and service as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. The Fall Prevention Program included that the Falling Leaf Program (FLP) has been designed to assist facility staff in this development. Steps include: review and determination of at-risk residents, prevention through addressing risks, appropriate fall respone, and initiation of effective interventions.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#11) was free from unnecessary pain medications. The deficient practice could result in residents experiencing adverse side effects. Findings Include: Resident #11 was admitted on [DATE] with diagnoses of pubic fracture, pulmonary embolism and hypertension. The care plan dated January 19, 2023 revealed the resident was on opiate medication related to pelvic fracture. Interventions included to administer medications as ordered and to monitor for side effects. Review of the physician order revealed for oxycodone (opioid narcotic) 5 mg (milligram) 1 tablet by mouth every six hours as needed for pain on a scale of 6-10. The MAR (Medication Administration Record) for February and March 2023 included that oxycodone was administered outside of the ordered pain parameter on the following dates: -February 11 at 8:18 p.m. for pain scale of 2; -February 18 at 8:23 p.m. for pain scale of 3; -March 24 at 8:50 p.m. for pain scale of 5; and, -March 25 at 9:03 p.m. for pain scaled of 0. The progress notes from February through March 2023 revealed documentation that on several occasions, resident #11 requested for oxycodone for her pain. However, the documentation did not that the physician was notified that medication was given outside of the ordered parameters. An interview was conducted on April 13, 2023 at 2:27 p.m., with a licensed practical nurse (LPN/staff #110) who stated that pain medications are given based on the resident's level of pain. The LPN said that medications like Tylenol (analgesic) would be given for a pain scale of 1-5, and stronger controlled medications such as oxycodone would be given for a scale of 6-10. The LPN said that if the resident's current medication was not adequate she would notify a provider to get an alternative order or make changes as necessary. Further, the LPN stated that giving medications outside the prescribed parameters could lead to side effects, such as lethargy, dependence, or being overmedicated. During an interview conducted with the Director of Nursing (DON/staff #32) on April 13, 2023 at 3:54 p.m., the DON stated reported that medications with parameters should be strictly followed; and that, her expectation was for pain medications to be given according to the ordered parameters by the physician. The DON stated that administering medications outside the ordered parameters could result in over sedation or pain not being controlled. A review of facility policy on Administering Medications revised on December 2012 included that medications must be given in accordance with the physician's orders.

Based on observations, staff interviews, and review of policy and procedure, the facility failed to ensure that expired supplies and medications were not available for resident use. The census was 85. The deficient practice may result in ineffective treatments and/or in residents receiving the expired medications. Findings include: An observation of the #100 medication room was conducted on April 13, 2023 at 2:04 p.m. with a licensed practical nurse (LPN/staff #80). There was a quadrivalent flucelvax (influenza vaccine) 2022-2023 formula, with an open date of March 8, 2023 written on the side of the box; and, two bags of 1000 ml (milliliters) 0.9% sodium chloride injection with a label that listed a resident who had been discharged from the facility in June, 2022. In an interview conducted with staff #80 immediately following the observation, the LPN stated that the influenza vaccine was good for 28 days after opening and should have been thrown out. The LPN also stated the two bags of sodium chloride injections should have been sent back to the pharmacy. An observation of the #200 medication room on April 13, 2023 at approximately 2:20 p.m. was conducted with staff #80. There was a package of daptomycin (antibiotic) 450 mg (milligrams) 4.128 mg/mL, with an expiration date of April 9, 2023. An interview was conducted on April 13, 2023 at approximately 2:30 p.m. with staff #80 who stated that the night nurses and central supply are responsible for checking the supply rooms for any expired supplies. She stated that expired supplies should be discarded and that pharmacy items would be sent back to the pharmacy. During an interview conducted with the Director of Nursing (DON/staff #32) on April 13, 2023 at 2:47 p.m., the DON stated that the expectation was that nursing staff would return expired medications and/or biologicals to the pharmacy for destruction. She stated that the administration of an expired product may cause side-effects and/or may be less potent. The facility policy on Storage of Medications revised April 2007 revealed that the facility shall store all drugs and biologicals in a safe, secure and orderly manner. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#12) received care and services to promote the prevention, healing, and prevent the development of additional pressure ulcers/injury consistent with professional standards of practice. The sample size was 3. The deficient practice increases the risk of pain, infection, and rehospitalization . Findings include: Resident #12 readmitted to the facility on [DATE] with diagnoses including COVID-19, type 2 diabetes mellitus and adult failure to thrive. The baseline risk for skin impairment care plan dated 02/17/23 related to bowel and bladder incontinence, weakness and a pressure ulcer present upon admission had a goal to have intact skin. Interventions included to follow facility policies and protocols for the prevention and treatment of skin breakdown. A Weekly Skin check and Wound assessment dated [DATE] revealed a popped blister with foam dressing had been identified on the resident's sacrum. However, a complete assessment of the wound was not identified in the clinical record. Review of Pressure Ulcer Documentation and Weekly assessment dated [DATE] revealed a Deep Tissue Injury to the resident's right heel. However, the wound to the resident's sacrum was not identified or addressed. On 02/22/23 the Weekly Skin check and Wound Assessment revealed a skin break, Moisture Associated Skin Damage (MASD), and fragile skin surrounding the lesion. Review of the note section of the assessment included that barrier cream was being applied to the coccyx and buttocks on every brief change. However, further review of the clinical record provided no evidence that a complete evaluation of the lesion had been provided. The 5-Day Minimum Data Set assessment dated [DATE] indicated the resident had admitted with one stage 3 pressure ulcer and one unable to be determined. A physician's order dated 02/25/23 included an air mattress for the prevention of skin breakdown. An alert progress note dated 02/25/23 at 11:15 p.m. included that while providing care to the resident, blood was noted in the resident's brief. Upon assessment of the area, an open area to the resident's sacrum was identified. The note indicated the area had deep purple non-blanching tissue to approximately 40% of the wound bed. The remaining wound bed was described with smooth, pink moist tissue with serosanguinous drainage. The note indicated that the writer had cleansed the area well and a silicone dressing was placed to protect the area. The note stated the Director of Nursing (DON) was notified. A wound note dated 02/27/23 at 2:23 p.m. included the resident's coccyx and surrounding area noted with a stage 3 pressure area. The wound bed was described with 20% slough, 10% eschar and 70% granulation. The surrounding area was observed with MASD. The note indicated that new orders were implemented. However, review of the clinical record provided no evidence that a complete wound evaluation had been performed. A physician ' s order dated 02/27/23 revealed cleansing the coccyx with normal saline, application of Medihoney (antibacterial/autolytic) and covering with a foam dressing. Change 3 times per week and as needed for saturated/dislodged dressing. However, review of the February 2023 Wound Administration Record did not include documentation to indicate whether or not dressing changes had been completed. The Pressure Ulcer Documentation and Assessment completed on 03/01/23 revealed a stage 3 pressure ulcer at the sacrum which measured 6 centimeters (cm) x 6 cm x 0.1 cm with serous drainage. The worst type of tissue noted was identified as eschar. Treatment included Medihoney and a foam dressing. A physician's order dated 03/01/23 revealed wound care to the sacrum which included cleansing with normal saline, application of Medihoney, and covering the wound with a foam dressing. Change 3 times weekly and as needed. The March 1, 2023 Wound Administration Record included a code 9, which indicated Other/See Nurse Notes. However, review of the nursing progress notes did not provide documentation of the rationale for not performing the dressing change. Review of the Weekly Skin check and Wound assessment dated [DATE] revealed an unstageable pressure ulcer to the resident's sacrum. Measurements included 10.0 cm x 7.0 cm x 0.2 cm. Per the notes, the wound presented with 40% eschar, 40% granulation and 20% slough, with no undermining or tunneling present to the wound bed. A moderate amount of serous drainage was noted with no signs or symptoms of infection present. A physician's order dated 03/09/23 included to cleanse the sacrum with normal saline, apply Santyl (exogenous bacterial enzyme) ointment, and cover with a foam dressing. Change 3 times weekly and as needed for wound care. On 03/16/23 a Weekly Skin check and Wound Assessment noted a stage 3 pressure ulcer to the resident's sacrum which measured 9.5 cm x 6.5 cm x 0.1 cm. According to the documentation, the wound presented with irregular shape. The wound bed was described as 20% slough, 40% eschar and 40% red granulation with some intact skin throughout. A large amount of serous drainage was observed with no signs or symptoms of infection, tunneling or undermining. An interview was conducted on 03/21/23 at 11:11 a.m. with a Certified Nursing Assistant (CNA/staff #70). She stated that she assists residents in preventing skin breakdown by rotating their position in the bed, helping them to get out of bed, if possible, and if they are incontinent, she will change them frequently. She stated that she reports skin breakdown to the nurse. During an interview conducted on 03/21/23 at 11:20 a.m. a Licensed Practical Nurse (LPN/staff #90) stated that when a CNA tells her that a resident has an open wound, she would go and observe the wound herself. She stated that she would immediately notify the wound nurse. On 03/21/23 at 11:32 a.m. an interview was conducted with the wound nurse (staff #40). She stated that when she is notified that a resident has an open wound, she will go and take a look at it immediately. She stated that she will take the DON along with her to stage the wound. She stated that after determining the type of wound, she would obtain orders and update the resident's care plan. She stated that if the wound is determined to be MASD, they would continue to apply barrier cream to the area. She stated that if the wound is assessed to be a pressure ulcer, it will be measured weekly. She stated that components of wound assessment include wound measurements, a description of the wound bed, signs or symptoms of infection, type and amount of drainage, and whether or not the resident is compliant with wound care. She stated that weekly skin checks and pressure ulcer assessments have been combined into one form. An interview was conducted on 03/21/23 at 12:00 p.m. with the DON (staff #96). She stated that preventative measures included educating the nursing staff, frequent skin checks, frequent turning/repositioning, a low air loss mattress, and skin checks while changing the resident's brief. She stated that when skin breakdown has been identified, her expectation includes notification of the nurse, the wound nurse and/or they would let her know. She stated that she expects that the provider will be notified and that orders will be obtained for treatment. She stated that the wound would be assessed and staged as soon as possible after discovery. She stated that she expects wounds to be assessed on a weekly basis and as needed. She stated that MASD is moisture-associated, but that the skin would not be open. She stated that if the skin opens then the wound would be staged. She stated that it did not meet her expectations for wound care and treatment not to have been provided in accordance with professional standards of practice. An observation of wound care was conducted on 03/21/23 at 2:19 p.m. with staff #40. Per observation, 4 open areas were identified at the sacral-coccyx area. The wound nurse stated that she measures the separate areas as one large pressure injury. The measurements indicated the entire wound area to be 8.5 cm x 4.5.cm x 4.0 cm. Measured separately, they were noted as follows: 1) 2.5 cm x 2.5 cm x 0.2 cm 2) 2.2 cm x 2.7 cm x 0.1 cm 3) 0.7 cm x 0.5 cm x 0.1 cm 4) 6.5 cm x 2.0 cm x 4.0 cm. She described the wound bed as red granulation tissue, with no undermining or tunneling. She stated that bone was not visible. However, she identified subcutaneous tissue. She stated that the periwound was scarred, there was a moderate amount of serous drainage, and that there were no signs or symptoms of infection. Upon further observation, she identified muscle tissue. On 03/21/23 at 3:03 p.m. a follow-up interview was conducted with the DON (staff #96). She stated that the last time she observed the resident's wound was 03/16/23 and that she measured the entire area, not the individual open areas one by one. She stated that at that time, the wound bed was partially obscured by slough. She stated that the wound would be a stage 4 pressure ulcer if the bone, muscle or tendon were visible. She stated that she would call it a stage 4. Review of the Wound Management Program, dated 2013, included the facility provides a comprehensive wound management program with a goal to promote the highest level of functioning and well-being of the residents and to minimize the number of residents that develop in-house acquired pressure ulcers. Residents with wounds are to be assessed weekly and reviewed in the skin and weight meeting, at least monthly. Each wound will be monitored and progress documented at least weekly by the wound care team into the electronic health record. Documentation is to include type, location, measurements, exudate, odor, description of wound bed, periwound assessment and treatment. If the wound has worsened or there is no improvement in two weeks, the treatment plan will be reevaluated as long as the wound is not deemed unavoidable by the resident's physician. The assistant director of nursing will monitor compliance as well as provide support and education when necessary.

