Every finding on record at Hilltop Park Post Acute

Based on observations and interviews, the facility failed to ensure facility menus met the needs of residents and were followed.Specifically, the facility failed to ensure correct and adequate portion sizes were served according to the menu extensions.Findings include:I. Menu extensionsThe posted menu included pineapple glazed ham, mashed potatoes, sliced parsley carrots. The dessert was orange dream cake.The menu extensions were provided by the nursing home administrator (NHA) on 6/25/26 at 7:55 a.m.The regular menu extensions documented serving sizes for the regular diet as three ounces of pineapple glazed ham, one half cup (four ounces by volume) of mashed potatoes, one half cup of parsley carrots, and one cupcake each for the orange dream cupcake.The soft and bite size level six menu extension documented serving sizes as a #8 (one half cup) scoop of ham, one half cup of mashed potatoes, and one half cup of parslied carrots. The mince and moist level five menu extension documented serving sizes as a #8 (one half cup) of ham, one half cup of mashed potatoes, and one half cup of minced and moist parsley carrots.The puree level four menu extension documented serving sizes as a #8 scoop (one half cup) of the puree ham, one half cup of pureed mashed potatoes and a #12 scoop (one third of a cup) of pureed carrots.II. Lunch meal observations and interviewsDuring a continuous observation of the lunch meal on 6/24/26, beginning at 10:46 a.m. and ending at 12:20 p.m., the following was observed: At 10:55 a.m. cook #1 said the blue #16 scoops (two ounces by volume) in the pan were for the puree and minced and moist diets. [NAME] #1 said the green scoop (#12 scoop and two and three fourths ounces by volume) was for the soft and bite size ham and mashed potatoes. A three ounce ivory handled portion control ladle was in the pan of sliced carrots. [NAME] #1 placed the #16 blue scoops in the pans of puree ham and carrots, the minced moist ham and carrots, and the green scoops in the pans of mashed potatoes and soft and bite size ham.At approximately 11:00 a.m. meal service began in the kitchen. Observations during meal service revealed the following:The mashed potatoes were served using the #12 green scoop (one third of a cup) for regular diets, mince and moist level six diets, soft and bite size level five diets and puree diets.-However, according to the diet extensions the mashed potatoes were to be served as a one half cup portion.The parslied carrots were served using the three ounce ivory handled portion control ladle for the regular diets and soft and bite size level six diets.-However, according to the diet extensions the parslied carrots were to be served as a one half cup portion for the regular and soft and bite size level six diets.The ham was served using the #12 green scoop for the soft and bite size diets.-However, according to the diet extensions the ham was to be served as a one half cup portion.Ham and carrots were served using the #16 blue scoop for the mince and moist level six diets and puree diets.-However, according to the diet extensions the ham was to be served as a one half cup portions for the mince and moist level six and puree diets; and, carrots were to be served as a one half cup portion for the mince and moist level diet and a one third of cup portion for the puree diet.III. Staff interviewsThe dietary manager (DM) and the registered dietitian (RD) were interviewed together on 6/25/26 at 2:30 p.m. The RD said he talked to cook #1 to see why he portioned the lunch meal as he did. The RD said cook #1 told him that because the facility had a couple residents with a puree diet and not very many residents with a minced and moist diet, the amount of food made for those residents was smaller in volume. The RD said cook #1 said if he used a four ounce scoop it was harder to fit in and scoop from the smaller pan. The RD said if the cooks used a smaller two ounce scoop the cooks should double that scoop to make it a four ounce portion. The RD said part of the inservice provided to the dietary staff (see below) was what the portions meant and that over the course of the day, if smaller portions were served that could potentially be 20% less of what was calculated to be served, and over the course of the week that can add up and that was the nutritional aspect of the meals.The DM said he did keep the diet extension sheet in the kitchen for the dietary staff and it was in the same binder as the food temperature logs.IV. Facility follow upA scoop size dietary education was provided by the NHA at 11:13 am. The inservice was provided to the dietary staff on 6/25/26 by the RD and the DM. It documented that scoops were categorized by a number which corresponded to the number of level scoops needed to fill one quart (32 ounces). To determine the portion size, you divide 32 by the scoop number (on the scoop). For example, a #16 scoop was 2 ounces, or approximately one fourth of a cup. A #12 scoop was 2.67 ounces or approximately one third of a cup. A #8 scoop was four ounces, or approximately one half of a cup.The education documented the importance of proper usage was that each resident received the recommended calories, protein and micronutrients and prevented united weight loss or gain by standardizing the volume served at point of service.

Based on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen.Specifically, the facility failed to ensure staff washed hands and changed single use gloves appropriately while preparing, plating and distributing ready to eat food in the main kitchen.Findings include:I. Professional referenceThe Colorado Retail Food Regulations (3/16/24), and retrieved on 7/2/26 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, unwrapped single-service and single-use articles, after handling soiled equipment or utensils; and, during food preparation: as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.14) Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (3-301.11) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. (3-304.15)II. ObservationsDuring a continuous observation of the lunch meal on 6/24/26, beginning at 10:46 a.m. and ending at 12:20 p.m., the following was observed: At 10:55 a.m. dietary aide #1 was at the sandwich station in the kitchen and wore black single use gloves on both hands. With gloved hands, dietary aide #1 cut a sandwich, holding the sandwich with her left hand, and the knife in her right hand. Dietary aide #1 picked up a paper meal ticket with her left gloved hand and set the ticket back down at the station in front of her. Wearing the same gloves, dietary aide #1 pulled two slices of bread from a plastic bread bag and placed them on the preparation table in front of her. Dietary aide #1 then used her gloved hands to separate slices of deli meat, which she placed on the sliced bread. Dietary aide #1 removed a lid from a pan on the cold station in front of her and with her right gloved hand removed a slice of cheese from the plan and placed it on the sandwich. She then walked away from the sandwich station to pick up six plates with her gloved hands in the plate rack.-Dietary aide #1 did not wash her hands and change her gloves after changing tasks and soiling the gloves and before touching ready-to-eat food.At 11:05 a.m while wearing the same gloves, dietary aide #1 placed a sandwich on a plate and cut the sandwich into quarters while holding the sandwich with her left hand. Dietary aide #1 then picked up meal tickets with her gloved hands, looked through them, and set them down at her station.-Dietary aide #1 did not wash her hands and change her gloves after soiling the gloves and before touching ready-to-eat foods.At 11:09 a.m. while wearing the same gloves, dietary aide #1 picked up meal tickets with both hands, looked through them, set them back down at her station, and pulled bread out of a bread bag. Wearing the same gloves, dietary aide #1 placed the bread slices in the conveyor toaster and then picked up and read through the meal tickets again with her hands. Dietary aide #1 set the meal tickets back down at her station.Wearing the same gloves, dietary aide #1 picked up a bag of bread with both hands and secured the top of the bread bag and set it back down. Dietary aide #1 then walked away from the cold station to dry storage and came back with two bags of bread. Wearing the same gloves, dietary aide #1 placed two slices of bread in the conveyor toaster, removed her gloves to wash her hands, then donned new gloves.-Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.At 11:15 a.m. while wearing single use gloves, dietary aide #1 wrapped a plate with clear plastic wrap. Wearing the same gloves, dietary aide #1 picked up tickets with both her gloved hands, looked at the tickets, set the tickets down at her station and then touched the top of the sandwich with her right gloved hand. Dietary aide #1 picked up and moved the bread bag with her hands, then she sorted the meal tickets with her gloved hands.-Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.At 11:19 a.m. dietary aide #1 moved a bag of bread with her gloved hands at her station. Wearing the same gloves, dietary aide #1 removed a lid from a pan at the station, touched the meal tickets, picked up and separated two plates with her gloved hands, and picked a piece of lettuce out of the pan to put on a plate. Dietary aide #1 placed the lid back on the pan and picked up and handled the meal tickets again with her gloved hands.At 11:20 a.m. while wearing the same gloves, dietary aide #1 picked up two tomato slices, placed them on a plate and then removed two toasted buns she had placed in the toaster. Wearing the same gloves, dietary aide #1 picked up two slices of cheese with her gloved hands and placed them on a plate.-Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.At 11:25 a.m. wearing the same gloves, dietary aide #1 placed the sliced cheese onto a burger patty and bottom bun, and moved the lettuce and tomato to the top of the burger patty. Dietary aide #1 then added the top bun on top of the burger. Wearing the same gloves, dietary aide #1 picked up meal tickets, sorted them and set them back down at her station.At 11:28 a.m. while wearing the same gloves, dietary aide #1 picked up two pieces of bread. She picked up five meal tickets with her hands, looked through them, set them down and then picked up three plates. Dietary aide #1 opened a bread bag, removed bread and put bread in the toaster. Dietary aide #1 then picked up meal tickets and sorted them while wearing the same gloves.-Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.At 11:33 a.m. wearing the same gloves, dietary aide #1 picked up a hamburger bun and placed a slice of cheese and sliced pickles on a bun and burger. Dietary aide #1 then picked up the meal tickets with her gloved hands, set the tickets down and then used both her gloves hands to put the bun on the top and cut the sandwich in half. -Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.At 11:36 a.m. wearing the same gloves, dietary aide #1 picked up a plate with a sandwich and pulled the plastic wrap off the plate. Dietary aide #1 used her left gloved hand to hold the sandwich and her right gloved hand to cut the sandwich with the knife. Wearing the same gloves, dietary aide #1 used her left hand to grab a pan from the stove and used a spatula to slide an omelet onto a plate. Dietary aide #1 used her left gloved hand to sprinkle cheese over the top of the omelet.Wearing the same gloves, dietary aide #1 picked up the meal tickets with both hands, set them back down and placed a plate in front of her. dietary aide #1 opened a plastic bread bag with her gloved hands, removed a bun and wrapped the bread back up and tied the plastic at the top of the bag to seal it. -Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.At 11:45 a.m. wearing the same gloves, dietary aide #1 cut a sandwich while holding the sandwich with her left hand and using her right hand to hold the knife. Dietary aide #1 then picked up a bun with her hands and placed it on the plate; with her right gloved hand she placed sliced cheese on the plate and then a piece of fresh lettuce she handled with both hands. Dietary aide #1 used her left gloved hand to add sliced pickles and then bacon slices to the sandwich with both gloved hands.-Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.At 11:50 a.m. wearing the same gloves, dietary aide #1 picked up lettuce and placed it on a bun. dietary aide #1 then placed bread on top, cut the bread and served the cut sandwich. She tied the bread bag back up with her gloved hands.At 11:55 a.m. wearing the same gloves, dietary aide #1 picked up and touched the meal tickets and set them back down at her station.At 11:59 a.m. wearing the same gloves, dietary aide #1 cut a peanut butter and jelly sandwich on a plate, holding the sandwich with her left gloved hand and using a knife in her gloved right hand. -Dietary aide #1 did not wash her hands and change her gloves after changing tasks and before handling ready-to-eat food.III. Staff interviewsThe dietary manager (DM), regional clinical resource and registered dietitian the (RD) were interviewed together on 6/25/26 at 2:30 p.m.The DM said every time you changed tasks you should wash your hands and change your gloves. The DM said if you walked away from what you were doing during the task you needed to wash your hands and change your gloves before continuing the task.The RD said he did not notice dietary aide #1 had not changed her gloves as needed during meal service but he was more focused on the diets. The RD said the dietary staff had received glove use and handwashing training during the last couple weeks (prior to the survey) that included to change gloves as often as needed and including when the staff touched their clothes. The RD said that was part of their re-inservice and it was more detailed this time than a couple weeks ago. The DM said he had them all wash their hands for hand washing training.The regional clinical resource said the staff all did return demonstrations for handwashing training.IV. Facility follow upA hand hygiene dietary education was provided by the NHA at 11:13 a.m. The inservice was provided to the dietary staff on 6/25/26 (during the survey) by the RD and the DM. It documented that kitchen staff must wash hands immediately before putting on gloves and after removing them, as well as after these specific triggers: immediately after entering the kitchen or starting a shift, touching the face, hair, clothes or body, handing trash, dirty dishes or chemical cleaning supplies, and changing tasks.Correct glove use protocols included the following: Task switching-the moment you move from handling one type of food to another; and the moment your close hand touches anything other than the food or clean prep utensils-this included touching your apron, face, hair, phone, trash cans, or a refrigerator handle.The education documented that residents have weakened immune systems. A trace amount of bacteria from a cook's hand could cause a facility-wide outbreak. Cross contamination in long-term care kitchens could cause foodborne outbreaks that were fatal to elderly residents. For kitchen staff, hand hygiene and glove use are critical infection control barriers.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of three medication carts.Specifically, the facility failed to ensure:-Residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened; and,-Medications were labelled appropriately with medication labels from the pharmacy.Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was provided by the regional clinical resource on [DATE] at 10:15 a.m. It read in pertinent part, Medication storage: If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is to be contacted for instructions regarding returning or destroying these items. Medication labeling: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. Only the dispensing pharmacy may label or alter the label on a medication container or package.II. ObservationsOn [DATE] at 7:54 a.m. Grand Heritage medication cart #1 was observed with licensed practical nurse (LPN) #4. The following items were found: There was one bottle of morphine sulfate 20 milligram per milliliter (mg/ml) oral solution stored in an appropriately labeled medication box.-However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #136.There was one vial of insulin lispro (Humalog).-However, the pharmacy label was destroyed, the box was labeled with a marker and the vial inside the box was not labelled with the resident's name or the date the medication was opened for Resident #57.On [DATE] at 8:52 a.m. the Heritage [NAME] medication cart was observed with LPN #5. The following items were found:There were three bottles of morphine sulfate 20 mg/ml oral solution stored in appropriately labeled medication boxes.-However, the individual medication bottles inside the boxes were not labeled with the resident's name or the dates the medications were opened, and the facility failed to remove discontinued medications from the medication cart in a timely manner for Resident #7 (see staff interview below).There was one fluticasone-salmeterol aerosol powder breath activated 250-50 microgram per actuation (mcg/act) inhaler stored in an appropriately labeled medication box.-However, the individual inhaler inside the box was not labelled with the resident's name or the date the medication was opened for Resident #96.On [DATE] at 9:07 a.m. the Medbridge medication cart was observed with the infection preventionist . The following item was found:There was one fluticasone-salmeterol (Wixela Inhub) aerosol powder breath activated 500-50 mcg/act inhaler stored in an appropriately labeled medication box.-However, the individual inhaler inside the box was not labelled with Resident #87's name.III. Staff interviewsLPN #4 was interviewed on [DATE] at 7:54 a.m. LPN #4 said it was important for the individual medication bottles labelled inside their respective boxes so the staff could identify who the medication belonged to if the box was damaged or lost.LPN #5 was interviewed on [DATE] at 8:52 a.m. LPN #5 said Resident #7 expired on [DATE], but her narcotic medications were still in the medication cart. He said Resident #7's other medications had already been removed from the medication cart, but the narcotic medications were still there because they were considered sensitive. LPN #5 said the director of nursing (DON) was responsible for removing items from the medication cart after a resident expired.LPN #5 said it was important to ensure the individual medication bottles were labelled inside their respective boxes in case the box was damaged or lost. LPN #5 used a marker to label the identified items in his medication cart with the residents' names.The infection preventionist was interviewed on [DATE] at 9:15 a.m. The infection preventionist said it was important to ensure the medications were labelled inside their respective boxes to prevent medication errors if the medication did not get returned to its box or if the box was lost. The infection preventionist used a marker to label the identified item in her medication cart with the residents' name.The DON was interviewed on [DATE] at 10:00 a.m. The DON said the handwritten label in place of the pharmacy label on the vial of insulin lispro was not an appropriate medication label. She said it was important to ensure the medication bottles were appropriately labelled inside their boxes to avoid medications from getting mixed up if the boxes were missing. The DON said nurse management or floor staff were responsible for removing medications from the medication carts after a resident expired. She said narcotics required two nurses for proper disposal of the medication from the medication cart to a safe to be destroyed, and she expected medications to be removed from the medication cart within 24 hours of the resident's expiration.

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment in three of four units.Specifically, the facility failed to:-Ensure the blinds, window sills, wall air conditioners and walls in resident rooms were clean and in good repair; and,-Ensure facility spas were in good working condition and the tile was in good repair. Findings include: I. Facility policy and procedure The Homelike Environment Policy, revised February 2021, was provided by the nursing home administrator (NHA) on 6/25/26 at 7:55 a.m. It read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment; inviting colors and décor personalized furniture and room arrangements. The Cleaning and Disinfecting Residents' Rooms policy, revised February 2026, was provided by the NHA on 6/25/26 at 7:55 a.m. It read in pertinent part, Resident rooms are cleaned regularly and as needed by housekeeping/environmental services. If the resident is in their room, request permission to enter and clean the room. If the resident is sleeping, showering, dressing, using the toilet, eating, or has visitors, reschedule the cleaning. Do not interrupt the resident during these activities to clean the room. Check the blinds, curtains, and windows. Clean if necessary. Terminal room cleaning: Check the blinds, curtains, and windows. Clean if necessary. II. Ensure the blinds, window sills, wall air conditioners and walls in resident rooms were clean and in good repair A. Observations On 6/21/26 at 3:15 p.m. the blinds in resident room [ROOM NUMBER] were coated with visible dust and cob webs. There were dead bugs in the window sill. On 6/21/26 at 4:48 p.m. Resident room [ROOM NUMBER] was observed to have a layer of dust on the window sill. There was dust and small pieces of debris in the wall air conditioner. On 6/22/26 at approximately 10:30 a.m. resident room [ROOM NUMBER] was observed to have multiple brown spots of various sizes, from approximately one quarter of an inch to one inch on the wall behind the bed from the privacy curtain in the middle of the room to the far wall. On 6/22/26 at 2:20 p.m. resident room [ROOM NUMBER] was observed to have approximately one inch of wallpaper missing around the perimeter of the walls of the bathroom between the baseboard and the wall. The edge of the wallpaper was peeling around the entire bathroom where the missing strip of wallpaper was. On 6/22/26 at 2:30 p.m. there was a hole observed the bathroom door of resident room [ROOM NUMBER]. On 6/24/26 at 10:05 a.m. Resident #121's wheelchair was observed to have small particles of white and gray dust and debris on one side of her wheelchair. On 6/24/26 at 10:10 a.m. room [ROOM NUMBER] was observed to have a missing door bolt, latch and face plate. Part of the door around the door handle was broken off and missing and exposed the interior of the door. On 6/24/26 at 3:10 p.m. room [ROOM NUMBER] was observed to have cob webs in the windowsill. The window jambs (sides and edge of the window opening) on the top and sides had multiple small pinpoint black spots. Wallpaper had peeled off the top and side window jambs and was hanging off the jamb approximately 2-3 inches for the three sides of the window. There was dust and debris inside the wall air conditioner and on the knobs. The wallpaper near the door to the room separated from the wall at the seams approximately six inches in length. The edge of the wallpaper was peeling around the entire bathroom where the missing strip of wallpaper was. B. Resident interviews The resident in room [ROOM NUMBER] was interviewed on 6/21/26 at 3:15 p.m. Resident #121 said the blinds in her room did not block the sun and she put the curtains up (over the blinds) a year ago. The resident in room [ROOM NUMBER] was interviewed on 6/24/26 at 10:05 a.m. Resident #109 said the dust from the wall air conditioner blew on her wheelchair leaving dust and debris on her wheelchair. The resident in room [ROOM NUMBER] was interviewed on 6/21/26 5:05 p.m. Resident #142 said her door was broken and had gotten stuck in the closed position and the maintenance director had to use tools to open the door. The resident in room [ROOM NUMBER] was interviewed on 6/22/26 at 2:30 p.m. Resident #105 said the hole was in the door prior to her moving into the room. She said she did not know what caused the hole. Resident #105 said no facility staff member had offered to fix it. The resident in room [ROOM NUMBER] was interviewed on 6/24/26 at approximately 3:10 p.m. Resident #10 said to look at the window in his room. Resident #10 said the wallpaper was peeling off his window. He said the facility sprayed the black spots in the window with bleach but the black spots did not disappear. Resident #10 said he did not have a window screen for his window. C. Staff interviews The housekeeping supervisor was interviewed on 6/25/26 at 2:13 p.m. The housekeeping supervisor said the staff had cleaned the bathroom walls in room [ROOM NUMBER], but the wallpaper was still brown and peeling from the bottom. She said the staff tried to clean the walls everyday but sometimes it was hard because the resident would be in the room and not let them clean. She said the resident in #305 would not let the staff clean the blinds because the resident had breathing problems. The housekeeping supervisor said that when staff did a deep clean, they cleaned the mattress, frame of the bed, privacy curtain, closet, walls, clean sheets, linens, pillow and cleaned the bathroom. She said the staff tried to clean the walls when a resident was discharged because it was very difficult to clean the walls while the resident was in the room. She said the air conditioning units were cleaned during the deep cleans and the staff dusted the unit and took the filters out and dust them. She said her staff deep cleaned everyday as best as they could if the resident let them. She said that her staff would tell her when they see something was broken or needs repaired and then she would let maintenance know. She said that window sills should be cleaned every day and privacy curtains should be cleaned on deep cleans. She said there was a list of rooms for each day that should be getting deep cleaned. She said she had permanent people scheduled for their permanent areas and those people have their certain duties. She said she would have her staff do their assigned duties first then she would walk their halls and point things out to them and have them clean those areas. She said that the shower rooms are cleaned everyday, sometimes more than once. She said that the certified nurse aides (CNAs) were responsible to clean after each resident. She said she was unsure of what the CNAs used to clean the showers. The NHA was interviewed on 6/25/26 at 4:06 p.m The NHA said they were remodeling the dry wall, FRP (fiberglass reinforced panels), blinds, lights, and were taking down wall paper in the facility. He said the door to room [ROOM NUMBER] was stuck and the maintenance director had to use something to open the door and it was going to be repaired and had been broken for approximately 10 days to two weeks. The NHA said room [ROOM NUMBER] had been sprayed in the window jamb. The NHA said when the facility turned rooms after a resident discharged they painted and cleaned the air conditioner, and there was no documentation of refusal to allow room cleaning. II. Failed to ensure facility spas were in good working condition A. Resident interview Resident #105 was interviewed on 6/22/26 at 2:30 p.m. Resident #105 said the shower head in the shower room was broken and wrapped with coban wrap (a lightweight, self-adhering wrap that is often used to secure dressings). She said she struggled to shower, because she used one hand to hold the shower head up and the other hand to support her nephrostomy site (a procedure to insert a thin catheter through the lower back directly into the kidney). B. Observations of shower rooms On 6/24/26 at 9:29 a.m. the following was observed: Outside of the Heritage [NAME] shower room, approximately one to two feet away from the door of the shower room, the ceiling tile was stained a yellow color and was drooping down. The paint on the wall beneath the ceiling tiles was bubbling and felt damp to the touch. The bubbled paint started from the ceiling and went halfway down the wall. The wall below where the paint was bubbled, dipped into where the floor meets the wall was visible. The floor appeared to be warped and was also soft when stepped on. Inside the entrance of the shower room there was about two and a half to three feet of tile missing from the baseboard of the shower room. The wall behind the missing tile was also damaged. There were four to five gouges missing from the wall. There was four to five inches of wall completely missing. There were pieces of the wall sitting crumbled on the floor. Inside the shower room stall the floor was wet from a leak that was dripping from the ceiling from a small hole (approximately one inch by one inch), the tiled floor was visibly wet. There was about a foot to a foot and a half of cracked tile inside the shower stall. On 6/24/26 at 9:50 a.m. the following was observed: Inside the Grande Heritage shower room the first and third shower stalls had coban wrapped around the shower heads and the shower head holders. On 6/24/26 at 9:57 a.m. the following was observed: Inside the Medbridge shower room stall (located on the second floor directly above the Heritage [NAME] shower room) there was a visible space (approximately half an inch) in the caulking where the floor tile meets the wall tile. C. Staff interviews CNA #3 was interviewed on 6/24/26 at 1:00 p.m. CNA #3 said the hole along the bottom of the entrance in the Heritage [NAME] shower room happened, because of equipment running into it. She said maintenance was aware of the damaged wall and had tile coming. She said she was not aware of the dripping hole in the ceiling. CNA #4 was interviewed on 6/24/26 at 1:09 p.m. CNA #4 said that she was unsure of how long the coban had been wrapped on the shower heads in Grande Heritage's first and third shower stalls. She said she thought the coban was there to help stop the leaking of the shower heads when they were being used. CNA #5 was interviewed on 6/24/26 at 1:19 p.m. CNA #5 said that the reason they used that first stall in the Medbridge shower room was because the other ones did not have the heat lights installed and the residents would get really cold without the heat lights. The maintenance director was interviewed on 6/24/26 at 2:30 p.m. The maintenance director said he was aware of the wall and ceiling outside of the Heritage [NAME] shower room. He said it was coming from the Medbridge shower room. He said he had caulked the Medbridge shower but needed to do it again. He said he was not aware that the moisture had gotten down into the lower part of the wall and the flooring outside of the Heritage [NAME] shower room. He said he was aware of the missing tiles inside of the Heritage [NAME] Shower room & the cracked tiles inside the shower stall. He said the tiles were on order and was waiting for them to come in. He said he was unaware of the leak inside the Heritage [NAME] shower stall. The maintenance director said that the shower heads and shower head holders in the first and third shower stalls in the Grande Heritage shower room, were on back order. He said he had ordered them and was notified they were on backorder. He said he wanted the same ones as before because he did not want to add more holes in the shower stalls by having to drill different holders into the showers.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection on two of four units. Specifically, the facility failed to:-Ensure housekeepers cleaned high-touch areas, used proper dwell times, used proper cleaning and disinfecting techniques and performed hand hygiene when cleaning residents' rooms;-Ensure staff followed enhanced barrier precautions (EBP) when providing care); and, -Ensure residents did not enter the soiled linen room.Findings include:I. Failed to ensure housekeepers cleaned high-touch areas, used proper dwell times, used proper cleaning and disinfecting techniques and performed hand hygiene when cleaning residents' roomsA. Professional referenceAccording to the Centers for Disease Control (CDC) Environment Cleaning Procedures (3/19/24), retrieved on 7/2/26 from https://www.cdc.gov.healthcare-associated-infections/hcp/cleaning-global/procedures.html, it read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. General surface cleaning process: Thoroughly wet (soak) a fresh cleaning cloth in the environmental cleaning solution. Fold the cleaning cloth in half until it is about the size of your hand. This will ensure that you can use all of the surface area efficiently (generally, fold them in half, then in half again, and this will create 8 sides). Wipe surfaces using the general strategies as above (clean to dirty, high to low, systematic manner), making sure to use mechanical action (for cleaning steps) and making sure to that the surface is thoroughly wetted to allow required contact time (for disinfection steps). For higher-risk areas, change cleaning cloths between each patient zone (use a new cleaning cloth for each patient bed). Common high-touch surfaces include: bedrails, IV poles, sink handles, bedside tables, counters where medications and supplies are prepared, edges of privacy curtains, patient monitoring equipment ( keyboards, control panels), transport equipment (wheelchair handles), call bells, doorknobs, light switches High-touch and frequently contaminated surfaces in toilet areas (handwashing sinks, faucets, handles, toilet seat, door handles) and floors.The CDC/ Environment Cleaning Procedures (revised 3/19/24) was retrieved on 7/2/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/supplies-and-equipment.html#cdc_generic_section_6-3-4-personal-protective-equipment-for-environmental-cleaning.It read in pertinent part, Best practices for glove usage for cleaning: perform hand hygiene immediately before putting on gloves and directly after taking them off. When use of gloves is indicated, always change them between each cleaning session (routine cleaning of a patient zone under contact precautions, terminal cleaning of a general patient area).According to the Spartan Chemical Company, Inc. Retrieved from: https://www.spartanchemical.com/search?s=BNC-15 on 7/2/26. It read in pertinent part BNC-15 disinfectant had a Three-minute contact time for most bacteria and viruses, and a five-minute contact time for norovirus B. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy and procedure, revised February 2026 was received from the nursing home administrator (NHA) on 6/25/26 at 7:51 a.m. It read in pertinent part, Apply gloves and other personal protective equipment (PPE) as indicated. Clean all high-touch areas with disinfectant solution: beside tables, overbed tables, chairs, phones, beds, lights, call bells, and bedrails. Mop the floors. Discard mop solution. Remove gloves and perform hand hygiene.C. ObservationsDuring a continuous observation on 6/23/26, from 12:07 p.m. to 12:30 p.m., housekeeper (HK) #1 was cleaning room [ROOM NUMBER], a double-occupancy room on the Grand Heritage unit. HK #1 used hand sanitizer and put on a pair of gloves. She pulled out her broom and dustpan from her cleaning cart and started sweeping side A (side closest to the door). She swept under his bed and picked up a box of Kleenex from the floor and put it on his bedside table. She then went directly to side B to sweep. She raised side B's bed and swept underneath. There was a fall mat leaning against a bedside table, she did not move the mat to sweep on the other side. She leaned her broom against pillows that were in a chair, then leaned down to remove a trash bag from side B's trash can. She then placed the trash bag into the dustpan. She then grabbed her broom and touched the pillows with her gloved hands, and emptied the dustpan into the trash compartment on her cart and replaced the broom and dustpan on her cart. HK #1 grabbed one clean rag from her cart and a red colored disinfectant, BNC-15. HK #1 did not change her gloves. She then sprayed the rag approximately five times, the rag was not saturated with the BNC-15 disinfectant. She then wiped down side A's television and then cleaned side B's television. She then wiped the windowsill and air conditioning unit. She then wiped above the lamps that were connected to the wall. She then moved to side A and wiped his bedside table. The areas that she wiped were visibly wet for five seconds or less. She then returned to her cart. She did not change her gloves.-HK #1 did not disinfect high-touch areas such as the residents' call light or bed remotes for the residents on either side of the room. -HK #1 did not use separate rags for each side of the room. The surfaces wiped with the rag with BNC-15 did not stay wet for the three-minute dwell time (see professional reference above). HK #1 grabbed the toilet brush and the receptacle that it was sitting in, out of the housekeeping cart. The toilet brush was sitting in the receptacle in a blue liquid. The toilet brush head was completely covered in the blue liquid. HK #1 opened the bathroom door and set the toilet brush receptacle and the toilet brush in the bathroom on the floor. She then returned to the cart and she grabbed a blue rag and a red rag and the BNC-15 disinfectant. She then went to the bathroom and sprayed the toilet with the BNC-15 disinfectant. She then sprayed the blue rag with the BNC-15 approximately five times, the rag was not saturated. She then wiped the mirror, towel rack, and then the sink. She then checked her phone and confirmed she had let the BNC-15 sit for three minutes on the toilet. She then flushed the toilet, put the blue cleanser that the toilet brush was sitting in inside the toilet, then cleaned the inside of the toilet bowl, she then tapped the toilet brush three times on the rim of the toilet to get the excess liquid off the brush then returned the toilet brush to its receptacle. She then wiped down the outside of the toilet with the red rag. She then took the bag of trash out of the trashcan, sprayed the trashcan with the BNC-15 and using the red rag she immediately wiped the trashcan and then put in a new trash bag. She then took the two rags, toilet brush receptacle and put them in her cart. She then took off her gloves and performed hand hygiene and put on new gloves. She then reached into the mop bucket and pulled two mop pads out. She put one on her mop handle and proceeded to push the mop from the door way on side A over to side B. She mopped the entirety of side B then proceeded to mop side A using the same mop pad. She then pulled the mop pad off and replaced it with the clean one she had pulled out earlier. She then mopped the bathroom. She pulled off the mop pad and then put the two mop pads in the dirty container on her cart. She then swept up the lint and debris with her broom and dustpan. She took off her gloves and performed hand hygiene. -HK #1 did not disinfect high-touch areas such as the residents' call light or door handles for the shared bathroom. The surfaces wiped with the rag with BNC-15 did not stay wet for the three-minute dwell time (see professional reference above). During a continuous observation on 6/24/26, from 8:45 a.m. to 8:55 a.m., HK #2 was cleaning room [ROOM NUMBER], a single-occupancy room on the Heritage unit.HK #2 performed hand hygiene and put on a pair of gloves. She entered the room and opened the bathroom door and sprayed the toilet and sink with BNC-15 disinfectant. The sink had personal hygiene items (toothbrush and toothpaste) sitting on the counter. She did not move the items prior to spraying the disinfectant. She then closed the bathroom door and sprayed a rag about five times with the BNC-15 disinfectant. The rag was not saturated with the disinfectant. She then wiped the side table and then the window sill. She emptied the trash can and then disposed of the bag in her cart. She did not change her gloves. -HK #2 did not disinfect high-touch areas such as the residents' call light or bed remotes for the resident in the room. The surfaces wiped with the rag with BNC-15 did not stay wet for the three-minute dwell time (see professional reference above). -HK #2 did not move the resident's personal hygiene items before spraying the disinfectant.HK #2 then swept the room. She then emptied the dustpan and replaced the broom and dustpan on her cart. She then grabbed two rags one green and one blue and took the toilet brush receptacle and disinfectant into the bathroom. She then poured some of the blue cleaner into the toilet bowl and cleaned the inside of the toilet with the toilet brush. She then used the green cloth to wipe down the sink. She then used the blue cloth to wipe the outside of the toilet. She then used the green cloth to wipe the handrail. She then went to her cart and replaced the toilet brush receptacle and discarded the dirty rags. She did not change her gloves. HK #2 reached into the cart and pulled out a mop pad from the mop bucket using the same gloves. She then mopped the bathroom floor. She then took that mop pad off of the mop handle and put it in the dirty area of her cart. She then reached in and grabbed another mop pad, using the same gloves and mopped the room. When she finished mopping the room she discarded the mop pad into the dirty area on her cart and then took off her gloves and performed hand hygiene. -HK #2 failed to change her gloves and perform hand hygiene after cleaning the toilet-HK #2 did not disinfect high-touch areas such as the residents' call light or door handles in the bathroom. The surfaces wiped with the rag with BNC-15 did not stay wet for the three-minute dwell time (see professional reference above). D. Staff interviewsHK #1 was interviewed on 6/23/26 at approximately 12:30 p.m. HK #1 said the BNC-15 had a three-minute dwell time. She said that she did not spray the room with the BNC-15, but she sprayed the toilet and let the disinfectant sit for three minutes. HK #2 was interviewed on 6/24/26 at 9:02 a.m. HK #2 said that high-touch areas were tables, lights, television controls, everything that the resident touches. She said she changed her gloves and performs hand hygiene when she left a room and when she cleaned the bathroom. The housekeeping supervisor was interviewed on 6/24/26 at 2:10 p.m. The housekeeping supervisor said the housekeepers should be spraying the rags, so that the rags were saturated with the disinfectant so that the areas that they were wiping will have a dwell time of three minutes. She said high-touch areas were door knobs, telephones, light switches, call lights and bed controls. She said the housekeepers should be cleaning all of those areas. She said the housekeepers should be using different rags for double-occupancy rooms. She said housekeepers should also use different mop pads for each side of the room. She said that housekeepers should not be tapping the toilet brush on the toilet, she said they should not do that because the contents and debris that is on the toilet brush could be sprayed on to other surfaces in the bathroom. She said housekeepers should always take their gloves off and perform hand hygiene after cleaning the toilet and bathroom and that they should not be spraying disinfectant near residents' personal hygiene items. II. Failed to ensure staff followed EBP A. Professional referenceAccording to the CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 7/2/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, it read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.B. Facility policy and procedureThe Enhanced Barrier Precautions policy and procedure, undated, was received from the NHA on 6/25/26 at 7:51 a.m. It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.)Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. Implementation of Enhanced Barrier Precautions: make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities include: Dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters, wound care: any skin opening requiring a dressing.C. ObservationsOn 6/22/26 at 10:02 a.m. Two unidentified certified nurse aides (CNA) were providing incontinence care for Resident #2. The two CNAs were not wearing gowns. After finishing Resident #2's incontinence care the two unidentified CNAs transferred Resident #2 into her wheelchair using the Hoyer lift (a mechanical lift). Resident #2 had an indwelling catheter. There was an EBP sign on the door along with the EBP supplies such as gowns and gloves. -The two unidentified CNAs failed to don the correct PPE when providing direct care to Resident #2, who was on EBP.On 6/23/26 at 10:46 a.m. Resident #150 was being assisted out of the shower room in the shower chair by an unidentified CNA. The unidentified CNA was not wearing a gown. Resident #150 had an enteral tube feed. The unidentified CNA did not put on a gown when entering Resident #150's room. CNA #3enteredResident #150's room to assist with care and did not put on a gown. Resident #150's door had an EBP sign as well as gowns and gloves. D. Staff interviewsCNA #3 was interviewed on 6/24/26 at 11:07 a.m. CNA #3 said she did not need to put on a gown when providing catheter care or showers to residents with tube feed or wounds. She said she did not need to wear a gown when providing incontinence care for residents with tube feeds, catheters, or wounds. CNA #6 was interviewed on 6/24/26 at 11:51 a.m. CNA #6 said she would ask the nurse if a resident was on EBP and why they needed EBP. She said if a resident was on EBP she would wear a gown, gloves, and a mask if needed. She said she would also make sure to wash her hands with soap and water. Licensed practical nurse (LPN) #6 was interviewed on 6/24/26 at 12:21 p.m. LPN #6 said there were different types of EBP. She said she would normally wear a gown, gloves and depending on the precautions, goggles or a mask. She said the PPE should be put on before entering the room and taken off before exiting the room. The infection preventionist (IP) was interviewed on 6/24/26 at 4:03 p.m. The IP said education was provided on EBP annually to all staff during the skills fair. She said any resident that had an open wound that needed to be covered, indwelling device, dialysis, PICC line, PEG tube, IV, and ostomy would have EBP. She said that there were signs on the doors of residents' that were on EBP. She said that she would do rounds on the floor to make sure that staff were using the EBP. She said that she would complete additional training and reeducation with staff who did not use the precautions. She said the staff who were observed not wearing the PPE should have been wearing PPE because they were performing high-contact activities. The director of nursing (DON) was interviewed on 6/25/26 at 11:45 a.m. The DON said that EBP should be followed for residents with wounds, catheters, and tube feeds. She said staff should be wearing at a minimum gowns and gloves. She said it was important for staff to wear the correct PPE because they could potentially introduce bacteria into the open area. III. Failed to ensure residents did not enter the soiled linen roomA. Professional referenceAccording to the CDC Laundry and bedding guidelines from the Guidelines for Environmental Infection Control in Health-Care Facilities (2003), retrieved on 7/2/26 from, https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.htmlIt read in pertinent part, The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patients' rooms, surgical/operating areas, and laboratories. Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage. Single bags of sufficient tensile strength are adequate for containing laundry, but leak-resistant containment is needed if the laundry is wet and capable of soaking through a cloth bag. Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service.B. ObservationOn 6/22/26 at 10:04 a.m. Resident #53 was helping Resident #113 open the soiled linen door. The soiled linen door had a coded lock. Resident #113 was able to push the correct code and start to open the door. Resident #53 then helped Resident #113 push the door open even more. Resident #113 tried to look through the bags of the soiled linens but then Resident #53 let the door close and both residents left the area. On 6/22/26 at 10:10 a.m. an unidentified CNA came out of a resident's room carrying soiled linen in a bag. The unidentified CNA opened the soiled linen door and Resident #113, came up to the CNA and began speaking to her. The CNA held the door open to the soiled linen room and Resident #113 began looking through the bags of soiled linens. The CNA then asked Resident #113 if she wanted to go and ask the laundry staff if they had seen any of her clothing. Resident #113 agreed. The CNA did not help Resident #113 wash her hands after going through the soiled linen. C. Staff interviewsCNA #3 was interviewed on 6/24/26 at 11:07 a.m. CNA #3 said that the soiled linen door was locked and residents cannot get in. She said she had never seen residents in that room. Registered nurse (RN) #2 was interviewed on 6/24/26 at 3:39 p.m. RN #2 said that the door to the soiled linen closes and locks automatically and that nurses and CNAs have the code for the door. She said she had never seen residents go into the soiled linen room before. The DON was interviewed on 6/25/26 at 11:45 a.m. The DON said it was not alright for residents to be in the soiled linen room. She said it was not okay for residents to be looking through bagged soiled linens. She said the staff member should not have allowed Resident #113 to look through the bags.