Based on clinical record review, staff interviews, and policy, the facility failed to ensure that 2 out of 3 residents reviewed (#7 and #13) received care and services to prevent and/or treat urinary tract infections. The deficient practice may increase the risks for pain, infection and rehospitalization . Findings include: -Resident #7 readmitted to the facility 07/06/22 with diagnoses including paroxysmal atrial fibrillation, benign prostatic hyperplasia with lower urinary tract symptoms and other obstructive and reflux uropathy. An indwelling catheter care plan dated 06/24/22 related to other obstructive and reflux uropathy had a goal to remain free from catheter-related trauma. Interventions included to monitor/record/report to MD signs or symptoms of UTI, including: blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse/temperature, change in behavior and change in eating patterns. A physician's order dated 06/24/22 at 2:19 p.m. included catheter care with soap & water or wipes every shift. A nursing progress note dated 07/26/22 at 3:00 a.m. indicated that the resident had a Foley catheter in place that was patent and draining amber yellow urine at that time. The note included that the resident was encouraged to drink more water due to his [lack of] output and the color of the urine. However, review of the resident's progress notes did not reveal that the provider had been notified of the changes. On 07/27/22 at 12:47 a.m. a nursing progress note indicated that the resident had a Foley that was patent and draining amber yellow urine. The note stated that the resident was encouraged to drink more water due to his output and the color of urine. However, the nursing progress notes provided no evidence that the provider had been notified. The physician progress note dated 07/27/22 at 3:13 p.m. revealed the resident had no new complaints. A late entry system note dated 07/28/22 at 12:47 a.m. revealed that the resident appeared to be more fatigued that shift, had not been able to use his whiteboard to answer questions, and that he had not eaten any dinner. The note included that the resident's Foley was in place and patent and that no signs of pain or discomfort were noted. However, there was no indication that the provider had been notified of the changes in the resident's status. Review of the July 7 - 28, 2022 Treatment Administration Record revealed catheter care was provided as ordered. On 07/29/22 at 6:50 a.m. an alert charting note revealed a change of condition in the resident's status. According to the note, the resident had a temperature of 102.3 F, blood pressure of 110/50, respirations of 26, pulse of 100, and an oxygen saturation level of 87% on room air. The note indicated that the resident was placed on oxygen and the provider was notified. An order to send the resident to the ER was obtained. The discharge Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive assistance for most activities of daily living, and he had an indwelling catheter. At 10:20 on 07/29/22 a nursing progress note stated the resident was transferred to the hospital and admitted to the ICU. A late entry History and Physical note dated 08/26/22 at 6:24 p.m. included that the resident had been admitted to the ICU for hypotension and septic shock. The note indicated that the resident had a bacteremia with pseudomonas and enterococcus faecalis, a UTI and cystitis. The resident also tested positive for COVID-19. According to the note, the resident was in acute renal failure upon presentation which had been resolved during his stay. -Resident #13 readmitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, Parkinson's disease and obstructive and reflux uropathy, unspecified. A functional bladder incontinence care plan initiated 05/26/22 related to bladder incontinence had a goal to remain free from skin breakdown due to incontinence and brief use. Interventions included to monitor/document for signs and symptoms of UTI, including: pain, burning, increased pulse, change in behavior, altered mental status and change in eating patterns. A review of the resident's vitals records dated 01/12/23 at 7:10 a.m. revealed the resident's blood pressure at 101/67, a pulse of 72, and a temperature of 96.9F. No respiratory documentation was identified on that date. Review of an alert progress note dated 01/12/23 at 6:38 p.m. included that the resident's daughter had requested that a urinalysis (UA) be obtained due to the resident's increased lethargy and decreased appetite. According to the note, the resident had a past history of frequent UTIs. The provider was notified and orders were received to obtain a UA with culture and sensitivity, if indicated, via straight catheterization. A physician's order dated 01/12/23 included straight catheterization to obtain UA with C&S, if indicated, one time only for lethargy. On 01/14/23 at 7:10 a.m. review of the resident's vitals records revealed a blood pressure of 98/60, pulse of 110, respirations of 16, and a temperature of 97.3F. However, review of the resident's progress notes did not indicate that the provider had been notified of the change in the resident's status. Per the lab results reported on 01/15/23 at 1:27 p.m., the culture and sensitivity (C&S) revealed for escherichia coli >100,000 colony-forming unit per milliliter (CFU/mL) and proteus mirabilis 10,000 - 50,000 CFU/mL - indicative of UTI. On 01/16/23 at 9:16 a.m. an alert nursing progress note included that the resident was fatigued and eating less than baseline. The note indicated that fluids were encouraged and that the UA C&S results report was in and had been reported to the provider. According to the note, nursing was awaiting further instruction at that time. A physician's order dated 01/16/23 at 2:54 p.m. revealed ampicillin (antibiotic) 500 milligrams (mg). Give 1 capsule three times a day for UTI. Review of the January 2023 Medication Administration Record revealed ampicillin was administered beginning at 10:00 p.m. on 01/16/23. On 01/17/23 at 7:02 a.m. the resident's vitals included a blood pressure of 113/64, pulse of 91, respirations of 20, and a temperature of 98.2F. An infection progress note dated 01/17/23 at 8:53 a.m. included that the resident was on antibiotics for a UTI, that she continued to complain of fatigue and loss of appetite. Per the note, no nausea, vomiting, diarrhea or shortness of breath was identified. A physician's progress note dated 01/17/23 at 10:52 a.m. revealed the resident had a recent UTI that week and that she was taking ciprofloxacin (antibiotic). However, review of the physician's orders did not include ciprofloxacin. On 01/18/23 at 9:18 a.m. a discharge summary note included that the resident had been transferred to the hospital via ambulance due to decreased level of consciousness per a provider's order. Review of the clinical record revealed the resident was readmitted to the facility on [DATE] at 3:00 p.m. According to the physician's progress note dated 02/21/23 at 2:46 p.m., the resident was on routine Hospice after hospitalization for septicemia/respiratory failure. Per the note, the resident was readmitted with nephrolithiasis with a right kidney stone and a nephrostomy tube. On 03/21/23 an interview was conducted with a Certified Nursing Assistant (CNA/staff #70). She stated that she provides catheter care and that she empties the catheters. She stated that signs and symptoms of a UTI would include confusion and fever. She stated that a darker urine color and/or less urinary output would be red flags for a UTI. She stated that she would notify the nurse if she observed those symptoms. An interview was conducted with a Licensed Practical Nurse (LPN/staff #90) on 03/21/23 at 11:20 a.m. She stated that the CNAs always check resident's with Foley catheters to make sure they have urinary output. She stated that symptoms of a UTI include fever, confusion and lack of urinary output. She stated that a darker color of urine might be a symptom, but that it might also be a symptom of not drinking enough water. She stated that her process would include notifying the provider of any changes and documenting the conversation in the resident's progress notes. On 03/21/23 at 12:00 p.m. an interview was conducted with the Director of Nursing (DON/staff #96). She stated that signs and symptoms of a urinary tract infection include a change of mental status, pain when urinating, fever, odor and changes to the color of urine. She stated that if nurses notice a change in urine color, the nurse would interview the resident to ensure that they are drinking enough. She stated that her expectation would include notifying the provider and obtaining an order for a urinalysis. She stated that it must be done right away. She stated that her expectations included that conversations with the provider be documented in the resident's progress notes. She stated that UA results will return within 24 hours and C&S results will return within 72 hours. She stated that the risks for not acting promptly on the results would include a UTI and/or the development of sepsis. She stated that in the case of resident #7, the provider should have been notified and that an order should have been obtained for a urinalysis. In the case of resident #13, she stated that she did not know why the results had taken so long to be returned and/or acted upon. She stated that the care and services did not meet her expectations. The Catheter Care, Urinary policy, revised September 2014, included that the purpose of the procedure was to prevent catheter-associated urinary tract infections. General guidelines included to observe the resident ' s urine level for noticeable increases or decreases. Observe the resident for complications associated with urinary catheters. Check the urine for any unusual appearance (i.e., color, blood, etc.) Observe for other signs and symptoms of urinary tract infection of urinary retention. Report findings to the physician or supervisor immediately. Report other information in accordance with facility policy and professional standards of practice. The Change in Resident's Condition or Status policy, revised December 2016, included that the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to implement the care plan for one resident (#53) regarding providing an assistive device. The sample size was 23. The deficient practice could result in residents' needs not being met. Findings include: Resident #53 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised March 5, 2020 revealed the resident has an Activities of Daily Living (ADL) Self Care Performance Deficit related to weakness, [CONDITION(S)], incontinence, obesity, history of [CONDITION(S)], scoliosis, [CONDITION(S)], and a history of falls. The goal included the resident will improve their current level of function in eating. Interventions stated the resident requires limited assistance to eat, and to give the resident a cup with a sippy type lid to assist with fluid intake. An annual Minimum Data Set assessment dated [DATE] revealed a score of 2 on the Brief Interview for Mental Status which indicated the resident had severely impaired cognition. The assessment also revealed this resident required extensive assistance with one-person physical assistance with eating. However, during an observation conducted of the resident on March 21, 2022 at 2:23 PM, the resident was observed slowly eating the meal and had a Styrofoam cup with a plastic lid and a straw on the bedside table. An observation was conducted on March 23, 2022 at 11:36 AM of this resident lying flat in bed. There were Styrofoam cups with straws on the bedside table. An observation was conducted on March 23, 2022 at 12:09 PM of this resident. Food and drinks in Styrofoam cups with straws were observed in front of the resident. An interview was conducted on March 23, 2022 at 2:02 PM with the Director of Rehabilitation (staff #7), who said the facility does not usually use the sippy type cup because they do not have many people who need them. She said that a sippy cup will usually have a lid that someone can use to prevent the liquid from spilling. Staff #7 said that usually she will have the Speech Therapist evaluate the resident to see if the resident needs a sippy cup. She stated this resident has not been evaluated. Staff #7 reviewed the care plan and stated that the resident should have a sippy type lid to assist with fluid intake. An interview was conducted on March 25, 2022 at 11:20 AM with a Licensed Practical Nurse (LPN/staff #9), who stated that she was not sure what adaptive equipment the resident required as she had not worked on this hall in some time but that she would check. This staff member reviewed the resident's clinical record and stated that the adaptive equipment in the care plan is to use a sippy type lid. This LPN walked to the resident's room and saw that this resident had a Styrofoam cup with a plastic lid and a straw and stated that the cup with a straw was not a sippy type lid. The LPN also stated that she had not seen sippy type lids in this facility. An interview was conducted on March 25, 2022 at 12:01 PM with the Director of Nursing (DON/staff #22), who stated her expectation is that the facility has to follow the care plan. She reviewed this resident's care plan and said that yes, this resident requires a cup with a sippy type lid. The DON stated that this resident needs a cup with the sippy type lid for grabbing the handles. The DON also stated that a Styrofoam cup with a plastic lid and a straw does not meet the requirements of a sippy cup. A facility policy titled Assistive Devices and Equipment revealed that this facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents. This policy included that devices and equipment that assist with resident mobility, safety and independence are provided for residents and that recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. The facility's Care Planning - Interdisciplinary Team care plan revised September 2013 revealed the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. This policy did not include implementing the care plan.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one sampled resident (#241) was provided pain management consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. The deficient practice could result in residents' pain not being managed. Findings include: Resident #241 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An alert progress note dated December 21, 2021 at 3:11 p.m. revealed the resident arrived at 1:24 p.m. via stretcher. The note included that at this time, the resident was resting in bed with eyes closed with call light and belongings within reach. A review of the clinical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission + GG for PDPM-V1 assessment form dated December 21, 2021 at 11:43 a.m. revealed the resident was admitted on [DATE] at 1:24 p.m. for PT/OT, medication management. The resident was alert and oriented to person, place, time, and situation. The assessment included the resident reported frequent back pain that made it hard to sleep at night and limited day-to-day activities. The resident rated the pain an 8 on a pain scale of 1-10. Current treatments or interventions for pain are PRN pain medications per orders, repositioning, quiet environment, distractions, and PT/OT. Review of a pain assessment dated [DATE] at 12:40 p.m. revealed the resident reported daily moderate pain, and that moderate pain on a pain scale of 1-5 is 2. The assessment also revealed the cause of the generalized pain was from the back post op/incision, and that moving, pressure, and staying in the same position for an extended period of time increased the pain. The assessment included PRN pain medication per orders, repositioning, quiet environment, distraction, and PT/OT. The assessment also included the plan of care includes satisfactory pain management, continuing with the current plan of care. Review of the care plan initiated on December 21, 2021 revealed the resident has pain and takes Tylenol. The goal was that the resident will voice a level of comfort. Interventions included administering analgesia medication as per orders, notifying the physician if the interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain. The PT Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The OT Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a nursing progress note by a Licensed Practical Nurse (LPN/staff #57) dated December 22, 2021 at 1:15 p.m. stated that the resident requested something stronger than Tylenol for pain, stated its not relieving enough. The note included the provider was notified and that the provider would be in that day to see the resident. The assessment did not include an assessment of the resident's pain. Review of the physician History & Physical (H&P) dated December 22, 2021 at 2:18 p.m. revealed the resident was brought in for an elective lumbar 2-3 decompression and L3-L5 fusion. The surgical course was uneventful but postsurgical course was complicated with confusion which is secondary to narcotics. The H&P stated the resident was taken off narcotics and given Tylenol for pain control. The resident was transferred to the skilled nursing facility for further management treatment. The resident's pain is not under control at this moment. The resident is lying in bed in no acute distress. The H&P also stated to continue current medications, PT/OT, and add [MEDICATION(S)] as needed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the Medication Administration Record (MAR) for December 2021 did not reveal the resident was administered [MEDICATION(S)] on December 22, 2021, the day the resident requested something stronger. The resident was not administered [MEDICATION(S)] until December 23 at 10:07 a.m. A restorative nursing note dated December 22, 2021 at 3:27 p.m. revealed the resident completed 15 minutes of bed mobility, rolling side to side, supine to sit EOB as tolerated. Continued review of the MAR dated December 2021 revealed pain evaluations were conducted every shift and that the resident had a pain level of 0 on all shifts except for the pain level of 4 the resident reported on December 22, 2021 during the 12-hour second shift, and a pain level of 3 on December 28, 2021 during the 12-hour first shift. However, review of the MAR did not reveal the resident was administered PRN pain medication for the pain level of 4 on December 22, 2021. An alert progress note dated December 23, 2021 at 3:16 a.m. revealed the resident was pleasant and cooperative. The note included the resident was resting in bed quietly at that time with the call light in reach. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Objective: vitals stable, resident lying in bed in no acute distress. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. It also included that the resident had no pain for the last 5 days. The eMAR general note dated December 27, 2021 at 11:01 a.m. revealed the resident had complaints the current pain medication is not taking care of the pain. The provider was notified and ordered [MEDICATION(S)] 50 mg by mouth every 8 hours as needed. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Objective: vitals stable, resident lying in bed in no acute distress. The note stated to discontinue [MEDICATION(S)] and add [MEDICATION(S)]. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Health Status Note dated December 28, 2021 at 5:10 a.m. revealed the resident was awake most of the shift. The provider recently ordered PRN [MEDICATION(S)] and the resident reports the [MEDICATION(S)] is not helping with the pain that the resident described as muscle spasms. The note included the provider was notified, awaiting response for further instructions. Review of the MAR for December 2021 revealed [MEDICATION(S)] was administered to the resident on December 27 at 11:26 p.m. and was not effective, and was not administered again until December 28 at 8:45 a.m. and was effective. The MAR did not reveal any other pain medication was administered on December 28, 2021. Further review of the December 2021 MAR revealed behavior tracking every shift for inability to sleep. From December 21-29, the MAR revealed 0 was documented for inability to sleep every shift. Review of the MAR dated December 2021 and the eMar notes revealed the following: -December 21 Tylenol administered for a pain level of 8 at 3:49 p.m., effective Follow-up Pain Scale was 0 -December 22 Tylenol administered at 2:37 a.m. for pain level 8, effective Follow-up Pain Scale was 0 -December 23 [MEDICATION(S)] administered at 10:07 a.m. for pain level 6, effective Follow-up Pain Scale was 0, and at 11:49 p.m. for pain level 8, effective Follow-up Pain Scale was 0 -December 24 No PRN pain medication administered -December 25 [MEDICATION(S)] administered at 8:38 a.m. for pain level 7, effective Follow-up Pain Scale was 0 -December 26 [MEDICATION(S)] administered at 2:02 a.m. for pain level 7, effective Follow-up Pain Scale was 0 -December 27 Tylenol administered at 7:19 a.m. for pain level 4, effective Follow-up Pain Scale was 1; [MEDICATION(S)] administered at 3:27 p.m. for pain level 6, effective Follow-up Pain Scale was 0 and at 11:26 p.m. for pain level 7, ineffective Follow-up Pain Scale was 6 The eMAR note included the resident stated It barely touched the pain, it feels like my muscle is spasming. -December 28 [MEDICATION(S)] at 8:45 a.m. for pain level 7, effective Follow-up Pain Scale was 0 and at 4:45 p.m. for pain level 7, effective Follow-up Pain Scale was 0 -December 29: Tylenol at 8:18 a.m. for pain level 7, effective Follow-up Pain Scale was 0 Review of the Weekly SNR Assessment - PDPM - V2 effective date December 28, 2021 at 9:45 a.m. revealed a NOMNC (Notice of Medicare Non-Coverage) will be issued on December 29, 2021, the anticipated discharge date is December 29, 2021, and that the discharge was driven by family/resident. A Social Services Progress Note dated December 29, 2021 at 11:05 a.m. revealed the resident was issued a NOMNC indicating the last covered day was December 31, 2021 and discharge January 1, 2022. The note included the resident voiced understanding and waived appeal rights to discharge. An eMar general note dated December 29, 2021 at 12:20 p.m. revealed the resident was discharged home with belongings and medications on hand. An interview was conducted on March 22, 2022 at 2:38 p.m. with a Licensed Practical Nurse (LPN/staff #82), who stated that when a resident is in pain, she checks to see if there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN reviewed the MAR for December 2021 and stated that Acetaminophen was administered only one time on December 22, at 2:37 a.m. Then, she reviewed the progress notes and stated that it looked like the resident asked for something stronger on December 22, 2021 at 1:15 p.m. and the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 22, 2021, which should have been available to the resident on the December 22, but was not administered until December 23, 2021. On March 23, 2122 at 9:29 a.m., an interview was conducted via phone with resident #241, who stated that she was being given Tylenol for pain medication and she kept telling staff that it was not working and she told more than one nurse. The resident stated that she remembered telling one nurse that she needed something stronger than the Tylenol and was told that she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident said the physician told her he would take care of it, but she did not receive stronger pain medication until the next day. The resident stated that she was in pain throughout the night. The resident stated that she would tell a nurse that she needed pain medication and that often the nurse did not return. She stated the night shift nurse would tell her that she had just received pain medication and would need to wait 2-3 hours. She stated that some nurses would tell her that rounds are done at 7:00 a.m. and that she would need to wait until then. The resident stated that she would ask for pain medication around 6:00 a.m. and was told to wait until rounds were done at 7:00 a.m. The resident stated that she would lie in bed crying at night because of the pain. She stated that one time she was crying and a nurse finally gave her something but she did not know what it was. The resident stated that she did not ask for pain medication prior, during, or after therapy because she was not brought up that way, that she was brought up to work through it. She stated that the therapists never offered or asked her if she needed pain medication. The resident stated that she does not remember any nurse asking her about her pain level when the medications were administered or at any other time. An interview was conducted on March 23, 2022 at 11:31 a.m. with the Director of Nursing (DON/staff #22). She stated that the LPN (staff #57) had resigned. She also stated that she had spoken with staff #57 about notifying the physician and documenting it when the pain medication did not work for resident #241. Then, she reviewed the progress note dated December 22, 2021 at 1:15 p.m. and confirmed that staff #57 had written the note which should have included a pain assessment describing the location and level of pain. The DON stated it is her expectation that the [MEDICATION(S)] tablet 10 mg give 1 tablet by mouth every 12 hours PRN for pain ordered December 22, 2021 should have been available to the resident that day and if it was not, staff #57 should have contacted the physician to obtain a one-time order for a pain medication that was available in the facility's Pyxis machine. Then the DON reviewed the MAR and stated that the [MEDICATION(S)] was not administered until the next day. The DON agreed that the resident's pain was not addressed in a timely manner and that nonpharmacological interventions could have been implemented, but there was no documentation to show the interventions were attempted. The DON also stated the nurse documented the pain medication effective on December 27, 2022 when the pain level was still a 1. Review of the facility's policy Pain Assessment and Management revised March 2015 revealed the purposes of the procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain include verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, etc.; changes in gait, skin color and vital signs, behavior such as resisting care, irritability, depression, decreased participation in usual activities; limitations in his or her level of activity due to the presence of pain; guarding, rubbing or favoring a particular part of the body; difficulty eating or loss of appetite; insomnia; and evidence of depression, anxiety, fear or hopelessness. Possible Physiological Signs of Pain included increased blood pressure, [CONDITION(S)], increased respirations, and diaphoresis. Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain control. The pain management interventions shall be consistent with the resident's goals for treatment. The policy also revealed if pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The facility policy, Administering Pain Medications, revised October 2010 stated the purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained. The following equipment and supplies will be necessary when performing this procedure. Standardized pain assessment tools, as indicated per facility protocol. For example, a Five (5)-point (or 10-point) Pain Intensity Scale with word modifiers. Conduct an abbreviated pain assessment if there has been no change of condition since the previous assessment. The assessment shall consist of at least the following components: -Whether pain has improved or worsened since the last assessment; -The general condition of the resident; -Verbal and non-verbal signs of pain. Administer pain medications as ordered.