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for two (#163 and #155) of three residents reviewed for discharge planning out of 62 sample residents. Specifically, the facility failed to:-Ensure the discharge planning process was documented, including the reason for discharge in Resident #163's electronic medical record (EMR); -Ensure the reconciled medication list, physician's orders and care plan provided to the resident at discharge were documented in Resident #163 and 155's EMRs;-Ensure Resident #155's discharge care plan was updated to include the resident's preference to transfer to another facility; and,-Ensure Resident #155's EMR contained documentation of the preparation provided to the resident prior to transfer to another facility in a form and manner the resident could understand. Findings include: I. Resident #163 A. Resident status Resident #163, age less than 65, was admitted on [DATE] and discharged on 10/31/25. According to the October 2025 computerized physician orders (CPO), diagnoses included acute respiratory failure, myocardial infarction (heart attack), end stage renal disease (loss of kidney function), congestive heart failure, vascular dementia (disrupted thinking caused by lack of blood flow to the brain) and metabolic encephalopathy (altered brain function). The 10/31/25 minimum data set (MDS) assessment documented in the staff assessment for resident cognition that the resident did not have a memory problem and was independent in making decisions regarding daily life. The assessment also revealed the resident needed partial to moderate assistance with activities of daily living (ADL) and was independent at meal time. The 10/31/25 MDS assessment documented the resident's discharge was an unplanned discharge and that the resident was discharged to a short-term general hospital. The assessment did not indicate the provision of the reconciled medication list to the resident at the time of discharge. -However, a review of the resident's discharge summary and staff interviews (see below) documented the resident discharged home and the discharge summary documented the resident was provided with a medication list. B. Record review The discharge care plan, initiated 10/1/25 and revised 12/19/25, documented Resident #163 would remain at the facility for long-term care due to her needing 24-hour nursing care and her family being unable to care for her at home. Pertinent interventions, initiated 10/1/25 and revised 12/19/25, included to encourage the resident's family to provide personal items as needed to create a more homelike environment; provide an arena such as interdisciplinary team (IDT) care conference for the resident, family and/or interested party to address plans for discharge and participate in the discharge planning process; review the plan of care as needed; and social services to schedule IDT care plan meetings upon admission, quarterly, and as needed. The 10/31/25 discharge summary and post-care instructions, provided by the nursing home administrator (NHA) on 6/24/26 at 10:00 a.m., revealed the following: The introduction documented copies of applicable documents were reviewed and provided to you (Resident #163). Please contact your primary care provider for further instructions. The discharge location was documented as home/community. The reason for discharge was documented as other, with no additional information documented as the reason for discharge. The primary care physician and the list of resources provided was not documented. The resident was documented as medically/therapeutically cleared for discharge, however the provider note on 10/30/25 failed to document any discharge notes. The records documented as provided were a medication list and care plan sent by paper (fax, copy of orders) with the resident. -However, the medication list and the care plan were not included in the discharge summary. The resident's name was typed in the signature of the receipt box but did not include a date of receipt. A review of Resident #163's EMR revealed the following: An 11/1/25 alert note documented Resident #163 was not in the facility and texted the director of nursing (DON) and staff would continue to follow up. An 11/1/25 EMR administration note documented Resident #163 was in the hospital. An 11/2/25 EMR administration note documented the resident was hospitalized . -However, according to the discharge evaluation and staff interviews (see above and below) the resident had been discharged home. C. Staff interviews The NHA, the DON, regional clinical resource #1 and regional clinical resource #2 were interviewed together on 6/25/26 at 4:00 p.m. The NHA said Resident #163 was informed she had community medicaid at her dialysis appointment and when that was communicated to the resident's niece, the niece said she would take the resident home. The NHA said the resident was to go to her appointment at the hospital and then discharge home with her niece. The DON said the resident's name could be electronically input into the discharge evaluation but no date was added. Regional clinical resource #1 said when the facility discharged Resident #163, the resident was not taken out of the system. Regional clinical resource #1 said the facility would submit a corrected MDS assessment for Resident #163 that updated her discharge location from the hospital to home. Regional clinical resource #2 said Resident #163 was not supposed to be listed as an active resident after discharge so the nurses were documenting the resident was still in the hospital (see above). The DON said the SSD could update the discharge plan, or the nursing staff could. II. Resident #155 A. Resident status Resident #155, age less than 65, was admitted on [DATE] and discharged on 1/27/26. According to the January 2026 CPO, diagnoses included chronic respiratory failure with hypoxia (lungs cannot adequately transfer oxygen to the bloodstream), malignant neoplasm of connective and soft tissue of right lower limb, including the hip (cancer of the soft tissue), and hypothyroidism. The 1/27/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The assessment revealed the resident needed moderate to substantial assistance for most of her ADLs. The 1/27/26 MDS assessment documented the resident's discharge was a planned discharge. The 1/27/26 MDS assessment documented the resident discharged to a skilled nursing facility. The 1/27/26 MDS assessment did not document provision of the current reconciled medication list to subsequent providers at discharge or to the resident at discharge. B. Record review The discharge care plan, initiated 5/23/25 and revised 2/1/26 (after her discharge), documented Resident #155 would remain in the facility for long-term care due to her need for 24-hour nursing care. Pertinent interventions included encouraging the resident to put personal items, as needed, in her room to create a homelike environment, reviewing the plan of care quarterly or as needed, social services to plan IDT care plan meetings upon admission, quarterly, and as needed. -However, the care was not updated to reflect the resident's preference to discharge to another facility. The 1/27/26 discharge summary and post-care instructions, provided by the NHA on 6/24/26 at 10:00 a.m., revealed the following: Resident #155's discharge location was documented as another skilled nursing facility. The reason for discharge was documented as resident preference. The records documented as provided were a medication list and care plan sent by paper (fax, copy of orders) with the resident. -However, the medication list and the care plan were not included in the discharge summary. A review of the resident's EMR revealed the following: A social services note, dated 2/19/25 at 9:59 a.m., documented that the business office assistant and the social services assistant spoke with Resident #155 about Medicaid redetermination and the need for her most recent bank statements. The note further documented that the business office assistant also spoke to the resident about the facility not receiving full payments. The note documented that the resident did not want to make full payments due to her purchasing her own food and medical supplies. -However, there were no further follow-up notes or documentation found in the resident's EMR about nonpayments. A social services note, dated 7/21/25 at 5:22 p.m., documented that Resident #155 wanted to obtain her state identification card and a copy of her social security card. The note documented that the resident hoped to discharge from the facility once she was clinically stable and she would apply for social security once she was discharged from the facility. The note documented that discharge planning was not done at that time. -However, no other follow-up notes or documentation were found in the resident's EMR about discharge plans or planning. Provider notes dated, 7/27/25, 10/23/25, 11/20/25, 12/10/25, 12/30/25 and 1/9/26 all documented, Resident #155 was planning to transition to the community within the month. The resident handled her own right hip wound by herself at the facility. She was able to manage her own finances plus other issues with the help of a transitioning team. The resident was informed she would get a three month supply of basic medications at discharge and continued to work with the facility. -However, discharge planning documentation was not found in the resident's EMR. A social services note, dated 1/22/26 at 3:40 p.m., documented that medical records and pertinent paperwork were sent per the resident's request. A social services note, dated 1/26/26 at 12:08 p.m., documented that medical records and pertinent paperwork were sent per the resident's request. -However, the note did not document the reason why records were being sent. A discharge summary note, dated 1/27/26 at 1:10 p.m., documented Resident #155 was being discharged to another facility. The note documented the resident left the facility around 12:00 p.m. with her belongings and that one of the facility's van drivers drove her to the new facility. The note documented the resident was in her wheelchair and was stable upon leaving. C. Staff interviews The NHA, the DON, regional clinical resource #1 and regional clinical resource #2 were interviewed together on 6/25/26 at 4:00 p.m. The NHA said that Resident #155 had not paid her share of cost and that the facility had gone to meet with her to discuss her payments. He said that Resident #155 told them that she was never going to pay her full payment. He said that they had discussed the different options and that Resident #155 was okay with being discharged to another facility. He said that Resident #155 was happy when they discussed where she would be going because they would accept her without payment. He said they had discussed the 30-day notice with the ombudsman, but because they were under the understanding that Resident #155 wanted to go, they did not notify the ombudsman when she was discharged . He said that there was no documentation of the conversations that were held with Resident #155. He said the facility should have updated Resident #155's care plan to reflect her preferences to discharge.

Based on observations, record review and interviews, the facility failed to provide catheter care in accordance with standards of professional practice for one (#118) of three residents out of 62 sample residents.Specifically, the facility failed to ensure:-The urinary catheter was changed timely for Resident #118; and,-Resident #118, who was incontinent of the bladder, received appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to the extent possible.Findings include:I. Facility policy and procedureThe Catheter Care policy, revised August 2022, was provided by the nursing home administrator (NHA) on 6/25/26 at 7:55 a.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections (UTI). Changing catheters: Residents who form encrustations that can quickly lead to an obstruction need more frequent catheter changes at intervals specific to the individual resident. The catheter should be changed before a blockage is likely to occur. When changing a long-term indwelling catheter, leave the catheter out for at least one hour, but no longer than two hours, to allow the urethral glands to drain. Complications: observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately: in the event of bleeding, or if the catheter is accidentally removed; if the resident complains of burning, tenderness or pain in the urethral area; or, if signs and symptoms of UTI or urinary retention occur.II. Resident #118A. Resident statusResident #118, age greater than 65, was admitted to the facility on [DATE]. According to the June 2026 computerized physician orders (CPO), the diagnoses included a history of UTI, a history of sepsis, benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of the bladder and a history of epididymitis (inflammation of the coiled tube behind the testicles responsible for storing and carrying sperm - commonly caused by bacterial infections, including UTI).The 5/22/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required substantial/maximal assistance with toileting and partial/moderate assistance with mobility.The 5/22/26 MDS assessment revealed the resident used an indwelling catheter.B. Resident interviewResident #118 was interviewed on 6/22/26 at 4:38 p.m. Resident #118 said it had been a long time since his urinary catheter was changed. He said it was last changed on 5/10/26 and it hurt so (explicit language) bad. Resident #118 said he screamed when the nurse inserted the catheter, and the nurse told him it would get better. He said the next morning he was covered in a pool of blood so deep it went up to his elbow while he was sitting up in bed. Resident #118 said the facility called the ambulance and sent him to the hospital where he was diagnosed with supraventricular tachycardia (SVT - an abnormal heart rhythm where the heart beats between 150 to 220 beats per minute) and traumatic Foley replacement.Resident #118 was interviewed again on 6/23/26 at 2:35 p.m. Resident #118 said urinary catheter changes were always uncomfortable, but the pain associated with the 5/10/26 catheter change was off the chart. He said he asked the nurse to stop and slow down during the catheter insertion, but the nurse told him the pain would improve. Resident #118 said after the nurse left his room he was able to fall asleep but woke up around 9:00 a.m. with a gross feeling. He said he lifted up the sheets and about stroked out because he was covered in blood.C. Record reviewResident #118's catheter care plan, initiated 12/18/25, revealed the resident had an indwelling catheter. Pertinent interventions included changing the catheter per the facility's policy and the physician's order; providing catheter care and emptying the catheter every shift and as needed; keeping the catheter anchored for security and to prevent trauma; and, notifying the physician of signs and symptoms of UTI such as mental status changes, foul smelling urine, color change in urine, hematuria (bloody urine), sedimentation, burning with urination and increased temperature.Review of the 5/11/26 urologist documentation revealed the following standard written physician's order:16 Fr Foley catheter with 5 ml of water in the balloon. Change once per month, ordered 5/11/26.-However, the facility failed to enter the physician's order from the urologist into the resident's electronic medical record (EMR).Review of Resident #118's June 2026 CPO revealed the following physician's orders:Indwelling catheter: 18 French (Fr) catheter with 10 milliliters (ml) of water in the balloon. Change as needed (PRN) for dislodging, leaking, obstruction, or clogging of the catheter, ordered 5/20/26 and discontinued 6/24/26.Indwelling catheter: 16 Fr catheter with 5 ml of water in the balloon. Change PRN for dislodging, leaking, obstruction, or clogging of the catheter, ordered 6/24/26 (during the survey).The 5/10/26 nursing progress note documented at 10:04 a.m. revealed report was given in the morning from night shift that indicated the catheter was changed at 3:00 a.m. and was bleeding but flushed. The resident called and said his catheter was hurting and bleeding. This nurse checked and noted the catheter came out with clotting bright blood. The note documented the nurse offered to change the resident's catheter. The resident responded No do not touch me, I want to go to the hospital. The hospital was called and the nurse spoke to the physician who said it was okay to send the resident for catheter replacement non-emergently. The ambulance was called for transport and the ambulance would arrive at the facility in the next 30 minutes. The resident was made aware.The nursing progress note documented on 5/11/26 at 12:52 a.m. revealed the Foley catheter changed per order on 5/10/26 around 3:30 a.m. The existing Foley catheter was removed and replaced with 20 Fr catheter with 10 ml balloon inflation. The note documented bleeding was noted after insertion. The Foley catheter flushed, patent and draining a small amount of urine mixed with blood. Pain medication administered before and after Foley catheter change per medication administration record (MAR). The resident tolerated the procedure with discomfort noted.-Review of the EMR did not indicate Resident #118's Foley catheter had been changed since 5/10/26, which indicated the resident's catheter had not been changed for greater than 30 days per the urologist's order.The 5/18/26 hospital discharge documentation revealed the resident was in his usual state of health when last night the resident felt like he was not having much urine output from his Foley. The facility nurse exchanged his catheter and it was a difficult insertion causing pain and trauma. The resident presented to the hospital initially due to hematuria following Foley catheter exchange. In the emergency department, the resident was noted to be in SVT to the 230s. The resident was admitted for hematuria and tachycardia. The resident met sepsis criteria with tachycardia, leukocytosis and infectious source on arrival. Urine cultures were positive for extended-spectrum beta-lactamase (EBSL) UTI in the setting of recent traumatic Foley insertion at outside facility. The note documented two of two blood cultures taken on 5/10/26 grew methicillin-resistant staphylococcus aureus (MRSA). The source of his MRSA bacteremia was unclear - transthoracic echocardiogram (TTE) was without evidence of infective endocarditis (IE), magnetic resonance imaging (MRI) spine without infectious source, no new hardware. The note documented the resident was discharged with a total of six weeks of Vancomycin (antibiotic) via a peripherally inserted central catheter (PICC) for high-grade MRSA bacteremia of unknown source.D. Observation and staff interviewThe assistant director of nursing (ADON) changed Resident #118's catheter on 6/24/26 at 12:05 p.m. The ADON said there was sediment buildup on the end of the catheter from sitting in the resident's bladder. III. Staff interviewsLicensed practical nurse (LPN) #2 and the director of nursing (DON) were interviewed together on 6/24/26 at 11:03 a.m. LPN #2 said she would notify the nurse about a residents' catheter if there was a change in condition, such as bloody urine or urine color change, so the nurse could document it and notify the physician. She said the catheter should be changed depending on the physician's order, which sometimes was weekly, but typically monthly. LPN #2 said the urinary catheter should be changed timely in order to prevent infection. She said she was familiar with Resident #118, but she did not know when his catheter was last changed. She said she needed to call her supervisor. The DON said Resident #118's catheter order was a PRN order, but she did not know the 5/11/26 urology order. The DON searched the resident's EMR and said the urology order was to change the catheter monthly. She said if Resident #118's catheter was last changed on 5/10/26 and the urology order on 5/11/26 said the catheter should be changed monthly, that the catheter was late and due to be changed.-The facility failed to ensure the urinary catheter was changed timely.The ADON was interviewed on 6/24/26 at 12:39 p.m. The ADON said Resident #118 had a lot of bleeding and urethral trauma from his previous catheter insertion. He said he thought the bleeding was related to the catheter getting pulled after it was secured to his leg. The ADON said the potential negative impact of traumatic catheter insertion could include Resident #118 not allowing the staff to place a catheter and showing a preference for the specialist to do it. He said it was important the catheter was changed timely for infection control and residents that grow sediment/crystallizations on the end of the catheter.The DON was interviewed again on 6/25/26 at 12:41 p.m. The DON said urinary catheters should be changed when they are clogged, dislodged or soiled, unless urology said otherwise. She said Resident #118's urinary catheter was not changed timely.The DON said the nurse called and told her she had difficulty inserting Resident #118's catheter on 5/10/26 and he went to the emergency room. The DON said she did not realize hours had lapsed between the insertion of the catheter and Resident #118 being sent out to the hospital. She said damage to the urethra and penis and psychosocial damage were potential negative outcomes of traumatic catheter insertions.

Based on observations, record review, and interviews, the facility failed to ensure proper treatment and assistive devices to maintain visual abilities for one (#105) of three residents reviewed for ancillary services of 62 sample residents.Specifically, the facility failed to ensure Resident #105 received her eye glasses timely after an optometrist wrote a prescription.Findings include:I. Resident #105A. Resident statusResident #105, age greater than 65, was admitted to the facility on [DATE]. According to the June 2026 computerized physician orders (CPO), her diagnosis included type 2 diabetes mellitus.The 5/25/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required partial/moderate assistance with toileting, showering and dressing. She required supervision or set-up assistance for other activities of daily living (ADL).The MDS assessment revealed the resident's vision was adequate and she did not use corrective lenses or glasses.-However, the resident was waiting to receive her prescription glasses (see interviews and record review below).B. Resident interview and observationsResident #105 was interviewed on 6/22/26 at 2:30 p.m. Resident #105 said she had been waiting on new glasses for three months now.On 6/23/26 at 11:45 a.m. Resident #105 was walking down the hallway toward her room. She was not wearing glasses. Resident #105 asked an unidentified staff member if she ever got a hold of the eye doctor, and the staff member replied that the eye doctor was at the facility and might be able to answer her questions.Resident #105 was interviewed again on 6/24/26 at 11:12 a.m. Resident #105 was not wearing glasses. She said the optometrist did not provide her glasses or an update about her glasses while at the facility yesterday. C. Record reviewReview of Resident #105's June 2026 CPO revealed the following physician's order:May have vision consult and follow up as needed, ordered 2/16/26.The 4/27/26 optometry note documented Resident #105 did not have glasses previously, and she had early cataracts (clouding of the eye's normally clear natural lens). Resident #105 was diagnosed with regular astigmatism (a refractive error where the eye lens is curved more like a football than a perfectly round basketball), hypermetropia (a refractive error where the eyeball is too short or the cornea is too flat), presbyopia (the natural, age-related loss of your eye's ability to focus on objects up close) and age-related nuclear cataracts bilaterally (in both eyes).Review of the 4/27/26 eyeglass prescription revealed the facility received a prescription for bifocal lens (the top portion of the lens corrects distance vision, while the lower portion handles close-up tasks like reading).-However, there was no further documentation regarding Resident #105 receiving her prescription bifocal lens.Review of Resident #105's comprehensive care plan, initiated 2/18/26, did not reveal a person centered care plan for the resident's prescriptive eye glasses.III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 6/24/26 at 12:46 p.m. CNA #2 said the optometrist probably came to the facility once per month, and any outside provider had a list of residents with an appointment that day. She said she did not know who was responsible for scheduling appointments. CNA #2 said she did not know if Resident #105 wore glasses or had vision concerns. She said the resident had not complained about her vision to her.Licensed practical nurse (LPN) #3 was interviewed on 6/24/26 at 3:25 p.m. LPN #3 said if a new order, such as new eye glasses, was received following an ancillary appointment, she would look at the appointment note to view the recommendations and enter a progress note based on the recommendations. She said the facility had an appointment scheduler who received a copy of the appointment note to review for follow up needs. LPN #3 said she had never heard that Resident #105 was supposed to wear glasses.The business operations manager was interviewed on 6/25/26 at 11:45 a.m. The business operations manager said she was filling in for the social services director (SSD) while she was out of the facility. She said she had experience in social work. The business office manager said if a resident received new glasses, her understanding was that the nursing team should be notified and a task for applying eye glasses would be initiated. She said the optometrist came to the facility probably about once per month, and the SSD was in charge of creating the list of residents needing to be seen by any ancillary specialists. The business office manager said she did not know if Resident #105 should be wearing glasses and she would have to go back and look. She said she did not know why the resident had not received eye glasses for a vision prescription dated 4/27/26, and she said she would have to look into this.The director of nursing (DON) was interviewed on 6/25/26 at 12:41 p.m. The DON said when there was a change in ancillary services, such as new eye glasses, social services should communicate with the floor nurses and the task or order should be updated. She said the optometrist came to the facility every month or every other month - unless someone needed follow up sooner. The DON said Resident #105 did not wear glasses, and was not wearing glasses in her photo within the facility's documentation system. The DON said the BOM was ordering the prescription eyeglasses now.The DON said the potential negative outcome of a resident going without their prescriptive eye glasses included bumping into something, falling and deteriorating vision/prescription changes.IV. Facility follow-upThe nursing home administrator (NHA) provided a receipt for Resident #105's prescription eyeglasses on 6/25/26 at 6:26 p.m. (after survey exit). The eyeglasses were ordered and paid for on 6/25/26 at 12:37 p.m. The NHA said delivery should be expected in one week. -However, Resident #105's prescription eyeglasses were not ordered for approximately two months.

Based on observations and interviews, the facility failed to ensure two (#150 and #2) of five residents were provided with personal privacy out of 62 sample residents. Specifically, the facility failed to ensure:-Resident #2's room door and privacy curtain were closed during incontinence care; and,-Resident #150 was fully covered per her preference while being transported from the shower room in the shower chair back to her room.Findings include:I. Resident #150A. Resident statusResident #150, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician's orders (CPO), diagnoses included active primary multiple sclerosis, gastrostomy status (having an artificial opening in the stomach for long-term enteral nutrition or gastric decompression), epilepsy, and cerebral infarction (stroke). The 3/25/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment further revealed the resident needed substantial to maximal assistance with showering, toileting and dressing. B. Resident interview and observationResident #150 was interviewed on 6/22/26 at 2:33 p.m. She said that there were things that residents had to deal with while living in a facility. She said things like having to be naked under a sheet while being pushed in the hallway to the shower room. She said there were times when she had to remind staff to close her door and pull the curtain and to make sure she was fully covered. She said staff were very goal-oriented and just wanted to move on to their next task. On 6/23/26 at 10:46 a.m. Resident #150 was being transported in the shower chair from the shower room back to her room. Resident #150 had her left arm resting on the left armrest of the shower chair. The sheet that was covering her was pulled up around her left elbow and her left breast and stomach were visible. C. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 6/24/26 at 11:07 a.m. She said that when she had to transport a resident to and from the shower room on the shower chair, she would make sure that the resident was completely covered. She said she used draw sheets to cover the resident's front and back. CNA #6 was interviewed on 6/24/26 at 11:51 a.m. She said sometimes the residents would bring clothes with them to change into in the shower room. She said when she had to use the shower chair to take them to and from the shower room, she would make sure the resident was completely covered. Licensed practical nurse (LPN) #6 was interviewed on 6/24/26 at 12:21 p.m. She said that she would expect the resident to have a blanket or sheet covering their front and back. She said all body parts should be covered. The director of nursing (DON) was interviewed on 6/25/26 at 11:45 a.m. She said that residents should be completely covered when being transported to and from the shower room. She said it is important to ensure the resident's dignity and privacy. II. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter, Alzheimer's disease, metabolic encephalopathy (brain dysfunction), and acute respiratory failure with hypoxia (lungs cannot adequately supply oxygen to the bloodstream). The 3/27/26 MDS assessment revealed the resident was rarely or never understood through staff assessment. The staff assessment revealed the resident had short-term and long-term memory problems, and her cognitive skills for daily decision-making were severely impaired. The assessment further revealed she was dependent on staff for all of her activities of daily living (ADL). B. ObservationsOn 6/22/26 at 10:02 a.m. Resident #2's roommate exited their room. She left the door open using the magnetized door prop to hold the door open. Resident #2 was lying in her bed, which was visible from the hallway. There were two unidentified CNAs performing incontinence care for Resident #2. The blinds to the window to the outside were open and the privacy curtains were not drawn. The door remained open for approximately 30 seconds to one minute while the staff were providing incontinence care to the resident. C. Staff interviewsCNA #3 was interviewed on 6/24/26 at 11:07 a.m. She said that they should have the door closed and if the door was opened they should close it again. She said the staff should also have the privacy curtains drawn and if the window blinds are open, they should close them. CNA #6 was interviewed on 6/24/26 at 11:51 a.m. She said always closed the door when she performed incontinence care. She said that if the door was opened she would close the door. She said she would also make sure that the privacy curtains were closed depending on the resident's preference. She said sometimes some residents did not like their curtains to be closed. LPN #6 was interviewed on 6/24/26 at 12:21 p.m. She said she would expect the CNA to close the door and the privacy curtain to be pulled during incontinence care. She said she would expect the CNA to close the door if it was opened during care. The DON was interviewed on 6/25/26 at 11:45 a.m. She said that the door should be closed and the privacy curtain should be pulled during incontinence care. She said it was important to ensure the resident had privacy and dignity.

Based on record review and interviews, the facility failed to ensure a response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to:-Make prompt efforts to work with residents to resolve their food grievances; and;-Fully investigate and document grievance resolutions and corrective action. Findings include:I. Facility policy and procedureThe Grievances/Complaints policy, revised 4/17/25, was provided by the director of nursing (DON) on 10/15/25 around 3:00 p.m. It read in pertinent part, The grievance officer, administrator, and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken.II. Resident interviewsResident #6 was interviewed on 10/15/25 at 9:45 a.m. Resident #6 said that she thought the food served at the facility was horrible; so she usually ordered sandwiches for lunch and dinner because they were more palatable than the hot food served by the facility.Resident #7 was interviewed on 10/15/25,at 10:00 a.m. Resident #7 said she did not like the food they served at the facility. Resident #7 said she informed the dietary staff of her food preferences, but that they did not accommodate her. She said she usually chose to eat sandwiches because the other food they served was unappetizing.Resident #3 was interviewed on 10/15/25 at 11:15 a.m. Resident #3 said she had put in verbal grievances about the food quality at the facility. She said that she would request specific food items from the kitchen and that she would not get the items as requested when her food tray arrived. She said that the food usually tastes burnt or freezer-burnt. She said that overall, the food quality was not good. She said that one time she had discussed her concerns with the dietary manager (DM), and he had told her that he had too many residents to feed each meal, so sometimes items would be missed and not everyone would like the meal. She said that since the conversation with the DM, nothing had changed about her meal ticket accuracy or the quality of the food.Resident #8 was interviewed on 10/15/25 at 12:00 p.m. Resident #8 said that he thought the facility's cook had it out for him because his food was either scorched or undercooked. He said that sometimes he was served cold food, and he usually did not get the items he requested. Resident #4 was interviewed on 10/15/25 at 4:00 p.m. Resident #4 said that the topic of the last resident council meeting was primarily about cold food and the facility's poor kitchen service. He said that the meeting did not change anything despite their grievances, and the residents were still being served cold food. He said that they had brought this topic up with the administration before, but that the issue was ongoing. He said the problem was due to the certified nursing assistants (CNA) leaving the food delivery cart doors open while delivering food trays to residents' rooms. He said that meal ticket accuracy had also been an ongoing issue with the kitchen not providing the resident the meals they had ordered and not providing condiments as ordered. He said that most of the problems occur during the morning meal. III. ObservationsOn 10/15/25, at 4:50 p.m., three CNAs were observed passing out dinner trays to residents. The trays were stored in a tall metal, uninsulated dinner cart that was delivered from the kitchen to the unit. The dinner cart did not plug into the wall and had no way of keeping food warm. The doors to the dinner cart were kept open as the CNAs delivered trays to the residents' rooms.IV. Record ReviewThe facility had seven grievances on record from July 2025 to September 2025 relating to food and mealtimes. Common themes across the two-month time frame reviewed were about meal ticket inaccuracy and residents receiving cold food. The facility and DM's response to the grievance reports failed to document efforts to resolve any of the resident concerns. The facility was unable to provide documented proof of any meaningful changes or steps being taken to correct the issues the residents brought forward or to prevent more resident complaints regarding the same issues. -Three grievance forms reviewed were written by residents who said they did not get items that they requested on their meal ticket from the kitchen. These three grievances were filed on 7/15/25, 7/28/25, and 9/15/25. The resolution section of the grievance filed on 7/15/25 documented says the kitchen staff needed to pay closer attention to detail, and the dietary manager (DM) would be notified about ticket inaccuracy. -Two grievance forms written on 7/24/25 and 8/5/25 were written by residents who said they were receiving cold food. The facility food committee meeting minutes from July 2025 and August 2025 documented the residents brought up the meal inaccuracy. The Residents told the DM and kitchen staff their experience was not good due to the meal ticket inaccuracy. The meeting minutes from August 2025 documented that meal ticket accuracy was worse, and residents were not getting items that they had requested. The August 2025 meeting minutes further revealed that residents received more inaccurate meal orders on weekends and evenings.Review of all in-service education sessions provided to the kitchen staff since July 2025 revealed the DM failed to include dining staff any training on ensuring meal ticket accuracy. Resident council meeting minutes from July 2025 and August 2025 revealed that the residents stated they were being served cold food.Seven of the seven grievance forms submitted since July 2025 concerning food and mealtimes were not fully completed. The grievances filed on 7/15/25 and 7/24/25 did not have the sections titled investigations and resolution of grievance/concern filled out. The grievance from 7/8/25 had both of these sections partially completed. Grievances filed on 7/9/25 and 9/15/25 had one of each section partially completed. The grievances filed on 7/28/25 and 8/5/25 did not have the resolution of grievance/concern section completed. The grievance from 8/4/25 had staff are great! Very helpful, good meals, but great service top to bottom scribbled in a large font in the actions taken section. V. Staff interviewsThe DM was interviewed on 10/15/25, around 5:00 p.m. The DM said that sometimes residents' food requests were not fulfilled by the kitchen staff. He said that sometimes details and special requests written on the meal tickets were missed. He said if an ordered food item was not delivered, he said one of the certified nurse aides (CNA) could go to the kitchen and get the item or the CNA could call the kitchen to request a dietary staff deliver the food item to the resident's floor. It was usual for the nursing staff go down to the kitchen to retrieve missing food items after the residents' food trays were delivered to the resident rooms when the residents wanted other food items. The DM did not think that resident requests for additional food items was the cause of the cold food complaints. The DON and regional nurse consultant were interviewed on 10/15/25 at 5:20 p.m., DON said that after reviewing the resident grievance forms submitted since July 2025, the facility's response did not meet her expectations for resolving resident grievances. The DON said that she felt like the kitchen would identify a problem and then fail to take corrective action. She said that her expectation was for grievances to be solved with staff education, continued communication with the resident, and improved practices. The regional nurse consultant said she would assist the facility in creating a new system for grievance resolution. The DON said the grievances submitted since July 2025 had not been documented appropriately, and she was disappointed in how one grievance in particular had food leaves the kitchen hot! written in the resolution section completed by staff. She said that was an incomplete resolution because it failed to include any staff training or inter-departmental collaboration to resolve the grievance.

Based on observations, record review, and interviews, the facility failed to provide one of three residents (#5) out of 21 sample residents, with timely and necessary treatment and services to prevent and manage an avoidable, facility-acquired pressure injury that resulted in the development of a stage 4 coccyx wound with osteomyelitis. Resident #5, who had a diagnosis of paraplegia, was admitted on [DATE] with intact skin. The resident was discovered with an unstageable pressure injury on his coccyx on 11/28/23, 14 days after admission. By 1/2/24, the pressure injury had progressed to a stage 4 pressure injury (full-thickness tissue loss with exposed bone, tendon, or muscle). And, on 6/6/24, x-rays revealed the presence of osteomyelitis, inflammation of the bone due to infection, requiring an extended course of antibiotic treatment. Interviews, observations, and record review revealed the facility failed to provide timely and necessary treatment and services to prevent the development of the resident's pressure injury and then, failed to provide the treatment and services necessary to manage the pressure injury and promote healing. Specifically: -Record review and interviews revealed the facility failed to timely provide Resident #5 with devices for pressure relief. Record review revealed a physician's order for an air mattress was not initiated until 2/21/24, approximately two and a half months after the pressure injury had developed and the order was not implemented until 3/10/24, 20 days later. Even then, the air mattress provided had been previously used and the facility was unable to provide documentation on how old the mattress was and how much use it had received, as well as provide an instruction manual on its proper use and settings. Further, an interview with Resident #5 revealed he was not repositioned routinely at night time unless he asked staff to do so. His care plan failed to include a directive for staff to assist the resident in turning and repositioning to offload pressure until 2/21/24, over a month after his pressure injury was assessed as a stage 4. -Record review revealed weekly skin assessments were not completed to ensure Resident #5's pressure injury was regularly monitored; physician orders for dressing changes were not followed and dressing changes were not performed in a manner to prevent infection. -Interviews, record review, and observations revealed the facility failed to ensure the nutritional support ordered on 2/21/24 (double protein) was consistently offered to Resident #5. Per the WCP, interviewed on 7/24/24 at 9:56 a.m., Resident #5's pressure injury was avoidable; he saw no other clinical issues that would contribute to the pressure injury. The facility's systemic failure to provide Resident #5 with timely and necessary treatment and services to prevent and manage his worsening pressure injury created an immediate jeopardy situation with the likelihood of serious harm to other residents with similar conditions. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Resident #5, who had a diagnosis of paraplegia, was admitted on [DATE] with intact skin. The resident was discovered with an unstageable pressure injury on his coccyx on 11/28/23, 14 days after admission. By 1/2/24, the pressure injury had progressed to a stage 4 pressure injury (full-thickness tissue loss with exposed bone, tendon, or muscle). And, on 6/6/24, x-rays revealed the presence of osteomyelitis, inflammation of the bone due to infection, requiring an extended course of antibiotic treatment. Interviews, observations, and record review revealed the facility failed to provide timely and necessary treatment and services to prevent the development of the resident's pressure injury and then, failed to provide the treatment and services necessary to manage the pressure injury and promote healing. Specifically: -Record review and interviews revealed the facility failed to timely provide Resident #5 with devices for pressure relief. Record review revealed a physician's order for an air mattress was not initiated until 2/21/24, approximately two and half months after the pressure injury had developed and this order was not implemented until 3/10/24, 20 days later. Even then, the air mattress provided had been previously used and the facility was unable to provide documentation on how old the mattress was and how much use it had received, as well as provide an instruction manual on its proper use and settings. Further, an interview with Resident #5 revealed he was not repositioned routinely at night time unless he asked staff to do so. His care plan failed to include a directive for staff to assist the resident in turning and repositioning to offload pressure until 2//21/24, over a month after his pressure injury was assessed as a stage 4. -Record review revealed weekly skin assessments were not completed to ensure Resident #5's pressure injury was regularly monitored; physician orders for dressing changes were not followed and dressing changes were not performed in a manner to prevent infection. -Interviews, record reviews, and observations revealed the facility failed to ensure the nutritional support ordered on 2/21/24 (double protein) was consistently offered to Resident #5. Per the WCP, interviewed on 7/24/24 at 9:56 a.m., Resident #5's pressure injury was avoidable; he saw no other clinical issues that would contribute to the pressure injury. The facility's systemic failure to provide Resident #5 with timely and necessary treatment and services to prevent and manage Resident #5's pressure injury, resulting in a stage 4 wound with osteomyelitis, created an immediate jeopardy situation with the likelihood of serious harm to other residents with similar conditions. B. Notice of immediate jeopardy On 7/24/24 at 6:39 p.m., the nursing home administrator (NHA) was informed of the findings of immediate jeopardy under F686, Pressure Injuries. C. Facility plan to remove immediate jeopardy The facility plan to remove immediate jeopardy read: Completion date of 7/25/24 Medical records review was completed on all residents by the director of nursing/designee to ensure weekly skin assessments were completed and treatments recommendations/orders were in place. A care plan audit was conducted by the director of nursing (DON)/designee to ensure that treatment recommendations/orders were on the care plan that the care plan was being followed. The DON/Designee audited all wound care orders to ensure that treatment orders from providers matched orders in the treatment administration record (TAR). All facility policies and procedures related to skin care, wound care and pressure injury prevention were reviewed and revised as needed. An audit of all pressure relieving devices and support surfaces was conducted by the DON/Designee. The DON/designee provided education to all nursing staff regarding the settings of resident air mattresses and how to ensure proper functioning. The DON/designee provided education to all licensed nurses on facility policies and procedures related to skin/wound care, as well as appropriate wound treatment measures. This included ensuring related residents had necessary support surface and pressure relieving devices. The DON/designee provided education to all licensed nurses on appropriate documentation which included transcription and entering of treatment orders on the physician's order sheet in the electronic medical record (EMR) and the residents TAR. The DON/Designee educated all nurse aids on preventative skin care. The consultant registered dietician provided education to the facility dietician which included professional standards and follow up on supplement recommendations. All residents returning from the hospital treatment recommendations/orders and wound care appointments will be transcribed and overseen by the DON/Designee. A QAPI PIP (quality assurance and performance improvement plan) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented monthly at the QAA meeting. monitoring/auditing and reporting will continue for a minimum of three months. D. Removal of immediate jeopardy The facility plan was accepted by the state survey agency on 7/25/24 at 4:00 p.m., based on the systemic changes outlined in the above plan to ensure pressure injuries would be immediately addressed through assessment, monitoring, and treatment. The immediate jeopardy situation was removed; however, the deficient practice remained at level G, isolated, actual harm. II. Professional references A. Classification of pressure injuries According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 7/30/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. B. Support surfaces 1. According to Joerns Healthcare PRO [NAME] Plus product details, retrieved online from https://www.joerns.com/product/p-r-o-matt-plus/ on 8/5/24, The P.R.O. [NAME] Plus is a non-powered mattress replacement system featuring our Pressure Redistribution Optimization (P.R.O.) Technology. With the addition of an optional control unit, the mattress provides powered immersion or alternating pressure therapy, allowing facilities to use one mattress for both pressure injury prevention and treatment. The P.R.O.Matt(R) Plus system is designed for a minimum service life of five (5) years, subject to the use and maintenance procedures stated in this manual. The P.R.O. [NAME] Plus is a reactive surface that allows the provision of optimal interface pressures through controlled air cell inflation for at-risk patients in the prevention and treatment of Stage 1 and 2 pressure injuries, and treatment of uncomplicated Stage 3 and 4 pressure injuries in patients with multiple turning surfaces. For Stage 3 and/or Stage 4 treatment, care staff should be able to position the patient off of the pressure wound in at least 2 positions. 2. According to Avacare Medical the How Long Can a Air Mattress Last, retrieved on 7/29/24 from: https://www.avacaremedical.com/blog/how-long-can-a-air-mattress-last.html#:~:text=Air%20mattresses%20can%20endure%20for,sharp%20items%20to%20prevent%20punctures, Air mattresses can assist with medical issues like pressure reduction or better blood circulation. Air mattresses can endure for two to eight years when properly maintained and used occasionally. When the air mattress isn ' t in use, thoroughly deflate it and put it in a carry bag to extend its lifespan. Keep the air mattress in a cool, dry area free of sharp items to prevent punctures. Don ' t over inflate the air mattress; avoid sitting on the edge of an inflated air bed to avoid seams ripping and bulging. III. Facility policy A. The Prevention of Pressure Injuries policy and procedure, revised April 2020, was received from regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It read in pertinent part: [P]purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Assess the resident on admission (within eight hours) for existing pressure injury risk factors, repeat the risk assessment weekly and upon any changes in condition. Reposition all residents with or without risk of pressure injuries or an individualized schedule, as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident ' s risk factors and current clinical practice guidelines. Provide support devices and assistance as needed Select appropriate support surfaces based on the residents' risk factors in accordance with current clinical practice. B. The Supportive Surfaces Guidelines Policy was provided by RNC #1 on 7/25/24 at 11:30 a.m. The policy read in pertinent part: [T]he purpose of this procedure is to provide guidelines for the assessment of appropriate pressure-reducing and relieving devices for residents at risk of skin breakdown. Redistributing supportive surfaces are to promote comfort for all bed or chair-bound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Supportive surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as a foam, gel, static air alternating air, or air loss mattress when lying in bed. For resident(s) who recline and are dependent on staff for repositioning, change their position at least every two hours IV. Resident #5 A. Resident status on admission Resident #5, age younger than 65, cognitively intact, with a diagnosis of paraplegia per his 6/11/14 minimum data set (MDS) assessment, was admitted to the facility on [DATE]. A skin assessment completed on admission (11/7/23) revealed Resident #5's skin was intact. In an interview on 7/24/24 at 11:30 a.m., registered nurse (RN) #1 and RNC #1 confirmed the resident's admission assessment documented the resident entered the facility with his skin intact. B. Resident status following admission - development, and worsening of a pressure injury on the resident's coccyx. On 11/10/23, a comprehensive skin assessment revealed Resident #5 had redness to his coccyx, and on 11/28/23, 14 days after admission, a wound physician's note revealed an unstageable pressure injury of the resident's coccyx. The onset of the coccyx wound on 11/28/24 was confirmed by RN #1 in an interview on 7/24/24 at 11:30 p.m. On 1/2/24, a wound physician's progress note identified the pressure injury as a stage 4 wound (full-thickness tissue loss with exposed bone, tendon, or muscle). On 6/4/24, an x-ray of the coccyx was ordered to rule out osteomyelitis, which was confirmed on 6/6/24. According to 6/12/24 skin/wound progress notes, on 6/11/24, the wound physician recommended a six-week course of antibiotics to treat the infection. On 7/24/24 at 9:56 a.m. the WCP was interviewed. He said Resident #5 had an avoidable facility-acquired pressure injury to his coccyx. The WCP said Resident #5 had no other clinical issues that could contribute to the wounds. The WCP was unaware of any changes in Resident #5 daily routines that could have contributed to the development or worsening of the pressure injury. The WCP said he noticed the wound was not healing so he suspected osteomyelitis and had an x-ray taken to confirm this diagnosis. The WCP said osteomyelitis requires a long-term use of antibiotics and residents need antibiotics moving forward for a minimum of six weeks. The WCP said Resident #5's wound had become stagnant so he cultured the wound. The WCP said the wound culture provided insight into the infection in the wound and what antibiotics would be successful in the treatment of the resident's osteomyelitis. The WCP said Resident #5 antibiotics had to be changed to medication that could kill the organisms. The WCP said any opening on the skin exposes the body to the environment which can lead to the colonization of bacteria leading to infection. The WCP said providing good wound care to an open area was important to prevent infections and many types of dressings can be used for healing so it was important to be done correctly. On 7/16/24, a coccyx wound culture was collected by the WCP. On 7/18/24, an order was written for placement of a peripherally inserted central catheter (PICC- used to administer intravenous medication) and, on 7/19/24, Cefepime (antibiotic) 2 grams and Vancomycin (antibiotic) 1500 mg IV (intravenous) was ordered for osteomyelitis. C. Facility failures 1. Record review and interviews revealed the facility failed to implement pressure-reducing measures to provide pressure relief and promote healing. a. Delay in initiating an air mattress and failure to ensure the air mattress was properly functioning to be effective. Record review: Record review revealed an order for an air mattress was not initiated until 2/21/24, seven and a half weeks after the coccyx wound was identified as unstageable. The resident's 11/7/24 comprehensive care plan further revealed an air mattress was not placed until 3/10/24, 20 days after the 2/21/24 order. Interviews and observations: Resident #5, interviewed on 7/24/24 at 4:36 p.m., said his current mattress was broken. Resident #5 said that the one he had before was worse. Resident #5 said that the laundry director told him this was the best mattress she could find. The resident was observed lying in his bed on an air mattress with a fitted sheet over the mattress. CNA #1 was interviewed on 7/24/24 at 4:31 p.m. CNA #1 said she checked the resident's air mattress when she did her morning rounds. She said she pushes on the mattress to ensure it is inflated and feels firm to touch. Regional nurse consultant (RNC) #1 and the DON were interviewed on 7/24/24 at 4:00 p.m. The RNC #1 said the facility did not have a system to track equipment repairs needed. The RNC said the only documentation to show when the air mattress currently on the resident's bed was ordered was 2/21/24. RNC #1 was interviewed again on 7/25/24 at 10:33 a.m. RNC #1 said the facility was unable to obtain the operator ' s manufacturer manual for the low-loss air mattress currently placed on Resident #5 ' s bed because the mattress was so old that it was no longer being manufactured or sold by any vendors. RNC #1 was unable to verify the age of the mattress or previous usage of the mattress. She said for that reason, the mattress will be replaced today in the afternoon when the resident gets out of bed. Licensed practical nurse (LPN) #3 was interviewed beginning on 7/29/24 at 9:42 a.m. She said air mattresses were not to have fitted sheets on them as it could restrict the function of the air mattress airflow. The resident's replacement air mattress, a P.R.O [NAME] Plus, was reviewed with LPN #3 for proper function and settings. The air mattress was set at #3 mode therapy and no cycle time. LPN #3 said the air mattress was not set to the right settings based on the physician's order and she needed to get the order clarified to match the settings available on the air mattress pump. The laundry director (LD) was interviewed on 7/29/24 at 10:33 a.m. The LD said she was responsible for managing and placing air mattresses on residents' beds once ordered. -The LD said she was responsible for making sure the mattresses were functioning properly. The LD said she did not monitor the function or integrity of the actual mattress; rather, she only referenced monitoring the pump and its function. When a mattress was not able to hold air and was not making the normal whooshing sounds she said she replaced the mattress pump but did not change out the actual mattress. The LD said the facility had several backup pumps in stock. Malfunction pumps were discarded. -The LD said the facility had recently purchased a couple of new pressure-relieving air mattresses but most of the air mattresses in stock were older and had been acquired by the previous facility owners. Some of the air mattresses were used more than others and they no longer tracked the age or length of time a mattress was used by one of the residents in the facility. -The LD said the facility did not have the manufacturer's manuals for the air mattresses and they did not know the exact age of the mattresses in stock. The LD said she did not know how old the mattress that Resident #5 had been using was or how much time it had been in use by other residents before it was placed on his bed. -The LD said the resident had been complaining about the mattress that was on his bed, saying that it was uncomfortable and was causing him a great deal of discomfort. The LD said she changed out his mattress on 7/28/24 (during the survey) with a new mattress that was approximately a month or two old. -The LD said the lifespan of a pressure-relieving air mattress was dependent upon how long it was in use. She was not sure but thought that an air mattress under continuous use was only effective for pressure relief for a year or two. The NHA confirmed the facility did not have a tracking system to determine how long the older pressure-relieving air mattress had been in use. The NHA said Resident #5 ' s mattress was changed to a newer mattress (on 7/28/24) when the facility was unable to verify the age or usage of the mattress on the resident's bed. b. Failure to timely and consistently implement turning and positioning of the resident. A review of the resident's 11/7/23 comprehensive care plan revealed a directive for staff to assist the resident in turning and repositioning as indicated/tolerated was not initiated until 1/3/24, about a month after the resident's wound was identified and after the wound physician's progress note identified the pressure injury as a stage 4 pressure injury, CNA #1, interviewed on 7/24/24 at 4:31 p.m., said Resident #5 was dependent on staff for positioning due to his medical condition. She said the resident did not refuse care when offered. Resident #5 was interviewed on 7/24/24 at 4:36 p.m. and said that the last time he got up in his wheelchair was last week for 2 to 6 hours. He said he gets up when he wants to. He said the CNAs come in to reposition him when he asks or if he needs to go to the bathroom. Resident #5 said at night, they do not come in and reposition him unless he asks them to. 2. Record review, observations, and interview revealed weekly skin assessments were not completed to ensure Resident #5's pressure injury was regularly monitored; physician orders for dressing changes were not followed and dressing changes were not performed in a manner to prevent infection. a. Weekly assessments March: -On 3/7/24 - no skin assessment was completed -On 3/14/24 - no skin assessment was completed April: -On 4/3/24 - no skin assessment was completed -On 4/17/24 - no skin assessment was completed May: -On 5/2/24 - no skin assessment was completed -On 5/23/24 - no skin assessment was completed June: -On 6/27/24 - no skin assessment was completed b. Orders and dressing changes Orders: A 12/4/23 wound care order read: clean wound to the coccyx with normal saline and apply clean dressing until it was assessed by the wound care team. -However, Resident #5 was seen by the wound physician on 11/28/23, per the 11/28/23 wound physician's note. As such, the order for dressings change was added 7 days after Resident #5 was seen by the wound physician. A 6/21/24 wound care order read: coccyx - cleanse with quarter strength Dakin's (used for cleaning) solution, apply skin barrier cream with zinc to peri wound, cut and apply silver alginate to wound bed, Cover with border gauze dressing. Change dressing every other day. -However, the June 2024 treatment administration records (TARs) revealed Resident #5 received dressing changes daily from 6/23 to 6/25/24. (This treatment order was discontinued on 6/25/24.) A 6/26/24 wound care order read: coccyx - cleanse with quarter strength Dakin's solution, apply barrier cream with zinc to peri-wound (around wound edges but not in the wound), cut and apply hydrofera blue (specialized wound dressing) to wound bed, cover with border gauze change dressing every other day. Order was discontinued on 7/2/24. -However, the June 2024 TAR record revealed Resident #5 dressing was changed daily from 6/26 to 6/30/24, and 7/1 to 7/2/24. The DON was interviewed on 7/24/24 at 12:34 p.m. The DON said the physician should be called when wound care was not administered per the physician's orders. Infection control: On 7/25/24 at 11:50 a.m., Resident #5 was observed receiving care for his coccyx wound. The DON, RN #1, and CNA #1 were present for wound care. Wound care was completed as ordered during observation. -However, RN #1 failed to place a barrier pad under the resident's wound during care. RN #1 was interviewed on 7/25/24 at 12:25 p.m. RN #1 said she should have placed a barrier pad under the resident during wound care to protect him and the linen from being contaminated during wound care. RN #1 said not placing a barrier pad could put the resident at risk for germs to get into the wound. 3. Interviews, record reviews, and observations revealed the facility failed to ensure the nutritional support ordered on 2/21/24 (double protein) was consistently offered to Resident #5. Record review revealed on 2/13/24, an order for a double protein diet was initiated. Dietary aide (DA) #1 was interviewed on 7/25/24 at 3:51 p.m. He said meal tickets for residents will identify special diet considerations in bold letters and allergies were highlighted. DA #1 said a double protein diet means they get two servings of protein items served. DA #1 said protein items were eggs, meat, milk, and cheese. -However, observations revealed the resident was not served double protein: On 7/23/24 at 1:20 p.m., the resident was served two ham and cheese sandwiches. The tray card had written in double ham. However, the ham sandwiches did not have double ham. The sandwiches had one slice of ham and a slice of cheese. At approximately 2:00 p.m., the resident consumed one of the ham and cheese sandwiches. On 7/24/24 at 12:25 p.m., the resident received his meal. The resident received two ham and cheese sandwiches. The dietary tray ticket instructed double protein, and in writing the ticket wrote double ham. The sandwiches had a slice of ham and a slice of cheese. The sandwiches did not have double meat. On 7/24/24 at 12:45 p.m., the registered dietitian consultant (RDC) observed the sandwich served to the resident. She confirmed it was not double the ham. The RDC asked the resident if he would like additional meat for his sandwich and he replied It is a little late, as he had consumed the majority of the sandwich. The registered dietitian (RD) was interviewed on 7/24/24 at 4:55 p.m. -The RD said Resident #5 told her he wanted to have double protein in his meals, as he did not want the health shake of beneprotein. The RD said that the resident was refusing the dinner health shake she discontinued the order for health shakes (4/19/24) although the RD confirmed the resident was consuming the morning and afternoon administrations. The RD said only the dinner beneprotein could have been discontinued, however, the resident had said he did not want to have it any longer and was now receiving double protein. But see observations above; the resident was observed not receiving double protein. -The RD said Resident #5 was not reviewed in a nutrition-at-risk meeting. The RD said she was aware the pressure wounds were worsening. The RD said the zinc and the vitamin C were recently bumped up a week due to the worsening. IV. Final interviews with the administration The NHA was interviewed on 7/29/24 at 11:05 a.m. The NHA said the interdisciplinary team (IDT) conducted daily clinical discussions which included talking about residents' wound and wound care needs. The NHA said he did not recall discussing Resident #5 ' s wound status and was not aware that Resident #5 ' s coccyx wound was infected. The NHA said he was more involved in working with the IDT on revamping the overall care and treatment programs for all residents, rather than knowing the individual treatment needs of each resident. The NHA said the DON took on the role of meeting the individual clinical needs of the residents. The NHA said he was working with the new DON to hire a full-time treatment nurse who would be tasked with managing resident wound care needs and working directly with the WCP to ensure proper treatment of the residents' wounds. The NHA said his goal was for the nursing department to make improvements in tracking and auditing the residents' wound care and treatment needs. The DON was interviewed on 7/29/24 at 11:15 a.m. The DON said she no longer followed the WCP. Instead, the wound care nurse was tasked with tracking the p[TRUNCATED]

Based on interviews and record review, the facility failed to ensure that all nursing staff had the specific competencies and skill sets necessary to identify, intervene, and notify the physician of residents' acute changes of condition related to wound development and treatment measures such as providing wound care and management of pressure relieving mattresses. This affected all residents with pressure wounds or those at risk for developing a pressure wound and contributed to Resident #5's pressure wound from worsening to a Stage 4 pressure wound with osteomyelitis (infection at the bone). Cross-reference F686 for failure to prevent worsening of a pressure injury. Specifically, the facility failed to assess all facility-hired nurse staff registered nurses (RNs), licensed practical nurses (LPNs) and certified nurse aides (CNAs) for competency in caring for residents with pressure injuries. Competencies not assessed included all of the following: reporting and documenting when a resident developed a new or worsening wound, assessing the condition or a wound, development and implementation of care plan interventions, ensuring and promoting healthy skin and healing of impaired skin; administration of physician-ordered treatments, and application and implementation of pressure relieving mattresses. Findings Include: I. Facility Policy The Staffing, Sufficient and Competent Nursing policy, revised August 2022, was provided by the nursing home administrator (NHA) on 7/29/24 at 4:38 p.m. It read in pertinent part: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of the respective relationship and certification requirements defined by state law. Staff must demonstrate the skills and techniques necessary to care for the resident's needs, including but not limited to, the following areas: basic nursing skills, skin and wound care and identification of changes in condition. Licensed nursing and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: -Programs for staff trained results in nursing competency; -Gaps in education are identified and addressed; -Education topics and skills needed are demonstrated based on the resident population; -Tracking or other mechanisms are in place to evaluate the effectiveness of training; and, -Training includes critical thinking skills and management care and complex environments with multiple interruptions. II. Record review On 7/25/24, a request was made to the regional nurse consultant (RNC) #1 and the NHA for the facility's annual competency assessment for all nursing staff. -The facility was unable to produce any documentation to show that the facility's licensed nurses had the specific skill sets necessary to provide competent care for residents' needs, as identified through resident assessments and described in the plan of care for residents with pressure injuries. -Additionally, the facility was unable to produce any documentation to show that the facility's CNAs had the specific skills to provide competent care for residents' needs, as identified through resident assessments and described in the plan of care for residents with pressure injuries. III. Interviews The NHA was interviewed on 7/29/24 at 2:22 p.m. The NHA said the new leadership took over ownership of the facility in April 2024 and they had not yet started the process to assess the competency of the nursing staff.

Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility failed to: -Ensure all direct and non-direct care staff received training in quality assurance and quality improvement (QAPI), compliance and ethics and resident rights; -Ensure all direct and non-direct care staff received training in all components of abuse training including abuse prevention, identification and types of abuse; -Ensure all certified nurse aides (CNA) received at least 12 hours of annual in-service training. Findings include: I. Facility policy and procedure The In-service Training, All Staff policy, dated 2021, was provided by the nursing home administrator (NHA) on 7/28/24 at 9:oo a.m. It read in pertinent part, All staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competencies in the topic areas of the training. Required training topics include the following: -Effective communication with residents and family; -Resident rights and responsibilities; -Preventing abuse, neglect, exploitation, and misappropriation of residence property including activities that constitute abuse neglect exploitation or misappropriation of residential property; -Procedures for reporting incidents of abuse neglect exploitation or misappropriation of resident property; -Dementia Management and Abuse Prevention; -Elements and goals of the facilities QAPI (quality assurance, quality improvement) program; -Infection prevention and control program standards, policies and procedures; -Behavioral Health; and, -The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities). II. Record review Staff training records related to QAPI, compliance and ethics, resident rights and abuse prevention and identification were requested from regional nurse consultant (RNC) #1 and the NHA on 7/25/24 at 8:42 p.m. Additionally, the training records of five CNAs were selected at random for review. -The facility was unable to provide documentation that all staff received the required training and no staff had received training on the facility's QAPI program. Cross-reference to F867 for failure to ensure QAPI improvement activities. -The records of the five randomly selected CNAs (#3, #4, #5, #6 and #7) were reviewed and none of the CNAs received all of the required training sessions (all required components of abuse training, QAPI, Compliance and ethics and resident rights) and none had received a total of 12 hours of annual in-service training. -The training records failed to document the training sessions' durations. III. Staff interviews The NHA was interviewed on 7/29/24 at 2:22 p.m. The NHA said the facility had not provided any staff training on the QAPI program but they would get started on planning for the training. The NHA said they had trained all staff on abuse. -However, the abuse training topic was on the topic of elder and dependent adult abuse reporting and not abuse prevention and identification. -Additionally, some staff received the training more than 12 months prior to the survey and had no record of being provided a refresher training on an annual basis The NHA was interviewed again on 7/31/24 in a follow-up regarding the CNA training records. The NHA said the annual CNA training was a bit bare and the facility would be working on getting the CNAs training up-to-date, along with the QAPI training. .

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for three (#2, #3 and #4) of four residents reviewed for discharge out of 21sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay and/or a final summary of the resident's status was completed for Resident #2, #3 and #4. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy and procedure, revised October 2022, was provided by regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It read in pertinent part, The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the residents status at the time of the discharge in accordance with established regulations governing release of resident information as permitted by the resident. The discharge summary shall include a description of the resident's:current diagnoses; medial history;course of illness, treatment, and or therapy since entering the facility;current laboratory, radiology, consultation and diagnostic tests;physical and mental function;ability to perform activities of daily living;sensory and physical impairments;nutritional status and requirements including weight, nutritional intake and eating habits, preferences and dietary restrictions; special treatments; mental and psychosocial status; discharge potential; dental condition; activities potential; rehabilitation potential; cognitive status; and, mediation therapy. II. Resident #2 A. Resident status Resident #2, age 73, was admitted on [DATE] and discharged on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included malignant neoplasm of tongue (cancer of the tongue), type II diabetes, and sensorineural hearing loss. The 3/25/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15 . He required setup assistance with activities of daily living (ADL). B. Record review The discharge summary, dated 4/16/24, documented the resident was discharged to his home with his wife. The discharge summary failed to show that all areas on the form were completed. -A review of the 4/16/24 discharge summary in the resident's electronic medical record (EMR) revealed the following areas were missing: -Physical and mental functional status including ADLs; -Mental, psychosocial and behavior status; -Cognitive status; -Dietary and nutritional status; -Activities potential; -Sensory and physical impairments; -Medial history; -Course of illness, treatment and/or therapy since entering the facility; and, -Current laboratory, radiology, consultation and diagnostic tests. III. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the April 2024 CPO, diagnoses included fracture of unspecified part of the neck of left femur, type II diabetes, heart disease and need for assistance with personal care. The 3/25/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup assistance with all ADLs. B. Record review -A review of Resident #3's EMR failed to show that a nursing summary with the recapitulation of the resident's stay was completed upon discharge. IV. Resident #4 A. Resident status Resident #4, age 66, was admitted on [DATE] and discharged on [DATE]. According to the April 2024 computerized physician order (CPO), diagnoses included calculus of bile duct with cholecystitis (gallstones), post traumatic stress disorder (PTSD), borderline personality disorder and need for assistance with personal care. The 3/25/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup assistance with all ADLs. B. Record review -A review of Resident #4's EMR failed to show that a nursing summary with the recapitulation of the resident's stay was completed upon discharge. V. Staff interviews Regional nurse consultant (RNC) #1 was interviewed on 7/23/24 at approximately 4:00 p.m. RNC #1 said, after reviewing Resident #3 and Resident #4's EMR, there was not a discharge summary. She said Resident #2's discharge summary was incomplete. The social service director (SSD) interviewed on 7/24/24 at 9:40 a.m. The SSD said she opened the discharge summary for a resident who was discharging and informed the interdisciplinary team (IDT) to complete their designated portions. She said the summary was to be completed on the resident's day of discharge. She said the discharge summary, the medication list and any pertinent information was provided to the family or the receiving facility. RNC #2 was interviewed on 7/29/24 at 3:30 p.m. RNC #2 said the nurse manager or discharging nurse was to ensure the discharge summary was complete prior to the residents' discharge. The director of nursing (DON) was interviewed on 7/29/24 at 3:36 p.m. The DON said she was not aware the nurse manager or the discharging nurse was responsible to ensure the discharge summary was complete prior to the residents' discharge.