Based on observations, clinical record review, resident, family member and staff interviews, and policy review, the facility failed to ensure that a call light was within reach of 1 resident (#50). The sample size was 23. The deficient practice could result in residents not being assisted timely with care. Findings include: Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan initiated on February 14, 2022 revealed the resident is at risk for fall and injury. Interventions included ensuring that the call light and frequently used items are within reach before leaving the room, and encouraging the resident to seek assistance with all transfers. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed that this resident requires extensive assistance and one-person physical assistance for bed mobility. A Care Plan dated March 23, 2022 revealed that the resident is at risk for falls related to confusion, gait/balance problems, and incontinence. This Care Plan included an intervention to be sure that the call bell is within reach and to encourage the resident to use it for assistance as needed, and that the resident needs a prompt response to all requests for assistance. However, during an interview conducted on March 21, 2022 at 11:07 AM, this resident's family member stated that the call bell has been found out of the resident's reach when coming in to visit with the resident around 9:30 AM - 10 AM in the mornings. The resident's family member stated that this morning the call light was found clipped on the roommate's cord, but most times the call light is found on the floor. This resident stated that often in the evening the call bell is out of reach. During an observation conducted of the resident lying in bed on March 23, 2022 at 11:59 AM, the call bell was observed on the floor behind the head of the resident's bed. An observation was conducted on March 25, 2022 at 8:45 AM of the resident lying in bed. The call light was observed on the floor behind the head of the bed. A Restorative Nursing Assistant (RNA/staff #77) was observed walking in the hall and was asked where this resident's call light was. This RNA entered the resident's room, greeted the resident and began searching for the call light and found it on the floor. Staff #77 asked where the resident wanted the call light. The resident responded on the bed on her side. The RNA placed the call light on the resident's side and clipped it to the blanket. An interview was conducted with this RNA immediately after this observation. She said that she had put the call light back where it belonged and that call lights are absolutely supposed to be left in reach of residents. She said that she is usually such a [NAME] about that but she left the room to drop off dirty linen and was coming back to double check. An interview was conducted on March 25, 2022 at 9:17 AM with a [NAME] (staff #109), who said she has worked on this resident's hall for 4 months. She said that this resident does not ask for much. She said that this resident does not throw things and that she had not seen the resident throw the call light. She said that if the resident wants a brief change or water, the resident will call. Staff #109 stated that there is a call light for each resident and that they place the call light where the resident can reach it. Staff #109 said that this resident keeps the call light on the bed. Staff #109 stated that sometimes the call light will drop and when someone in the hall walks by, the resident will call them. (However, the call light had a clip to keep it on the bed.) An interview was conducted on March 25, 2022 at 12:01 PM with the Director of Nursing (DON/staff #22), who said that her expectations are that the call light has to be within reach of the resident. The DON said that the call light being on the floor did not meet her expectation because the resident would not be able to reach it. A facility policy titled Answering the Call light revealed that the purpose of this policy is to respond to the resident's requests and needs. This policy included that when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one of two sampled residents (#341) and the resident's representative was notified in writing of a transfer/discharge with the required information and failed to send a copy of the notice to the Office of the State Long Term Care Ombudsman. The deficient practice could result in residents and representatives not being informed of their discharge/transfer in writing and the Ombudsman not being providing a copy of the transfer/discharge notices. Findings include: Resident #341 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An alert charting change of condition note dated February 13, 2022 at 4:22 PM stated that resident #341 was showing stages of confusion, shortness of breath, tachypnea, noted abdomen distention, and 3+ [CONDITION(S)] to the bilateral lower extremities. The resident voiced difficulty with swallowing. The change of condition was reported to the physician. The physician ordered the resident to be evaluated at the emergency room . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A discharge assessment dated [DATE] at 5:05 PM stated that the reason for the assessment was that the resident was to be transferred to the hospital. The assessment indicated the date and time of the transfer and the hospital in which the resident was transferred to. The parties notified were the responsible party, the Physician, The Director of Nursing (DON), and the Executive Director. Information on the facilities bed hold policy and the readmission policy was located on the discharge assessment. Further review of the discharge assessment revealed there was no information regarding an explanation of the right to appeal to the State; the name, address (mail and email), and telephone number of the State entity which receives appeal hearing requests; information on how to request an appeal hearing; information on obtaining assistance in completing and submitting the appeal hearing request; and the name, address, and phone number of the representative of the Office of the State Long-Term Care ombudsman as required. No evidence was revealed that the resident and the resident's representative was provided a written copy of the notice of transfer/discharge with the required information, or that a copy of the notice was sent to the Office of the State Ombudsman. An interview was conducted on March 24, 2022 at 10:15 AM with a Licensed Practical Nurse (LPN/staff #103). The LPN stated that for a resident experiencing a change in condition, she would notify the Physician, the Director of Nursing (DON), the charge nurse and the resident's representative and document the notifications. Staff #103 stated an order to transfer the resident to the hospital would be obtained from the physician. She stated that she would complete a discharge assessment and transfer the resident with a face sheet and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that as far as she knows, the facility does not provide those notices to residents or their representatives. An interview was conducted on March 24, 2022 at 11:02 AM with the DON (staff #22). The DON stated that when a nurse determines that a resident may need to be transferred to the hospital for a higher level of care, after assessing the resident, she expects the nursing staff to notify the provider, obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained that the facility's current practice for notifying the resident and their representative of a facility-initiated transfer in writing, is to send the resident to the hospital with a copy of the E-interact discharge assessment. The DON explained that the E-interact discharge assessment would notify the resident and their representative of what happened that led up to the hospitalization and would further notify them of the bed-hold policy. Further she stated that they did not have an official form that notifies the resident or their representative in writing of their rights or whom they can contact such as an ombudsman. The DON stated that she was unable to provide a completed Notice of Transfer or Discharge Form for resident #341. Further, she stated she was unable to provide a blank copy of a Transfer or Discharge Notice as the facility did not currently have a form with the required contents via email. However, the DON was able to provide evidence that the Ombudsman was notified of resident #341 being discharged from the facility on February 13, 2022, but was not able to provide evidence a copy of the written notice was provided to the Ombudsman. The facility's policy titled Transfer or Discharge Documentation revised December 2016 stated that when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. When a resident is transferred or discharged from the facility, information that will be documented in the medical record includes the basis for the transfer or discharge and that an appropriate notice was provided to the resident and/or legal representative. The policy did not include providing the resident and the resident's representative a written notice of the transfer/discharge with the required information and did not include providing a copy of the transfer/discharge to the ombudsman.

Based on clinical record reviews, staff interviews, observations, and review of facility policy and procedure, the facility failed to ensure two of two sampled residents (#62 and #63) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: -Resident #62 admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan initiated on February 7, 2022 revealed the resident has altered respiratory status/difficulty breathing related to [CONDITION(S)], COVID-19. The goal was that the resident would have no complications related to shortness of breath. The interventions included providing oxygen as ordered. Review of a nurse progress note dated February 17, 2022 revealed the resident arrived at the facility with oxygen via nasal cannula at 3 liters per minute. Review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident received oxygen therapy while a resident during the look-back period. Review of the Weights and Vital Signs Summary from March 13, 2022 to March 23, 2022 revealed daily documentation of oxygen saturation/oxygen via nasal cannula, except for March 14, 2022 as there was no documentation for that date. Multiple observations were conducted of the resident being administered oxygen via nasal cannula. Observations were conducted on March 21, 2022 at 3:02 p.m.; March 22, 2022 at 8:37 a.m.; March 23, 2022 at 1:29 p.m.; and March 24, 2022 at 10:00 a.m. However, review of the physician's orders did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on March 24, 2022 at 10:09 a.m. with a Certified Nursing Assistant (CNA/staff #70). She stated that resident #62 had been receiving oxygen for approximately 1 to 1.5 years and received the oxygen continuously except when the resident refused it. An interview was conducted on March 24, 2022 at 10:28 a.m. with a Licensed Practical Nurse (LPN/staff #44). She stated that when she has a resident on oxygen, she would check the oxygen order and the oxygen saturations every day. She stated she would call the physician if she was unable to maintain the resident's oxygen saturations. The LPN stated that there has to be a physician's order to administer oxygen to a resident. She stated that resident #62 is being administered oxygen and has been for approximately a year. The nurse reviewed the physician's orders and stated that the resident did not have a current order for oxygen administration. The LPN stated the resident should not have been receiving oxygen without an order, and the facility protocol was not followed. -Resident #63 admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment dated [DATE] at 5:41 PM revealed resident #63 had experienced shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring). Additionally, the assessment stated that the resident was receiving oxygen via nasal cannula. However, the flow rate was not indicated. Review of the current care plan initiated on February 21, 2022 revealed the resident had altered respiratory status/difficulty breathing related to [CONDITION(S)]. The goal was that the resident would have no complications related to shortness of breath. The interventions included providing oxygen as ordered. An activity initial assessment progress note dated February 21, 2022 at 1:18 PM stated resident #63 was able to verbalize concerns and can make needs known and use oxygen. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an MDS assessment dated [DATE] included the resident received oxygen therapy while a resident during the look-back period. Review of the Weights and Vital Signs Summary for February 2022 revealed multiple dates of documentation of the resident's oxygen saturation with supplemental oxygen via nasal cannula. Multiple observations were conducted of the resident being administered oxygen via nasal cannula. Observations were conducted on March 22, 2022 at 8:45 AM; March 23, 2022 at 2:45 PM; and March 24, 2022 at 10:03 AM. However, review of the physician's orders did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on March 24, 2022 at 10:05 AM with an CNA (staff #45). The CNA stated that when a resident is admitted to the facility a nurse will receive a report from the hospital then relay to the CNAs if the resident requires the use of oxygen. Staff #45 identified resident #63 as receiving oxygen therapy since being admitted to the facility. During an interview conducted with an LPN (staff #103) on March 24, 2022 at 10:15 AM, the LPN stated newly admitted residents that require oxygen must have a physician's order. She explained that the physician's order should contain the route of administration and the flow rate. Additionally, the LPN stated that the order should state the parameters for the resident oxygen saturation level, and when to notify the physician. The nurse reviewed resident #63's record and stated that she did not see a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] An Interview was conducted with the Director of Nursing (DON/staff #22) on March 24, 2022 at 11:02 AM. The DON stated that if a resident is receiving oxygen, her expectation of nursing staff is that the resident has a physician's order for oxygen. The DON stated that a physician order should include the route of administration, such as a mask or nasal cannula, the liter flow rate with instructions to titrate the flow rate with parameters for oxygen saturations. The DON reviewed the clinical record for resident #62. The DON stated that resident #62 has oxygen orders from a previous admission however when the resident readmitted , the order was not put in the resident's record until March 24, 2022. The DON reviewed the record for resident #63 and stated there is no order for oxygen. The DON stated that she did not know how the oxygen orders were missed because there were care plans for oxygen for both residents. The DON stated there is risk to these residents because they may not be getting assessed appropriately. She stated documentation is not accurate if the residents are actually receiving oxygen and there is no order. The DON stated that not having a physician's orders for oxygen does not meet her expectations for appropriate administration of supplemental oxygen. The facility's policy titled Oxygen Administration revised 2010 stated the purpose of this procedure is to provide guidelines for safe oxygen administration. The policy also stated that the staff should verify that there is a physician's order for this procedure, and review the physician's orders or facility protocol for oxygen administration.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident's (#9) drug regimen was free from unnecessary drugs. The sample size was 5. The deficient practice could result in the resident receiving medications that are not necessary. Findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure (SBP) less than 100. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 2/7/2022, BP 99/50; 2/8/2022, BP 90/65; 2/9/2022, BP 98/64; and 2/11/2022, BP 84/56. Review of the MAR for March 2022 revealed the resident was administered [MEDICATION(S)] at bedtime when the SBP was less than 100 on: 3/1/2022, BP 93/43; 3/5/2022, BP 98/58; 3/9/2022, BP 90/54; and 3/11/2022, BP 98/62. Further review of the clinical record did not reveal evidence that the physician was notified when the medication for hypertension was administered outside the ordered parameters. During an interview conducted with a Licensed Practical Nurse (LPN/staff #44) on 03/24/22 at approximately 09:47 AM, the LPN reviewed the MARs for resident #9 and stated that the blood pressure medication has parameters. This nurse stated that they would take the resident's blood pressure and give the medication if it was within the parameters ordered by the physician. The LPN stated if the blood pressure was below the parameter, they would hold the medication as ordered. The nurse reviewed the MAR for March 2022, in particular the dates of March 1, 5, 9, and 11, and stated that the resident's blood pressure was below the parameters and they would not have given the medication. This staff member stated that on the aforementioned dates the medication was documented as given. The LPN stated that if she had given the medication, she would have notified the resident's provider for further direction and would have documented the communication. Staff #44 reviewed the progress notes and stated there was no note of communication with the physician. On 03/24/22 at 01:17 PM, an interview was conducted with the Director of Nursing (DON/staff #22), who identified the aforementioned medication had been given outside of the parameters ordered by the physician. The DON stated that the medication should not have been given. The DON stated the expectation is that the medication would be held. The DON stated if the medication was given outside of the parameters ordered, it would be the expectation of the facility that the physician would be notified and monitoring of the resident would be done. The DON reviewed the resident's clinical record and stated there was no documentation regarding any communication of this medication administration. A review of the facility's policy Administering Medications revised December 2021 revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The policy also included allergies to medications and vital signs, if necessary, must be checked/verified for each resident prior to administering medications.