Based on record review and interviews, the facility failed to ensure each resident was permitted to remain in the facility and not transfer or discharge for three (#6, #4 and #3) of four residents reviewed for discharge out of 21 sample residents. Specifically, the facility failed to: -Have documentation from Resident #6's physician regarding the reason for the resident's facility-initiated discharge; -Document the specific resident need(s) that could not be met at the facility, the facility's attempts to meet the resident's needs and the services available at the receiving facility to meet the resident's need(s) for Resident #6; -Document the discharge planning process in Resident #6's electronic medical record (EMR); -Ensure Resident #6's necessary information, including the resident's comprehensive care plan goals, was provided to the receiving facility; and, -Provide Resident #4 and Resident #3 with an appropriate and safe discharge process. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy and procedure, revised October 2022, was received from regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It revealed in pertinent part, When a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge. Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long term care hospital, or inpatient rehabilitation facility are assisted in selecting a post-acute care provider that is relevant and applicable to resident's goals of care and treatment preference. Data used in helping the resident select an appropriate facility include the receiving facility's standard patient assessment data, quality measure data and data on resource use. A member of the interdisciplinary team (IDT) reviews the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: the evaluation of the resident's discharge needs, the post discharge plan and the discharge summary. II. Resident #6 A. Resident status Resident #6, age 66, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), hypothyroidism (decreased function of thyroid), type II diabetes (abnormal glucose control), hemiplegia affecting right side (decreased function on the left side of body) and bipolar (abnormal thought process). The 6/12/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required supervision assistance with dressing and toileting. Resident #6 required set up assistance with eating and personal hygiene. B. Resident interview Resident #6 was interviewed on 7/23/24 at 12:13 p.m. Resident #6 said if residents complained about an issue in the facility, the facility made the residents leave. Resident #6 said he had no intentions of leaving the facility but after he complained about staff, the facility was making him move. He said the facility had him sign a discharge notice on the same day he complained about staff. Resident #6 said the new facility his current facility was transferring him to was further away from his family and would strain their ability to visit him. C. Record review The 6/29/23 comprehensive care plan, revised 3/11/24, revealed Resident #6 was to remain in long term care at the facility as he required 24-hour nursing care. Interventions included reviewing the plan of care/initially/quarterly or as needed and social services was to document changes to the discharge goals per resident preference as indicated. -There was no other documentation on the care plan for discharge/transfer goals or planning. The electronic medical record (EMR) revealed Resident #6 was issued a Nursing Home Notice of Involuntary Transfer or Discharge on 6/14/24. -The involuntary discharge notice failed to document the reason the resident was being discharged or the reason the resident's needs could not be met at the facility. Review of Resident #6's EMR revealed there were no progress notes regarding the resident's discharge to another facility until 7/23/24, the day of the resident's discharge. Further review of Resident #6's EMR revealed there was no physician documentation which detailed the reason for the resident's facility-initiated discharge. D. Staff interviews The medical director (MD) was interviewed on 7/29/24 at 11:15 a.m. The MD said he had not been informed of a facility-initiated 30-day discharge notice for Resident #6. RNC #1 was interviewed on 7/25/24 at 4:20 p.m. RNC #1 said residents required a physician's order for discharge/transfer. RNC #1 said the social services department did not appropriately document the discharge planning for Resident #6. Registered nurse (RN) #1 was interviewed on 7/29/24 st 2:05 p.m. RN #1 said when a resident discharged to another facility she sent a resident profile, current medication order, treatment orders and the resident's remaining medications, if the doctor allowed them to be sent, to the receiving facility or home with the resident. RN #1 said she did not send a care plan to the facility where Resident #6 transferred to because she was unaware she needed to send a care plan. RNC #2 was interviewed on 7/29/24 at 2:08 p.m. she said the facility had not been sending a comprehensive care plan with residents when they were discharged or transferred. The director of nursing (DON) was interviewed on 7/29/24 at 3:36 p.m. The DON said when a 30-day discharge notice was given to a resident, it was discussed with the interdisciplinary team (IDT) prior to the notice being given. She said Resident #6 had behaviors and would throw food at the certified nurse aides (CNA). She said he had cut an aluminum can, which could have been used as a weapon. The DON said the facility had sent Resident #6 to the hospital when he had unsafe behaviors. She said he would return to the facility and would apologize for the behavior incidents but continued to have behaviors. The DON said Resident #6 was moved to a private room to ensure other residents' safety. She said Resident #6 had the right to appeal the 30-day notice. -However, review of Resident #6's EMR revealed no documentation which indicated the resident had been provided with the contact information to request an appeal of the discharge. Cross-reference F623 for failure to provide notice before discharge. The nursing home administrator (NHA) was interviewed on 7/25/24 at 4:40 p.m. The NHA said there was no documentation in Resident #6's EMR to indicate the facility's discharge planning process for the resident. The NHA said the facility had been working with the social services department for the past six months related to multiple issues. 20287 III. Resident #4 A. Resident status Resident #4, age 66, was admitted to the facility on [DATE]. According to the April 2024 CPO, diagnoses included calculus of bile duct with cholecystitis, post traumatic stress disorder, borderline personality disorder and need for assistance with personal care. The 3/25/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup assistance with activities of daily living (ADL). B. Record review The against medical advice (AMA) release form, dated 4/23/24, read in pertinent part, This document serves to certify that the above named resident (Resident #4) at the above named facility, is leaving the facility against the advice of the attending physician. The resident acknowledges that he/she has been informed of the risks involved and hereby releases the attending physician and the facility from all responsibility from all ill effects which may result from such discharge. -Resident #4 did not sign the document and there was no documentation to explain why the resident did not sign the document. Review of Resident #4's EMR revealed the following progress notes: A progress note, dated 4/23/24, documented Resident #4 told the nurse she needed to go to the bank and would walk if she had to. She was told by the social service director (SSD) that in-house transportation was not available. Resident #4 said she was going to walk to the bank and informed the nurse that Resident #3 was going with her. The nurse said it was too far and the resident said she was going to go because walking a mile was nothing for her. The nurse notified the DON and the NHA. The social service progress note dated 4/23/24 documented Resident #4 was told that walking to the bank was not advised and a medical pass would be needed from the physician. The resident verbalized understanding but continued to state she was leaving. The progress note further documented Resident #4 was alert and oriented and able to make her own decisions. Resident #4 was aware that if she did walk to the bank it would be against medical advice. -Resident #4's progress notes failed to show that the facility oriented and prepared the resident regarding her discharge in a form and manner that the resident could understand. -Review of Resident #4's EMR failed to show any interventions were tried prior to informing Resident #4 she would be discharged AMA if she left the facility to go to the bank and would not be allowed to return to the facility. -Review of Resident #4's April 2024 CPO did not reveal a physician's order which indicated the resident was unable to leave the facility without a physician's order. -Review of Resident #4's EMR failed to reveal a physician's order or a physician's progress note which documented the reason for the resident's discharge, the resident needs that could not be met by the facility or the attempts made by the facility to meet the resident's needs. IV. Resident #3 A. Resident status Resident #3, age less than 65, was admitted to the facility on [DATE]. According to the April 2024 CPO, diagnoses included fracture of unspecified part of the neck of left femur, type II diabetes, heart disease and need for assistance with personal care. The 3/25/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. He required set up assistance with activities of daily living. B. Record review The against medical advice (AMA) release form dated 4/23/24 read in pertinent part, This document serves to certify that the above named resident (Resident #3) at the above named facility, is leaving the facility against the advice of the attending physician. The resident acknowledges that he/she has been informed of the risks involved and hereby releases the attending physician and the facility from all responsibility from all ill effects which may result from such discharge. -Resident #3 did not sign the document and there was no documentation to explain why the resident did not sign the document The form was signed by the nurse and the receptionist. -Resident #3's progress notes failed to show that the facility oriented and prepared the resident regarding her discharge in a form and manner that the resident could understand. -The progress notes did not reveal any documentation in regards to Resident #3 leaving the facility with Resident #4. -Review of Resident #3's April 2024 CPO did not reveal a physician's order which indicated the resident was unable to leave the facility without a physician's order. -Review of Resident #3's EMR failed to reveal a physician's order or a physician's progress note which documented the reason for the resident's discharge, the resident needs that could not be met by the facility or the attempts made by the facility to meet the resident's needs. V. Staff interviews The DON was interviewed on 7/23/24 at approximately 4:00 p.m. The DON said Resident #4 and Resident #3 were discharged against medical advice (AMA) and no medications were sent with the residents. She said the residents were only sent with their personal belongings when they were discharged AMA. The SSD and the NHA were interviewed together on 7/24/24 at 9:40 a.m. The SSD said Resident #4 was discharged against medical advice because she said she wanted to go to the bank. The SSD said the resident was not allowed to leave the facility without a physician's order. She said Resident #4 was not allowed to use the in-house transportation as she had used it before and was rude to the bus driver. The SSD said when Resident #4 went to the bank, she was rude to the bank teller. The SSD said she told Resident #4 if she walked to the bank it was not safe and she could fall. The SSD was unable to provide any interventions which she used in order to help Resident #4 to get to the bank prior to the resident leaving the facility on 4/23/24. She said because the resident insisted she was leaving to go to the bank, she was told it was against medical advice if she left. The SSD said Resident #3 was discharged against medical advice because he was going to accompany Resident #4 to the bank. The SSD said Resident #3 did not have a physician's order to leave the facility alone. She said anytime the resident wanted to leave the facility, a physician's order was needed or it was considered leaving against medical advice. The SSD said Resident #3 was cognitively intact and understood if he left the facility with Resident #4 he would be leaving against medical advice. The NHA said Resident #3 was discharged against medical advice, because he was getting himself involved with Resident #4, who wanted to leave. The NHA said he paid for a hotel for Resident #4 and Resident #3 for five days. The facility receptionist (FR) was interviewed on 7/25/24 at 1:33 p.m. The FR said she was at the front desk on 4/23/24 the day Resident #4 and Resident #3 left the facility against medical advice. The FR said she did not ask the residents any questions or try to convince the residents to remain in the facility. The FR said the residents did not speak to her when they left the facility.

Based on observations, record review and interviews, the facility failed to ensure resident rights were promoted and dignity was maintained for seven (#10, #15, #17, #18, #19, #20, and #21) of seven residents out of 21 sample residents. Findings include: I. Facility policy The Resident Rights policy, revised February 2021, was provided by regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident right to a dignified existence, to be treated with respect, kindness and dignity, to self determination and to be supported by the facility in exercising his or her rights. II. Resident group interview The resident group interview was conducted on 7/23/24 at 1:00 p.m. The group consisted of seven residents (#10, #15, #17, #18, #19, #20, and #21) who were interviewable based on assessment and facility. The residents stated they continued to have concerns with being treated with respect and dignity. The concerns were as follows: Residents said they were not allowed to leave the facility without a physician's order. Residents said they could not go to the convenience store which was located across the street from the facility. Residents said they felt like they were treated as if they were children. Residents said they did not understand why they were not allowed to leave the building on their own. One resident said he was in jail at a prior time during his life and being unable to leave the facility made him feel like he was in jail. III. Staff interviews The social service director (SSD) and the nursing home administrator (NHA) were interviewed on 7/23/24 at 9:40 a.m. The SSD said residents were not allowed to leave the building without a physician's order pass. She said it was a safety measure because a resident might fall if they walked outside of the building. She said if a resident wanted to leave the building then the nurse would call to get a physician's order for the pass. She said the physician's order pass was usually for four hours. The SSD said two residents were discharged against medical advice because the two residents wanted to leave the building without a physician's order pass. Cross-reference F622 for failure to follow appropriate discharge requirements.

Based on record review and interviews, the facility failed to develop and implement an effective discharge planning process for two (#16 and #2) of four residents reviewed for discharge planning out of 21 sample residents. Specifically, the facility failed to: -Ensure the discharge planning process was documented in Resident #16's and Resident #3's electronic medical records (EMR); and, -Ensure the interdisciplinary team (IDT) was a part of the ongoing discharge process for Resident #16 and Resident #3. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy and procedure, revised October 2022, was provided by regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It read in pertinent part, Every resident is evaluated for his or her discharge needs and has an individualized post discharge plan. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. II. Resident #16 A. Resident status Resident #16, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included fracture of the left patella (fracture of the knee), major depression and need for assistance for personal care. The 5/15/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with activities of daily living (ADL) but needed set up assistance with lower body extremities. The MDS assessment indicated the resident had an active discharge plan and a referral was made. B. Record review The discharge care plan, initiated on 8/8/23 and revised on 5/31/24, revealed the resident desired to return to an independent living apartment. The goal was for the resident to be discharged when her clinical and rehabilitation goals were met. Pertinent interventions included discussing with the resident and family regarding the discharge planning process and reviewing progress made toward discharge. -The care plan was not updated until 5/31/24, after the resident was discharged . The 3/28/24 primary care progress note documented the resident was seen by the primary care provider. The note documented the resident reported feeling frustrated that she was not sure when she would be able to leave the facility. The note documented the resident said the facility was supposed to help her leave, but her discharge was recently put on hold. The resident said she did not know how long it was going to take to discharge. -Review of the resident's progress notes failed to reveal a discharge plan documented for Resident #16 or follow up from the 3/28/24 primary care progress note. The 5/23/24 care conference note documented the resident was going to be discharged on [DATE] to an independent apartment with home health services. -A review of Resident #16's EMR did not reveal documentation indicating the facility had assisted the resident with her discharge goals. -A review of the resident's EMR failed to show the reasons for the discharge and who had made the decision and that the IDT was involved. -A review of the April 2024 CPO did not reveal a physician's order was obtained for the resident's discharge. C. Staff interviews The director of nursing (DON) was interviewed on 7/23/24 at approximately 4:00 p.m. The DON said there was not a physician's order for the resident's discharge. She said the process was to obtain a physician's order prior to the resident's discharge. The social service director (SSD) was interviewed on 7/24/24 at 9:40 a.m. The SSD said Resident #16 was discharged to an independent living facility. The SSD said she reviewed the resident's EMR and said there was no documentation that indicated the discharge plan for Resident #16 or any follow up after the resident's 3/28/24 physician's visit. The social service assistant (SSA) was interviewed on 7/24/24 at 9:45 a.m. The SSA said the resident worked with an independent agency to find housing. The SSA said the facility did not assist with the resident's discharge. III. Resident #2 A. Resident status Resident #2, age 73, was admitted on [DATE] and discharged on [DATE]. According to the April 2024 CPO, diagnoses included malignant neoplasm of the tongue (cancer of the tongue), type II diabetes and sensorineural hearing loss. The 3/25/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. He required set up assistance with ADL. The MDS assessment documented the resident had an active discharge plan, however a referral was not made, as it was not wanted. B. Record review The discharge care plan, initiated on 3/26/24, revealed the resident's goal was to be discharged home to live with his wife when cleared to be discharged . The goal was to have a safe transition to home. Pertinent interventions included coordinating durable medical equipment, coordinating home health and the nursing staff to provide discharge instructions and education for all physician's orders. -The care plan was not updated throughout his stay. -A review of the resident's progress notes failed to reveal a documented discharge plan for Resident #2. -The resident's EMR failed to document the reasons for the discharge, who had made the decision to discharge and that the IDT was involved. The 4/23/24 progress note documented the resident was discharged home with all medications and wound care supplies. Home health care was arranged. Education was provided for medication administration and wound care steps. -The progress notes and care plan failed to reveal that the facility had a discharge plan which was a safe discharge. C. Staff interviews The SSD was interviewed on 7/24/24 at 9:40 a.m. The SSD said Resident #2 was discharged to his home with his wife. She said she reviewed the resident's EMR and said there was no information or plans documented for the resident's discharge. She said when a resident desired to return to home, a plan should be created and services, such as home health care, arranged. RNC #1 was interviewed on 7/24/24 at 10:00 a.m. RNC #1 said the social work consultant would ensure the SSD received education on the discharge planning process.

Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation for one (#2) of three residents out of 21 sample residents to ensure a safe discharge from the facility. Specifically, the facility failed to: -Provide Resident #2 and his representative with the correct information regarding the resident's nutritional and tube feeding needs when the resident was discharged ; -Provide Resident #2 and his representative with discharge education or training related to the resident's feeding tube; and, -Provide Resident #2 and his representative with a discharge summary and discharge instructions in a language they understood. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy and procedure, revised October 2022, was provided by regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It read in pertinent part, Every resident is evaluated for his or her discharge needs and has an individualized post discharge plan. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. II. Resident #2 A. Resident status Resident #2, age 73, was admitted on [DATE] and discharged home on 4/23/24. According to the April 2024 computerized physician orders (CPO), diagnoses included malignant neoplasm of the tongue, type 2 diabetes, and sensorineural hearing loss. The 3/25/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required setup assistance with activities of daily living (ADL). The assessment revealed the resident received a therapeutic and mechanically altered diet. B. Resident representative interview The resident's representative was interviewed via phone on 7/22/24 at 11:38 a.m. via a Russian interpreter. The representative said she was the primary caretaker for Resident #2. She said she got the supplies for the resident's tube feeding from his oncologist's office after his discharge because the facility did not provide the supplies when he was discharged . The representative said Resident #2 was currently using the eternal feeding. C. Registered dietitian (RD) interview The registered dietitian (RD) from Resident #2's oncologist's office was interviewed via phone on 7/24/24 at 1:37 p.m. The RD said she saw Resident #2 on 5/17/24, approximately one month after he had been discharged from the facility. She said the resident was not discharged from the facility with any feeding tube equipment and the resident and his representative were not provided any education regarding the resident's feeding tube upon his discharge. The RD said Resident #22 had lost weight and appeared weak since his discharge . She said the resident's representative had told her the resident was only eating handfuls of food, as he was not able to eat much orally due to the resection of his tongue. She said the representative told her the resident had not been using the feeding tube for nutrition after his discharge because the facility had not provided them with tube feeding supplies. D. Record review The discharge care plan, initiated 3/26/24 documented Resident #2 would discharge home with his representative when he had been cleared to discharge home. Pertinent interventions included coordinating medical equipment, pharmacy, home health and in-home support services. Nursing was to provide discharge instructions and education for all physician orders and offer family training with the resident's representative as needed. -Review of Resident #2's electronic medical record (EMR) failed to show documentation which indicated the resident and/or his representative had been provided with training related to the resident's feeding tube and nutritional needs. The 4/19/24 physician's order documented med pass 2.0 was to be administered twice daily after dinner. The resident was no longer NPO (nothing by mouth). The progress note dated 4/22/24 documented a physician's order for the resident to discharge home and a phone number for a translator who could help Resident #2 and his representative with discharge education. The progress note dated 4/23/24 documented Resident #2 discharged home with all of his medications and wound care supplies. Education was provided to the resident and a home health nurse for medication administration and wound care steps. -The progress note failed to document whether the resident would be receiving tube feedings upon discharge or if the resident or the resident's representative was provided with discharge education related to his feeding tube. Review of Resident #2's discharge summary dated 4/23/24, which was provided to the resident's representative when the resident was discharged , revealed the dietary and nutritional needs section was left blank. -However, the discharge summary included an attachment which was also provided to the resident's representative when the resident discharged .The instructions on the attachment read in pertinent part, Enteral Feed Order: after meals and at bedtime for hydration/ fluids 150 milliliters (ml) water flush after bolus (a method of administering nutritional formula through a feeding tube using a syringe) feedings. -Additionally, the facility failed to provide the discharge summary and discharge instruction to the resident and his representative in their preferred language of Russian. A 5/17/24 clinical support note from the resident's oncologist office, written by the oncologist's office RD, documented Resident #2 had been eating pureed foods at home, in portions the resident's representative described as handfuls. The resident ate oatmeal and yogurt in the morning on 5/16/24 and had soup and some meat the representative had pureed in a blender for lunch. The resident did not eat dinner on 5/16/24. The representative reported they did not have any tube feeding formula at home because they were not provided any when the resident was discharged from the facility. Resident #2's representative had been flushing water through the resident's feeding tube throughout the day but she said she did not receive any additional education on how to use the resident's feeding tube. E. Staff interview The director of nursing (DON) was interviewed on 7/24/24 at 9:05 a.m. The DON said the Resident #2's tube feedings were discontinued prior to the resident's discharge from the facility. The DON said the resident was eating a full pureed meal a few weeks prior to discharge and therefore he was not discharged with tube feeding formula or tube feeding supplies. She said the resident had been eating pureed food at the facility since 4/19/24. -However, the discharge summary, which was provided to Resident #2's representative when the resident was discharged , failed to document specific dietary and nutritional information and included instructions for providing the resident with water flushes following bolus tube feedings (see record review above).

Based on record review and interviews, the facility failed to provide notice of discharge to the resident or their representative and the Office of the State Long-term Care Ombudsman at least 30 days before the resident's discharge for one (#6) of four residents reviewed for discharge out of 21 sample residents. Specifically, the facility failed to provide Resident #6 an appropriate written notice of discharge from the facility that included: -The reason for transfer or discharge; -The location to which the resident was being transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email) and telephone number of the entity which receives such requests; and, -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy and procedure, revised October 2022, was received from regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It revealed in pertinent part, When a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of the resident information and as permitted by the resident. II. Resident #6 A. Resident status Resident #6, age 66, was admitted on [DATE] and discharged on [DATE] (during the survey). According to the July 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), hypothyroidism (decreased function of thyroid), type II diabetes (abnormal glucose control), hemiplegia affecting right side (decreased function on the left side of body) and bipolar (abnormal thought process). The 6/12/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required supervision assistance with dressing and toileting. Resident #6 required set up assistance with eating and personal hygiene. B. Resident interview Resident #6 and a family member were interviewed together on 7/23/24 at 12:13 p.m. Resident #6 said if a resident complained about an issue to the facility staff, the facility would discharge the resident. Resident #6 said he was given a discharge notice on the same day he complained about the staff. Resident #6 said he was being transferred to a facility further away from his family which was going to strain their ability to visit him. Resident #6 said the facility looked for places for him to go but he was not involved with finding a new place. He said he was just told which facility he would be transferred to. Resident #6 said he was unaware of his right to appeal the transfer/discharge but he said, at this point, he did not want to stay in the current facility. C. Record review The resident's electronic medical record (EMR) revealed Resident #6 was issued a Nursing Home Notice of Involuntary Transfer or Discharge on 6/14/24. The notice documented the resident was being transferred or discharged because it was necessary to meet the resident's welfare and the resident's welfare could not be met in the facility. The notice was signed by the nursing home administrator (NHA) and the resident on 6/14/24. The notice revealed only the local long term care ombudsman was notified by the facility on 6/14/24. The form failed to identify: -The location the resident was being transferred to; -That the State Long-term Care Ombudsman was notified of the transfer/discharge; -Information regarding the resident's appeal rights, including the name, address (mailing and email) and telephone number of the entity which receives such requests; and, -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request. -The resident's EMR failed to provide physician documentation regarding how the facility was unable to provide care to Resident #6, which required him to be transferred/discharged to another facility. A social service progress note on 6/12/24 revealed Resident #6 had a care conference on 6/11/24 and was identified as a long term resident. -There was no documentation to indicate a discussion had taken place at the care conference regarding Resident #6 having behavior concerns or a potential for the resident needing to be transferred or discharged from the facility. -A review of the resident's EMR did not reveal any other progress notes written for transfer/discharge of Resident #6 in the EMR until 7/23/24, the day of transfer/discharge. On 7/23/24 at 12:46 p.m. (during the survey) a social service progress note revealed Resident #6 was aware he was being transferred to another facility and he no longer wanted to be a resident at the facility. III. Staff interviews Registered nurse (RN) #1 was interviewed on 7/29/24 at 2:05 p.m. RN #1 said Resident #6 was transferred to another facility related to behaviors consisting of threats towards others and himself. -However, there was no documentation in the resident's EMR that indicated Resident #6 exhibited behaviors that could not be managed in the facility which required him to be transferred or discharged to another facility. The NHA was interviewed on 7/29/24 at 3:55 p.m. The NHA said transfers/discharges were discussed in the morning stand up meetings. The NHA said he was not aware of the appeal process. He said he reviewed Resident #6's involuntary transfer/discharge paperwork and said he did not see the appeal section on the paperwork Resident #6 signed. The NHA said the facility notified the local ombudsman and he believed the ombudsman could review the appeal process with residents if needed. The NHA said he reviewed additional involuntary transfer/discharge notices and said the facility used two different forms. He said it was up to his business office manager (BOM) on which form was used. The BOM was interviewed on 7/29/24 at 4:22 p.m. The BOM said he only reviewed transfers/discharges during the triple check meeting for billing purposes. He said he did not determine what forms were used in the facility. The NHA was interviewed again on 7/29/24 at 5:15 p.m. The NHA said the facility did not have any records to show why they were unable to provide Resident #6 care to support the involuntary transfer/discharge.

Based on record review and interviews, the facility failed to provide evidence that a quarterly statement was provided to the resident and/or resident representative for two (#9 and #12) of three residents reviewed for personal funds out of 21 sample residents. Specifically, the facility failed to: -Provide Resident #9 and Resident #12 or their legal representatives a copy of the resident's personal funds financial statement on at least a quarterly basis; -Ensure Resident #9 and Resident #12 or their legal representatives reviewed and signed the form required to give the facility authorization to manage the resident's personal funds; and, -Ensure Resident #9 and Resident #12 or their legal representatives were informed when the resident's total funds reached an amount that required a spend down. Findings include: I. Facility Policy The Management of Residents' Personal Funds policy, dated 2021, was provided by regional nurse consultant (RNC) #1. The policy read: Should the resident elect to have the facility manage his or her personal funds, it must be authorized in writing by the resident or the resident's representative and a copy of such authorization must be documented in the resident's record. II. Resident trust fund authorization form The Authorization and Agreement to Manage Resident Funds form read in pertinent part: l authorize the (facility name) to hold safeguard, manage, and account for my personal funds. Resident trust fund account type: -Transferring: By establishing this account, I authorize the (facility name) to transfer my monthly patient responsibility for care costs amount, if any, due to the (facility name) from this resident trust account to the (facility name) operating account. My monthly personal needs allowance remains in my resident trust account. I authorize the (facility name) to adjust my personal needs allowance amount. -Non-Transferring: All funds deposited to this resident trust account remain in this account, until I authorize the withdrawal of funds in writing. My account will be managed as follows: I. (Facility name) will give me a written receipt for all expenditures and deposits regarding any funds I deposit with (facility name). 2. (Facility name) will maintain a record of all transactions regarding my account in accordance with generally accepted accounting principles. 3. I will have access, at any time upon request, to the above record and will receive an itemized quarterly statement of my account. III. Resident #9 A. Resident status Resident #9 under the age 65, was admitted on [DATE]. The 4/15/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. B. Resident and resident representative interview Resident #9 was interviewed on 7/24/24 at 11:30 a.m. Resident #9 said he was not provided any personal funds statements of his account since admitting to the facility, nor was his legal representative provided the statements. He said they had been trying to get the business office manager (BOM) to provide his personal funds statements to his legal representative but it had not been provided as requested. Resident #9's legal representative and financial power of attorney (FPOA) was interviewed on 7/26/24 at 12:49 p.m. The FPOA said she had been trying to get the facility's BOM to honor her FPOA and send her Resident #9's financial statements, but no one from the facility had responded to her request. The FPOA said she had provided documentation of her FPOA status several times and the facility had still failed to communicate with her about Resident #9 finances, which were managed by the facility. C. Record review Review of Resident #9's Authorization and Agreement to Manage Resident Funds document, dated 4/23/24, revealed the form was not signed by the resident or the resident's legal representative. IV. Resident #12 A. Resident status Resident #12, age 89, was admitted on [DATE]. According to the July 2024 computerized physician's orders (CPO), diagnoses included dementia. The 7/17/24 MDS assessment revealed the resident had severely impaired cognition with a BIMS score of four out of 15. B. Resident representative interview Resident #12's secondary legal representative was interviewed on 7/29/24 at 3:16 p.m. The secondary representative said she was never consulted about Resident #12's finances and was told that she had no say in the resident's finances, despite being the resident's secondary legal representative and being involved in making decisions about the resident's care. The secondary representative said she was aware the resident had a need to spend down money in the past and wanted the resident to get a larger television because the one she had in her room was small and she had a hard time seeing the picture. The secondary representative said she was unsure if that spend down was used or what the facility had spent the money on. Resident #12's primary legal representative was interviewed on 7/29/24 at 3:23 p.m. The primary representative said she was the resident's primary legal representative but she lived out of state so she relied heavily on the resident's secondary legal representative to provide her first hand information about how the resident was doing and be the person to represent Resident #12 in person at the facility. The primary representative said she and the secondary representative collaborated on decision-making to make sure the facility was acting in the best interests of Resident #12. The primary representative said she had never been provided with a copy of Resident #12's financial statements and the facility had been managing the resident's funds since October 2018. C. Record review Review of Resident #12's Authorization and Agreement to Manage Resident Funds documents, dated 10/13/2020 and 4/24/23, revealed the forms were not signed by the resident or the resident's primary or secondary legal representative. V. Staff interviews The BOM was interviewed on 7/29/24 at 2:26 p.m. The BOM said he managed the residents' personal funds accounts and provided the residents, and the residents' representatives when applicable, with quarterly statements of their personal funds accounts. He said when a resident's personal funds account was near or over the allowable total balance, he notified the resident and the social worker that the resident needed to spend down their excess funds to maintain their eligibility for nursing care. The BOM said Resident #9 had a conservator (a person, official, or institution appointed by a court to take over and manage the estate of an incompetent individual) and he believed that he had talked to the conservator about Resident #9's personal funds and the need to spend down his excess funds. -However, Resident #9 was competent and did not have a conservator. On 3/8/23, Resident #9 had self-appointed a legal representative to act as his FPOA on his behalf in all matters of finance, including banking. The BOM said Resident #12 had a guardian and he was working with the resident's guardian to manage the resident's funds and spend down her excess funds. The BOM said the residents' financial statements were last provided for the past quarter at the end of July 2024.

Based on interviews, observations, and record review, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for four (#174, #99, #20, and #95) of four residents reviewed for respiratory care out of 46 sample residents. The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice. -The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe. -The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a Trilogy ventilator (ventilator) at bedtime and managed her trach care and ventilator care herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the resident's bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) responded and placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services, including a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation of immediate jeopardy for serious harm. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice. -The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe. -The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a ventilator at bedtime and managed her trach care and ventilator herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services. Moreover, the facility lacked a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation of immediate jeopardy for serious harm. B. Facility notice of immediate jeopardy On 3/7/24 at 10:55 a.m. the nursing home administrator (NHA) and director of nursing (DON) were notified that the facility's failure to ensure staff was aware of the status of respiratory equipment, and understood respiratory care procedures for residents with trachs and ventilators, created a situation of immediate jeopardy for serious harm. C. Plan to remove immediate jeopardy 1. The plan On 3/7/24 the NHA presented the following plan to address the immediate jeopardy situation which read in pertinent part: Identification of residents affected or likely to be affected: the facility took the following actions to address the citation and prevent any additional residents from suffering any adverse outcomes. On 3/6/24 the respiratory provider evaluated all current residents with a tracheostomy. The DON/designee audited residents with tracheostomy medical records to ensure the presence of physician's orders and resident specific care plan interventions for the care of their tracheostomy. The DON/designee obtained a bedside supply list and assessed all current residents with a tracheostomy to ensure that any needed tracheostomy care equipment and supplies were at the bedside. The facility took the following actions to prevent any adverse outcomes from reoccurring. On 3/7/24, the policy for tracheostomy care and suctioning were reviewed/revised. Removed aseptic technique for trach care. On 3/6/24 the respiratory provider provided education to licensed nursing staff on tracheostomy care, suctioning, placement of the Trilogy (ventilator), providing nebulizers via trach and following the individualized interventions in each resident care plan, physician's orders for trach care and ensuring trach care equipment/supplies were readily available at the bedside. By 3/15/24, staff who were not present during training will be educated prior to their next working shift and provide return demonstration with training listed above. On 3/7/24 a PRN (as needed) order was added to Trilogy (ventilator) residents orders on placing residents on the Trilogy in the event the resident is not able to provide self-care. On 3/7/24 the DON/designee placed a respiratory flow sheet at the bedside for tracheostomy care documentation. On 3/7/24 the DON/designee provided training to licensed staff on the bedside supply list, respiratory flow sheet for documentation. The DON/designee will audit respiratory flowsheets five times weekly for 30 days, then three times weekly, for 30 days, then one time weekly for 30 days. Results will be reviewed in QAPI to determine further monitoring. Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. The respiratory provider will audit supplies weekly and provide trach supplies for tracheostomy residents. In the event a supply is running low, nursing will reach out and order additional supplies from the provider. In the event of a respiratory change a Licensed nurse will evaluate the resident, provide care within their scope of practice, for further needs a provider will be contacted to provide further orders. If further emergency management is needed 911 will be contacted for hospital transfer. 2. Interviews with staff involved in the training outlined in the plan above revealed a continued lack of understanding regarding specialized respiratory care and services. Registered nurse (RN) #2 was interviewed on 3/7/24 at 5:47 p.m. She said she received training from the respiratory therapist (RT) on 3/6/24. She said she did not receive any instruction on how to work with the ventilator machine. She said she did not usually work with that resident and did not have contact with it. RN #3 was interviewed on 3/7/24 at 5:50 p.m. The RN said she had training on 3/6/24 on suctioning and trach care with a return demonstration. She said she did not receive ventilator training from the facility. LPN #6 was interviewed on 3/7/24 at 5:50 p.m. LPN #6 said she had done the training, however, she did not perform a return demonstration and only repeated the information back verbally. She said she did not get training on the ventilator. LPN #7 was interviewed on 3/7/24 at 5:54 p.m. LPN #7 said she had training on the suction machine and humidifier with the RT. She said she had received training on the ventilator on 1/31/24 before the resident was admitted . RN #4 was interviewed on 3/7/24 at 5:55 p.m. RN #4 said she received training but did not do a return demonstration and did not receive training for the ventilator or on administering a nebulizer treatment through a trach. LPN #5 was interviewed on 3/7/24 at 5:55 p.m. LPN #5 said she received training on 3/6/24 but not on the ventilator as she does not have one on her floor. 3. Based on the interviews above, the facility conducted a second training with licensed nursing staff later in the day on 3/7/24. LPN #7 was interviewed on 3/7/24 at 7:45 p.m. LPN #7 said the staff had training on trach care, trach mask nebulizer treatments, suctioning, connecting the resident to the ventilator, updating the resident care plan, setting up an aerosol, changing the inner cannula, and connecting the ventilator to oxygen. She said the staff did return demonstrations on everything in the training. RN #3 was interviewed on 3/7/24 at 7:45 p.m. RN #3 said the training included suctioning, physician's orders, plans of care, trach site cleaning, nebulizer treatments and where to find supplies. She said supplies were in the crash (emergency) cart and resident rooms. She said the training also included information about the ventilator and how to put it on a resident. She said the staff performed return demonstrations. LPN #5 was interviewed on 3/7/24 at 7:46 p.m. LPN #5 said staff were re-shown how to do trach care with the insertion and removal of inner cannulas, sectioning sterile technique, how to apply nebulizer treatment to a trach, the ventilator machine application, compressor, humidifier adjustments based on oxygen level, cleaning the stoma (the area of skin around the trach), replacing the trach tube, what to do in an emergency, where the supplies are located in the resident's room and on the crash cart, how to suction through the ventilator, ventilator care plans, and physician orders. RN #4 was interviewed on 3/7/24 at 7:50 p.m. RN #4 said the training included suctioning, nebulizer, and connecting a resident to a ventilator machine. She said there was information on supplies and where to get them. She said the staff did a return demonstration. RN #2 was interviewed on 3/7/24 at 7:51 p.m. She said the staff were re-educated on trach care, cleaning, sterile suction, how to use the ventilator, nebulizer treatments given through the trach, care plans, and physician orders. She said the staff were also trained on where equipment and supplies were to be at the bedside, on the crash cart, and in the oxygen room. D. Removal of immediate jeopardy On 3/7/24 at 8:01 p.m., the NHA and the DON were notified that the immediate jeopardy was lifted based on evidence of the facility's implementation of the plan. However, the deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Facility policy and procedure A. The tracheostomy care policy and procedure, dated 8/2013, was provided by the DON at 1:25 p.m., it read in pertinent part: The purpose of the procedure is to guide tracheostomy care and the cleansing of reusable tracheostomy cannulas. Tracheostomy care should be provided as often as needed, at least once daily. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Check physician orders. Clean the removable inner cannula. Unlock the inner cannula. Gently remove the inner cannula by rotating counterclockwise while lifting away from the resident. Clean with a brush. Rinse with saline and dry with pipe cleaners. Replace the cannula carefully and lock in place. Ensure there is an emergency tracheostomy set at the resident's bedside. B. The mechanical ventilation: setup and monitoring policy and procedure, revised 10/2010, was provided by the respiratory care director (RCD) on 3/6/24 at 1:17 p.m. It read in pertinent part: The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency. Verify there is a physician's order for this procedure. Review the physician's orders, including instructions for: Tidal volume (the size of the breath); Ventilatory rate (the number of breaths); Pressure limits (how high or low the pressure delivered by the machine should go). In an emergency, a qualified nurse may initiate (start) mechanical ventilation and then obtain specific orders. Review the resident's care plan to assess for any special needs of the resident. Only a qualified nurse or respiratory therapist can initiate mechanical ventilation, based on an appropriate physician order. Steps in the procedure. Check for proper functioning of the lights, alarms, filters, fittings and the humidifier. Start the ventilator. Listen to the resident's lungs and document breath sounds. Connect the ventilator to the resident. Adjust the ventilator alarms so they can be heard by staff responsible for monitoring the resident. Document the resident's status and chart all ventilator settings. III. Resident #174 A. Resident #174, age 62, was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. According to the March 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (low oxygen), chronic respiratory failure with hypoxia, pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, pneumonia, acute respiratory distress, pulmonary disease, chronic obstructive pulmonary disease (COPD), and hemiplegia (paralysis of one side of the body) and hemiparesis following cerebral infarctions (stroke) affecting right dominant side. 1. The 3/2/24 minimum data set (MDS) assessment documented the resident was unable to perform the brief interview for mental status (BIMS). The resident was dependent on maximal assistance for eating, personal hygiene, toileting, bathing, upper and lower body dressing, rolling left and right, and moving from sitting to lying in bed. 2. Admission orders dated 3/2/24 read the resident had a tracheostomy with an inner cannula. An admission summary note on 3/2/24 at 2:09 p.m. documented the resident was unable to successfully use a speaking valve via his trach tube. 3. A review of the resident's record and observations revealed a brief hospitalization on [DATE], readmission on 3/3/24 with secretions and the need for suctioning, and respiratory distress on 3/6/24 when a mucus plug obstructed his airway. A respiratory therapy assessment and evaluation dated 3/2/24 at 12:17 p.m. documented the resident had coarse crackles bilaterally (both lungs) and had a strong productive cough with thick mucus. An Admission summary note dated 3/2/24 at 12:22 p.m. documented the resident often needed suctioning. An alert note dated 3/2/24 revealed the resident was discharged to the hospital for a displaced trach tube. He returned to the facility on [DATE] with a diagnosis of pneumonia, and care plans for his trach care, respiratory care, and pneumonia were initiated. A medication administration note dated 3/5/24 at 10:04 p.m. documented that the resident required suctioning. A medication administration note dated 3/6/24 at midnight documented the resident required suction and that treatment was effective. A nurse's note dated 3/6/24 at 7:15 a.m. documented trach care rendered including suctioning several times with sizable phlegm (mucus). An observation of the resident on 3/6/24 at 2:05 p.m. during a brief tour with the respiratory care director (RCD) revealed Resident #174 was struggling to breathe. B. Staff interviews revealed the facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs and failed to outline procedures and responsibilities to obtain such supplies. 1. At the time of the observation of Resident #174 struggling to breathe (see above), the RCD said the resident's trach tube did not have the inner cannula in place. Further, the nurse said there were no suction catheters in the room; the RCD had to leave the room to obtain more supplies. 2. The RCD was interviewed on 3/6/24 at 12:52 p.m. and 1:43 p.m., and again on 3/7/24 at 9:00 a.m. -He said Resident #174 had a mucus plug on 3/6/24 at 2:05 p.m. when he was observed in respiratory distress. He said he had removed the inner cannula to the trach on 3/6/24 at 9:00 a.m. -He said Resident #174 had three inner cannulas when he returned from the hospital on 3/3/24 and the inner cannula he removed at 9:00 a.m. was the last inner cannula provided by the hospital. He said he had informed the DON that morning that the resident needed more inner cannulas due to the resident being out of supply. He said the nursing staff should have called the respiratory provider for supplies on 3/4/24 or 3/5/24. -He said the tracheostomy residents in the building did not have the supplies they needed for care. 3. The DON was interviewed on 3/6/24 at 2:50 p.m. and again on 3/7/24 at approximately 9:10 a.m. -She said she had called the respiratory service provider on 3/6/24 at 11:45 a.m. after the RCD informed her Resident #174 was out of inner cannulas and the inner cannulas were delivered at 2:00 p.m. She said nursing staff should contact the respiratory vendor when the last box of inner cannulas is opened. She said the resident had a history of plugging his trach with mucus plugs. -She said the facility could have requested a monitor that alarmed from the respiratory service provider for Resident #174 but had not done so. 4. Licensed practical nurse (LPN) #8 was interviewed on 3/7/24 at 9:22 a.m. -LPN #8 said the RCD had informed her of the removal of the resident's inner cannula on the morning of 3/6/24. She said Resident #174 had a lot of secretions and needed to be cleaned and suctioned frequently and that morning, they had increased their monitoring of the resident to hourly. -She said she had put her head into the resident's room on 3/6/24 and he had waved her into the room for care when he was having difficulty breathing. She said she had not realized the resident was out of inner cannulas before 3/6/24. She said she had checked the suction supplies but not the inner cannula supply on 3/4/24 and she had not called the respiratory service provider because she did not realize there was a problem. She said she believed the RCD was to call for supplies. 4. The certified respiratory therapist (CRT) from the respiratory service provider was interviewed on 3/6/24 at approximately 2:50 p.m. -The CRT said their service came to the facility as needed or when a request was made for supplies. He said a member of customer service came to the facility on ce a week; however, that person did not carry supplies. He said the service only comes to the facility if the facility calls in a request. -The CRT said he comes to the facility on ce a month to perform trach changes. He said not having an inner cannula on the resident's type of trach (Shiley XLT) meant an ambu-bag could not be connected if there was an emergency. He said a resident could develop a plug if an inner cannula was not in place. -The CRT said he had done nurse training on trach care and suctioning in January 2024. IV. Resident #99 A. Resident #99, under age 65, was admitted on [DATE] and readmitted on [DATE]. According to the March CPO, diagnoses included obesity with alveolar hypoventilation (low ventilation of the lungs), acute pulmonary edema, tracheostomy, obesity, fluid overload, hypertension (high blood pressure), pulmonary hypertension (high blood pressure affecting the lungs), history of pulmonary embolism (blood clot), and history of Covid-19. 1. According to the 1/24/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident respiratory requirements were not listed in the MDS or the person-centered care plan. 2. Record review revealed the resident had a trach tube and used a Trilogy ventilator (ventilator). A nurse's note dated 10/14/23 at 8:26 p.m. documented the resident was dependent on a trach tube with oxygen and used a ventilator at bedtime. A nurse note dated 10/21/23 at 5:55 a.m. documented the resident required assistance with trach care. A physician history and physical note dated 10/24/23 at 6:10 a.m. documented the resident was admitted with chronic hypoxic (low oxygen) respiratory failure and continued on the ventilator. Resident #99 had 2 liters (L) of oxygen requirement while resting and 3L with exertion and nighttime ventilator use since February 2022. A readmission summary note, dated 1/24/24, documented the resident returned from the hospital and was trach-dependent with 2L of oxygen. B. The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. 1. Resident interview Resident #99 was interviewed on 3/6/24 at 1:35 p.m. She said she did her own trach care and suctioning. She also said she put the ventilator on herself at night; however, she said she did not know what her ventilator settings were. 2. Record review On 3/6/24, at the time of the survey, the resident's care plan for respiratory care initiated on 2/7/24 documented the resident was at risk for complications with the respiratory system due to chronic respiratory failure. Interventions included administering IS (incentive spirometry) every two hours as needed. -However, Resident #99 did not have a care plan for tracheostomy care, suctioning, trach changes, or use of the ventilator at night. On 3/6/24, at the time of the survey, a review of Resident #99's orders revealed the orders did not address the ventilator she wore at her trach tube (invasive ventilation) at night. On 3/6/24, a review of Resident #99's record revealed no evidence that the facility documented her use of the ventilator at night. 3. Observations On 3/6/24 at approximately 1:45 p.m. during a brief tour with the RCD of Resident #99's room, there was no ambu-bag at the bedside, the water in the humidification chamber was pink in color instead of clear, there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. 4. Staff interviews The DON was interviewed on 3/6/24 at 1:40 p.m. She said there was a ventilator in the building used for invasive ventilation at night through Resident #99's trach tube. She said there should be orders and a care plan for the tracheostomy and ventilator settings. She said the facility did not think about the ventilator being a ventilator, only as a BIPAP (bilevel 2 positive airway pressure support). She said the night shift took care of the resident's ventilator care. The RCD was interviewed on 3/6/24 at 1:43 p.m. He said there should be a care plan and orders for the ventilator and it should be plugged into a red outlet. He said there should be a backup trach set at the bedside. The DON was interviewed again on 3/6/24 at approximately 2:50 p.m. She said the ventilator should be plugged into a red outlet in case of a power outage. She said it could lead to death if the ventilator should stop working while the resident was attached to it and the power went out. V. Resident #95 A. Resident #95 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonia, tracheostomy, chronic respiratory failure, obstructive sleep apnea, hypertension, reduced mobility, and convulsions. The resident's record revealed the resident had a tracheostomy. B. The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95. 1. Observations Registered nurse (RN) #1 was observed on 3/5/24 at 1:02 p.m. administering medications to Resident #95. RN #1 went into the resident's room to administer an Albuterol nebulizer treatment via trach. She said she was unsure how to apply the nebulizer treatment to the resident's trach and she called for assistance. The assistant director of nursing (ADON) came to help. The ADON said the resident was able to hold the nebulizer in her mouth; however, the nebulizer device did not have a mouthpiece attached to it. The resident was unable to hold it on her own; staff had to hold it for her. The ADON placed the corrugated end of the nebulizer into the resident's mouth and held it for the resident. RN #1 and the ADON were needed elsewhere and they requested another nurse come to hold the nebulizer treatment in the resident's mouth until it was completed. LPN #1 came into the resident's room and said the nebulizer should not have been in the resident's mouth, but rather attached to the trach. LPN #1 turned off the nebulizer machine and attached the nebulizer to the resident's trach for proper administration. 2. Staff interviews LPN #1 was interviewed at 1:35 p.m. and said the resident may not have gotten the effect of the medication since it was not initially delivered via the trach. LPN #1 reviewed the resident's orders and they did not direct the resident to receive the nebulizer treatment via her mouth. The RCD was interviewed on 3/5/24 at 1:40 p.m. He said nebulizer treatments should be given via trach if the resident had one to ensure medication reached the lungs. The CRT was interviewed on 3/6/24 at 3:02 p.m. The CRT said the easiest way to administer the nebulizer via trach is by way of the trach mask. He said when a nebulizer is administered via mouth, it should have a mouthpiece. He said the corrugated end should not be in the resident's mouth. The ADON was interviewed on 3/7/24 at 2:35 p.m. The ADON said she was flustered and should have taken the time to appropriately administer the nebulizer treatment. She said giving the medication via mouth may not have been as effective as if the resident had gotten it via the trach. She said the mouthpiece was missing from the nebulizer and she should have gotten a new setup or applied it directly to the trach. VI. Resident #20 A. Resident #20 was admitted to the facility on [DATE] with diagnoses that included pneumonia and respiratory failure. A review of the resident's record revealed the resident had a tracheostomy B. The facility failed to ensure proper trach care for Resident #20. 1. Observations Resident #20's trach care was observed on 3/6/24 at 8:40 a.m. LPN #9 performed trach care on Resident #20. LPN #9 used four swabs, swabbing all the way around the tracheostomy site with each swab. LPN #1 said the inner cannula was to be changed every three days and she had checked it earlier in the morning and it was clean. 2. Interview The CRT was interviewed on 3/6/24 at approximately 2:50 p.m. He said staff should be using a one-swab technique for trach care, using one swab on top and tossing it in the trash, one swab on the bottom and tossing it, and the same on the other side of the trach tube. He said staff should not go all the way around the trach tube with one swab, stating it could create infection or cause problems in the area around the tube.

Based on resident observation, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening of a pressure injury for one (#1) of three residents with pressure injuries out of 14 sample residents. Resident #1, who required extensive assistance with activities of daily living from staff members for bed mobility, transfers, dressing, and toilet use, was known to be at risk for skin impairment due to her immobility, poor nutrition, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide regular wound assessment to include the status of the resident's wound with the location, measurements, and a visual description (color, odor, draining or if the skin was hot) of the wound and surrounding skin. They failed to refer the resident to a wound specialist when the sacral wound open and exposed the resident's tissue under the top layer of skin until approximately two months after admission and 30 days after the hospital provided the facility with specific orders for wound care on 6/28/22 including a recommendation to provide debridement to remove damaged tissue at the wound site. Additionally, the resident was not provided with the appropriate size pressure relieving low loss air mattress, as recommended and the orders for a wound care ointment that would have facilitated the debridement. The resident's wound worsened and when assessed at the hospital one day after discharge the wound was found to have increased in size with black necrotic tissue. Due to the facility's failures to regularly assess and document the findings the resident sacral pressure injury, follow the hospitals order for wound care treatment and provide timely referral to the wound care specialist Resident #1's wound increased in size and developed necrotic tissue. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 9/22/22. Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable [CONDITION(S)] Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. -Bruising indicates suspected deep tissue injury Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/ tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers an extend into muscle and/ or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover ' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Risk Factors and Risk Assessment -Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries; -Consider individuals with a Category/Stage 1 pressure injury to be at risk of developing a Category/Stage 2 or greater pressure injury; -Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries; and, -When conducting a pressure injury risks assessment: Use a structured approach; Include a comprehensive skin assessment; Supplement use of a risk assessment tool with assessment of additional risk factors; Interpret the assessment outcomes using clinical judgment; Skin and Tissue assessment -Assess the pressure injury initially and as soon as possible after admission/transfer to the healthcare service; -Rre-assess at least weekly to monitor progress toward healing; -Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment; and, -Monitor the pressure injury healing progress Support Surfaces For individuals with a pressure injury, consider changing to a specialty support surface when the individual: Cannot be positioned off the existing pressure injury. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. II. Facility policy and procedure The Skin Management Guidelines policy procedure, dated March 2022, was provided by the nursing home administrator (NHA) on 9/20/22 at 5:00 p.m. It read in pertinent part, Purpose: to describe the process steps required for identification of patients at risk for the development of skin alteration, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. Pressure injury: localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. Can present as intact skin or an open ulcer and may be painful. Skin alterations and pressure injuries are evaluated and documented by the licensed nurse; -Admission/Readmission Evaluation upon admission with a heat to toe skin evaluation; and; -Weekly by the wound team for pressure injuries or complex wounds. Body audits are completed: -By the licensed nurse daily for patients with pressure injuries and documented on the treatment administration record; new findings are documented in progress notes. The Pressure Ulcer Scale for Healing (PUSH Tool) is used to document the healing status of pressure injuries. It is initiated upon identification of a pressure injury and is updated weekly by the wound team during wound wounds until the wound heals. The PUSH Tool utilized the following metrics which are converted to a sub-score which is then calculated to determine healing: -Length times width - provides calculation of overall surface area -Exudate amount - determined after removal of the dressing and before the application of any topical agents; and -Tissue type - identifies the most advanced tissue type noted. Wound rounds are completed weekly on pressure injuries and complex wounds. III. Resident status Resident #1, under the age of 65, was admitted on [DATE], and readmitted from the hospital several times on 5/26/22, 6/28/22 and 7/13/22, then discharged from the facility on 7/27/22 and did not return. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/7/22 admission minimum data set (MDS) assessment, revealed that the resident had intact cognition with a brief interview for mental status (BIMS) of 13 out of 15. The resident needed extensive assistance with activities of daily living (ADL) including bed mobility, transfers, and toilet use. The resident did not walk. The MDS assessment documented the resident was a risk for developing pressure injuries but had no pressure injury upon admission. The 7/27/22 discharge MDS revealed the resident had an unhealed unstaged pressure injury with slough/eschar at discharge. IV. Resident interview and observations The resident was not present in the facility at the time of the investigation, due to being sent to the hospital on 7/27/22. V. Record review A. Care plan Resident #1's comprehensive care plan initiated 5/17/22, revealed a care focus documenting the resident was at risk for alteration in skin integrity related to impaired mobility. The goal of the care focus was to decrease/minimize skin breakdown risks. -The only interventions documented were to encourage repositioning; use assistive devices as needed (no individualization or specifics provided); and observe skin condition with ADL care daily; report abnormalities. -The care focus was last revised on 5/17/22 and had no additional interventions or revisions as the resident's pressure injury worsened. B. Facility progress notes, treatment records, and hospital treatment notes Admission evaluation dated 5/16/22 revealed the resident had a stage 1 wound on the sacrum (at the bottom of the spine and lies between the lumbar/lower spine and the coccyx at the tailbone ). The wound was described as 100% pink tissue with no drainage measuring 1.5 centimeters (cm) by 1 cm; with a care focus, identifying the resident was at risk for alterations in skin integrity related to impaired mobility and catheter use. Interventions included: Encourage repositioning, as needed; using assistive devices; as needed; and observe skin condition with activities of daily living (ADL) care daily; report abnormalities. The May 2022 treatment administration record (TAR) documented orders for weekly body audits and application of [MEDICATION(S)] (a self-adherent, soft silicone foam dressing that minimizes trauma to the wound) to skin breakdown on the coccyx, every day shift; start date: 5/17/22. The resident was discharged to the hospital on 5/17/22 for respiratory distress; and readmitted to the facility on [DATE]. The facility had medication orders from the hospital but were unable to find the hospital treatment records for that hospitalization . -The director of nursing (DON) was interviewed on 9/20/22 at 12:22 p.m. The DON said the facility did not have any treatment records for what care and treatment was provided to the resident during the 5/17/22 to 5/27/22 hospitalization . Admission/readmission evaluation dated 5/27/22 revealed the resident had a pink, non-blanchable, wound on the sacrum being treated with [MEDICATION(S)] dressing and frequent turning. -The wound assessment did not provide wound measurements or other details of the condition of the resident's wound. The June 2022 TAR documented orders for application of [MEDICATION(S)] to skin breakdown on the coccyx, every day shift; and a body audit every Monday for skin observation. A nurse signed off that the 6/6/22 body audit was completed but did not document the status of the wound with measurements or description. The resident was discharged to the hospital on 6/11/22 for diabetic ketoacidosis (uncontrolled blood glucose). The hospital discharge plan of care dated 6/28/22 revealed the resident received a wound care consultation while inpatient and received specific instruction for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan of care documented in the discharge instructions: To Coccyx: 1. Gently cleanse with incontinence wipes, avoid rubbing and friction. Please attempt to remove any loose crusting, necrotic tissue, or exudate. 2. Apply dime thick layer of Triad hydrophilic (a zinc-oxide based sterile coating designed to manage low to moderate levels of exudate, while promoting a moist wound healing environment to facilitate autolytic debridement, the breakdown, of damaged tissue at a wound site) wound dressing; to open wound only; three times a day. 3. Add ostomy powder to triple cream ([MEDICATION(S)]/[MEDICATION(S)]/ [MEDICATION(S)] ointment) to create a thick paste and apply to periwound (skin that surrounds the open wound) three times a day. May alternate with clear-aid (white [MEDICATION(S)]-based ointment) after each incontinence episode, or as needed. 4. Limit number of linens and incontinent pads under patient to avoid folds and heat trapping (use on each). 5. Leave open to air. Please keep patient on a low air loss (LAL) mattress. Place one flat sheet from head of bed to foot of bed (no fitted sheet) and under pads placed side by side (not stacked) underneath patient to allow for maximum airflow of low air loss mattress to reach patient's skin. Ensure the firmness of the bed is appropriate for the patient's weight. Please check to ensure the bed is plugged in, powered on and AP (alternating pressure) is activated at least once a shift. Setting can be verified on the control box at the foot of the bed. -Skin guard (low air loss mattress) operation tip sheets available on the RN (registered nurse) dashboard -Please reposition patients on the right and left side only. No supine (on back). Please place your hand under the sheet after repositioning the patient to ensure coccyx is offloaded. If the hand cannot be placed under the coccyx, the patient is not turned enough. -Float heels and ensure heel lift boots Standard XL (extra large) on both feet at all times while in bed. Assess for proper placement every two hours (heel palpable in heel opening). Please ensure boot wedges are in use if the patient's feet are internally or externally rotating. The resident was readmitted to the facility on [DATE]. The resident physician assessed the resident on 6/30/22. The physician's note documented the resident had a chronic pressure ulcer on the sacral region unspecified stage. treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor. -The wound was not measured or described, when the resident returned from the hospital. None of the hospital wound treatment orders including the recommendation to attempt to remove any loose crusting, necrotic tissue, or exudate was documented or implemented into the resident treatment orders. The June 2022 treatment orders for wound care remained the same after readmission to the facility through 7/26/22 (see June 2022 TAR orders above). -The director of nursing (DON) was interviewed on 9/20/22 at 12:22 p.m. The DON was unable to verify if the nurses or physician read the hospital treatment recommendations for wound care as written into the 6/28/22 hospital discharge instructions. The resident was discharged back to the hospital on 7/4/22 for diabetic ketoacidosis and readmitted to the facility on [DATE]. The hospital treatment notes dated 7/6/22 documented the resident was referred for a wound care consult for a sacral decubitus (pressure injury). The hospital wound care consult was not included in the discharge paperwork. -The director of nursing (DON) was interviewed on 9/20/22 at 12:22 p.m. The DON was unaware that the hospital had assessed the resident for a sacral wound and said the facility did not have any documentation of the wound consult conducted by the hospital. The readmission evaluation note dated 7/13/22 revealed the resident's skin was warm and dry with one opening approximately 2 cm by 3 cm to the coccyx in which epithelial (top layer of skin) tissue (whitish pink) was exposed. The area was cleaned and covered with a foam dressing. The July 2022 TAR had orders for a weekly body audit the weekly body audit for 7/18/22 was not signed as completed and there was no nursing documentation about the status (measurement or description) of the resident's sacral wound. The 7/25/22 administration of the body audit was signed with no accompanying nursing note to document the status of the resident's sacral wound. -There was no documentation of the resident's sacral wound from 7/13/22 to 7/26/22. On 7/26/22 the resident's medical record revealed the resident was referred to the wound care specialist for the first time since admission. The medical practitioner wound progress Note dated 7/26/22 at 9:48 a.m. read in pertinent part: Comprehensive history: Initial wound care: Today, I am seeing (resident age and gender) at (name of facility) for an unstageable pressure ulcer to coccyx. The current treatment is foam dressing. Location - Coccyx. Type -pressure. Pressure severity - unstageable. Length in cm - 2.5. Width in cm - 1.5. Depth in cm - undetermined. Drainage amount -moderate. drainage type - serous (clear, thin, and watery exudate that typically appears during the [CONDITION(S)] stage of wound healing). Wound base - slough (a by-product of the [CONDITION(S)] phase of wound healing which contributes to delayed wound healing, and prevents an accurate wound assessment). Slough color/ description - 100% yellow. Diagnosis/Plan: 1. Cleanse with facility wound cleanser; 2. Apply border foam, change every 3 days and prn loose or soiled; and, 1. Pressure reducing mattress/Chair cushion 2. Encouraged to turn and reposition per facility. 3. Barrier cream needed to protect and reduce friction and reduce risk of moisture associated skin damage; 4. Nutritional intake as per RD's (registered dietitian) recommendation; and; 5. Patient educated on comprehensive prevention programs including, local care, repositioning, offloading, and nutrition. Wound status - liable (unstable). The progress note dated 7/27/22 at 2:09 a.m., documented Resident #1 was sent to the emergency room for assessment due to continued high blood glucose levels. The hospital admission note revealed the resident had a pressure injury to the coccyx. The note read in pertinent part: The wound was assessed to have necrotic slough to the base of the wound with a small amount of pink and pale non-granular (unhealthy) tissue. The right side of the wound had slough with a darker, black discoloration. The periwound (skin surrounding the pressure injury) had blanchable [CONDITION(S)] (skin turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed. Blanchable skin indicates signs of inflammation). Wound Assessment: -Unstageable pressure wound with slough and necrosis (dead tissue). Drainage: Scant serosanguinous (bloody fluid). Wound Length (cm) 3 cm. Wound Width (cm) 3.2 cm Wound Depth (cm) 0.1 cm. Wound bed with greater than 75% adherent slough (yellow devitalized (dead) tissue that can be stringy or thick and firmly attached on the tissue bed). VII. Interviews Registered nurse (RN) #1 was interviewed on 9/19/22 at 4:00 p.m. RN #1 said the certified nurse aides (CNAs) performed daily skin checks during incontinent care and dressing and grooming tasks. The CNAs were expected to report any alterations or problems with a resident skin to the nurse on duty. The nurse on duty/floor nurse was responsible to perform weekly visual observations and assessment of each resident's skin and document the status of a resident skin condition including pressure wounds or other impairments of the resident's skin. If a CNA reported a new wound, the nurse was responsible to assess the skin condition and report the findings to the resident's physician for treatment recommendations/orders. The floor nurses did not measure or stage a resident's pressure injury/wound but would document the visual assessment in the resident's medical chart in progress notes. If the resident had a stage 2 or higher staged pressure injury the resident would be seen by the wound care team. The team of nurses/doctors would provide weekly assessments, treatment orders, and additional treatments as needed. The team would provide orders for routine wound care which the floor nurse would carry out. RN #1 said a stage 2 pressure injury was a wound caused by pressure and was characterized by an opening in the resident's skin. If the resident had intact skin preventative care was to be provided such as barrier care after incontinent care, repositioning and other pressure relieving measures as assessed to be appropriate. RN #1 said a resident should be referred to the wound care team as soon as the resident's skin had any breaks at the top layer. The nurse practitioner/wound specialist (NPW) was interviewed on 9/20/22 at 1:40 p.m. The NPW said the first time and only time she saw Resident #1 was on 7/26/22 after receiving a referral to see the resident just days before the visit. The NPW was in the facility weekly to perform wound wounds for residents with advanced pressure injuries (stage 2 and above). The NPW was told the resident had recently been admitted to the facility with an unstageable pressure injury. The NPW was unaware the resident had an open pressure injury that was documented back to 6/28/22 (see record review above). The NPW said upon assessment on 7/26/22 the resident wound could not be staged and severity of the depth could not be determined because the wound was fully covered (100%) slough (dead tissue) which needed to be removed in order to measure depth; For this reason the wound was classified as unstaged (see 7/26/22 wound note above). The NPW could not say with 100% certainty that the resident's wound development and progression was unavoidable, but said the wound was unstable and wound healing was anticipated to be slow with delayed healing due to the resident's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The NPW said she recommended the resident's mattress be replaced with an appropriate pressure relieving mattress. Nursing staff were expected to provide ongoing monitoring of a resident's pressure injury/wound and document the wound status with wound dressing changes and report any changes in the wound occurring between the NPW's weekly wound rounds. So changes could be addressed timely, as wounds could worsen quickly if not monitored and treated timely. The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 9/20/22 at 3:45 p.m. The DON said the nurses were responsible for reviewing all hospital discharge paperwork and entering hospital medication and treatment orders into the resident's medication administration and treatment administration records. The unit manager was responsible to double check that all orders were entered properly and then send the entered order to the resident's physician for final review and approval. The DON was not sure why the nurses missed Resident #1's 6/28/22 hospital wound treatment orders for the sacral wound and why the resident was not referred to the wound care specialist when the resident's sacrum was documented as having an open pressure injury. The DON acknowledged the nursing staff should have read the entire 6/28/22 hospital discharge packet and all orders written in the document should have been addressed. VIII. Facility follow-up The DON provided a plan of corrective action on 9/20/22 at 5:00 p.m. The DON said the facility had been working on improving pressure injury prevention; it was a work in progress they continue to improve upon. The facility started its improvement plan 9/9/22. The plan read in pertinent part: Residents will receive care to prevent pressure ulcers and residents with pressure ulcers receive services to promote healing, prevent infections and prevent new pressure ulcers. Analysis: -Skin audit indicates notifications; evaluations; comprehensive wound note; care plan; and Kardex (summary care plan) are areas of opportunity (identified for improvement practices). -Staff are not familiar with the skin program.