Based on clinical record review, resident, family member and staff interviews, and policy review, the facility failed to ensure that one resident's (#395) medical record was accurately documented regarding advance directives. The sample size was 23. The deficient practice could result in residents having inaccurate records regarding advance directives. Findings include: Resident #395 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan initiated on [DATE] revealed the resident was a full code. An Advance Directive dated [DATE] scanned into the clinical record revealed the resident's code status was Do Not Resuscitate. On [DATE] at 1:57 PM, review of the resident's clinical chart dashboard indicated that the resident was designated as full code status and cardiopulmonary resuscitation would be used to revive and support the resident. During an interview conducted with the resident and the resident's family member on [DATE] at 12:25 p.m., the resident stated that the code status is full code. The family member stated that there was some confusion over the code status on admission, but that the advanced directive was clarified as full code the next day. In an interview conducted with a Licensed Practical Nurse (LPN/staff #44) on [DATE] at approximately 09:47 AM, the LPN stated that she would look for a code status on the dashboard for that resident. Review of resident #395's dashboard with the LPN revealed the resident was a full code. This staff member stated that if someone needed to be transferred they would print the advance directive out from the computer. The LPN reviewed the resident's advance directive on the computer and identified that the code status was marked Do Not Resuscitate. Staff #44 stated that if they identified conflicting advance directives, they would discuss it with the resident or a family member if the resident was incapacitated for clarification and complete a new form. The LPN stated this inaccuracy should be reported to social services. On [DATE] at 1:17 PM, an interview was conducted with the Director of Nursing (DON/staff #22). During the interview regarding this resident's code status, the DON retrieved a current code status dated [DATE]. The form indicated the resident was a full code. The DON stated that the form was retrieved from a new section of the medical record system. Staff #22 stated the nurses were going to be trained to the new section of the system and that she was not sure the nurses had access to this section of the medical record. The DON stated this could cause confusion. The facility's Advance Directives policy stated the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on personnel record reviews, staff interviews, the Facility Assessment, facility documents, and policy and procedures, the facility failed to provide evidence that 2 of 10 sampled staff (#24 and #15) were provided training on dementia management. The deficient practice could result in staff not being knowledgeable of how to care for and respond to residents with dementia. Findings include: Review of the Facility Assessment updated March 22, 2022 revealed that common diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Types of care that the facility population required and the facility provided included: behavioral health needs, Alzheimer's and dementia, active or current substance abuse disorders, psycho/social/spiritual support, and assistance with activities of daily living. The Facility Assessment stated that the staff training/education and competencies included care/management for persons with dementia and resident abuse prevention. -Review of the personal record for a certified occupational therapy assistant (staff #15) revealed a hire date of July 28, 2021. The personnel record contained a form titled, Knowledge Track of a checklist of training that included Behavioral Health and Trauma-Informed Care in Long-Term Care and Preventing and Reporting Elder Abuse. Further review of the file did not reveal training for dementia. -Review of the personal record for a speech therapist (staff #24) revealed a hire date of October 28, 2020. The personnel record contained a form titled, Knowledge Track, of a checklist of training that included Behavioral Health and Trauma-Informed Care in Long-Term Care and Preventing and Reporting Elder Abuse. Further review of the file did not reveal training for dementia. During an interview conducted with the Director of Nursing (DON/staff #22) on March 23, 2022 at 1:51 p.m., she stated that staff #24 and staff #15 did not complete dementia training. Facility documentation states all staff require dementia in-service. On March 24, 2022 at 10:50 a.m., an interview was conducted with Human Resources (staff #1), who stated that she is responsible for reviewing the employee personnel records to ensure the checklist for training is completed by staff during orientation. She said, the Director of Rehabilitation (staff #7) is responsible for ensuring training is completed by the therapists, and maintains the therapy personnel records. Then, she reviewed documentation for dementia training and stated that staff #24 and staff #15 did not attend the dementia training provided by the facility. An interview was conducted on March 24, 2022 at 11:01 a.m. with the Director of Rehabilitation (staff #7). She stated that therapy staff are required to complete dementia training and that she has the training for therapy staff and went to get it. When she returned, she said that she had reviewed the training checklist and acknowledged that dementia training was not on the list. Then she stated dementia training might have been provided under Behavioral Health and Trauma-Informed Care in Long-Term Care. The course description for, Behavioral Health and Trauma-Informed Care in Long-Term Care states in this course, you will learn about different kinds of trauma, the principles of trauma-informed care and key elements in providing it. You will also learn about mental health disorders, other than dementia, and psychosocial issues that residents may have as well as general, non-pharmacological ways to support them in reaching optimum emotional, social, mental and physical well-being. Review of the course description for, Preventing and Reporting Elder Abuse In this course, states learners will explore the aging process, and how it can lead to increased vulnerability and risk for abuse in older adults. From there, learners will dive deeper into the different types of abusive behavior, as well as risk factors and indicators of abuse, as well as how to intervene and report elder abuse at your facility. It did not include dementia in the course description. The facility, 2022 Staff Education Schedule, includes Dementia Basics (National Alzheimer's Month) scheduled for November 2022. When the DON provided the 2022 Staff Education Schedule, she stated that all staff are also required to complete the training on the schedule annually. The facility's Dementia Basics In-Service, dated 2017 states in-service on dementia for all staff members. Learning competencies: -Explain the difference between dementia and [CONDITION(S)] -Identify different types of dementia-most common types -Discuss the different stages of Alzheimer's disease -Explain nursing care required for persons with dementia -Describe 3 caregiver goals -Discuss 3 communication techniques to use when communicating with a person with dementia.

Based on facility documentation, staff interviews, and policy and procedures, the facility failed to ensure all posted daily nurse staffing data was retained for a minimum of 18 months. The deficient practice could result in posted nurse staffing data not being available for public access and review. Findings include: Review of the facility's Daily Staff Postings forms did not include a posting form for February 11, 2022 and March 1, 2022. On March 24, 2022 at 12:36 p.m., an interview was conducted with the Staffing and Central Supply (staff #120), who stated that the Director of Nursing (DON/staff #22) helps her with staffing schedules and the Daily Staff Posting forms. During the interview, she reviewed a file that she said contained all the Daily Staff Posting forms and stated that she was not able to find the Daily Staff Posting forms for February 11, 2022 and March 1, 2022. Then she reviewed the facility documentation on the computer and stated that she could not find those Daily Staff Postings. She was observed along with other staff looking in the room behind the reception desk. Staff #120 stated that there were no Daily Staff Postings found in the back room. She stated that she and other staff had looked through all the drawers in the reception area and could not find any Daily Staff Postings. Staff #120 said the postings are all kept in the file that she had already reviewed. An interview was conducted on March 24, 2022 at 1:36 p.m. with the DON (staff #22), who stated that she is responsible for completing the Daily Staff Postings and she reviews the postings the day after it is posted. The DON stated that postings are required every day and she is aware that the postings for February 11, 2022 and March 1 2022 are missing. The facility's policy, Posting Direct Care Staff Numbers, revised August 2006 revealed the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The previous shift's forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location. Once a form is removed, it shall be forwarded to the Director of Nursing Services' office and filed as a permanent record. The policy stated records of staffing information for each shift will be kept for a minimum of eighteen (18) months or as required by state law (whichever is greater).

Based on observations, clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to prevent pressure ulcer development and failed to provide appropriate care and treatment for [REDACTED]. Findings include: -Resident #7 was admitted to the facility on (MONTH) 15, 2011, with [DIAGNOSES REDACTED]. Review of a Treatment Record dated (MONTH) (YEAR), revealed Weekly skin check per facility protocol. There was no documentation on the Treatment Record to indicate if a weekly skin check was conducted. Review of a Skin Integrity Risk care plan dated (MONTH) 3, (YEAR), revealed the resident was at risk for skin breakdown. The approaches included Weekly skin check . There was no documentation in the clinical record that the weekly skin checks were being conducted. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), revealed the resident did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of a wound care log dated (MONTH) 4, (YEAR), revealed the resident had a facility acquired stage 2 pressure ulcer to her lateral left heel filled with serosanguinous fluid. Review of a Daily Medicare Note dated (MONTH) 5, (YEAR), revealed Left lateral heel Stage 2 blister 4 centimeters by 4.6 centimeters filled with serosanguinous. [MEDICATION NAME] and Kerlix daily. There was no documented evidence on the (MONTH) (YEAR) Treatment Record that [MEDICATION NAME] was applied to the resident's left heel and wrapped with Kerlix until (MONTH) 21, (YEAR). Review of the clinical record revealed no documented evidence that the weekly skin assessments were being conducted after a stage 2 pressure ulcer was observed on the resident's heel. A Daily Medicare Note dated (MONTH) 19, (YEAR) revealed Right (left) great toe 2 centimeters by 2 centimeters eschar. Right (left) heel 7.5 centimeters by 5 centimeters. Blister forming eschar. Continue [MEDICATION NAME]. Cover with Kerlix daily. A Wound Care Note dated (MONTH) 19, (YEAR) revealed .Large blood filled blister to left heel. Wears protective boots, unusual to develop an unstageable pressure ulcer without pressure or shoe. She has protection with the boots and does not walk. Hoyer lift .She has 7.5 centimeters by 5 centimeters has become eschar, flatter and measurements have increased. Will continue [MEDICATION NAME] and Kerlix daily attempting to maintain the cap. It has been noted that a second blood filled blister has appeared medial right great toe and is reabsorbing with a smaller eschar .Pressure injury .Offloading and wound clean and dry .7.5 centimeters by 5 centimeters by 0.1 centimeters eschar 100% unstageable (left heel) .2 centimeters by 2 centimeters eschar 100% unstageable . Review of a physician's orders [REDACTED]. Change daily. Diagnosis: [REDACTED]. A Left Heel Wound Daily Medicare Note dated (MONTH) 21, (YEAR), revealed .Heel dressing changed and intact. Patient awaiting transport to her surgeon appointment. Patient returns from appointment early due to daughter canceling her second appointment . Review of a Resident Weekly Skin Check Sheet dated (MONTH) 28, (YEAR) revealed Left heel-Eschar intact. [MEDICATION NAME] every shift . A Daily Medicare Note dated (MONTH) 1, (YEAR), revealed Dressing to left heel. [MEDICATION NAME] applied to eschar-eschar is intact . Review of a wound care log dated (MONTH) 2, (YEAR), revealed Vascular. Left heel. Left great toe. No measurements were documented on the wound care log. A Daily Medicare Note dated (MONTH) 2, (YEAR) revealed Dressing to left heel done .Eschar intact . Review of a Resident Weekly Skin Check Sheet dated (MONTH) 3, (YEAR), revealed Left heel-Eschar intact. 5 centimeters by 4.6 centimeters . Review of an undated wound care log revealed Vascular. Left heel. 5 centimeters by 4.6 centimeters. Eschar intact . A Daily Medicare Note dated (MONTH) 9, (YEAR), revealed Dressing to left heel done-eschar remains intact. No drainage or odor noted .[MEDICATION NAME] applied to eschar wrapped with Kerlix, boot applied to left foot, pillow placed under legs for comfort and pressure relief. Review of a Resident Weekly Skin Check Sheet dated (MONTH) 10, (YEAR), revealed Left heel-eschar intact. 