Based on record review and interviews, the facility failed to ensure one (#5) of three residents reviewed for accidents out of seven sample residents remained free from falls and accidents. Specifically, the facility failed to complete a fall risk assessment upon Resident #5's admission to the facility, develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury. Resident #5 fell on [DATE] (six days after her admission to the facility) and sustained a right patellar fracture. The facility failed to put interventions into place to prevent further falls and injuries. After the initial fall and major injury, the resident fell two more times, without any effective interventions put into place by the facility. Resident #5 fell on [DATE] (nine days from her first fall) and did not sustain an injury. The facility failed to conduct a root cause analysis of the resident's fall and update the resident's care plan with effective person-centered approaches. Nine days later, on 2/15/22, Resident #5 fell and sustained a hip fracture. After the resident returned from the hospital, the facility failed to determine the root cause of the fall, determine the resident's fall risk and update the plan of care with person-centered approaches to prevent further falls and injuries. Findings include: I. Facility policy and procedure The Fall Practice Guide, reviewed December 2011, was provided by the director of nursing (DON) on 2/24/22 at 2:14 p.m. It revealed, in pertinent part, Falls among elderly patients are a common source of both high injury severity and mortality. Of the elderly who fall, 20 percent (%) to 30% suffer moderate to severe injuries such as hip fractures or head traumas that reduce mobility and independence, and increase the risk of premature death. Upon admission, review hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for, experiencing a fall. Interview the patient and family or responsible party about the patient's history of falls, possible causes of those falls and interventions that did or did not work to prevent further falls. Complete the patient admission/readmission screen answering the specific questions regarding the patient's history of actual falls and the on-going risk for falls. The patient's initial care plan is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's risk factors. When the interdisciplinary team designs the comprehensive care plan to address the problems associated with potential or actual falls, a measurable goal is developed and a target date is established. Approaches are selected based on the patient's preferences, risk factors, comorbid conditions and willingness to participate with the plan of care. It is important to establish care plan goals with input from the patient and family or responsible party. For the patient with a history of falls, the goal may focus on limiting injuries from the falls. II. Resident #5 A. Resident status Resident #5, age 83, was admitted on [DATE], readmitted on [DATE] and discharged from the facility on 2/21/22. According to the February 2022 computerized physician orders (CPO), the diagnoses included [CONDITION(S)], history of falling, need for assistance with personal care, muscle weakness, right patellar fracture and a left hip fracture. The 1/29/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of eight out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing and toileting and extensive assistance of one person for personal hygiene. It indicated the resident had experienced falls within one to six months prior to her admission to the facility. B. Record review The memory impairment care plan, initiated on 1/27/22, revealed the resident had cognitive loss as evidenced by short and long term memory impairment. The interventions included: approach and speak to the resident in a calm manner, explain each activity and care procedure prior to beginning and provide cueing and prompting for such things as activities, personal care or room location. The urinary incontinence care plan, initiated on 1/22/22, revealed the resident had urinary incontinence related to poor sphincter control. The interventions included adjusting the resident's toileting times to meet her needs and identifying the resident's voiding pattern and establishing a toileting program. The fall risk care plan, initiated on 1/22/22, documented the resident was at risk for falls due to a diagnosis of [CONDITION(S)] with the goal to minimize the resident's risk for falls. The interventions included having commonly used articles within easy reach, reinforce the need to call for assistance and reinforce wheelchair safety as needed such as locking breaks. -The comprehensive care plan and the interventions were developed on 1/22/22, the day of the resident's admission. The facility failed to update the comprehensive care plan with person-centered interventions during the resident's entire stay at the facility. It did not include Resident #5's actual falls while at the facility, on three occasions, with two major injuries sustained. It did not include a root cause analysis or pattern of the resident's falls to determine appropriate and effective person-centered approaches to prevent any further injuries sustained from falls. It documented the resident had urinary incontinence, to establish a voiding pattern and then plan the resident on a toileting program, however the resident's medical record did not yield documentation that the resident was placed on a toileting program or that her toileting needs were even evaluated or established. A review of the resident's medical record on 2/23/22 at 11:27 a.m. did not reveal documentation that a fall risk assessment had been completed upon the resident's admission to the facility. The admission nursing assessment documented the resident had cognitive impairment and incontinence which contributed to the resident's fall risk factors, however it did not identify the fall risk level or interventions to address the resident's fall risk factors. 1. Fall incident on 1/28/22 The 1/28/22 nursing progress note documented licensed practical nurse (LPN) #5 heard a bang coming from Resident #5's room at 2:43 a.m. The resident was found getting up in the wheelchair. LPN #5 documented she assisted Resident #5 to the toilet, into the wheelchair, and then back to bed with the assistance of a certified nurse aide (CNA). LPN #1 documented she reminded the resident to use her call light. The progress note did not include documentation the resident had been assessed by a registered nurse (RN) following the incident and prior to being assisted by LPN #5 to the toilet, into the wheelchair and back to bed. It did not document an interview with the resident to indicate what had caused the loud bang. It did not document that the resident had been assessed for an injury at all. (See the DON interview below). Cross reference F658: the facility failed to ensure an assessment was completed by a registered nurse (RN) after falls were sustained. It indicated approximately an hour after Resident #5 fell , she began to complain of pain in her right knee. A small red abrasion and mild swelling was observed on the resident's right knee. LPN #5 documented she would contact the physician to obtain an x-ray. At 4:00 p.m. the nursing progress note documented the result of the x-ray of Resident #5's right knee showed a patellar fracture. The physician was notified and ordered the resident to be sent to the hospital for evaluation. The 1/28/22 hospital emergency room notes documented that the resident experienced an acute patella fracture with joint swelling. It indicated the fracture did not require surgery and to return to the facility for pain management and physical therapy. The 1/28/22 investigation report indicated the resident had transferred herself to her wheelchair and then to the bathroom. The resident was too unsteady on her feet when she tried to transfer herself to the toilet. The resident was found sitting in the wheelchair without an incontinence brief. LPN #5 documented, her and a CNA assisted the resident to the wheelchair and then to bed. The resident, an hour later at 3:43 a.m., complained of pain to the right knee with a red abrasion and swelling observed. LPN #5 called the nurse practitioner (NP) who ordered an x-ray. The conclusion of the investigation documented the CNA and LPN #1 did not see the resident on the floor. -It did not include any person-centered preventative measures or interventions to prevent further falls and injuries. The 1/28/22 nursing progress note (completed by the DON) documented according to the statement from the nurse, Resident #5 walked to the bathroom and fell to the ground, landing on her right knee. The resident sustained a fracture to the right knee. According to the resident's roommate, she observed Resident #5 walk toward the bathroom and then fall to the ground. It indicated the facility staff assisted the resident up off the ground and to the bathroom. A review of the resident's comprehensive plan of care showed the facility failed to update the care plan with personalized interventions. The care plan had not been updated since 1/22/22, the resident's date of admission to the facility. 2. Fall incident on 2/6/22 The 2/6/22 nursing progress note documented the RN saw the resident sitting on the edge of the bed at 8:00 p.m. The resident scooted her hips forward and slid off the bed, onto the floor. The bed was in the low position and the resident did not hit her head. It indicated the resident did not sustain any new injuries and the nurse notified the physician and family. The 2/6/22 incident report documented the same description of the event as described in the nursing progress note above. The rest of the incident report was left blank. It did not include a resident interview to determine why the resident was trying to get up out of bed, a conclusion to the investigation or person-centered interventions to prevent further falls and injuries. The 2/10/22 nursing progress note documented the resident was lying in bed and safety measures were in place. It did not indicate what safety measures were being used. A review of the comprehensive care plan showed it had not been updated since the resident's date of admission or included person-centered interventions or safety measures. 3. Fall incident on 2/15/22 The 2/15/22 nursing progress note documented the RN heard a loud bump and found the resident lying on the floor. The resident had apparently rolled out of bed and landed on the floor. Resident #5 was guarding her left hip and said she was in pain. The physician was notified and ordered the resident to be sent to the hospital. The 2/15/22 incident report documented the same description of the event as described in the nursing progress note above. The rest of the incident report was left blank. It did not include a resident interview to determine why the resident was trying to get up out of bed, a conclusion to the investigation or person-centered interventions to prevent further falls and injuries. The 2/15/22 hospital notes revealed the resident was admitted to the hospital for left hip pain caused from a fall. According to the paramedics, the resident said she got up from her bed to get a bag of chips and suddenly lost her balance and fell directly onto her left hip. The hospital x-ray documented the resident sustained an acute moderately displaced trochanteric (between the cervical region and the shaft) fracture to the proximal (situated nearer to the center of the body or the point of attachment) left femur. III. Staff interviews LPN #1 was interviewed on 2/24/22 at 11:40 a.m. She said fall risk assessments were completed for every resident upon their admission to the facility. She said the fall risk assessment helped to determine if the resident was a high risk for falls and which safety measures should be put into place. She said the admission nurse created the comprehensive care plan upon the resident's admission to the facility and it should be updated throughout the resident's stay as things changed with the resident's care. She said when a resident sustained a fall, the resident should be assessed immediately for injury. She said any licensed nurse was able to assess the resident after a fall. She said once it was determined the resident did not sustain an injury, the resident should be assisted back to bed and an incident report completed. She said the nurse was responsible for putting immediate interventions into place and documented that in the progress notes. She said the department managers reviewed the falls, finished the fall investigation and made any changes to the care plan. The DON and NHA were interviewed on 2/24/22 at 1:15 p.m. The DON said if a resident was found on the floor, the RN should be contacted to assess the resident for injury. She said an LPN was not able to conduct an assessment because it was not within their scope of practice. She said it was important for an RN to complete an assessment to ensure the resident did not sustain any underlying injuries. She said the RN assessment should be documented in the resident's medical record. She said the nurse should complete a facility incident report following the fall, which included a description of the event, resident and other witness interviews, immediate interventions put into place and notifications of the physician and the family. She said the incident report was reviewed by the interdisciplinary team (IDT). She said the IDT would determine if the immediate intervention was sufficient and ensure it was updated on the comprehensive care plan. She said each incident report was discussed in the morning meetings. She said the nurse on the floor was responsible for putting immediate interventions into place and documenting that intervention in the progress notes and on the comprehensive care plan. She said the comprehensive care plan should be constantly changed and updated throughout the resident's stay at the facility. She said Resident #5 was admitted to the facility from a sister facility. She said she did not request a care plan or other nursing assessments prior to the resident being admitted . She said the referral did not document if the resident was considered a fall risk. She said based on the resident's diagnosis of [CONDITION(S)], difficulty walking and abnormality of gait, she would consider the resident a fall risk. She said the incident on 1/28/22 was considered a fall because the nurse and CNA did not see it occur and came to the room when they heard a loud bang and the resident's roommate saw the resident walk to the bathroom and fall to the ground, hitting her knee. She said Resident #5 had sustained a patella fracture to the right knee and was transferred to the hospital. She said the facility had not put any interventions into place following the resident's fall or updated the comprehensive plan of care. She said for the falls sustained by Resident #5 on 2/6/22 and 2/15/22, the facility did not put any person-centered interventions into place following the falls. She acknowledged the incident reports for 2/6/22 and 2/15/22 were left blank with the exception of the event description. She said each incident report should have been reviewed by the IDT in the morning meetings. She said it did not appear as though they were reviewed. She said these falls for Resident #5 were missed and she was not sure what happened. She confirmed the resident's medical record did not document the resident's voiding pattern. She said the resident was not placed on a toileting program while she was at the facility, as was included as an intervention in the comprehensive care plan. She confirmed the resident's comprehensive care plan was not person-centered, did not document effective interventions to reduce falls and prevent injury and was not updated since the date of her admission. She said the resident's medical record did not have documentation of a fall risk assessment being completed. She said a fall risk assessment should have been completed upon the resident's admission to the facility and after each fall. She said the fall risk assessment was important in determining how high of a fall risk a resident was and which interventions should be implemented upon admission and after each fall. IV. Additional information The facility did not provide any additional information such as staff education or audits following the survey process.

Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#3 and #42) of three residents reviewed out of 29 total sample residents. Specifically, the facility failed to: -Provide adequate pain management during routine wound care for Residents #3 and #42; -Notify the physician when pain medications were ineffective for Residents #3 and #42; -Ensure Resident #3's pain was managed in line with the resident's goals for effective pain management and acceptable pain level; and, -Conduct a comprehensive pain assessment on a routine basis for Resident #42. These facility failures contributed to Resident #3 and Resident #42 experiencing undue severe pain. The residents did not receive adequate pain management prior to or during routine wound care, and suffered unnecessary pain as a result. The facility staff made multiple statements both residents cried out or yelled out during past and present wound care, however, the staff failed to ensure the residents were at an acceptable pain level prior to and during wound care. Findings include: I. Facility policy and procedures The Pain Practice Guide policy, dated November 2011, was provided by the nursing home administrator (NHA) via email on 8/30/21 at 12:06 p.m. It read in pertinent part, The purpose of the Pain Practice Guide is to describe the process steps for techniques and interventions to prevent and, or manage pain, both chronic and acute. Appropriate pain management can result in better quality of life. A pain interview is a required component of the minimum data set (MDS) assessment. Conducting ongoing subjective pain evaluations outside of the resident assessment instrument (RAI) are important to provide a comprehensive description of a patient's pain status. If current complaints of pain or conditions exist that may be associated with pain, notify the physician and obtain orders for treatment. Re-evaluate patients with pain regularly; evaluation of a patient's pain is recommended on a daily basis. Results are documented on the medication administration record (MAR) following each observation. Patients with a score of four to seven twice in a seven day period, or who had one score of eight, nine, or 10 are reported to the physician for possible treatment adjustment. Pain may fluctuate over time so appropriate pain evaluation is essential. A re-evaluation of signs and symptoms of pain is completed to determine if additional interventions or an alternative course of action is needed. II. Resident #3 A. Resident status Resident #3, age younger than 70, was admitted on [DATE] and readmitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/12/21 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. He required one-person limited assistance for bed mobility and dressing, one-person extensive assistance for personal hygiene, and two-person extensive assistance for transfers and toilet use. The resident received scheduled and as needed pain medications. He did not receive non-medication interventions for pain. He had pain almost constantly. On a pain scale of zero to 10, with zero being no pain and 10 being the worst pain the resident could imagine, he rated his pain at a score of eight. B. Observation On 8/25/21 at 11:48 a.m., Resident #3's sacral wound was observed during weekly wound rounds with the wound doctor (WD), the assistant director of nursing (ADON), and the resident assessment coordinator (RAC). The resident was positioned on his side to enable the WD to perform the wound measurements and change the dressing to the wound. The wound was large, and a nickel sized white area of bone was observed in the deepest depth of the wound. After measuring the wound, the WD proceeded to clean the wound with saline. Resident #3 yelled out that it hurt whenever the WD touched the inside of the wound with the gauze she was using to clean the wound. After cleaning the wound, the WD proceeded to pack the wound with alginate rope. The resident immediately tensed his entire body and began crying. He continued to yell out in pain throughout the rest of the wound dressing change, stating that it hurt. C. Record review The August 2021 CPO revealed Resident #3 had the following orders for pain: -Tylenol tablet (Acetaminophen) 650 milligrams (mg) every six hours as needed for pain rated 1-5, initiated 8/4/21; -[MEDICATION(S)] Tablet 5 mg every 12 hours for pain, initiated 8/4/21; -[MEDICATION(S)] tablet 10 mg every six hours as needed for pain rated 6-10, initiated 8/4/21; and, -Pain evaluation every shift for monitoring of patient's pain level, initiated 8/4/21. -The CPO did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's care plan, initiated 5/13/21, revealed the resident had pain to his sacrum related to a stage 4 pressure wound. Pertinent interventions included administering pain medication per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The care plan did not include an intervention for the resident to be premedicated with pain medication prior to wound care. Review of Resident #3's progress notes revealed the following wound round documented on 8/25/21 at 12:42 p.m: Resident readmitted on [DATE] with the following skin alterations: Coccyx: Dimensions: 5 centimeters (cm) by 9.5 cm by 1.1 cm, 70% granulation (healthy) tissue, 30% slough (dead tissue); minimal drainage, peri-wound scarring. Treatment: alginate rope packed into wound, covered with foam. Do treatment every other day. Wound culture obtained. Right second toe trauma, measures 1.5 cm by 1.5 cm by 0.1cm. Treatment: clean with wound cleanser, cover with dry dressing, Change daily. Nutrition assessment completed 6/25/21. Braden score = 19 on 8/4. Pain assessment completed on 8/4/21. Resident pre-medicated for pain, minimal complaints during treatment. -Despite the progress note's documentation that Resident #3 was premedicated for pain prior to wound care, review of Resident #3's MAR for 8/25/21 revealed the resident had not received any as needed pain medication since 4:58 a.m., and the resident was out of the facility at [CONDITION(S)] during the 8:00 a.m. medication administration and had not received his scheduled dose of pain medication at that time. In addition, the observations of the resident crying out in pain several times and saying it hurt during the wound care did not indicate Resident #3's pain was minimal or managed well to an acceptable level for Resident #3. Review of Resident #3's comprehensive pain assessments revealed the following: -7/5/21: Documented the resident's pain goal was a 3. His highest pain level had been an 8, and his lowest pain level had been a 2; -7/29/21: Documented the resident's pain goal was a 3. His highest pain level had been a 9, and his lowest pain level had been a 4; and, -8/5/21: Documented the resident's pain goal was a 3. His highest pain level had been a 7, and his lowest pain level had been a 5. Review of the every shift pain evaluations on Resident #3's July 2021 MAR revealed the following: There were 90 opportunities for pain evaluation - out of the 90 opportunities the following was indicate: -There were 10 shifts when the pain level was not documented; -There were 31 shifts when the resident's pain was rated at a 3 out of 10 or below, which was the patient's stated goal for pain level; -There were 25 shifts when the resident's pain was rated at a 4 or 5 out of 10; and, -There were 24 shifts when the resident's pain was rated at a 6-10, and of those, there were 4 shifts when his pain was rated at a 10 out of 10. Further review of the resident's July 2021 MAR revealed he received as needed pain medication 47 times during the month. The effectiveness of the medication was documented as unknown 11 times, and ineffective two times. There was no documentation to indicate if the physician had been notified when the medication was ineffective. Review of the every shift pain evaluations on Resident #3's August 2021 MAR revealed the following: There were 67 opportunities for pain evaluation; out of the 67 opportunities the following was indicate: -There were 30 shifts when the resident's pain was rated at a 3 out of 10 or below, which was the patient's stated goal for pain level; -There were nine shifts when the resident's pain was rated at a 4 or 5 out of 10; and, -There were 28 shifts when the resident's pain was rated at a 6-10, and of those, there were 2 shifts when his pain was rated at a 10 out of 10. Further review of the resident's August 2021 MAR revealed he received as needed pain medication 44 times during the month. The effectiveness of the medication was documented as unknown 4 times, and ineffective one time. There was no documentation to indicate if the physician had been notified when the medication was ineffective. D. ADON interview The ADON was interviewed on 8/25/21 at 4:25 p.m. The ADON said Resident #3 usually had quite a bit of pain during the wound dressing changes. She said the nursing staff had premedicated him with pain medication prior to the dressing being changed. The ADON said the resident's pain medication might not be effective enough for him. She said the nurses should follow up with the physician regarding his pain level during wound dressing changes. -Despite the ADON statement that Resident #3 had received pain medication prior to the wound dressing change, review of Resident #3's MAR for 8/25/21 revealed the resident had not received any as needed pain medication since 4:58 a.m., and the resident was out of the facility at [CONDITION(S)] during the 8:00 a.m. medication administration and had not received his routine dose of pain medication at that time. II. Resident #42 A. Resident status Resident #42, age 84, was admitted on [DATE]. According to the August 2021 clinical physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/15/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of six out of 15. She required two-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident received scheduled pain medications. She did not receive as needed pain medications or non-medication interventions for pain during the look-back period of the assessment. She exhibited the following indicators of pain or possible pain on a daily basis: non-verbal sounds (crying, whining, gasping, moaning, or groaning), vocal complaints of pain (that hurts, ouch, stop), and facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). Resident is on hospice B. Observation On 8/25/21 at 10:34 a.m., Resident #42's sacrum wound was observed during the weekly wound rounds with the WD, the ADON, and the RAC. Resident #42's wound had a wound VAC (vacuum-assisted closure) device attached to her wound to assist with healing of the wound. The resident was positioned on her side to enable the WD to perform the wound measurements and change the wound VAC dressing. After measuring and cleaning the wound, the WD proceeded to reapply the wound VAC dressing to the wound. The WD cut a piece of black foam and used a cotton swab to pack it into the wound to ensure the foam was in contact with the undermining edges (tissue under the wound edges that had become eroded and extended under the skin into the subcutaneous tissue area) of the wound. Resident #42 cried out several times and said it hurt while the WD was packing the foam into the wound. The WD apologized and continued to place the dressing on the wound. When the WD had completed the dressing and attached the suction hose to the top of the wound dressing, she turned the wound VAC back on. The resident again cried out saying it hurt as the machine suctioned the dressing into place over the wound. The ADON and the WD repositioned the resident and left the room. C. Record review The August 2021 CPO revealed Resident #42 had the following orders for pain: -[MEDICATION(S)] Tablet 600 mg two times a day for pain related to polyosteoarthritis, initiated 7/10/19; -[MEDICATION(S)] (Concentrate) Solution 100 mg/5 milliliters (ml), give 0.5 ml four times a day for pain related to polyosteoarthritis, initiated 8/5/2020; -[MEDICATION(S)] 20mg/ml, give 0.5 ml every two hours as needed for pain, initiated 5/20/2020; -[MEDICATION(S)] HCl tablet 20 mg three times a day for pain related to polyosteoarthritis, initiated 2/5/21; and, -Pain Evaluation every day shift for monitoring of the patient's pain level, initiated 3/28/19. -The CPO did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's care plan, initiated 7/21/2020 and revised 7/31/2020, revealed the resident had pain related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident would call out when being transferred via mechanical lift, or when changing positions and during toileting needs. Pertinent interventions included adjusting the times of the resident's activities of daily living and treatment activities so that they occured after pain benefits had been achieved (wound dressing changes, etcetera), reporting nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etcetera, collaborating care with hospice, and notifying the physician if pain frequency/intensity worsened or if current pain regimen had become ineffective. Review of Resident #42's progress notes revealed the following wound round documented on 8/25/21 at 10:35 a.m: Chronic stage 4 coccyx 1.3 cm by 0.6 cm by 0.5 cm undermining one to four o'clock of 3.5 cm. 100% granulation. Moderate drainage serosanguinous. Periwound rolled. Care plan in place to promote healing and prevent additional ulceration and infection. Premedicated for pain. Pressure relieving mattress in place. Improvement noted. Last Braden score= 9 on7/2/21. Resident on hospice services. Goal of treatment to avoid complications and maintain comfort. -The wound progress note failed to document the had stated it hurt during the wound care. Review of Resident #42's August 2021 MAR revealed she had been medicated with as needed pain medication on 8/25/21 at 10:11 a.m. However, the nurse had documented on the MAR that the pain medication was ineffective. -There was no documentation indicating that hospice or the primary physician had been notified regarding the ineffectiveness of the pain medication. Further review of Resident #42's August 2021 MAR revealed the resident had received only four doses of as needed pain medication for the entire month, despite the fact that her wound VAC dressing was changed every Monday, Wednesday, and Friday, indicating she had not been premedicated for all of her dressing changes. Review of Resident #42's comprehensive pain assessment history revealed the resident had not had a comprehensive pain assessment conducted since 1/25/21. For Resident #42 who had a BIMS of six out of 15, the facility failed to monitor her for nonverbal pain indicators and ensure the resident's pain was at a tolerable or acceptable level for her. D. Interviews The WD was interviewed on 8/25/21 at 10:54 a.m. The WD said Resident #42 was on hospice services and her wound was slow to heal. She said her goal for the wound was to prevent it from worsening because it caused the resident pain. Registered nurse (RN) #1 was interviewed on 8/25/21 at 12:13 p.m. RN #1 said Resident #42 would often cry out when she was being repositioned or during wound care. She said the resident had scheduled pain medication and should be medicated with as needed pain medication prior to wound care. RN #1 said she had given Resident #42 pain medication at 10:11 a.m., a half an hour before the wound care was performed. She said she marked the as needed pain medication ineffective because Resident #42 had pain during the wound care. RN #1 said if the resident said she was hurting, then she would agree that is an indicator she had pain and the pain medications were not effective. She said perhaps her pain medications should be re-evaluated, and they should look into getting something such as a numbing medication to help with the pain during wound care. Certified nurse aide (CNA) #5 was interviewed on 8/25/21 at 2:00 p.m. CNA #5 said Resident #42 cried out a lot when she was repositioned. She said the resident would frequently say ow when they moved her or the nurses did wound care. CNA #5 said she would let the nurses know when the resident was in pain so they could give her pain medication. The ADON was interviewed on 8/25/21 at 4:25 p.m. The ADON said Resident #42 would often yell out in pain and say that it hurt when staff changed her wound VAC dressing. She said the resident was medicated prior to the dressing change. The ADON agreed the pain medication might not have been effective because Resident #42 still had pain despite receiving the medication half an hour before the wound dressing change. She said the nurses should follow up with the physician about getting pain medication that might be more effective for her. III. Additional interviews Licensed practical nurse, (LPN) #1 was interviewed on 8/25/21 at 3:58 p.m. LPN #1 said if a resident could verbalize pain, she evaluated their pain based on what the resident told her. She said if a resident was unable to verbalize pain, she used other indicators such as crying, facial grimacing, moaning, and yelling out to determine if the resident might have pain. LPN #1 said if a resident had pain despite scheduled pain medications, she would look to see if they had an as needed pain medication and administer that. She said if the resident had scheduled and/or as needed pain medications that did not seem to be effective for the pain, she would call the physician and see about getting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 was interviewed on 8/25/21 at 4:04 p.m. RN #2 said she evaluated residents for pain based on whether or not the resident said they had pain. She said she also looked for facial grimacing, and other physical signs such as body tensing and increased blood pressure and pulse as indicators of pain. She said she would also use non-medication interventions such as repositioning and dimming the lights to see if that helped with the pain. RN #2 said if the non-medication interventions were not effective, she would medicate a resident with their pain medications. She said nurses should give the pain medications and then return within an hour to assess if the pain medications were effective. RN #2 said if pain medications do not seem to be effective, nurses should call the physician and see about getting a different order for pain medications that might be more effective. She said notification of the physician should be documented in the nurses progress notes. CNA #4 was interviewed on 8/25/21 at 4:11 p.m. CNA #4 said residents showed pain by screaming out when they repositioned them or by facial grimacing. She said would tell the nurses if she thought a resident was in pain so the nurse could give them pain medications.

Based on observations, record review and interviews the facility failed to prevent the worsening of stage four pressure ulcers for two of two (#3,#42) out of 29 residents reviewed. The facility failed to ensure all interventions were completed and implemented as ordered by Resident #3's physician. Resident #3 who was admitted with a stage 4 pressure ulcer, and was a known high risk for the development and worsening of the already existing pressure ulcer did not have his pressure ulcer interventions implemented consistently to avoid the Stage 4 pressure ulcer from becoming worse. Resident #3's pressure ulcer went from 2.5cm long by 9 cm wide by 0.1 cm deep on 8/19/21 to 5 cm long by 9.5 cm wide by 1.1 cm deep on 8/25/21. During this time Resident #3 experienced increased and constant pain (cross-reference F697), to the point of Resident #3 making a comment, this really hurts!. during a wound treatment that occurred during the survey. Furthermore, during the wound observation on 8/25/21 the wound dressing that was on the resident was dated 8/21/21. The treatments were not completed as ordered by the physician to encourage and promote healing for Resident #3's wound. The wound doctor (WD) spoke to the assistant director of nursing (ADON) and said the wound would not heal if the nursing staff did not pack the wound with the alginate rope and use an appropriately sized dressing. See wound observations. The facility failed to ensure physician orders for wound care were followed appropriately in order to avoid a worsening Stage 4 pressure ulcer for Resident #42. The nurse who changed the wound VAC (vacuum-assisted closure) device prior to the date the wound doctor changed the dressing did not pack the black foam dressing into the wound as was specified in the order. The black foam was not touching the undermined edges (tissue under the wound edges that had become eroded and extended under the skin into the subcutaneous tissue area) of the wound as it should have been, and therefore the undermining measurements of the wound increased in size. The facility failures of not following wound care orders and completing the dressing change as ordered lead to a worsening of the stage 4 pressure ulcer for Resident #42 who was already in a compromised health status. Resident #42 sustained unnecessary pain because of this action. (cross-reference F697) I. Facility policy The Pressure Ulcer policy, revised in December 2013, was received from the nursing home administrator (NHA) on 8/31/21 at 1:05 p.m. It is read in the pertinent part: Interview the resident and or representative upon admission about the resident's risk factors for developing pressure ulcers.The initial assessment included the Braden Scale for predicting pressure sore risks.The registered dietician should complete a nutritional assessment for each resident to determine if they have nutritional deficiencies. The Braden scale is completed for a resident at the time of admission and then weekly for the next three weeks after that. Then the scale is completed quarterly and with a significant change. If the patient does not have skin alterations but does have the risk factors for developing pressure ulcers such as incontinence, limited movement, friction and shear or nutrition then an initial plan of care will be developed. The facility should assign a wound management team with such staff members as a dietician, physical therapist and nurse. This team should evaluate the skin conditions of residents on a weekly basis. Findings should be documented in the residents ' record. II. Resident #3 A. Resident status Resident #3, age 65, was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/12/2021 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview of a mental status score (BIMS) of 15 out of 15. He required extensive assistance with transfers, personal hygiene and toilet use. He also required limited assistance with bed mobility and dressing. MDS indicated Resident #3 had a stage four pressure ulcer on his coccyx upon admission to the facility on [DATE]. B. Observations 8/23/21 -At 3:15 p.m. A pressure relieving cushion was observed on Resident # 3's wheelchair. There was an air mattress on his bed. Wound care observation and statements by wound doctor (WD) and Resident #3 On 8/25/21 at 11:48 a.m., Resident #3's coccyx wound treatment was observed during weekly wound rounds with the WD, the assistant director of nursing (ADON), and the resident assessment coordinator (RAC). The ADON helped position the resident on his side to enable the WD to remove the old dressing from the wound. The old dressing did not completely cover the wound on the resident's coccyx. The lower half of the wound was observed not covered by the foam dressing which had been placed over the wound on 8/21/21. -The next treatment should have been done on 8/23/21 according to the physician orders every other evening, see orders below) The WD removed the foam dressing from the wound. There was no alginate rope packing in the wound when she removed the dressing. The WD spoke to the ADON and said the wound would not heal if the nursing staff did not pack the wound with the alginate rope and use an appropriately sized dressing. -Nursing staff were not following physician orders to help heal the residents' wound. Pink, granulated (healthy) tissue was visible in some parts of the wound, in addition to areas which were covered with yellow slough (dead tissue). A nickel sized white area of bone was observed in the deepest depth of the wound. The WD measured all aspects of the wound. The wound measured 5.0 centimeters (cm) long by 9.5 cm wide by 1.1 cm deep. After measuring the wound, the WD cleansed it, packed it with alginate rope, and placed a foam dressing over the entire wound. She did not debride the wound.The cleansing and packing of the wound caused the resident to cry out with pain during the process. Progress notes dated 8/25/21 at 12:42 p.m. included Resident # 3 was premedicated for pain before the procedure and had minimal complaints of pain. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 said I need to go to the hospital because this wound was not going to heal here at this place. The ADON helped the resident reposition when the WD was finished applying the dressing, and the WD left the resident's room. -The resident was not sent to the hospital. C. Record review for Resident #3 Physician orders dated 6/10/21, body audit every day for skin observation. Physician orders dated 7/10/21, Cleanse coccyx wound with wound cleanser, pat dry and pack into tunneling with alginate rope and cover with foam dressing. Change the dressing every other evening shift. The treatment administration record (TAR) for July 2021 and August 2021 revealed the following information: July 2021, indicated the wound treatment was not performed on five days out of 31 days reviewed and the body audit was not performed on four out of the 31 days reviewed. August 2021, indicated the wound treatment was not performed on three days out of 26 days reviewed and the body audit or skin check was not performed on five out of 26 days reviewed. Care plan revised on 8/9/21 included Resident #3 had a stage four pressure ulcer of the sacral area. The interventions recommended were: administer analgesics as needed, administer wound treatment per physician orders, pressure redistributing support surface and repositioning during activities of daily living (ADL's.) Wound note dated 8/25/21 at 12:42 p.m. revealed the following information, The dimensions were 5 centimeters (cm) long by 9.5 cm wide by 1.1cm deep. There was 70% granulation tissue, 30% slough; minimum drainage, and peri-wound scarring. Wound note dated 8/19/21 at 10:51 a.m. revealed the following information, The dimensions of the wound were 2.5 cm long by 9 cm wide by 0.1 cm deep. There was 70% granulation tissues, 30% slough, minimum drainage and peri- wound scarring. 8/11/2021 @ 12:47 p.m. General Progress Note Note Text: Body audit note: Patient has no new areas of skin breakdown noted. The Wound Care team was here today to do his dressing change. Patient tolerated the procedure well with PRN pain medication for the coccyx wound. Wound note dated 8/11/21 at 11:42 a.m. The dimensions of the wound were 2.5 cm long by 11cm wide by 0.2 cm deep.There was 80% granulation tissue, 20% slough, minimum drainage, and peri-wound scarring. This was documented by nursing staff. D. Interviews Resident interview Resident #3 was interviewed on 8/23/21 at 3:01 p.m. He said the nurses don ' t change his wound dressing as often as they should. He said the dressing should be changed every day and the nurses were doing it every three days. He said he thought his wound on his bottom was getting worse and his pain was on a scale of six out 10 most of the time. Wound doctor interview The wound doctor (WD) was interviewed on 8/25/21 at 12:07 p.m. The WD said the nurse who had changed the dressing on 8/21/21 had not packed the wound with alginate rope and had used the wrong size dressing over the wound. She said the wound had worsened from the previous week when she had last seen it. The WD said the previous week's measurements for the wound were 2.5 cm long by 9.0 cm wide by 1.0 cm deep. She said the length of the wound had doubled in size in one week. The WD said the wound for Resident #3 was not going to heal if staff did not complete the dressing changes with the wound supplies specified in the order or cover it with a properly sized dressing. RN #2 was interviewed on 8/25/21 at 3:30 p.m. She said the last time she provided wound care for Resident #3 was 8/21/21. She said she would be providing wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The assistant director of nursing (ADON) was interviewed on 8/26/21 at 3:30 p.m. She said Resident #3 had a stage 4 pressure ulcer on his coccyxs upon admission to the facility. She said the evening nurse on the unit did the dressing changes for the resident's wound. She said this was to be done every other day. IV. Resident #42 A. Resident status Resident #42, age 84, was admitted on [DATE]. According to the August 2021 clinical physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/15/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of six out of 15. She required two-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She was at risk for developing pressure ulcers, and had a current stage 4 pressure ulcer. Resident is on hospice B. Wound observation On 8/25/21 at 10:34 a.m., Resident #42's sacrum wound was observed during the weekly wound rounds with the WD, the ADON, and the RAC. Resident #42's wound had a wound VAC (vacuum-assisted closure) device attached to her wound to assist with healing of the wound. The ADON positioned Resident #42 on her side to enable the WD to remove the wound VAC and assess the sacrum wound. The WD turned off the wound VAC and began removing the dressing. When the WD removed the dressing from Resident #42, the black foam covering the wound opening was one piece of foam. There was not any other foam packed into the undermined area of the wound. The WD said the black foam over the opening of the wound was not packed into the wound as it should have been. She said to the ADON that because the foam was not placed in the wound as it should have been, the undermining (tissue under the wound edges that had become eroded and extended under the skin into the subcutaneous tissue area) in the wound had not decreased. The wound was observed to have pink tissue throughout the inside of the wound. There was no slough noted in the wound bed. The WD proceeded to measure all aspects of the wound. The opening of the wound measured 1.3 cm in length by 0.6 cm in width by 0.5 cm in depth. The WD used a cotton swab to measure the area of the wound where undermining was present. The undermining area was from the one o ' clock position to the four o ' clock position and measured 3.5 cm deep under the surface of the skin. (this was a larger surface area as originally measured on 8/5/2021) The WD proceeded to clean the wound and reapply the wound VAC dressing to the wound. The WD cut a piece of black foam and used a cotton swab to pack it into the wound to ensure the foam was in contact with the undermining edges of the wound. Resident #42 cried out several times and said it hurt while the WD was packing the foam into the wound. The resident did not ask the WD to stop. The WD apologized and continued to place the dressing on the wound. The WD did not stop the wound care to give the resident a break. The WD did not ask the resident if she needed pain medication. (F697 cross-reference Pain management) When the WD had completed the dressing and attached the suction hose to the top of the wound dressing, she turned the wound VAC back on. The resident again cried out saying it hurt as the machine suctioned the dressing into place over the wound. The ADON and the WD repositioned the resident and left the room. C. Record review Review of Resident #42's August 2021 CPO revealed the resident had the following physician's order for her coccyx stage 4 pressure wound: apply wound VAC at 125 millimeters of mercury (mmHg) (measurement of pressure). Change on Monday, Wednesday and Friday for wound care. Pack foam into undermining, located at two to four o'clock. The order had a start date of 8/5/21. Review of Resident #42's care plan, initiated 7/20/2020 and revised 1/18/21, revealed the resident had a pressure ulcer to her sacrum. Pertinent interventions included administering treatment per physician orders, collaborating care with hospice, encouraging and assisting as needed to turn and reposition, and providing follow up care with the physician as ordered. Review of the resident's progress notes revealed the following weekly wound round notes: 8/19/21: Chronic stage 4 Coccyx 1.5 cm by 0.8 cm by x 0.5 cm, undermining from one to four o'clock of 3 cm. 100% granulation. Moderate drainage serosanguinous. Peri wound rolled. Care plan in place to promote healing and prevent additional ulceration and infection. Premedicated for pain. Pressure relieving mattress in place. Improvement noted. Last Braden score= 9 on 7/2/21 (the Braden scale is an evidence-based assessment tool used for identifying resident risk for pressure ulcer development; a score of nine out of 23 indicates very high risk for developing pressure ulcers). Resident on hospice services. Goal of treatment to avoid complications and maintain comfort. 8/25/21: Chronic stage 4 Coccyx 1.3 cm by 0.6 cm by 0.5 cm, undermining from one to four o'clock of 3.5 cm.100% granulation. Moderate drainage serosanguinous. Peri wound rolled. Care plan in place to promote healing and prevent additional ulceration and infection.Pre medicated for pain. Pressure relieving mattress in place. Improvement noted. Last Braden score= 9 on 7/2/21. Resident on hospice services. Goal of treatment to avoid complications and maintain comfort. Review of the August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain medications were not effective. -Cross-reference F697 Pain Management D. Interviews The WD was interviewed on 8/25/21 at 10:54 a.m. The WD said Resident #42 was on hospice services and her wound was slow to heal. She said her goal for the wound was to prevent it from worsening because it caused the resident pain. The WD said the outer surface of the wound had improved since the last time she saw it. However, she said the undermining on the wound had worsened from the previous week because the foam had not been applied to the wound correctly. Licensed practical nurse (LPN) #3 was interviewed on 8/26/21 at 9:57 a.m. LPN #3 said she could not remember the last time the facility provided training on wound VACs. She said she had been doing wound VAC dressing changes for a long time, so she was comfortable changing them. She said if nurses were not comfortable changing a wound VAC dressing, there should be a nurse in the facility who could assist them. LPN #3 said she would not have packed the black foam into the undermining on Resident #42's wound, however she said she would conduct the dressing change according to what was prescribed in the physician's orders. RN #1 was interviewed on 8/26/21 at 10:10 a.m. RN #1 said nurses at the facility had a general knowledge of wound vacs. She said the nurses had not received specific training on how to change the dressing on Resident #42's wound. RN #1 said she was comfortable with changing wound VACs because she had been working with them for awhile. She said if a wound had undermining present, the black foam should be packed into the opening of the wound to ensure the foam was touching all of the undermined surfaces of the wound to help promote healing of the wound. RN #1 said if the foam was not touching all of the wound surfaces, the wound would likely worsen. The ADON was interviewed on 8/26/21 at 10:29 a.m. The ADON said most of the nurses should know how to change wound VAC dressings. She said the facility had not conducted any formal training with the nurses on wound VACs. The ADON said if a nurse had a question regarding a specific wound VAC, there was always a nurse around who could assist them. She said several nurses changed Resident #42's wound VAC at various times. She said the nurses should be packing the black foam into the undermining of the wound as the physician's order directed. The ADON said the foam had not been packed into the wound correctly to prevent worsening of the undermining in the wound. She said she had completed education with the nurses on how to change Resident #42's wound VAC on 8/25/21, and had the nurses sign off that they had been educated.

Based on record review and interview, the facility failed to protect 18 residents (Residents #1, Resident #4 - #21) residing in the secure unit from abuse. Resident #1 was severely cognitively impaired and resided on the secure unit with 17 other cognitively impaired residents. A certified nurse aide/activities assistant (AA) reported on 3/25/2020 that on 3/24/2020, she observed a staff member yank Resident #1 out of his chair, which was located back from the table where the activity was underway and a distance from other residents. Then, using two hands, the staff pulled on the resident's left arm, causing the resident to yell out, that hurts, stop. Yet, the staff member did not stop, and continued to pull the resident up out of his chair, sitting him down in a chair across the room. The facility failed to address the 3/25/2020 report of abuse by the AA in a comprehensive manner until 5/22/2020, during survey and almost two months after the incident. This failure made it likely the 18 cognitively impaired residents residing in the secure unit were at risk for abuse if immediate action was not taken. Cross-reference F550E, F610E, F726E and F835E Findings include: I. IMMEDIATE JEOPARDY A. Findings of immediate jeopardy Resident #1 was severely cognitively impaired and resided on the secure unit with 17 other cognitively impaired residents. A certified nurse aide/activities assistant (AA) reported on 3/25/20 that on 3/24/20, she observed a staff member yank Resident #1 out of his chair which was located back from the table where the activity was underway and a distance from other residents. Then, using two hands, the staff pulled on the resident's left arm, causing the resident to yell out, that hurts, stop. Yet, the staff member did not stop; she continued to pull the resident up out of his chair, sitting him down him in a chair across the room. The facility failed to address, in a comprehensive manner, the 3/25/2020 report of abuse by the AA until 5/22/2020, during survey and almost two months after the incident. Specifically, the facility failed to identify and interview staff and residents present at the activity on 3/24/2020. Moreover, the staff identified, Licensed Practical Nurse (LPN) #1 and registered nurse (RN) #1, continued to work on the secure unit. The facility's failure to address the AA's report in a comprehensive manner prior to survey resulted in a failure by the facility to take steps to protect residents in the secure unit, all of whom are cognitively impaired, from potential abuse by staff. On 5/21/2020 at 4:12 p.m., the nursing home administrator (NHA) was notified the failures above created an immediate jeopardy situation that placed all residents in the secure unit at risk for serious harm (abuse by staff). B. Facility plan to remove immediate jeopardy On 5/22/2020, the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Request to remove lmmediate Jeopardy as of May 22, 2020 F-600 This serves as (the facility's) response to the Immediate Jeopardy Notification that the center received on May 21, 2020 The submission of this plan does not constitute agreement or an admission on the part of (the facility) as to the accuracy of the statements or conclusions contained in the notification. The facility took immediate action through Quality Assessment Performance Improvement relative to Resident # I incident upon identification of the issue on 5/21/2020. Immediate Actions: Resident # I no longer resides in the center Employee involved in investigation was suspended Nursing Home Administrator and Assistant Nursing Home Assistant Administrator were educated on The Patient Protection Guideline to include how to conduct an investigation and Special Consideration: Abuse, Neglect, Exploitation or Misappropriation Investigation by the Regional Director of Operations. Staff working in the center were educated on The Patient Protection Guideline on May 21, 2020 by the Director of Nursing and Staff Development Coordinator. Like Residents: Residents who reside on the (secure) Unit were identified as like residents. Interviewable residents were queried related to abuse with the attached questionnaire by social services on May 22, 2020. Non-interviewable residents will have a body assessment completed for any injuries of unknown origin by Staff Development Coordinator and licensed nurses by May 22, 2020. Any Trends and concerns from review of like residents will be addressed a??d then discussed with QIPI May 22, 2020. System Revisions: Immediate education of 100% of facility staff on patient protection expectations Including but not limited to the training for prevention; protection, identification, and investigation of all allegations of abuse, neglect, mistreatment and misappropriation of property. And the reporting and responding to the appropriate individuals and agencies will be completed by NHA or ANHA. No employee will be allowed to work until they have completed the education. This education was started on May 21, 2020 and will be completed by May 28, 2020 The NHA and ANHA were educated on May 21, 2020 Any allegations of abuse or neglect will be reported immediately via phone to NHA/ANHA 24 hours per day, 7 days per week. NHA/ANHA will direct staff with next steps of investigation, including resident protection and reporting. As of 5/22/2020 there remain 97 of 146 staff requiring education on abuse which will be completed prior to the start of their next scheduled shift. Ongoing Monitoring Random weekly interviews and body assessments will be completed of three patients regarding abuse beginning May 26, 2020 and continuing for four weeks. Results will be reviewed at QAPI meeting on June 24th to determine next steps for ongoing monitoring. Each investigation will be reviewed to ensure a comprehensive abuse investigation has been completed by the NHA. The facility QAPI committee through Ad Hoc or full QAPI shall monitor weekly for 4 weeks to review any trends and findings, issues or concerns-and develop plan of action for follow up and resolution. The document was signed by the nursing home administrator (NHA) C. Removal of immediate jeopardy On 5/22/2020 at 1:10 p.m., the nursing home administrator was notified that its abatement plan had been accepted and the immediate jeopardy removed. However, based on record review and interviews, deficient practice remained at an E level, potential for more than minimal harm at a pattern. II. Policy and procedure When requested, the nursing home administrator (NHA) provided the policy titled, Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention. The NHA reported on 5/2/6/2020 this was the only abuse policy. The document read, The facility must develop and implement written policies and procedures that: prohibit and prevent abuse, establish policies and procedures to investigate allegation, include training and establish coordination with the QAPI (quality assurance performance improvement) program. However, the NHA did not produce additional policies and procedures to investigate allegations and establish coordination with QAPI when further policies and procedures were requested. III. Report of abuse involving Resident #1 and failures in facility response A. Resident #1 Resident #1, age 91, admitted [DATE] and passed away on 5/5/2020. According to the May 2020 computerized physician's orders [REDACTED]. The resident resided on the secure unit until his death. According to the 4/1/2020 minimum data set (MDS) assessment, the resident was severely cognitively impaired and was unable to complete the brief interview for mental status (BIMS). Staff documented the resident had short and long-term memory problems and was severely impaired regarding decision-making. The MDS documented the resident had no behaviors during the review period. He required supervision with ambulation and transfers and extensive assistance with grooming and dressing. The resident was unable to complete a pain assessment with staff; however, staff documented the resident would complain of pain one to two days during the review period. Care plan review revealed the following issues had been identified: -Left arm pain, plan created 10/31/17 for which he received pain medication. Although staff interviews (5/15/20) indicated the resident always complained of pain, there was no documentation indicating the resident frequently called out in pain, -History of verbal aggression towards others (curse or threaten to punch caregiver during attempts to redirect) related to cognitive impairment, hard of hearing, misinterpretation of environment/actions of others. -Inappropriate sexual behavior asking whose lap he can sit on. Interventions included explain effects of behavior on others, set limits for acceptable behavior, avoid conversations that could initiate or encourage inappropriate behavior, provide supervision in social gatherings/recreation programs and redirect resident to available empty chair in room. B. Facility report of abuse 3/24/2020 1. Record review Review of the facility abuse investigations on 5/15/2020 revealed a report of abuse involving Resident #1 on 3/24/2020. The facility interviewed the AA on 3/25/2020 at 4:36 p.m., the day she reported the incident. Her report read in pertinent part: -I was sitting doing an activity with residents and (Resident #1) asked if he could sit in a chair, he joined us about 8 ft. (feet) away and was participating. About 5 minutes into the activity the nurse (nurses' name/ RN #1 crossed out and error written above) comes in and says to Resident #1, you can't sit there. She walked over to him and yanked him out of the chair and using 2 hands . pulled on his left arm, and he yelled out and said stop but she continued to pull him up. -(The nurse) walks over to another table and sits him down by himself. Today (3/25) during lunch, Resident #1 said my arm hurts, rubbing his left arm. I told his sitter and she told the nurse. The nurse came to check him out and he stopped complaining. I didn't say anything to the nurse at the time, because the nurse has a reputation of being intimidating and I was afraid. I didn't tell anyone else. 2. AA interview The AA, who no longer worked at the facility, was interviewed on 6/5/2020 at 2:04 p.m. She said the date of the incident (3/24/2020) she was doing an activity with approximately five residents in the common area in the secure unit while sitting at a table. She said Resident #1 wandered in and said, Hey I'm still alive. He sat down in a chair which was located back from the table where the activity was underway and nowhere near other residents, and began participating in the activity with the other residents. RN #1, who was working as a CNA that day, came into the room and looked at Resident #1 and grabbed his arm and yanked him up out of his chair and said, you can't sit there. Resident #1 said, that hurts, stop, and RN #1 moved the resident to another chair across the room. She said RN #1 sat down next to him and did not say a word but began to look at her phone. The AA said the next day she returned to work and UNK #1 (Resident #1's sitter) asked the AA what had happened because Resident #1 was complaining of pain in his shoulder. The AA said she told UNK #1 what had happened, then went to LPN #1 and told her that the resident was complaining of pain. She said LPN #1 was watching something on her phone and said she would take care of it. The AA said in about 20 to 30 minutes LPN #1 went into the resident's room to give him medicine. The AA said she was nervous about reporting the incident and had heard that RN #1 had threatened people in the past. She said she also knew there were two other CNAs in the room, although she could not remember their names, who had witnessed the incident and thought they would tell someone. She said at that time, she was nervous and thought they would shrug it off. The AA said she asked the director of nurses (DON) to whom she could report abuse and the DON told her she could tell her. The AA told the DON, who said she would let the Assistant NHA (ANHA) know and then the ANHA came and interviewed her. C. The facility failed to investigate the incident on 3/24/2020 in a comprehensive manner and as a result, failed to take timely and appropriate measures to protect residents in the secure unit, all of whom are cognitively impaired, from potential abuse by staff. Cross-reference F610. The ANHA and the NHA acknowledged the facility investigation of the events on 3/24/2020, completed 3/31/2020, was incomplete and re-opened the investigation 5/22/2020 after immediate jeopardy was called during survey. Record review and interview of the facility's 3/31/2020 abuse investigation revealed the 3/24/2020 incident was reported to the police and the state agency, the resident's chart was reviewed, and a skin evaluation was conducted. The nurse on duty (LPN #1) was suspended upon administration receiving the AA's report on 3/25/2020, and she returned to work the next day, although the investigation was not signed as completed until 3/31/2020. Record review, confirmed by interview with the ANHA and NHA, revealed only three interviews were obtained during the 3/31/2020 abuse investigation; interview with the AA (see above), Resident #1 and LPN #1 the nurse on duty 3/24/2020. -In his interview, Resident #1, who had severe cognitive impairment (see 4/21/2020 MDS above), said his arm was better now and he broke it playing tennis. -In her interview, LPN #1 said she did not recall any incident with Resident #1 on 3/24/2020. The investigation concluded the allegation of abuse was unsubstantiated. The CNA (activities assistant) believed she had witnessed rough handling of Resident #1 on the afternoon of 3/24/2020 by the nurse . no other witnesses to the encounter. Resident #1's skin check revealed no signs of rough treatment and there have been no outward changes in his behaviors towards staff or fell ow residents. Yet, the facility investigation did not explain how it was determined that there were no other witnesses to the incident, based on the limited interviews obtained. Per the AA interview on 6/5/2020 (see above), there were other staff in the room as well as other residents attending the activity who she thought might report the incident. In summary, the facility completed its investigation on 3/31/2020 without attempting to identify the staff member who could have been involved in the incident described by the AA. The AA, in her interview on 3/25/2020, identified RN #1, but the RN's name was crossed out and no other name was inserted. When LPN #1 reported she did not recall any incident with Resident #1 on 3/24/2020, there was no evidence the facility attempted to interview RN #1 or other staff who worked on the unit that day until almost two months later, after being informed of immediate jeopardy during survey. At that time, the investigation of the incident was reopened. This placed residents on the secure unit at risk for serious harm (abuse). LPN #1 and RN #1 were interviewed on 5/15/2020 at 1:45 p.m. -LPN #1 said she kind of remember something but didn't hear about it for a few days and then asked Resident #1 if he was in pain. That was all she remembered; she said she did not remember hearing anything about the resident getting pulled or bruising. She said the resident always complained of pain and no one had told her anything about the incident, although per the ANHA she was suspended for the day and interviewed the next morning before returned to work. -RN #1 said she did not know anything about the incident and agreed Resident #1 always complained of pain, even when no one touched him. But see the resident's care plan above, lacking any reference to the resident frequently calling out in pain. The re-opened abuse investigation of the 3/24/2020 incident on 5/22/2020 involved interviews with the AA, LPN #1, and RN #1 as well as a number of other staff and residents. LPN #1 and RN #1 were suspended pending outcome of the investigation, which revealed RN #1 had not worked on 3/24/2020, per review of the punch detail, although, per the AA, RN #1 had worked that day as a CNA (see interview above). The investigation concluded on 5/27/2020 and again, the allegation was determined to be unsubstantiated. However, due to the nature of the allegation and the observations made during the investigation, staff were to receive additional education regarding the provision of care for individuals with dementia, including dignity and alternative methods of communicating to promote the highest level care and wellbeing for the residents. Interview with the NHA and the ANHA revealed no staff education on abuse, neglect or mistreatment (other than education of the AA on timely reporting) was conducted upon completion of the abuse investigation on 3/31/2020. D. Current observations of staff interactions with residents in the secure unit. The AA, in an interview on 6/5/2020, stated she had seen RN #1 do other things to residents on the secure unit such, as yell at them, ignore them and belittle them. She said she had never reported anything that she had witnessed until 3/25/2020, as RN #1 intimidated her. Review of the staffing schedules revealed LPN #1 and RN #1 have continued to work in the secure unit since 3/24/2020. Review of their files revealed no training in abuse recognition or prevention or management of residents with dementia and/or difficult behaviors from 3/31/2020 and until 5/7/2020, a training that was conducted in response to a different allegation of abuse. Observations in the secure unit on 5/15/2020 at approximately 10:40 a.m., revealed RN #1 standing next to a male resident who was sitting at a dining room table in the communal dining room. He attempted to stand up. Without speaking to the resident, RN #1 took his arm and directed him back into a sitting position. Further observations and staff interviews on 5/15/2020 and 5/22/2020 revealed staff in the secure unit failed to not know or use residents' names, referred to residents as feeders, and failed to acknowledge or speak to the residents they were assisting. (Cross-reference F550).

Based on record review and staff interview the facility failed to ensure one (#3) of three sample residents received adequate assistance to prevent accidents. Specifically the facility failed to ensure Resident #3 received the required assistance of two staff members during cares. Resident #3 was admitted to the facility with a known history of muscle weakness and [MEDICAL CONDITION]. She required extensive assistance with all activities of daily living (ADL) care and two person assistance with mechanical lift for transfers. On 5/12/2020 she was transferred out of her bed with a mechanical lift, received a shower and transferred back into her bed with a mechanical lift all with the assistance of one certified nurse aide (CNA). Once Resident #3 was in bed this CNA provided cares without the assistance of another staff member and as she rolled the resident to one side Resident #3 slid out of bed onto the floor landing on her knees. This action by the CNA, not following the residents prescribed plan of care, contributed to the harm of Resident #3. Resident #3 sustained a left distal femur fracture and was sent to the hospital. Cross reference: F835-Failure to administer facility effectively. Findings include: I.Resident status A. Resident #3 1. Resident status Resident #3, under [AGE] years old, admitted to the facility on [DATE]. According to the face sheet resident [DIAGNOSES REDACTED]. According to the 5/8/2020 minimum data set (MDS) assessment the resident had no cognitive impairment with a brief interview of mental status (BIMS) of 15 out of 15. The resident had no behaviors documented in the MDS. She required extensive assistance with all ADLs. 2. Record review a. Care plan The care plan, revised on 3/17/2020, documented the resident required transfers to be completed with a total mechanical lift with assistance of two people. The goal was for the resident to receive assistance to meet ADL needs. Interventions included two person assistance with bed mobility, assist with shower as needed and transfer using mechanical lift with assistance of two staff. b. Progress note The 5/12/2020 nursing progress note documented at 12:30 p.m. documented the nurse was called into the resident's room at 11:50 a.m. where Resident #3 was found on the floor; CNA #5 was in the room. The CNA said while changing the resident, Resident #3 rolled out of bed onto the floor. Resident #3 landed on both of her knees, but did not complain of pain and the nurse who assessed the resident did not identify neuro issues, redness or bruising to knees or feet. The nurse practitioner ordered bilateral knee two view x-rays and a left ankle x-ray. Resident #3's family was contacted. The 5/12/2020 nursing progress note documented at 4:19 p.m. documented the nurse contacted the resident's family to provide the results of the x-ray after the fall. The x-ray revealed a left-distal femur fracture. 3. Investigation report 5/12/2020 Resident #3, statement dated 5/12/2020 at 4:30 p.m. documented I got back from my shower (CNA #5 name) put me back into my bed with the full lift. It was just me and her in the room during the incident. I was lying in the bed after the transfer wth (CNA #5) rolled me towards her in the bed to help me get dressed. I was too close to the edge. My right leg went off the bed and the rest of me went with. I told (CNA #5) that I was starting to slip off the bed. She tried to hold me up by my torso, but I outweigh her, and I went down. I landed on both of my knees and the rest of me fell to the floor as well. It was an accident. I felt pain in both of my knees, but my right leg hurts more than the left. CNA #5, statement dated 5/12/2020 documented, in pertinent part: After giving the resident a shower I placed her back in bed and began the dressing process for her. When I rolled her facing the door, her legs came off the bed and I could not control them. Her feet began to push me backwards and her upper body began to slip from the bed. I was trying to control her head and upper body, she was lowered to the floor onto her knees. I lowered her to the floor and called for help. I was alone in the room. I got her up to the shower with the full body lift alone. After her shower, I placed her back to bed with the full body lift, alone. Yes I am aware (the resident needs two person assistance). She is a large and heavy patient and I knew by the process of deduction that she would need 2 people to help. It was just a lack in judgment to get my work done. The investigation report signed by the ANHA documented: -Summary of alleged incident, in pertinent part: On 5/12/2020 the resident was on the floor landing on her knees and fracturing her left distal femur. Staff stated she knew the resident was a 2-person assist for bed mobility but she chose not to use a second person. -Conclusion: Failure on the part of staff to follow care plan or exercise good judgement in her duties resulted in major injury in the form of a fracture to this resident. Neglect is substantiated. 4.Staff interview Licensed practical nurse (LPN) #5 was interviewed on 5/15/2020 at10:05 a.m. She said she was the nurse working the night Resident #3 fell . She said she immediately implemented that all CNAs must go in with another CNA regardless of the residents bed mobility. 5.Facility follow-up The Facility Past-Non-Compliance checklist dated 5/13/2020 documented the facility would complete the following: -Identify CNA's role in reviewing and following Kardex (CNA communication for residents); -Identify bed mobility procedure; -Education initiated with CNAs on Bed Mobility Procedure including obtaining additional assistance and needed equipment as indicated and following the Kardex and appropriate documentation; and -The facility will monitor residents who require assistance with bed mobility and audit that staff are following the Kardex and documenting appropriately.

Based on observations, record review and interviews, the facility failed to provide pain management services for one (#61) of one resident reviewed for pain of 42 sample residents to ensure the highest practicable physical, mental and emotional well-being, in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences. Specifically, Resident #61's pain was not adequately managed, contributing to the resident experiencing unrelieved pain and undue anxiety especially during transfers. Findings include: I. Facility policy and procedures A copy of the pain management policy was requested from the nursing home administrator (NHA) on 3/5/2020 at 9:15 a.m. However, only a copy of the pain practice guide flowchart was provided by the director of nursing (DON) on 3/5/2020 at 2:00 p.m. A copy of the pain management policy was not provided by the facility. II. Resident status A. Resident #61 Resident #61, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the March 2020 computerized physician orders [REDACTED]. According to the 10/20/19 MDS, the resident weighed 115 pounds (lbs) and was five foot two and half inches tall. According to the 1/19/2020 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She required extensive two-person assistance for all activities of daily living (ADLs) except for eating, where she required extensive one-person assistance. The MDS assessment revealed the resident was on a scheduled pain medication regimen to include PRN (as needed) medications. Self indicators for pain included vocal complaints of pain and facial expressions. The assessment documented the resident complained of pain three to four days out of five days, yet the electronic medication administration record (eMAR) documented the resident did not report any pain. B Pain Management Plan The March 2020 CPO included an order dated 3/28/19 for a pain evaluation every day shift for monitoring of the resident's pain level. The resident's pain was to be assessed at 6:00 a.m. The resident's March 2020 CPO revealed current orders for pain control included: -Biofreeze Gel 4 % (Menthol (Topical [MEDICATION NAME])) apply topically to bilateral hips and knees topically every eight hours as needed for pain. -Biofreeze Gel 4 % (Menthol (Topical [MEDICATION NAME])) apply topically to the neck and lower back three times a day for pain. -[MEDICATION NAME] Tablet 650 mg (milligrams) by mouth every six hours as needed for mild pain; give tylenol before [MEDICATION NAME]. -[MEDICATION NAME] Tablet 600 MG by mouth two times a day for pain. -[MEDICATION NAME] Tablet 325 MG give two tablets by mouth every eight hours for pain, not to exceed 3 grams/24 hours. -[MEDICATION NAME] Gel 1 % ([MEDICATION NAME] Sodium) apply four grams (gms) to bilateral knees topically three times a day for OA ([MEDICAL CONDITION]). -[MEDICATION NAME] Tablet 15 MG give two tablets by mouth two times a day for pain; give 30 mg. -[MEDICATION NAME] 20mg/ml (milliters) give 0.5 ml by mouth every four hours as needed for pain. -[MEDICATION NAME] (Concentrate) Solution 20 MG/ML; give 0.5 ml by mouth in the morning every Tuesday and Thursday for pain prior to a shower. -[MEDICATION NAME] 20mg/ml; give 0.25 mg/ml by mouth in the morning every Monday, Wednesday, Friday, Saturday, and Sunday for pain 30 minutes prior to the hoyer lift transfers. C. Observations On 3/2/2020 at 10:51 a.m., two unknown CNAs were observed entering the resident's room with the hoyer (mechanical) lift and the door was closed behind them. Indecipherable screaming and yelling was heard from behind the closed door. When the door was opened, Resident #61 was observed sitting in her wheelchair. The resident was assisted out of her room to the hall by the front lobby The resident was observed to have tears in her eyes and on her cheeks. Staff was not observed to notify the nurse of the resident's screaming and crying. On 3/3/2020 at 8:40 a.m., screaming was heard from behind the closed door to Resident #61's room. The resident was assisted out of her room in her wheelchair. Noteable tears were in her eyes and on her cheeks. Staff was not observed to notify the nurse of the resident's screaming and crying. On 3/3/2020 at 1:32 p.m., the resident was observed being transferred from the wheelchair to the bed with the use of the hoyer (mechanical) lift. Certified nurse aides (CNAs) #14 and #8 assisted with the transfer. The resident yelled saying the room was too hot. The resident wanted CNA #8 to transfer her without the use of the hoyer lift. The resident expressed a fear of falling out of the wheelchair and started to cry when she was leaned forward in order to place the sling behind her. The resident became agitated as the sling was placed behind her. The resident verbalized Ow, ow as the CNAs moved the resident's legs to place the sling between her legs. The resident was lifted slowly with the hoyer lift and set down on the bed. Once more the resident verbalized Ow, ow. The resident said she was afraid of the hoyer lift, that it was uncomfortable and hurt her bones. She said it made her feel unstable. On 3/4/2020 at 8:31 a.m., screaming was heard from behind the closed door to Resident #61's room. The resident was assisted out of her room in her wheelchair. Noteable tears were in her eyes and on her cheeks. Staff was not observed to notify the nurse of the resident's screaming and crying. D Resident interview The resident was interviewed on 3/3/2020 at 2:32 p.m. When the resident spoke about the transfers with the hoyer lift, she had tears in her eyes and started to cry. She said her bones were brittle and when the staff used the hoyer lift, it folded her up and tightened her bones. She said she had pain from her knees to her hips and the mechanical lift crunched her bones. She said the pain had been awful and once more became tearful. She said she has asked staff a hundred times not to use the hoyer lift, but she said the staff just walked off or said you know we cannot do that. The resident was interviewed a second time on 3/5/2020 12:21 p.m. She said the facility just wanted to keep her in pain. She said she was not certain if there was anything that could help her pain. She said she did not want to use the hoyer lift because it hurt her bones. The resident was unable to verbalize her current level of pain or what an acceptable level of pain would be. III. Record review A. Pain assessment From 8/28/18 through 3/27/19, the CPO revealed an order for [REDACTED]. This order was discontinued on 3/27/19 and revised to every day shift. B. Care plan The care plan initiated on 11/29/18 revealed the resident had pain related to [MEDICAL CONDITION]. The interventions for pain management included administering pain medications per physician orders, adjusting times of ADLs and treatment activities to achieve the [MEDICATION NAME] benefits, notify the physician if pain frequency and/or intensity worsens or if current [MEDICATION NAME] regimen became ineffective, and report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, and change in breathing. The resident's needs were to be met by the facility with the assistance of an outside hospice agency. Interventions included to notify the hospice agency if there was a change in condition, unrelieved pain, or death. The therapy discharge communication form dated 1/28/19 was provided by the director of rehabilitation (DOR) on 3/3/2020 at 6:11 p.m. It revealed the resident had arthritic joint pain and required maximum assistance or the use of the hoyer lift for transfers. The facility failed to reassess the resident for the effectiveness and continued use of the hoyer for transfers as it related to the resident's complaint of pain. An order to notify hospice if pain management was not effective 30 minutes after medication administration was completed and pain continued to be greater than six out of 10 was discontinued on 11/26/19. C. Medication administration record (MAR) and narcotic record The February 2020 eMAR revealed the resident's pain was assessed every day shift at 6:00 a.m. Only one time during this month, on 2/9/19, was it documented the resident reported a pain level of seven. All of the remaining days the resident reported no pain. However, the observations showed the resident was assisted out of bed after 8:00 a.m., and therefore, her pain was assessed while she remained in bed. The March 2020 eMAR revealed the resident's pain was assessed every day shift at 6:00 a.m. At no time was it documented the resident reported any pain. The March 2020 CPO included an order dated 3/28/19 for a pain evaluation every day shift for monitoring of the resident's pain level. VII. Staff interviews CNA #8 was interviewed on 3/3/2020 at 1:22 p.m. CNA #8 said the resident had pain everytime she was transferred with the hoyer lift due to her contractures. CNA #14 was interviewed on 3/3/2020 at 1:25 p.m. CNA #14 said the resident did not like the hoyer lift. She said the resident yelled out in increased pain when she was transferred with the hoyer lift, due to increased pain from her contractures. Registered nurse (RN) #3 was interviewed on 3/5/2020 at 1:05 p.m. RN #3 said the resident was in bed when she administered her pain medication and the resident did not report any pain. She said her pain medication was administered 30 minutes prior to her being transferred out of bed to the wheelchair with the use of a hoyer lift. She said she relied on the resident to let her know when she was in pain, as the resident was alert and oriented times three. She said the resident's pain used to be assessed every shift, but it changed about a year ago. She said residents with an even room number were assessed in the morning and residents with an odd room number were assessed in the evening. She was not certain why there was a change. She said the current way of monitoring a resident's pain just one time a day did not provide a true assessment to determine if the interventions provided to the resident were effective. The DON was interviewed on 3/5/2020 at 1:48 p.m. The DON said the resident was being seen by hospice, who provided her pain medications related to her diagnosis. She said the resident's pain medications had recently been changed in the hope of better managing her pain. She said the resident's pain was assessed and documented on the MARS just once a day in the morning, which may be before the resident was transferred from the bed to the wheelchair. The DON was uncertain as to the exact time the resident was assisted out of bed in the morning. She said she was not certain if the resident's pain was assessed during and/or after the transfers. She said the resident did have PRN (as needed) medications available.