5 centimeters by 4.6 centimeters . Review of a wound care log dated (MONTH) 17, (YEAR), revealed Vascular left heel 5 centimeters by 4.6 centimeters. [MEDICATION NAME]. Review of a Resident Weekly Skin Check Sheet dated (MONTH) 17, (YEAR), revealed Eschar remains intact . A wound care log dated (MONTH) 24, (YEAR), revealed Stage 3. Left heel. 2.2 centimeters by 2.9 centimeters. Sharp debridement. Eschar cap lifting. Review of a Resident Weekly Skin Check Sheet dated (MONTH) 24, (YEAR), revealed Eschar cap lifted . Review of a physician's orders [REDACTED]. Discontinue previous wound care orders. Cleanse with normal saline. Pat dry. Apply Medi Honey to wound bed. Apply Foam/Silicone Border. Change Monday, Wednesday, Friday. A wound care log dated (MONTH) 7, (YEAR), revealed Vascular. Left heel. 3 centimeters by 2 centimeters by 0.1 centimeter. Eschar . An interview was conducted with an LPN (licensed practical nurse), staff #39 on (MONTH) 11, (YEAR) at 12:30 p.m. The LPN stated that the resident's skin is assessed upon admission to the facility and by CNAs (certified nursing assistants) during showers. The LPN stated that the CNAs notify the licensed nurses if a resident has any skin issues. The LPN stated that when she administers medications throughout the day, she looks at the resident's skin and tries to look at the resident's skin when CNAs showered the residents. The LPN stated that the facility did not have any scheduled structure as to how often residents should have their skin assessed and that it is not documented in the clinical record. The LPN stated that if she observed a pressure ulcer on a resident, she would notify the DON (director of nursing) and wound nurse. The LPN further stated that weekly skin assessments are conducted if an identified concern is observed. An interview was conducted with the DON, staff #53 on (MONTH) 11, (YEAR) at 1:50 p.m. The DON stated that a skin check is performed on admission and by the CNAs at every shower. The DON stated that if the CNAs identify a skin issue, it is reported to a licensed nurse. The DON stated the licensed nurse should also observe the resident's skin during a shower and should probably document it on the CNA shower sheet. The DON stated the licensed nurses only document on the residents who have pressure ulcers, not on the residents who are without pressure ulcers. The DON further stated that the resident's wound that she assessed on (MONTH) 10, (YEAR), was an unstageable wound from a debridement from a previous pressure ulcer. Review of the facility's policy Prevention of Pressure Ulcers/Injuries included .Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly . -Resident #5 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], (YEAR), revealed a BIM's score of 14 which indicated the resident was cognitively intact. The assessment also included the resident was at risk for pressure ulcers. The current care plan revealed the resident was at risk for skin breakdown related to limited mobility. The care plan goal was to have no signs or symptoms (s/s) of infections or complications. The interventions included to provide treatment as ordered, turn and reposition as tolerated, observe for s/s of infection, and to notify the physician of any abnormalities or worsening. Review of the weekly skin checks dated (MONTH) 20 and 29, (YEAR), revealed the resident had a small non-blanchable spot on the left heel and that the left heel was being floated. Further review of the clinical record revealed there was no additional documentation in (MONTH) (YEAR) regarding the left heel. Review of the Weekly Skin check dated (MONTH) 5, (YEAR), revealed the resident had a small non-blanchable spot on the left heel. Review of the clinical record revealed no other documentation regarding the left heel. During an interview conducted with the resident on (MONTH) 9, (YEAR) at 9:58 a.m., the resident stated that she has a pressure ulcer on her left heel and that she is keeping her heel elevated. An observation of the heel revealed reveal a light to moderate black/purple darkened area on the left heel. The resident's heels were observed floated. During an interview conducted on 07/10/18 at 11:31 AM with the DON (staff #53), the DON stated that the resident does not have a pressure ulcer on the left heel. She stated that it is a skin callous or excoriation. An observation was conducted of the resident's left heel on 7/10/18 at 1:35 p.m., with staff #53. The DON stated the light to moderate black/purple darkened area on the resident's left heel measured 1.7 cm (centimeters) x 1.2 cm and was irregular in shape and the surrounding tissue was light pink. The DON also stated the left heel was excoriated and not a pressure ulcer. Staff #53 stated that there was no order treatment and that they have not provided a treatment to the left heel. During an interview conducted on 7/10/18 at 10:27 AM with LPN (staff #38), she stated that she was unaware the resident has a pressure ulcer on the left heal. She also stated the resident has not said anything regarding a pressure ulcer on either of her heels and has not complained of pain. The LPN further stated that if she observed a pressure ulcer or skin change on a resident, she would notify the wound nurse, who would document the skin issue and contact the physician for orders. An interview was conducted with the wound nurse (staff #36) on 07/10/18 at 10:42 AM. The wound nurse stated that she is unsure when the dark area on the resident's left heel was first observed, but that she was made aware of it maybe about 3 weeks ago. She stated that she is applying skin prep to the site. The wound nurse also stated that there is no order to apply skin prep to the heel or to off-load pressure to the heel. She further stated that she conducts weekly skin checks and has not observed the ulcer getting better or worse. Staff #36 stated the staff prevents pressure ulcers by turning and repositioning residents and off loading pressure points for residents that are at risk. She also stated that she documents on pressure ulcers and wounds at least weekly. An interview was conducted with staff #53 on 07/11/18 at 9:55 AM. The DON stated that her definition of Excoriation is a pink area of skin that is warm, or a friction or tear of the skin usually caused by pulling or rubbing the skin on a surface such as a bed sheet. She also stated that the excoriation may appear as a darkened area. The DON stated the excoriation was first observed about 2 weeks ago. The facility's policy regarding wounds revealed a wound is identified by skilled assessment on the resident's initial placement into the facility. If the wound nurse has no orders, she would contact the physician for record and for wound orders. The wound nurse then follows the orders using proper technique. -Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The admission physician's orders [REDACTED]. The nursing Admission assessment dated [DATE], revealed a surgical wound to the right hip with an [MEDICATION NAME] dressing in place. A Braden Scale for Predicting Pressure sore Risk was completed on 02/04/18. The resident's score was 14 which indicated the resident was a low risk for the development of a pressure injury. A Skin Integrity Risk Care Plan initiated on 02/04/18, revealed the resident was at risk due to limited mobility, nutritional compromise, variable intake, dementia, decreased functional ability, incontinence of bowel and bladder, and advanced [MEDICAL CONDITION]. Interventions included to notify the physician for worsening abnormalities, promote adequate nutrition and hydration, supplements as ordered, treatments as ordered, Registered Dietician consult, promote good hygiene and pericare, keep skin clean and dry as much as possible, turn and reposition as tolerated, pressure relieving device to the chair as needed, preventative measures (i.e. gerigloves, pads, etc), and encourage the resident to get out of bed as tolerated. The interim care plan included to perform weekly skin assessments. A physician's orders [REDACTED]. A Daily Nurse's Progress note for the evening shift on 02/18/18, revealed the resident was repositioned every 2 hours, Dermaseptine was applied to the open area on the coccyx, and the resident's heels were floated. A Daily Nurse's Note dated 02/19/18, revealed the resident was turned and positioned and skin care was provided with each incontinent episode as needed. The note included cream was applied to the buttocks and open area as ordered. Review of the Wound Nurse rounding notes for 02/20/18, revealed the resident was receiving Dermaseptine each shift, was reposition while in bed, and the heels were floated. The note did not include a description of the skin or wound. Review of the Wound Team rounding report dated 02/21/18 documented resident #236 had sutures removed from a surgical wound, but there was no mention of an open area to the coccyx. A Daily Progress Note dated 02/22/18, revealed the resident was repositioned every 2-3 hours and that Dermaseptine was applied to the open area. A Daily Progress Note dated 02/23/18, revealed the resident was repositioned every 2 hours and Dermaseptine was applied to the coccyx. A NP Progress note dated 02/26/18, revealed the resident is being seen for follow-up of a right [MEDICAL CONDITION] and a new pressure ulcer. The Skin Observation section included that there is a dime-sized ulcer on the resident's coccyx and the right gluteal fold is reddened and excoriated and blanchable. The Plan included a [DIAGNOSES REDACTED]. Turn every 2 hours while in bed. A physician's orders [REDACTED]. A Daily Nurses Note dated 02/27/18, revealed Decubitus precautions in place. Review of the Wound Team rounding report dated 02/28/18, revealed resident #236 had cream applied to the perineum and gluteal fold. The measurements and treatments section included Dermaseptine every shift/reposition while in bed/float heels. There was mention of an open area to the coccyx. Review of the Certified Nursing Assistant (CNA) ADL (Activities of Daily Living) Tracking Form for (MONTH) (YEAR), revealed the resident was total dependence for bed mobility and required the assistance of one person on the day shift and required extensive assistance of one person on the evening and night shift. Review of the Treatment Record for (MONTH) (YEAR), revealed the following: -the application of Dermaseptine was not documented as completed 4 times; -repositioning while in bed each shift was not documented as completed 4 times. A Daily Nurse's Note dated 03/01/18, revealed the resident was repositioned in bed every 2 hours. A physician's orders [REDACTED]. Review of a Daily Progress Note dated 03/03/18, revealed the resident was turned every 2-3 hours, and wound care was administered as ordered to the coccyx. A Daily Progress Note dated 03/04/18, revealed the resident was repositioned every 2-3 hours, and wound care was administered as ordered to the open area on the coccyx. Review of the Wound Team rounding report dated 03/07/18 revealed resident #236 had a wound to the coccyx with measurements of 4.6 cm (centimeters) x 2.5 cm x 0.6 cm and undermining from 9 o'clock to 1 o'clock at 2.4 cm. [MEDICATION NAME] was applied to the wound. Bed roll gauze to the wound and undermining with Dermafilm 6 x 6; change daily. This was the only description and measurement of the open area to the coccyx found in the clinical record and there were no orders found in the clinical record for this treatment. A Daily Progress Note dated 03/10/18, revealed the resident was repositioned every 2-3 hours, and the dressing was changed to the open area on the coccyx. Review of the CNA ADL Tracking Form for (MONTH) (YEAR), revealed the resident was total dependent for bed mobility and required the assistance of one person on the day shift, limited assistance of one person for the first 5 days of the month, and then extensive assistance of one person for the remainder of the admission. The resident consistently required extensive assistance of one person on the night shift. Review of the Treatment Record for (MONTH) (YEAR), revealed the following: -The application of Dermaseptine to the gluteal fold/peri-area was not documented one shift; -The Saline/[MEDICATION NAME] dressing was not documented as completed on 2 days; Of the 27 Daily Progress Notes completed on this resident, there were only 9 notes that had documentation interventions or treatments were provided. Only one note had documentation that Decubitus Precautions were in place. An interview was conducted on 07/11/18 at 10:10 AM with the Licensed Practical Nurse/Wound Nurse (staff #36). The nurse stated a wound consult would not be ordered for redness and excoriation. She stated that if she saw an order for [REDACTED]. A telephonic interview was conducted on 07/11/18 at 08:40 PM with the former Registered Nurse/Wound Nurse (staff #97) who was the nurse at the time of this resident's admission. Staff #97 stated a [MEDICATION NAME] dressing can be used for any type of open wound, including a pressure ulcer. Staff #97 stated the facility did not have a wound specialist that would come in and see residents, and that if a Wound Consult was ordered, she would see the resident in conjunction with the resident's physician. An interview was conducted on 07/12/18 at 10:10 AM with the Nurse Practitioner (staff #96), who stated when she was made aware of the wound to the resident's coccyx, she and the former wound nurse assessed the wound. Staff #96 stated the resident's backside had been reddened for a while and then it opened up. She further stated the Dermaseptine was the appropriate treatment to continue at that time. Staff #96 stated that in regards to the use of [MEDICATION NAME] on the wound and no order, that it was possible the wound nurse asked about it and then neither of them wrote the order. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries revealed the purpose was to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Under the Mobility/Repositioning section, the policy included a resident should be repositioned hourly if bed- or chair-bound, every 2 hour if dependent on staff for positioning, and more frequently or as needed based on the condition of the skin and the resident's comfort. The policy also included staff will evaluate, report, and document potential changes in the skin. Review of a document titled Wound Policy presented by the Director of Nursing included the wound nurse or appointee will follow physician's orders [REDACTED].

Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure that two residents (#79 and #86) who were non compliant with following safety rules for smoking were reassessed in order to determine if they were safe to smoke independently and safe to keep their own smoking materials, and failed to assess one resident (#64) to determine if she was safe to smoke independently and safe to keep her own smoking materials. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. In addition, on April 25, 2017, one resident (#15) who stated that she smokes frequently and kept her own smoking materials, had not been assessed in order to determine if she was safe to smoke independently and safe to keep her own smoking materials. Findings include: On April 24, 2017 at 4:00 p.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to ensure that one resident (#79) who was previously found in the facility with a lit cigarette, was reassessed in order to determine if she was safe to smoke independently and safe to keep her own smoking materials. During the survey, this resident was observed smoking on the patio unsupervised. Also, one resident (#86) who was assessed to be an independent smoker and was then found to be non compliant with following the safety rules for smoking, was not reassessed in order to determine if she was able to smoke safely independently. This resident was also observed smoking without supervision. Further, one resident (#64) who smoked and kept her own smoking materials, had not been assessed to determine if she was safe to smoke independently and safe to keep her own smoking materials. The Administrator (staff #117) presented a plan of correction on April 24, 2017 at 5:34 p.m. The Administrator was informed that the plan of correction failed to include the following: the in-service topic regarding smoking which staff will be in-serviced on; the projected completion date of the in-services; who will be supervising residents who smoke; and who will be monitoring that smoking materials are stored secured by staff for supervised residents. The Administrator was also informed of the need to clarify the contradicting entries in the Smoking Policy and the Resident's Smoking Contract related to the storage of smoking materials. A revised plan of correction was received at 6:15 p.m. The Administrator was informed that the plan of correction failed to include how the facility will monitor the plan of correction to ensure that it is being implemented; the date the in-service training of all staff will be completed; and whether the scheduled smoking times are set times for supervised smokers or independent smokers or both. Another plan of correction was received at 7:45 p.m. and was accepted at 8:00 p.m. The plan included the following: a revision of the facility's smoking policy; immediate in-service of staff on the Smoking Policy; to supervise residents who require supervision with smoking; smoking schedules with designated times with assigned supervising staff; provision of a locked box for smoking paraphernalia which will be kept in rooms of independent smoking residents; identification of all residents who smoke and to complete smoking assessments of all residents; completion of smoking contracts for residents who are able to safely smoke independently; and random checks for supervision in the smoking area at designated times. Multiple observations were conducted of the facility implementing their plan of correction, which included that residents who required supervision with smoking were being supervised, the smoking schedule was being followed, staff in-services were being completed regarding their smoking policy and supervision of residents, locked boxes were observed in resident's rooms who were identified as independent with smoking, and smoking materials were being stored in the medication carts for residents who require supervision with smoking. The Condition of Immediate Jeopardy was abated on April 26, 2017 at 9:30 a.m. An interview with the Director of Nursing (DON/staff #7) was conducted on April 24, 2017 at 11:00 a.m. She stated that there were no residents in the facility who smoked. At 11:10 a.m., the DON stated the facility does not have a list of residents who smoke, because the residents who smoke are all from the Rita Unit (rehabilitation unit) and these residents are alert and oriented and are independent with smoking. She said there is a designated smoking patio for residents who smoke from the Rita unit. She also stated that there are no residents from the Rincon (long term care unit) who smoke. She further stated that the facility does not have a smoking schedule, because all of the residents who smoke are from the rehabilitation unit and are independent. The DON stated that the facility does not have a policy on smoking. A few minutes later, staff #7 provided a piece of paper with handwritten names of three residents, two of the names were resident #79 and #86. On the top left side of the note was handwritten smokers. -Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident resided on the Long Term Care unit. Review of a history and physical conducted prior to the resident's admitted d February 17, 2017, revealed the resident was having difficulty with ADL's (activities of daily living), due to a prior CVA (cerebrovascular accident). The note stated the resident had a history of [REDACTED]. Review of the admission assessment dated [DATE] revealed the resident was independent with transfers and ambulation, but required assistance with ADL's. The documentation included that the resident was alert and oriented and had a personal habit of smoking. A resident smoking assessment dated [DATE] identified that the resident was a smoker. The assessment included the following: the resident was physically capable of holding her cigarette and lighter; was capable of lighting and extinguishing her own cigarette without assistance; was able to call for help; was able to move without assistance to the smoking area; was alert and oriented, and that the resident did not have a history of poor judgement regarding safety. On this assessment, there was a section which included the following statements: Resident may smoke supervised by staff or Resident may not smoke at this time. The form included a space to check which one applied. However, both of these statements were checked. In the comment section it stated that the resident demonstrated ability to smoke safely at this time. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15, which indicated the resident had no cognitive impairment and was independent with bed mobility and transfers. Review of the daily medicare note dated April 2, 2017 revealed resident #79 was able to make needs known, was able to follow instructions at times, was unaware of safety precautions, and was alert and oriented x 2. The note further included the resident was found walking down the hall with a lit cigarette and that the cigarette was taken, and the dangers of smoking in the building were explained to the resident. Despite documentation that the resident was found with a lit cigarette inside of the facility, there was no documentation that the resident was reassessed regarding her ability to smoke safely. An observation was conducted on the smoking patio on April 24, 2017 at approximately 12:00 p.m. Resident #79 was observed seated in a chair smoking a cigarette. Another resident (#86) was also smoking at this time. There were no staff present on the patio. Also observed on the table where the residents were seated was a plastic cup with cigarette butts in it, which were mixed with a liquid. An interview was conducted with a licensed practical nurse (LPN/staff #119) on April 24, 2017 at 2:20 p.m. She stated that resident #79 was supposed to be supervised when smoking. An interview was conducted with resident #79 on April 24, 2017 at 2:27 p.m. She stated that sometimes she keeps her cigarettes with her and sometimes she gives them to staff to keep. She stated that she did not have any cigarettes right now, but when she smokes she receives cigarettes from resident (#86). An interview was conducted with a certified nursing assistant (CNA/staff #33) on April 24, 2017 at 3:44 p.m. She stated that there are only two residents on the 300 hall (Rincon/Long Term Care unit) who smoked, resident #86 and resident #64. She stated that both of these residents are independent and do not require supervision with smoking. She was unaware of any other residents who smoked on this unit. She stated if residents require supervision with smoking, the CNA would take the resident outside and observe them while they smoked. She also stated the residents keep their own cigarettes. After IJ was identified at 4 p.m. on April 24, 2017, a resident smoking contract was signed by resident #79 and a facility representative on April 24, 2017. The contract included that the resident acknowledged the smoking policy and agreed to abide by it's terms. The contract included the following: all smoking items will be stored in a locked container in her possession, and the resident agreed not to share any smoking items with any other residents or light cigarettes for other residents. The contract also included that if the resident violated the contract, she would not be able to keep her own smoking materials and agreed to allow the facility to store the items. The contract further stated the resident will smoke at designated times set by the facility, agreed to use proper receptacles for smoking paraphernalia and understood this agreement was made to ensure the safety of all residents in the facility. However, prior to completing this smoking contract, resident #79 was not reassessed in order to determine if she was able to safely smoke independently, as the previous assessment contained conflicting documentation regarding the resident's ability to smoke safely independently and additional documentation showed that the resident had not followed the safety rules for smoking. Two smoking assessments were completed on April 25, 2017, which included that the resident broke the smoking contract and included the following: the resident had a history of [REDACTED]. for help; was able to move without assistance to designated smoking area; has a history of poor judgment regarding safety to herself/others; resident is not alert and oriented and can not consistently perform safe smoking techniques. The assessment further included the resident required staff supervision with smoking, and her smoking materials would be stored by staff. A smoking care plan was first developed on April 25, 2017. The resident was identified to be at risk for injury related to smoking, as evidenced by weakness. The care plan identified that the resident was a smoker and was giving her cigarettes to other smoking residents. Approaches were as follows: perform a smoking assessment according to facility policy; explain/show the resident where designated smoking areas were and smoking times; monitor when smoking to assure resident's safety; keep all smoking material at the nurse's station; for the resident to have supervised smoking; and to follow the smoking schedule. An interview was conducted with a LPN (staff #119) on April 25, 2017 at 11:30 a.m. She stated resident #79 was assessed to be a supervised smoker from the smoking assessment which was done in February 2017. She said the resident had a signed contract (on April 24) indicating the resident was now independent with smoking. She stated this contract would supercede the previous assessment which determined the resident required supervision, and due to the contract being the most recent document in the chart, she stated this was the current status. However, she stated the resident had already violated her contract, as she was seen this morning handing a cigarette to resident #86. She stated that since the resident had violated her independent smoking contract, she would be reassessed and put back on supervised smoking. Staff #119 also included that the resident's smoking materials were stored in a locked box in the medication cart. An interview was conducted with resident #79 on April 25, 2017 at 11:40 a.m. She stated that she had her cigarettes as of this morning and that she had signed a smoking contract which stated that she was independent to smoke as of last night. She stated staff saw her trying to share a cigarette with resident #86 and that after this incident, her cigarettes were taken away and stored in the medication cart. She stated they informed her that she had to be supervised when smoking. An interview was conducted with an activity staff member (staff #118) on April 25, 2017 at 11:55 a.m. She stated that resident #79 and #86 had gone out to smoke this morning. She said she observed resident #79 sharing cigarettes with resident #86. She stated that resident #86 was out of cigarettes and had a nicotine patch on but removed it. She stated she immediately notified staff who stated they would put resident #79 back on supervision and her cigarettes would be locked in the medication cart. -Resident #86 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident resided on the Rincon unit (long term care unit). A smoking assessment dated [DATE] included documentation that the resident was a non-smoker. Another smoking assessment dated [DATE], included the following questions and answers: -Does the resident smoke? Yes -Is the resident's memory and ability to recall adequate? No - Is the resident physically capable of holding a cigarette, lighter, lighting and extinguishing own cigarette without supervision? No - Is resident able to move without assistance to designated smoking area? No - Is the resident alert and oriented and can consistently perform safe smoking techniques? No This assessment further included that the resident may smoke supervised by staff. A nursing note also dated March 14, 2017 included the resident was not aware of safety precautions and was not cooperative with care and treatment plan. The note included the smoking assessment had been completed and the resident required supervision to smoke. A 30 day MDS assessment dated [DATE] included the resident had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. The MDS also assessed the resident as non-ambulatory, required extensive assistance with bed mobility and hygiene and required total assistance with transfers. A third smoking assessment was completed 13 days later on March 27, 2017, which included the following questions and answers: -Does the resident smoke? Yes - Is the resident physically capable of holding a cigarette, lighter, lighting and extinguishing own cigarette without supervision? Yes - Is resident able to move without assistance to designated smoking area? Yes - Is the resident alert and oriented and can consistently perform safe smoking techniques? Yes This assessment also included that the resident was able to smoke without supervision. However, there was no clinical record documentation or an explanation on the smoking assessment as to how the resident's ability to smoke safely had improved, since the last smoking assessment done on March 14. A review of the April 2017 nursing notes revealed the following regarding the resident's smoking: -April 3: smoking with supervision. -April 5: (A late entry for April 4) resident found outside in courtyard area smoking, a witness observed the resident hiding cigarettes and lighter, resident is non-complaint with care and refuses to follow safety rules for smoking, resident approaches visitors and other residents asking for cigarettes and a lighter. -April 6: smoking with supervision. -April 9: smoking with supervision. -April 11: resident wants her cigarettes handy, however, she was told that her cigarettes have to go to the person who will be supervising her. Despite documentation that the resident was not following safety rules for smoking, was hiding smoking materials and was asking other residents for cigarettes and a lighter, there was no documentation that the resident was reassessed for the ability to safely smoke independently. On April 24, 2017 at approximately 12:00 p.m., resident #86 was observed outside on the patio smoking, unsupervised. Resident #86 was seated in a wheelchair and was observed to remove cigarettes and a lighter from a small pouch. The resident then proceeded to light and smoke the cigarette. On April 24, 2017 at 1:30 p.m., an interview was conducted with resident #86. The resident stated that she smoked without supervision and confirmed that she had her cigarettes and lighter in her room. The resident would not state where in her room she kept her cigarettes and lighter. An interview was conducted on April 24, 2017 at 3:00 p.m. with a LPN (staff #55). She stated the resident was assessed to require supervision when smoking. Staff #55 stated that the facility did not have scheduled smoking times and that all residents' smoking material were to be locked in the medication carts. However, after an inspection of the medication carts, she stated that no smoking materials were in the carts. Staff #55 further stated that there were residents with dementia on this nursing unit, so all cigarettes and lighters must be locked up because They could burn the building down. On April 24, 2017 at 3:50 p.m., an interview was conducted with a CNA (staff #14). She stated that resident #86 was an independent smoker. Staff #14 stated the facility use to allow residents to keep their own smoking supplies if they were independent smokers, but changed it awhile ago, so that all residents' smoking materials were to be locked in the medication carts, because of the hazards with lighters. She further stated that no residents require supervision while smoking. Following the identification of the IJ, a smoking contract was signed by resident #86. The contract was dated April 24, 2017 and included the following: 1. I agree to keep all smoking items in my possession. 2. I agree not to share any of my smoking items with any other residents or offer residents smoking items. 3. I agree not to light any smoking materials for any other residents. 4. I understand that if I violate this contract, I give up my privilege to control my own smoking material and agree to allow the facility to store my smoking items and that I will smoke at the designated times set by the facility. 5. I agree to use proper receptacles for disposable of smoking paraphernalia. 6. I understand that this agreement is made to ensure the safety of all residents in this facility. On April 25, 2017, another smoking assessment was provided. This assessment included that the resident violated the smoking contract and now required supervision while smoking. On April 28, 2017 at 10:00 a.m., an interview was conducted with the Director of Nursing (staff #7). Staff #7 stated that residents should not have smoking materials on their persons. -Resident #64 was readmitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident resided on the Long Term Care unit. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident was cognitively intact. According to a hospital physical therapy assessment and treatment plan dated April 14, 2017, the resident had a history of [REDACTED]. A hospital consultation note dated April 16, 2017 revealed the resident continues to use tobacco. Review of the clinical record revealed the resident resided on the Rincon unit (Long Term Care) unit. Review of the admission nursing assessment dated [DATE] revealed the resident was oriented, had clear communication and that the resident does not smoke. The activity assessment dated [DATE] revealed the resident was alert and oriented x 2 and was independent with her choice of activities. The assessment also included the resident had a current interest to smoke. Review of a Resident Smoking assessment dated [DATE] revealed this form had a line marked across the assessment questions. Also included on the form was a section with the following statements: Resident may smoke supervised by staff, Resident may not smoke at this time, and Resident must wear smoking apron at all times while smoking. This section also had a line marked through these statements. On the bottom right side of the page was a handwritten note which stated that the resident agrees not to smoke at this time. This assessment was signed by a licensed practical nurse (LPN/staff #55). On April 24, 2017 at 11:20 a.m., the DON provided a list of residents who smoked in the facility. Review of this list revealed that resident #64 was not included. In an interview with resident #64 conducted on April 24, 2016 at 3:01 p.m., the resident stated that she goes out on the patio and smokes alone or with other residents. The resident stated that she keeps her cigarettes and lighter with her, because she does not trust staff to keep them. She stated that she has her cigarettes and lighter on her at this time, however, she did not want to show them. An interview with a CNA (staff #33) was conducted on April 24, 2017 at 3:44 p.m. Staff #33 stated that there are only two residents who smoke on the Rincon hall (long term care unit) and resident #64 is one of them. She further stated that the resident is independent with smoking and does not require supervision when smoking. After the IJ was identified on April 24, 2017, a Resident Smoking Assessment was completed on April 25, 2017 and included the following: the resident has inadequate memory and ability to recall; was not physically capable of holding a cigarette/lighter and lighting and extinguishing own cigarette without assistance; was not able to extinguish if a lit cigarette or ash fell on her and/or others; was not able to move without assistance to designated smoking area; was not alert and oriented and was unable to consistently perform safe smoking techniques. The assessment also included that the resident may smoke with staff supervision. However, in the comment section it was written that the resident had stated that she has smoked in the past, but does not have a current desire to smoke and does not want to smoke in the near future. An interview was conducted on April 25, 2017 at 1:17 p.m., with the social services director (staff #89), the Administrator (staff #117) and the DON (staff #7). Staff #89 stated that the determination of whether residents smoke independently or require supervision when smoking is subjective and is based on nursing judgment. In another interview with the resident conducted on April 26, 2017 at 8:49 a.m., she stated that she goes out to the patio alone to smoke whenever she wants too, and keeps her smoking materials (cigarettes and lighter) with her. She also stated that she has not quit smoking and the last time she smoked alone was on the morning of April 25. In an interview with a CNA (staff #40) conducted on April 28, 2017 at 8:56 a.m., she stated that prior to being readmitted , the resident would go out on the patio and smoke independently. The CNA stated that she has not seen the resident smoke since returning from the hospital. -Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A hospital History and Physical dated March 12, 2017 (prior to admission) included Half to 1 pack per day smoker for the last [AGE] years . According to a Resident Smoking assessment dated [DATE], the Resident is currently on Isolation, is a smoker. However, none of the ten questions on the smoking assessment had been answered and there was no documentation to indicate if the resident required supervision with smoking or was safe to smoke independently. A nurses note dated March 28, 2017 included the resident was no longer on isolation. A review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. On April 24, 2017 at approximately 11:20 a.m., the facility provided a list of residents who smoked, and resident #15 was not included. During an interview conducted at approximately 1:25 p.m. on April 25, 2017, the resident stated that she was a smoker. She stated that she usually went outside three or four times a day and last went outside to smoke at 10:00 a.m. on April 25. She further stated that she keeps her cigarettes in her room and that she was provided a locked box to keep her cigarettes. At this time, a locked box was observed in the resident's room on the bedside table. However, review of the clinical record revealed no documented evidence that the resident was assessed as of April 25 at 1:25 p.m., in order to determine if she was able to safely smoke independently. On April 25, 2017 at 1:56 p.m., a current list of residents who smoked was requested. At 3:25 p.m., the Administrator and DON provided current smoking assessments for residents who smoked and a smoking assessment for resident #15 was included. Upon admission, the facility provided a Smoking Policy revised as of April 2012. The policy included that the facility shall establish and maintain safe resident smoking practices. The policy also included the following: 7. The staff shall consult with the attending physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges. 8. Any smoking related privileges, restrictions and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 9. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 11. The staff will review the status of a resident's smoking privileges periodically, and consult as needed with the Director of Nursing Services and the Attending physician. 12a. Residents with independent smoking privileges shall be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession .; d. Resident with independent smoking privileges may not give smoking articles to other residents with restricted smoking privileges. (Note: Anyone who observes this happening shall report it to the On-Duty Charge Nurse immediately). 13a. Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision .c. Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking. Prior to the IJ (on April 24, 2017), the DON provided a policy titled, Smoking Policy-Employees (revised December 2007.) The DON stated this smoking policy was the smoking policy that they used for staff and residents. Review of this smoking policy revealed, It is the policy of this facility to provide our employees with as near a smoke-free environment as possible and to ensure safe smoking practices for those who smoke. The policy included a section titled, Residents and Visitors and included the following: a. While this policy applies primarily to our staff, certain smoking restrictions apply to our residents and visitors. b. Residents and Visitors are not permitted to smoke in any area that is not designated as a smoking area. A resident who is confined to his/her room and is a smoker, as with all residents will be assessed for safe smoking status and reasonable accommodations will be considered. Under the section for Reporting Violations, it included that it is the responsibility of all personnel to report smoking violations and violations should be reported to the department director as soon as practical.

Based on observations, clinical record review, staff interviews, review of the Center for Disease Control (CDC) guidelines and policies and procedures, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were followed for one resident (#8) with active Clostridium Difficile (C-diff). As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On March 30, 2016 at 2:28 p.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator and Director of Nursing (DON) were informed of the facility's failure to implement infection control procedures for one resident (#8) who was on contact precautions for[DIAGNOSES REDACTED]. A certified nursing assistant (CNA) was observed entering the resident's room, without donning a gown. The CNA then removed a full red trash bag from the resident's room and without washing his hands, carried the red trash bag down the hall to the soiled utility room and touched the key pad to access the room and went inside. The CNA then exited the soiled utility room without washing his hands and walked to the nurse's station and touched the counters. In addition, an environmental service aide (housekeeper) was observed exiting this same resident's room with a gown on and then removed the gown and disposed of the gown in the housekeeping cart, which was in the hallway. The service aide did not wash his hands prior to exiting and touched multiple items on the housekeeping cart. The Administrator presented a plan of correction on March 30, 2016 at 3:20 p.m. At 3:31 p.m., the Administrator was informed that the plan of correction needed to address disinfecting the contaminated areas. The plan of correction also needed to address staff education regarding following infection control procedures, including the use of personal protective equipment (PPE), prior to entering resident's rooms on contact isolation and the trash disposal procedures. A revised plan of correction was presented on March 30, 2016 at 3:38 p.m. The revised plan of correction was accepted at 4:05 p.m. on March 30, 2016. The plan included staff inservice's regarding contact precautions, PPE, the cleaning of contact surfaces with an appropriate disinfectant, and performing audits of infection control practices. Multiple observations were conducted on March 31, 2016 of the facility implementing their plan of correction. Staff who were interviewed were knowledgeable of infection control procedures, including contact precautions. The Condition of Immediate Jeopardy was abated on March 31, 2016 at 10:25 a.m. Resident #8 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a nursing note dated March 8, 2016 revealed the resident was alert and oriented x 4 and was incontinent of bowel and bladder. A nursing note dated March 8, 2016 at 10:45 a.m., included that isolation precautions were in place. However, a nursing note for this same day documented that isolation precautions were discontinued by the physician. A physician's order dated March 20, 2016 included that a stool sample was ordered for[DIAGNOSES REDACTED], due to loose stools. A physician's order dated March 21, 2016 documented that the resident was to receive [MEDICATION NAME] (antibiotic) 500 milligrams three times daily and for [MEDICATION NAME] (antibiotic) liquid 125 milligrams four times daily. The order also included for isolation precautions. Review of a care plan dated March 21, 2016 revealed the resident was on contact precautions for[DIAGNOSES REDACTED]. Interventions included to educate staff on precautions and maintaining proper handwashing and precaution techniques. Another care plan dated March 21, 2016 included the resident was receiving antibiotic therapy for[DIAGNOSES REDACTED]. One of the interventions was to maintain isolation precautions. Review of a history and physical assessment by the nurse practitioner dated March 22, 2016 revealed the resident had[DIAGNOSES REDACTED] and was on isolation and antibiotics. A nurses note dated March 26, 2016 included the resident continues on [MEDICATION NAME] for[DIAGNOSES REDACTED] and had one loose stool this shift and that isolation precautions were in place. An observation was conducted on March 30, 2016 at 12:37 p.m., outside of the resident's room. A sign was posted which stated Contact precautions. There was also a cart with gowns and gloves located just outside of the resident's room. At this time, a CNA (staff #56) was observed to enter the resident's room with gloves on, but did not don a gown and was carrying an empty red colored plastic trash bag. He then exited the room carrying a full red colored plastic trash bag, with no gloves on and walked down the hallway to the soiled utility room. The CNA was observed to touch the key pad and enter a code to access the room. The CNA entered the room and then quickly exited and walked to the nurses station. The CNA was then observed to touch the counters at the nurses station and his uniform. Following this observation an interview was conducted with CNA #56. He stated that he had gloves on, but did not put on a gown when he entered the resident's room. He said that he took off the gloves in the room and threw them into the red trash bag, and then took the trash out of the room. He stated that he did not wash his hands in the resident's room and then went to the soiled utility room and touched the keypad. He said he did not wash his hands in the soiled utility room either. The CNA stated that he thought it was ok if he did not use PPE when he was removing the trash. Another observation was conducted on March 30, 2016 at 12:45 p.m. of CNA #56 opening this same residents room door from the inside. The CNA was observed touching the inside door handle with his bare hands and then exited the room, without washing his hands. Following this observation, CNA #56 acknowledged that he had not washed his hands after touching the inside door handle with his bare hands, prior to exiting the room. An observation was conducted March 30, 2016 at 1:07 p.m. At this time, an environmental housekeeping service aide exited the resident's room and walked into the hallway, with an isolation gown on. The service aide then removed the gown and placed it in the trash bag located on his housekeeping cart, which was in the hallway. The service aide was not observed to wash his hands. The service aide then touched multiple items on the housekeeping cart and then pushed the cart down the hall and parked the cart by the soiled utility room. Following this observation an interview was conducted with the environmental service aide. He stated that he should have washed his hands. An interview with the environmental services supervisor (staff #150) was conducted on March 30, 2016 at 1:08 p.m. He stated that the service aide was new, but had been trained to remove the isolation gown and gloves in the room and wash his hands in the resident's bathroom. He also stated his staff are required to disinfect their equipment immediately after cleaning isolation rooms. An interview with the nursing supervisor (staff #49) was conducted on March 30, 2016 at 1:18 p.m. She stated that isolation precautions require two people to take out the trash. She explained that the person in the room wears the PPE and the person outside of the room has gloves on. She stated the person with the PPE removes the trash in the resident's room and discards it into another red trash bag, which is held by the other person who is outside of the room. An interview with the Assistant Director of Nursing (staff #92) was conducted March 30, 2016 at 1:38 p.m. She stated that staff are supposed to wash their hands after caring for residents with[DIAGNOSES REDACTED]. The facility policy for standard precautions included the following regarding hand hygiene: wash hands after removing gloves. Gloves: wear gloves when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and wash hands immediately before going to another resident to avoid transfer of microorganisms to other residents or environment. Gowns: wear a gown that is appropriate to the task you are performing. Remove gown and perform hand hygiene before leaving the resident's room. A review of the policy regarding Isolation-Categories of Transmission-Based Precautions included that transmission based precautions will be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Transmission based precautions will be used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. The policy included that in addition to standard precautions, implement contact precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring contact precautions include; diarrhea associated with[DIAGNOSES REDACTED]. The policy further included to apply gloves and a gown upon entering a room on contact precautions and remove the gloves before leaving the room and perform hand hygiene. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. A review of the facility policy for[DIAGNOSES REDACTED] included that preventative measures will be taken to prevent the occurrence of[DIAGNOSES REDACTED] infections among residents. When caring for residents with diarrhea or fecal incontinence caused by[DIAGNOSES REDACTED], staff will maintain vigilant handwashing with soap and water, rather than alcohol based hand rubs, for the mechanical removal of[DIAGNOSES REDACTED] spores from hands. Due to the persistence of[DIAGNOSES REDACTED] spores for prolonged periods of time, the environment shall be disinfected with a disinfecting agent recommended for[DIAGNOSES REDACTED]. Review of the 2007 CDC guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands, who have touched a contaminated surface or item. For prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines included to use gloves and gowns when entering patients rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. The guidelines also included to discard gowns and gloves before exiting the patient room to contain pathogens, especially those that have been implicated in transmission through environmental contamination.

Based on clinical record reviews, observation, staff interviews, and policy review, the facility failed to ensure that one resident (#53) was provided care and services to prevent the deterioration of a pressure ulcer, and failed to ensure that one resident (#204) did not develop a pressure ulcer. Sample size was 3. Findings include: -Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission assessment dated [DATE], revealed that both of the resident's heels were boggy, with redness that was nonblanchable. A physician's orders [REDACTED]. An interim care plan for pressure ulcers was developed for the stage 4 pressure ulcer present upon admission, however, the care plan was not updated to reflect the boggy heels with redness, nor the physician's orders [REDACTED]. Review of the Resident Weekly Skin Check Sheet dated November 27, 2014, revealed that the resident's heels were boggy and reddened. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE], revealed that the resident had severe cognitive impairment and was totally dependent of two staff members with ADLs. In Section M., the assessment identified that the resident was at risk for developing pressure ulcers, and had a stage 4 pressure ulcer that was present upon admission and two stage 1 pressure ulcers. In Section V. the care area of pressure ulcers triggered and the decision was to proceed to care planning. A comprehensive care plan was developed for pressure ulcers, however, it did not include the condition of the resident's heels, nor of the need to float the heels. There was no further clinical record documentation regarding the left heel until December 22, 2014. A physician's orders [REDACTED]. The next wound assessment documentation regarding the stage 2 pressure ulcer was on a wound note dated December 29, 2014. The note included the left heel pressure ulcer was a stage 2 intact blister, which measured 5 centimeters (cm) by 5 cm., and was dark purple in color. Review of a wound consultant note dated December 31, 2014, revealed the following: left heel pressure ulcer measured 5 cm by 5 cm, deep tissue injury, and was black in color. Review of the December 2014 TAR revealed that the physician ordered treatment to apply skin prep was not done as ordered. On December 22, 24, 26, 27, 28, 30, and 31, the treatment was only provided once a day, instead of twice a day as ordered. Also, the treatment was not provided on December 23 and 25. In addition, the December 2014 TAR included the order to float the heels while in bed, however; there was no documented evidence that this was done. The next wound assessment was completed seven days later on January 7, 2015. The wound note included the resident had a left heel pressure ulcer that measured 3 cm by 5 cm and was now 100% black eschar. The note also directed the staff to provide skin prep and float the heels. The wound nurse's note dated January 7, 2015, documented that the left heel stage two pressure ulcer had evolved into an unstageable pressure ulcer, with 100% black eschar. Review of the January 2014 TAR revealed the order to float the heels while in bed, however; there was no documented evidence that this was consistently done. An observation of wound care to the left heel pressure ulcer was conducted on January 8, 2015, with a licensed nurse. The heel pressure ulcer measured 3 cm by 4 cm, with 100% black eschar. The resident was noted to have been severely contracted, with one leg over the other. An interview was conducted on January 14, 2015, with a licensed practical nurse (LPN). The LPN stated that the wound nurse does the dressing changes if a wound vac is in use and once per week for all other wounds. She stated that otherwise, the nurse caring for the resident does the daily wound care. She also stated that she does not know why the wound care was not done as ordered. An interview was conducted with the wound nurse on January 14, 2015. The wound nurse stated that she was new to this position that until recently, she did not know that she was supposed to do care plans for pressure ulcers. She also said that she measures the wounds weekly. An interview was conducted with the Director of Nursing (DON) on January 15, 2015. The DON stated that the nurses should be documenting that the heels are floated on the TAR, when the physician has written an order for [REDACTED].> -Resident #204 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident discharged on [DATE], to home. The physician's admission orders [REDACTED]. A review of the October 21, 2014, Braden scale for predicting pressure ulcer risk, revealed that the resident was identified to be a high risk. A review of the nursing admission assessment dated [DATE], revealed that the resident was alert, oriented, able to communicate, and required a two person assist for transfers and ambulation. Per this assessment, there were no pressure ulcers noted upon admission. A physician's orders [REDACTED]. -[MEDICATION NAME] mixed with A&D ointment 50/50 to the sacrum, groin and spine areas every shift and prn (as needed). -Turn resident side to side every two hours. However, a review of the October and November 1 through 9, 2014 TARs (Treatment Administration Records) revealed inconsistent documentation that the resident had been turned every two hours or that the treatment had been provided every shift as ordered. Review of facility documentation revealed that on November 10, 2014 during a skin sweep of the facility, the resident was found to have a stage 2 pressure ulcer on the sacrum, which measured 1 by 1 cm. A physician's orders [REDACTED]. -Turn the resident every one hour. -Cleanse with a moist cloth, pat dry, and apply [MEDICATION NAME] three times a day. A review of the November 2014 TARs again revealed documentation that the prescribed treatment for [REDACTED]. In addition, the physician's orders [REDACTED]. A history and physical dated November 12, 2014 included that a stage 2 pressure ulcer was present on the resident's sacrum. Per the documentation, a thin scab/eschar was present in the center of the wound and that it was approximately 10% of the wound. Further review of the clinical record revealed that there were no Braden Scale assessments that were done in November 2014, despite the physician's orders [REDACTED].>An interview was conducted on January 14, 2015, with the DON. Following a review of the closed clinical record she confirmed that the stage 2 pressure ulcer was acquired at the facility, and agreed that the physician's treatment orders had not been consistently implemented. Per the DON, if it was not documented, then it was not done. Review of the facility's policy on physician's orders [REDACTED]. Not signing and leaving holes is not acceptable and means not done. A policy for pressure ulcers was requested and the DON stated that she was unable to provide a policy for pressure ulcers.

Based on clinical record review, review of facility documentation, observations, staff interviews, review of the National Pressure Ulcer Advisory Board (NPUAP), and review of facility policy and procedure, the facility failed to prevent the development of a stage IV pressure ulcer for one resident (#133). This resident sustained [REDACTED]. Findings include: Resident #133 was admitted to the facility March 31, 2009. A quarterly Minimum Data Set assessment with an observation end date of May 18, 2011, included the resident's cognitive skills for daily decision making were severely impaired. Also included was that the resident had no ulcers wounds or skin problems, but that the resident had pressure reducing devices for her bed and wheelchair, was turned and repositioned, and received nutritional supplements. Clinical record review revealed a care plan for [MEDICAL CONDITION] dated May 23, 2011, that included that the resident experienced lower extremity [MEDICAL CONDITION]. A fall care plan last updated July 25, 2011, encouraged the resident to take rest periods and also documented that if the resident refused to take a rest period she may remain up since she was a fall risk. Review of facility documentation included a shower day skin inspection form dated June 23, 2011, that documented that tthe resident experienced no skin problems. Review of a shower day skin inspection dated June 27, 2011, documented a "black scab on left outer foot" for resident #133. Also revealed was that both the certified nursing assistant (CNA) and licensed staff had signed off on this June 27 shower day skin inspection. Additional clinical record review revealed no evidence that the resident's physician had been notified regarding this change in skin status. A nurses note dated July 5, 2011, included that the resident was noted to have a black scab on her left outer foot which looked infected. A second nurses note also dated July 5, 2011, included that the resident's foot was going between the pedals and sitting on a bolt that holds strap on back of pedal. Also included was that the resident now had a pad over her foot rests and behind her legs, and that the resident had an "unstageable" pressure ulcer. A nurse practitioner progress note eight days after the discovery of the black scabbed area dated July 5, 2011, included that the resident was prone to pressure over her bony prominences, had peripheral artery disease with cool circulation, had mild [MEDICAL CONDITION] normally and was at high risk for skin breakdown. Despite resident #133's known risk factors, also documented was that the resident's wheel chair pedals had padding and now it was off. A wheel chair leg support cushion and padding were reordered/replaced at this time. A risk for pressure ulcer care plan last updated July 19, 2011, included various interventions to prevent the development of pressure ulcers since the resident was at risk for the development of a pressure area. Interventions included to notify the nurse immediately of any new areas of skin breakdown noted during bathing or daily care and to report changes in skin status to the physician. Further review of this care plan revealed no specific interventions related to the resident's feet when positioned in her wheelchair. Observations on August 10, 2011, included that the resident had a foam overlay to her foot pedals. In an interview conducted on August 11, 2011, a CNA who had cared for resident #133 stated that they used a pad between her feet to keep her feet on the pedals and not fall through the middle. The CNA further stated that they did not sign off when the staff implement the intervention but that they did follow the resident's care plan. The CNA also stated she thought she remembered the pad between the resident's feet being documented on her care plan. In an interview conducted on August 10, 2011, licensed staff was unable to locate any notification of the resident's physician or any treatment orders initiated on June 27, 2011. In an interview conducted August 11, 2011, the director of nursing (DON) also stated she could not find documented evidence of notification of the resident's physician on June 27, 2011. The DON further stated that on July 5, 2011, a temporary pad was put in place when she was made aware of the pressure sore and that the formal padded cushioning was ordered at that time. The DON further explained that the shower sheets go to the unit manager and then were passed on to the DON usually within a day since they have stand up meetings and did clinical rounds. However, in this case the DON stated she was not made aware of the pressure area until July 5, 2011. An interview was conducted with therapy staff on August 11, 2011, and revealed that the resident had been evaluated in the past for potential fall issues but not related to her foot pedals. Therapy staff further stated that if something like foot padding was related to fall interventions, they would likely be involved but if it was for skin issues, it many times would be a nursing intervention. The NPUAP revised its definition of pressure ulcers, "...Pressure ulcers are usually located over bony prominences, such as the sacrum, coccyx, hips, and heels, and are staged according to the extent of observable tissue damage..Effective treatment depends on a thorough assessment of the developing wound...Perform a head to toe skin assessment at least daily, especially checking pressure points..." Review of facility policy Pressure Ulcer Prevention included that "...A resident who enters the center without pressure ulcers...does not develop pressure ulcers... unless the individual's clinical condition demonstrates that they were unavoidable..."

Based on clinical record review, observations, staff, complainant, and equipment supplier interviews, review of facility policy and procedure, review of manufacturers instructions, review of the hospital records, and review of facility documentation, the facility failed to safely transfer one resident (#125) via hoyer lift (mechanically assisted transfer) which resulted in a transfer to a local emergency room (ER) for a posterior scalp laceration and hematoma. The resident sustained [REDACTED]. Findings include: Resident #125 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan regarding activities of daily living function included an update on May 9, 2011, that the resident now required a two person hoyer lift for transfers however no information was documented regarding the resident's assessment for use of the hoyer, which included what sling size was appropriate for her weight. Further review of the resident's care plan revealed that the resident had sustained a fall on June 1, 2011, with no injuries. Review of the hospital records revealed that on July 25, 2011, the resident was transferred to the ER for a posterior scalp laceration and hematoma. Clinical record review revealed a resident progress note dated July 26, 2011, that included "...Resident had fall 7/25/11 from hoyer during shower transfer. Investigation to follow. Resident has hematoma with two staples to head. Bruise to shoulder, compression fx (fracture)..." Clinical record review revealed a resident progress note dated July 28, 2011, as a follow up to the fall on July 25, 2011, that included that the "...Resident slid out of hoyer. Two aids assisting with transfer resident moved in sling to scratch self and went to floor..." Review of facility documentation dated July 28, 2011, of the fall investigation included that the two CNA's (certified nursing assistants) transferred the resident were asked to demonstrate the procedure that they had utilized at the time of the resident's fall on July 25. Included in the investigation was that the sling used for the transfer at the time of the fall "...Had a blue tag (extra large size)..." On August 9, 2011 at 3:00 p.m. an observation of a hoyer transfer was completed. In an interview immediately following the observation the two CNA's completing the transfer stated that two CNA's and sometimes three were present for all hoyer lifts. The CNA's stated each resident who was hoyer dependent was issued a personal sling which is kept in their room for their use. An interview was conducted with a CNA on another hall on August 9, 2011 at 3:15 p.m. The CNA demonstrated the care plan for the resident which indicated that the resident used a medium sling and was a two person transfer. She stated that the staff always used at least two people for hoyer transfers. An interview was conducted on August 11, 2011 at 8:00 a.m. with the Administrator and Director of Nurses (DON). The DON stated that the sling that was used to transfer that resident was an extra large. The DON further stated this resident weighed 132 pounds at the time of the accident. In response to a specific question regarding recent changes in the resident's weight staff further stated the resident had not lost weight. The DON stated that the slings were assigned to the resident and each resident had their own sling. The DON stated that the staff were in-serviced on hire on the use of the hoyer lift. She stated that the staff were required to give a return demonstration. A review of facility documentation regarding hoyer lift and associated sling sizes included a chart posted at the nurses station which outlined to use a "yellow" or a medium size sling for a resident who weighed 99 to 210 pounds. Also included was that an extra large or "blue" sling would be utilized for a resident who weighed between 270 to 600 pounds. In a follow up interview conducted on August 11, 2011 at 1:15 p.m., the administrative staff stated that immediately following the investigation of the incident on July 28, 2011, re-education of all staff members was conducted on proper safe utilization of a hoyer lift which included proper selection of sling size based on resident weight was implemented. During this interview on August 11, 2011, in response to a specific question as to why the CNA's utilized a sling with a blue tab staff stated that it was the sling that was in her room so they assumed it was for her. Staff further added that included in the training implemented beginning July 28, 2011, was that the licensed nurses would be required to assess the resident for the proper sizing of the hoyer sling. The CNA's were instructed to ask the nursing staff for guidance in selection of sling size. An interview was conducted with a licensed nurse on August 10, 2011 at 3:15 regarding hoyer lift transfers. She stated she had been in-serviced on hoyer lifts recently with great emphasis placed on using the correct size of sling to be used. She stated she had not had training in the use of the hoyer lift previously. . In an interview conducted on August 15, 2011, a representative of a hoyer lift supplier stated that a resident with a weight of approximately 130 pounds would need to use either a small or medium sized sling. Using an extra large sling would add the complication of all the extra material as well as the possibility the resident could slip out of the sling. A request for a copy of the facilities policy and procedure for the use of a hoyer lift was made on August 11, 2011. The facility staff provided a copy of a check list utilized for mechanical lift training. This training check list revealed that a mechanical lift transfer was a two person procedure (minimum) and may require three staff members but did not document the need to ensure that the sling being utilized matched the resident's care plan. The manufactuer's information documented that with or without head support and the use of a padded "u" sling, the resident would need to use a size medium for a 99 to 210 pound person.

Based on clinical record review, staff interviews and review of facility policy and documentation, the facility failed to ensure that two residents (#s129 and 313), who were identified to be at high risk for falls, received supervision and interventions and as a result both residents sustained falls, including one (#129) who sustained a hip fracture. The census sample size was 40. Findings include: -Resident #129 was admitted on [DATE], with [DIAGNOSES REDACTED]. A fall risk evaluation dated April 12, 2010, revealed the resident was at high risk for falls with a score of 14. A falls care plan dated April 16 revealed a score of 22 and required that two staff members were to be present for personal care and when turning the resident. On June 9, 2010, the resident was reassessed to be at minimum risk for falls with a score of five (low risk). Upon further review of this document there was an error identified and the resident should have scored an eight (still low risk) since she had a [DIAGNOSES REDACTED]. A nursing entry dated June 9, documented that the resident's fall risk score had changed from 14 to five and that the resident continued to require total assistance from staff with transfers and positioning. The care plan was revised on June 9 and documented a fall score of five and directed staff to provide total assistance for the resident with transfers and posturing. The annual MDS (Minimum Data Set) assessment dated [DATE], assessed the resident as being totally dependent for care and required two or more staff to assist for transfers, bed mobility, dressing, toilet use and bathing. Section V. of the Resident Assessment Protocol Summary (RAPS) of the MDS assessment triggered the resident for falls and activities of daily living (ADL's) and directed staff to develop care plans accordingly. On July 11, 2010, the resident sustained [REDACTED]. A post fall evaluation was completed on this same date. The description of the resident's fall revealed that the resident rolled over when staff went to apply cream to her buttocks. The resident fell off the bed onto her legs and buttocks. The resident's statement was documented on this form and she said that only one one staff member was present to assist her at the time of her fall. The summary of Interdisciplinary team findings included that the resident was not a high fall risk but required two staff to be present for skin care. A subsequent fall risk evaluation dated July 11 identified the resident as a high fall risk with a score of 19. This contradicted what the Interdisciplinary team had identified. On July 12 the resident was again assessed for fall risk and the resident now scored 12 (moderate risk), which contradicted the MDS assessment. The care plan was updated at this time but did not identify any new interventions. There was no documented reason for the discrepancies in the fall risk scores and the reasons for the repeated evaluations. On August 6, 2010, a nursing note entry documented that a Certified Nursing Assistant (CNA) had approached the nurse and stated that while the staff member was providing the resident with personal care that the resident rolled off of the bed. The nursing note entry continued by stating that 911 was called per resident request since she was in a great deal of pain and staff were unsuccessful in getting her back to bed. The resident was then transported to the hospital and diagnosed with [REDACTED]. A post fall evaluation dated August 6 description of the fall revealed that the resident rolled out of bed while being turned to receive personal care. The summary of the Interdisciplinary Team stated that the resident will now be a two person assist for all ADL care, even though this had previously been identified in her assessment and care plan as well as in the prior Interdisciplinary evaluation from July 11. The ADL's care plan dated August 24, 2010, revealed that the resident was to be a two person assist with turning, repositioning and personal care for stability. On September 17 the physician ordered that the resident was to be transferred from her bed to a chair or from the car to the bed by four staff members. One of the staff members was to be a nurse. The care plan was revised with this physician order on this same dated. Another physician's order dated September 27 documented that the resident was to be transferred with four staff members and again directed staff to include one nurse in this process. An interview was conducted with the resident on November 8. The resident stated that the day of her last fall she was moved onto her side in bed by a CNA. When the CNA was unable to apply cream to her buttocks she moved her over more and then she rolled out of bed onto the floor. After her fall, resident stated that she was to then have two staff members assist her when she received personal care. The resident went on to say that the doctor had told her that she should have had two staff members assist her prior to her fall in July. An interview was conducted on November 8, 2010 at 12:10 with two CNAs who both stated the resident has always required two staff members to assist her. On November 8 an interview was conducted with the Director of Nursing (DON) at 12:25p.m. The DON stated that if a resident was identified as high risk for falls, they become part of the falling star program. When a resident was identified as a falling star, stars go on the outside of their doors to notify staff and they receive individualized care. The DON stated if a resident fall did occur, all parties were notified and a post assessment was conducted. The DON stated that there were discrepancies with the fall risk assessments. She also stated that she could not recall any staff in-services after the resident's first fall. The facilities policy entitled "Accidents and Supervision to Prevent Accidents" stated that the center provided an environment that was free from accident hazards over which the center has control and provided supervision and assistive devices to each resident to prevent avoidable accidents. This included systems and processes designed to identify hazards and risks, evaluates and analyzes hazards and risks, implements interventions to reduce hazards and risks, and monitors for effectiveness and modifies approaches when necessary. -Resident #313 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record and nursing assessment done on admission revealed the resident fall risk summary score result was 26, indicating the resident was at high risk for falls. The admisson fall risk assessment also revealed that resident #313 was disoriented daily, complacent, had decreased sensation and or coordination in extremities, visual deficits, uses a device ie. wheelchair for transfers, has a shuffled gait and balance problems, can ambulate and transfer safely with one person assist, on mediations that may cause light headedness, dizziness and hypotension. The fall risk history revealed a recent decrease in mobility, episodes of sudden weakness, dizziness, unsteadiness with position change and previous falls within six months An interim care plan dated October 05, 2010, also identified the resident at high risk for falls, related to a history of falls and weakness. Interventions documented were appropriate for her condition. The resident was documented to have sustained falls on October 6 and 8, 2010. A post fall evaluation dated October 08, 2010 at 11:00 p.m., revealed the resident fell on the floor mat by her bed. The family was notified of the fall and of the resident's need for a private sitter. Review of the resident's updated care plan revealed a new intervention of a private sitter. Despite evidence in the nurses notes that a private sitter was present with the resident, no documentation was located in the clinical record detailing what assistance the sitter could provide or was expected to provide to the resident. A post fall evaluation dated October 19, 2010, revealed that the resident had been in the therapy restroom, was given the call light and advised to call for assistance when she was finished. The resident was found on the floor lying on her right hip with a skin tear to left lateral forearm. Review of nurses notes on October 19, 2010, revealed that the resident fell in the therapy restroom, and that the sitter was not present at the time. In an interview conducted on November 08, 2010, at 1:15 p.m., therapy staff stated that she would stay with residents while they use the restroom depending on the residents impulsiveness and their state of confusion. Staff also stated if the resident had a sitter, the sitter may or may not remain with them while they were in therapy In an interview conducted on November 08, 2010, at 1:30 p.m., two nursing assistants on the therapy unit where resident #313 resided stated that a sitter role in helping the resident depended on the sitter's background, and in some cases a sitter may help the resident with going to the bathroom and other activities of daily living, and in other cases not. In the case of resident #313, staff stated she would not allow the nursing assistants to assist her in the bathroom as she insisted that her sitter be the one to help. In an interview conducted on November 09, 2010, administrative staff stated that a sitter/companion may administer direct care if they have the proper certification. Review of the facility policy entitled " Accidents and Supervision to Prevent Accidents", included that the center provides an environment that is free from accident hazards over which the center has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Review of the facility policy entitled " Private Duty Sitters/Companions" documented that private duty sitters/companions follow instructions issued by the nurse supervisor/charge nurse and may not administer direct care to the resident unless authorized in writing by the attending physician and proper certification has been validated. Also included was that the private duty sitters/companions notifies the center when unable to provide care and /or sit with the resident.