Based on record review and interviews, the facility failed to ensure three (#109, #52 and #69) of three residents reviewed for accidents of 41 sample residents remained free from falls, and failed to ensure water temperatures for multiple residents were within a safe range. The facility failed to ensure Resident #109, who was admitted after a fall at her home who sustained a pelvic fracture and was a known fall risk, received the care and services necessary, including adequate supervision when walking, to keep her safe from falls. Resident #109 fell on [DATE] while she walked to the bathroom after the certified nurse aide (CNA) failed to use a gait belt (security measure that is placed around the residents waist) and left her side to open the bathroom door, leaving Resident #109 without the contact support she required and was assessed for, to prevent further falls. Subsequently, because of this action by the CNA, Resident #109 sustained a left humerus (arm) fracture. -The facility failed to ensure for Resident #52, a fall investigation was accurately and completed in its entirety and interventions were implemented following a fall from which Resident #52 sustained a right [MEDICAL CONDITION]. -The facility failed to ensure nursing staff used the proper mechanical lift for Resident #69 to prevent falls and potential injuries and failed to follow through on education of nursing staff after the incident. -The facility failed to ensure water temperatures in resident rooms were kept at a safe level to minimize the potential for burns. Findings include: I. Failure to ensure Resident #109 received the necessary supervision and assistance required during cares, which resulted in a fall with a sustained fracture. A. Resident interview The resident was interviewed on 2/27/19 at 3:19 p.m. She said she had been admitted to the facility on [DATE] after falling at home and sustaining a pelvic fracture. She said she was fearful of falling and was receiving physical and occupational therapy to increase her strength before she could return home. She said after she was admitted to the facility, she had sustained a fall on 2/19/19. She said she activated her call light because she required toileting assistance. She said the certified nurse aide (CNA) did not use a gait belt and did not stand behind her to provide assistance as she walked to the bathroom with the walker. She said the CNA had assisted her to stand up from the bed and then walked away to open the door to the bathroom. She said the CNA had told her to use her walker to walk to the bathroom but did not provide assistance while she walked with the walker. She said the CNA did not use a gait belt and did not provide her hands on assistance to walk to the bathroom. She said the CNAs were aware she required hands on assistance when walking and the use of a gait belt. She said she lost her balance and fell backwards hitting her head and falling on the left side. She said she felt a severe amount of pain following the fall. She said she was sent to the hospital the next day by staff and was informed at the hospitals that she had a fracture to her left upper arm (humerus). B. Resident status Resident #109, age 82, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 2/19/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required extensive assistance of two people with bed mobility and toileting. She required extensive assistance of one person with transfers, locomotion on and off the unit, dressing and personal hygiene. C. Record review Based on the record review and interviews (see below), the facility had knowledge and identified on 2/13/19 upon the residents admission of the resident's functional limitations (unsteady gait, history of falling and weakness) requiring one-person hands on assistance with transfers, toileting and ambulation prior to the fall on 2/19/19. The facility did not ensure the proper level of assistance was provided which placed her at risk for falls and increased her need for care and supervision to prevent further falls. The transferring care plan, initiated on 2/13/19, revealed the resident required assistance with transferring from one position to another. The interventions included to provide one-person guidance and physical assistance. The falls care plan, initiated on 2/13/19, revealed the resident was at risk for falls due to a history of falls and unsteady gait. The interventions included to provide one-person assistance with transfers, toileting and ambulation. The 2/13/19 physical therapy evaluation and plan of treatment revealed the resident felt unsteady when standing and walking and worried about falling. It indicated the resident required minimum assistance (25% physical assistance from the therapist) with walking and transfers and required the use of a two-wheeled walker. It indicated the resident required skilled physical therapy services to facilitate with all functional mobility, promote safety awareness, enhance rehabilitation potential, improve dynamic balance, increase functional activity tolerance, increase lower extremity range of motion and strength, minimize falls and decrease complains of pain. The 2/15/19 physical therapy treatment notes indicated the resident continued to require minimum assistance with ambulation, transfers and required the use of a two-wheeled walker. The 2/18/19 physical therapy treatment notes indicated the resident required stand-by assistance with ambulation and required the use of a four-wheeled walker. The activities of daily living (ADL) care plan, initiated on 2/18/19, revealed the resident had a self-care deficit related to a left pelvic fracture, pain and deconditioning. The interventions included the resident would receive the assistance necessary to meet ADL needs and receive assistance with daily hygiene as needed. -This was added the day of the fall D. Fall review The 2/19/19 nursing progress notes revealed the resident was being assisted to the bathroom by the CNA, lost her balance and sustained a fall. It indicated the resident fell on her left side and complained of severe pain to the left shoulder. The physician was notified and ordered an x-ray of the resident's left shoulder. The 2/19/19 fall incident report revealed the resident was being assisted to the bathroom by the CNA. The resident was standing by her bed using a walker. The CNA left the resident to open the door to the bathroom. When the CNA turned around, the resident was found on the ground. It indicated the resident expressed losing her balance, hitting her head and had left shoulder pain. The conclusion indicated the resident would be assisted to the bathroom with a gait belt and with one-person assistance. The 2/20/19 nursing progress notes revealed the resident continued to complain of left shoulder pain. Upon assessment by the registered nurse (RN), there was noted left shoulder swelling and pain with movement. The physician was notified and ordered for the resident to be sent to the emergency room for further evaluation. The 2/20/19 hospital discharge instructions revealed the resident was admitted to the hospital for a proximal humerus fracture to the left arm. The treatment was to place the resident in a sling for six to eight weeks and keep the arm immobilized and follow up with an orthopedic physician. E. Staff interviews CNA #3 was interviewed on 3/4/19 at 2:53 p.m. She said Resident #109 had sustained a fall while at the facility following her initial admission. She said she was not present during the fall. She said she was told the resident fell while walking to the bathroom unassisted. She said the CNA had left the resident to open the door to the bathroom, when the resident fell . She said the resident sustained [REDACTED]. She said the resident had required assistance with ambulation since her admission to the facility. She said the resident had a history, prior to the fall at the facility on 2/19/19, of getting dizzy while ambulating. She said the CNA should have opened the door to the bathroom prior to assisting the resident out of bed. She said the CNA should have used a gait belt and provided hands on assistance while the resident ambulated to the bathroom. She said following the resident's fall, she now required extensive assistance of two people with ambulation and toileting. RN #1 was interviewed on 3/4/19 at 3:00 p.m. He said prior to the resident's fall on 2/19/19, the resident required hands-on assistance with ambulation and toileting. He said the resident walked with a walker with the hands-on assistance from staff. He said the facility staff should always use a gait belt when providing hands-on assistance to the resident. He said he was not present on 2/19/19 when the resident had sustained a fall. He said he was informed during report from the previous shift, the resident was walking behind the CNA to the bathroom when she lost her balance and fell hitting her head and falling on the left side. He said the CNA was not providing hands-on assistance to the resident while she ambulated to the bathroom. He said on 2/20/19, the day after the fall, the resident had continued to complain of severe pain to the left side of her upper body. He said he notified the physician who then ordered for the resident to be sent to the hospital for further evaluation. He said the resident returned to the facility with a fracture to the left humerus. The director of rehabilitation (DOR) was interviewed on 3/4/19 at 3:10 p.m. She said the resident was admitted to the facility following a fall with a pelvic fracture. She said the resident had an unsteady gait and weakness following the fall prior to her admission to the facility. She said prior to the fall on 2/19/18, the resident fluctuated in her level of care between requiring minimum assistance and stand by assistance. She said stand by assistance required a staff member standing behind and beside the resident while holding onto the gait belt while the resident ambulated. She said minimum assistance required 25 percent of physical help of the therapist while ambulating. She said the level of assistance was different between the physical therapists and the CNAs because of their level of training. She said the staff on the floor, prior to the fall on 2/19/19, should have provided hands on assistance while the resident ambulated. She said all staff should always use a gait belt when providing ambulation assistance with a resident. She said the resident should not have been walking by herself to the bathroom. She said the CNA should have used a gait belt and provided hands on assistance while the resident was walking. The director of nursing (DON) was interviewed on 3/5/19 at 3:00 p.m. She said the resident had sustained a fall on 2/19/19, after being admitted to the facility. She said, according to the notes, the CNA had assisted the resident to the bathroom and the resident fell backwards hitting her head and landing on the left side. She said the resident had sustained a left humerus fracture. She said she did not know if the CNA had provided hands on assistance to the resident during ambulation. After reading the incident report, the DON confirmed the CNA had been at the door to the bathroom and did not provide hands on assistance or the use of a gait belt while the resident was ambulating. She confirmed the resident's plan of care, initiated upon the resident's admission to the facility on [DATE], indicated the resident was to have hands on assistance of one person while ambulating. She said the CNA should have provided hands on assistance when the resident walked to the bathroom while utilizing the gait belt for safety. She said she was unsure if the CNA was provided education following the resident's fall. II. Failure to ensure fall interventions were in place following a fall and upon readmission to the facility in which Resident #52 sustained a right [MEDICAL CONDITION] A. Resident status Resident #52, age 87, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 1/26/19 MDS assessment revealed the resident had short-term and long-term memory impairment. He had moderate impairment for making decisions regarding tasks of daily life. He required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review 1. Fall incident on 1/2/19 The 1/2/19 nursing progress note revealed the resident was calling out, saying help me, help me and was found on the floor of his room near the wall. The resident sustained [REDACTED]. The resident was unable to move the right leg, the right hip was tender to touch and the right leg was turned outside. The physician was notified and ordered for the resident to be sent out for further evaluation. The hospital notified the facility the resident would be admitted to the hospital for a right [MEDICAL CONDITION]. The 1/2/19 acute care transfer assessment revealed the resident was transferred to the hospital on [DATE] due to complaints of right hip pain. It indicated the resident used a walker, forgot to use it when ambulating, had an unsteady gait and did not call for staff assistance when getting up out of bed. It indicated the resident required stand by assistance when getting up out of bed. The 1/2/19 fall assessment revealed the resident sustained [REDACTED]. It indicated the resident was sent to the hospital for an evaluation. It did not indicate any fall interventions put into place. The 1/2/19 incident report revealed a summary of the fall incident that took place on 1/2/19. The quality assurance (QA) investigation report, a part of the fall investigation, revealed multiple sections were left blank: documents reviewed, people interviewed, timeline of events, summary of critical information obtained during investigation, action taken, and the conclusion. It did not indicate any fall interventions that would be put into place following the resident's return to the facility from the hospital. 2. Record review indicated the fall plan of care was not updated with new fall interventions following the 1/2/19 fall incident with a subsequent right [MEDICAL CONDITION]. The fall care plan, initiated on 12/29/18 (prior to the fall on 1/2/19) revealed the resident was at risk for falls. It indicated the resident was at risk for falls due to right hip surgery and weakness. The interventions included to reinforce the need to call for assistance and encourage the resident to change positions slowly. -The care plan was revised on 1/28/19 , however, did not add any additional appropriate and resident centered interventions for a resident with dementia to help prevent further falls and to promote safety awareness. The cognitive communication deficit care plan, initiated on 1/9/19 (following the fall on 1/2/19), revealed the resident was working with speech therapy to improve on his cognitive communication abilities to complete reasoning tasks related to familiar situations. The transferring care plan, initiated on 1/8/19 (following the fall on 1/2/19), revealed the resident required assistance from one position to another as evidenced by lower extremity weakness related to a hip replacement. The interventions included to use a gait belt to facilitate a safe transfer and maintain the ability to transfer safely with help. C. Staff interviews RN #1 was interviewed on 3/4/19 at 3:00 p.m. He said when a resident sustained [REDACTED]. He said the RN would also assess for pain, check vital signs, range of motion and determine if it was safe to move the resident. He said the physician and family and/or responsible party should be notified in the event of a fall. He said the nurses on the floor were responsible for completing a progress note, incident report, fall assessment and pain assessment following a fall. He said the nurses were responsible for putting immediate interventions into place following a fall and updating the care plan. He said nursing management reviewed the incident reports in the morning clinical meetings. He said nursing management would add interventions as needed and would update the care plan as needed. RN #4 was interviewed on 3/4/19 at 12:30 p.m. She said Resident #52 had dementia and would get up without assistance. She said the resident had fallen on 1/2/19 and sustained a right [MEDICAL CONDITION]. She confirmed the resident's plan of care did not include any interventions following the fall on 1/2/19. The DOR was interviewed on 3/4/19 at 3:10 p.m. She said all incident reports, including falls, were reviewed during the morning clinical meeting. She said therapy would follow up on any falls as directed during the morning clinical meeting. She said the nursing management team, along with therapy, would review the incident report and any interventions put into place and determine if additional interventions were required. She said the QA investigation report was also reviewed and updated during the morning clinical meeting by the management staff. She said nursing was responsible for completing the QA investigation report updating the resident's plan of care. The DON was interviewed on 3/5/19 at 3:00 p.m. She said when a resident sustained [REDACTED]. She said if it was determined the resident did not sustain a major injury, the staff would assist the resident back to bed and begin neurological checks. She said the RN was responsible for completing the incident report, determine the cause of the fall, complete the incident management report and determine immediate interventions to be put into place in an attempt to prevent further falls. She said the unit manager would review the incident management report, update the care plan, ensure the physician and family were notified of the fall and bring the incident report to the morning clinical meeting. She said the interdisciplinary team reviewed each fall incident in the morning clinical meeting. She said the QA investigation report was reviewed to ensure it was filled out completely and the IDT would determine if any additional interventions should be put into place. She said nursing was responsible for completing the QA investigation report and updating the care plan. She confirmed the QA investigation report for Resident #52 was not completed and was missing documentation in the following areas: documents reviewed, people interviewed, timeline of events, summary of critical information obtained during investigation, action taken, and the conclusion. She said the QA investigation report should be filled out completely. She confirmed the care plan for Resident #52 was not updated following the fall on 1/2/19 with interventions. She said the plan of care should have been updated to reflect any new interventions upon the resident's re-admission to the facility following his hip surgery. III. Resident #69 sustained injury of a skin tear to left elbow and left knee after staff used the wrong lift for transfer A. Resident status Resident # 69, age 85, was initially admitted on [DATE], and readmitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 1/25/19 MDS assessment revealed the resident was moderately cognitively impaired with a score of eight out of 15 on the BIMS. Her preferred language was Russian. She required extensive assistance with bed mobility, transferring, dressing, toileting, bathing and hygiene. She was at risk for developing pressure ulcers, and had moisture associated skin damage. B. Record review An incident report dated 9/24/18, was provided by the director of nursing (DON) on 3/6/19 at 8:45 a.m The incident report read in part, Resident #69's knees gave out during a transfer from the wheelchair to bed using a sit to stand lift and two CNAs. The resident suddenly went limp, knees buckled and she fell forward. According to the incident report she obtained a skin tear to the left elbow and left knee when she went down. There was no size or description of the wounds documented. It further revealed under summary, the CNA'S' were using wrong equipment for transferring the resident. The incident report was incomplete, sections titled: investigation report, timeline of events and conclusion were blank. The incident report revealed the staff were educated on using the care plan as a reference, and in serviced on how to use transfer equipment. C. Staff interview The DON was interviewed on 3/6/19 at 9:40 a.m. and a copy of the staff education for the incident on 9/24/19 was requested. The DON was unable to provide any documented education with the staff regarding this incident. IV. Water Temperatures Observations On 2/27/19 at 6:20 p.m., Resident #24's family member had filled a basin of hot water to assist the resident with shaving. The family member said the water was hot and needed to sit for a few minutes to cool off. On 2/28/19 at 5:00 p.m., the water temperature was taken in room [ROOM NUMBER] and found to be 129.0 degrees F. Beginning at 5:13 p.m. on 2/28/19, the maintenance director (MTD) accompanied the surveyor as water temperatures were randomly taken throughout the building. The temperatures were as follows: --room [ROOM NUMBER] the water temperature was 129.0 F. --room [ROOM NUMBER] the water temperature was 126.3 degrees F. --room [ROOM NUMBER] the water temperature was 127.0 degrees F --room [ROOM NUMBER] the water temperature was 128.4 degrees F. --The sink in secured unit (Arcadia) in the dining room was 129.7 degrees F --room [ROOM NUMBER] the water temperature was 125.0 degrees F. Record review The water temperatures provided by the MTD were taken primarily daily. However, the times documented were the mornings and the early afternoons. There were no times the water temperature was taken in the evening. The following water temperatures above 120 degrees F were recorded: --room [ROOM NUMBER] was 124 degrees F on 1/29/19 --room [ROOM NUMBER] was 123 degrees F on 1/29/19 --room [ROOM NUMBER] was 123 degrees F on 2/26/19. Staff interview The MTD was interviewed on 2/28/19 at 5:30 p.m. The MTD said his assistant took the water temperatures. He verified the water temperatures were taken either in the morning or afternoon and none in the evening. He said the mixer valve might be malfunctioning and he would have it looked at. The MTD said the water temperatures for resident areas should not be greater than 120.0 F.

Based on observations, record review and interviews, the facility failed to ensure five (#85, #24 , #75, #105 and #51) of five residents who entered the facility with limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable, out of 41 sample residents. Resident #85, who met all goals of physical therapy after being admitted with a left femur fracture, had an avoidable decline in her walking ability after staff failed to follow the recomendations of the physical therapist. The staff failed to contact the physician for orders, failed to update the care plan with interventions after therapy ended, and failed to initiate recommendations for walking with the resident. As a result of the facility's failures Resident #85 went from walking 150 feet with standby assistance to now being wheelchair bound and extensively dependent on staff. Additionally, the facility failed to ensure: -Residents #24 and #75 received passive range of motion; -Resident #105 received treatment and interventions for hand contractures; and -Resident #51 received restorative care to prevent a further decline in ambulation. Findings include: I. Facility policies and procedures A. The Range of Motion: Active/Passive policy was provided by the staff development coordinator (SDC) on 3/5/19 at 11:30 a.m. It read in pertinent part: To improve or maintain joint mobility and minimize potential of contractures. Active range of motion exercises are performed by the patient with instruction and supervision provided by nursing or therapy staff. Passive range of motion exercises involve nursing and therapy staff moving the patient's joints through range of motion. Verify range of motion(active or passive) and patient specific tasks on kardex. Suggested documentation: care provided in plan of care (P[NAME]), document in progress notes if unusual observations and/or complaints and subsequent interventions including communications with medical practitioner or rehabilitation therapist as clinically indicated. B. The ADL/Functional Rehabilitation Restorative Nursing Practice Guide was provided by the SDC on 3/5/19 at 11:30 a.m. It read in pertinent part: Restorative nursing includes nursing interventions that assist or promote a patient's ability to attain and maintain their maximum functional potential, that are individualized to specific patient needs. Most often the focus is on restoring or compensating for skills lost through disuse or changes in patient condition. Functional decline can lead to depression, withdrawal, social isolation, and complications of immobility such as incontinence, contractures, pain and pressure ulcers. II. Resident #85 A. Resident status Resident #85, age 89, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 2/6/19 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of zero out of 15. The resident required extensive assistance with activities of daily living. The resident did not have any behaviors. The resident was coded as not walking in room or corridor. The initial MDS assessment completed on 5/9/18 showed the resident required extensive assistance with walking in the corridor. The BIMS was not completed but she was documented to have memory problems and moderately impaired decision making abilities. B. Baseline at admission The initial evaluation by the physical therapist on 5/3/18 showed the resident ambulated 20 feet with a front wheel walker with moderate assist. C. Progress with physical therapy The resident was seen by physical therapy and occupational therapy beginning on 5/3/18. The notes were as follows: The 5/3/18 long term goal was for the resident to ambulate 100 feet with stand by assist with a front wheel walker, and safely perform functional transfers with stand by assist while maintaining good safety awareness in order to facilitate increased participation with functional daily activities. --5/8/18 the resident ambulated 15 feet with minimum assist with front wheel walker --5/11/18 the resident ambulated 30 feet with front wheel walker and the therapy was extended. --5/16/18 the resident ambulated 75 feet with two turns with front wheel walker with minimal assistance. --5/22/19 the resident ambulated 150 feet twice with a front wheel walker with contact guard. --5/28/18 the resident ambulated 150 feet twice with front wheel walker with contact guard. 6/2/18 the resident ambulated 150 feet with a front wheel walker with contact guard. The discharge summary from physical therapy dated 6/4/18 showed the short and long-term goal was met by evidenced by: Ambulation 5/3/18 baseline ambulated 20 feet with moderate assistance 5/24/18 ambulated 150 feet with contact guard assistance 6/4/18 met the goals set for ambulation. Transfers 5/3/18 baseline maximum assist with transfers 5/24/18 required minimum assist with transfers 6/4/18 met the goals set for stand by assist with transfers. The caregiver training and education was provided on 6/4/18. The staff were educated on functional status and ambulation of short distance with front wheel walker and contact guard. The discharge summary instructed to keep the resident at her current function to ambulate short distances with a front wheel walker. C. The resident experienced a functional decline in her abilities Although the facility was educated on the therapy discharge summary on 6/4/18, a physician order [REDACTED]. The medical record failed to show evidence the walking program was initiated timely. Furthermore, the resident experienced a functional decline in her walking abilities. The care plan was updated on 9/20/18 by a registered nurse (RN) to include the resident was to walk to the dining room at each meal, assist of one with gait belt as tolerated. The physician order [REDACTED]. However, on 9/20/18 the order was discontinued. The medical record failed to show evidence of the reasons for the discontinued order. On 8/3/18 the nursing progress note documented the resident was one person assist with sit to stand transfers, and used the wheelchair for mobility. On 8/7/18 the nursing progress note documented the resident used the wheelchair for mobility and all transfers were completed by staff. An 11/2/18 nursing progress note documented, Pt is A & O X 1 (alert and oriented to self) ADL's (activities of daily living) done by staff. One person assist for transfer. Pt (patient) can pivot, uses wc (wheelchair) for mobility with assistance . no change of condition . On 11/7/18 the nursing progress note documented, .Pt (patient) is wheelchair bound, able to propel self short distance. An 11/15/18 nursing progress note documented the resident was wheelchair bound. The 12/11/18 care conference note documented the resident had several falls in the past quarter and staff continue to monitor for unsafe situations and intervene as needed. Medical record review revealed the resident was not injured during the falls she experienced, but she did not receive therapy for evaluation, strengthening or training after any of the falls. The 1/26/19 nursing progress note documented it was reported during incontinent care that redness was noted in the resident's coccyx area and right buttock area. The CNA was reminded to reposition the resident in bed. There was no evidence of therapy evaluation or treatment. The 1/31/19 nursing progress note documented the resident was maximum assist with her ADLs and was propelled to the dining room by staff in her wheelchair. D. Walking notes The medical record failed to show documentation of ambulation to all the resident's meals, and ambulation was not documented on a daily basis. The only associated notes were as follows: -8/28/18 did not walk -8/31/18 did not walk -9/6/18 refused to walk -9/13/18 did not walk -9/16/18 refused to walk -9/18/18 did not walk -9/19/18 did not walk. The medical record failed to show any further documentation. The physician order [REDACTED]. E. Observations On 2/27/19 at approximately 12:15 p.m., the resident was assisted into the dining room via her wheelchair. At approximately 1:00 p.m., she was assisted out of the dining room via her wheelchair. On 3/5/19 at 5:47 p.m., the resident was observed to be assisted from bed. Certified nurse aide (CNA) #15 and CNA #12 spoke to the resident and told her they were going to transfer her into the wheelchair. The resident responded with words that did not make sense. The CNAs proceeded to put a gait belt around the resident's waist. Then both of the CNAs assisted her into the upright position. Each CNA held the resident on either side of the gait belt and both physically lifted the resident. The resident did not assist with the transfer. Once she was in the wheelchair, they lifted her to get her further back in the chair. F. Interviews The director of nurses (DON) was interviewed on 2/28/19 at 3:14 p.m. The DON said the facility did not have a restorative program. Registered nurse (RN) #6 was interviewed on 3/5/19 at 12:00 p.m. The RN said the resident was not able to ambulate. She said the resident used to ambulate, however, she had experienced falls, and her function deteriorated. She said the resident continued to sit in the common area so they could keep an eye on her. The RN said the resident was a two person transfer. CNA #12 was interviewed on 3/5/19 at 5:56 p.m. The CNA said the resident did not walk. She said that she used to walk and she was a good walker, however, she started to have falls, and they wanted to keep her safe. She said the resident was not on any sort of walking program. CNA #15 was interviewed on 3/5/19 at 6:00 p.m. The CNA said the resident did not have the strength to walk and that she was a two person transfer. III. Resident #24 A. Resident status Resident #24 was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident had severe cognitive impairment with a BIMS score of zero out of 15.The resident required total care of two plus staff for activities of daily living. He had functional limitations of range of motion on both sides of both upper and lower extremities. The resident had no behavior issues. B. Lack of range of motion assistance The resident and his medical power of attorney were interviewed on 2/27/19 at 6:15 p.m. The resident said he was unable to move his extremities on his own. He said he did not receive range of motion (ROM). 1. Observations On 2/27/19 at approximately 12:30 p.m., the resident's bilateral hands were in a closed position.The resident was unable to move his arms or legs. On 3/4/19 at 9:20 a.m., the resident was observed to be assisted out of bed by certified nurse aide (CNA) #17 and CNA #7. The resident was assisted out of bed utilizing a full mechanical lift. The resident was dressed in a pair of pants and a long sleeve shirt. When the pants were placed on the resident, the resident's legs were lifted approximately one inch off of the bed, enough to get the pant legs on. The resident was then rolled from side to side to pull the pants up. When he was in his wheelchair, the resident's shirt was put on. CNA #7 was observed to put her hand into the arm sleeve of the shirt. She then proceeded to hold the resident's hand and pull the shirt sleeve over his arm. The same process occurred on the resident's other sleeve. ROM was not offered and not encouraged. The care was completed with the CNAs assisting with brushing the resident's teeth. Range of motion did not occur during the above observations. On 3/4/19 at approximately 4:45 p.m., the resident was observed to be assisted to bed by CNA #12 and CNA #7. Range of motion was not completed while they assisted the resident to bed. ROM was not offered and not encouraged during his care with ADLs. 2. Record Review The resident's CNA Kardex report did not document anything about range of motion. The care plan (no date) identified risk for skin alteration related to resident refusal to do ROM. The goal was for the resident to have better functional mobility. The intervention was to encourage ROM during activities of daily living and use splints and hand rolls as ordered. 3. Interview The DON was interviewed on 3/5/19 at 3:38 p.m. The DON said the resident should receive ROM. She said the resident's hands were stiff and required ROM. She said the restorative was integrated into nursing care. She said she was concerned ROM was not happening and that she would perform education. C. Lack of wheelchair repositioning assistance The resident and his medical power of attorney were interviewed on 2/27/19 at 6:15 p.m. The resident said he chose to go to bed at 2:00 p.m. daily. The resident said he got up usually at 9:00 a.m. The resident said once he was up in his wheelchair, he was not repositioned and was not offered to be repositioned. 1. Record review The (MONTH) 2019 CPO documented an order to reposition frequently every shift as resident allows, and document resident refusals. The care plan with no date identified the resident was at risk for skin integrity related to limited mobility and incontinence. The interventions were to encourage to reposition as needed, use assistive devices as needed. 2. Observations The resident was up in his wheelchair from 9:20 a.m. to 4:45 p.m., without being offloaded for nearly eight hours. On 3/4/19 at 9:20 a.m., the resident was observed to be assisted out of bed by CNA #17 and CNA #7. The resident was assisted out of bed utilizing a full mechanical lift. On 3/4/19 at approximately 4:45 p.m., the resident was observed to be assisted to bed by CNA #12 and CNA #7. The resident was assisted into bed utilizing a full mechanical lift. 3. Interviews CNA #17 was interviewed on 3/4/19 at 10:00 a.m. The CNA said once the resident was up, he stayed up in his wheelchair until he went back to bed around 2:00 p.m. The CNA said this was his daily routine. The DON was interviewed on 3/5/19 at 3:38 p.m. The DON said the resident should be asked if he would like to go back to bed or to be re-positioned as he was at risk for skin breakdown and pressure injury. IV. Resident #75 A. Resident status Resident #75, age 72, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 1/28/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She had no mood or behavior symptoms. She required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. She received no restorative therapy. She had functional limitations in range of motion with impairment on one side of her upper and lower extremity. She used a wheelchair for mobility. B. Record review The (MONTH) 2019 CPO included an order for [REDACTED]. Review of the resident's care kardex revealed she used an electric or manual wheelchair to move about the facility. She was to have passive range of motion (PROM) to her right hand before applying the splint and upon removal of the splint. The care plan initiated 2/20/19 revealed the resident was at risk for further contracture to her right hand/wrist due to a history of right hand contracture and disease process with interventions to perform PROM and encourage participation, apply splint to her right hand/wrist per order. -She had an inability to independently mobilize related to [MEDICAL CONDITION] requiring a powered wheelchair assessment with interventions to have occupational therapy (OT) assess for fitting and/or training. -She was at risk for complications due to musculoskeletal problems related to [DIAGNOSES REDACTED] of her right hand with interventions to provide orthosis to right hand. Review of the (MONTH) 2019 electronic treatment record (ETAR) revealed 19 documentations that the right hand orthosis was not applied. Review of the nursing progress notes from 2/13/19 through 3/5/19 revealed 21 documentations that the splint for her right hand could not be found, was unavailable, and that staff would keep looking for it. -The 2/19/19 9:33 p.m. nursing progress note indicated the director of nursing had been notified the splint was missing. -The 2/25/19 10:49 p.m. nursing progress note indicated the unit manager (UM) had been notified of the splint missing. -The 2/27/19 4:53 a.m. nursing progress note indicated the splint was missing and there would be a follow up with therapy in the morning. Review of the 2/13/18 therapy discharge communication form and the 3/7/18 occupational therapy (OT) discharge summary revealed instructions to the nursing staff for the maintenance program, including positioning maneuvers and splinting/orthotic schedule to facilitate improved functional abilities. Apply splint to right upper extremity for a maximum of eight hours within a 24 hour period. The form also included picture diagrams of PROM for a [DIAGNOSES REDACTED] arm with instructions to complete on the resident's upper extremities. The sign-in training sheet included 13 staff signatures. Review of the 12/19/18 OT evaluation and plan of treatment form revealed the resident was referred to OT to assess for a power wheelchair to improve quality of life through increased mobility. The assessment concluded the resident had impaired right and left upper extremity range of motion and impaired trunk strength. She would benefit from a powered wheelchair to achieve functional ability and quality of life. C. Observations On 2/28/19 at 1:00 p.m., Resident #75 was observed on the second floor, in the common area, seated in her wheelchair to the side of a computer desk. She was attempting to use the computer mouse with her left hand. She was leaning to the left with her left arm resting on the desk. On 3/4/19 at 9:15 a.m., the resident was being transported from the dining room to her room in her wheelchair; she was leaning far to the left. There was a pillow between her side and the wheelchair arm. - At 9:54 a.m., the resident was seen sitting in her room in front of the television leaning far to the left with her arm hanging toward the floor. She said therapy had not offered or provided her with anything to help keep her straight in the chair. She did not have the call light near her. She could not maneuver the wheelchair on her own. Certified nurse aide (CNA) #6 was alerted the resident needed help. - At 10:43 a.m., the resident was sitting in her room, leaning far to the left with her arm dangling toward the floor, and had slid down in the wheelchair. Her roommate turned the call light on for her to alert staff she needed help. On 3/5/19 at11:20 a.m., the resident was seen sitting in the dining room, beside a table in her wheelchair; she was leaning far to the left. D. Resident and staff interviews Resident #75 was interviewed on 3/5/19 at 2:42 p.m. She said staff did not provide any range of motion (ROM) exercises for her. She said she was supposed to have a splint on her right hand but it had been missing for several weeks. She said the staff knew it was missing but it had not been replaced. The director of rehab (DR) was interviewed on 3/5/19 at 3:40 p.m. She said she had done several evaluations on the resident for positioning and the need for a splint on her right hand. She said the resident used to have a motorized wheelchair and the facility had been working on getting her another one. She said she was unaware that the resident was leaning to the left or that her splint had been missing. She said she was not notified the splint was missing. Licensed practical nurse (LPN) #6 was interviewed on 3/5/19 at 4:53 p.m. She said the splint for the resident's right hand had been missing for at least a couple weeks and the unit manager and the director of nursing (DON) were aware. V. Resident #105 A. Resident status Resident #105, above age 60, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 2/18/19 MDS assessment revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, transfers, and dressing. She required extensive assistance of one staff member with eating and personal hygiene. She was always incontinent of bowel and bladder. She was positive for one fall. She was positive for functional limitation in range of motion with impairment on both sides of her upper and lower extremities. She used a wheelchair for mobility B. Record review The (MONTH) 2019 CPO included orders to place pillows under both arms for protection at all times while up in wheelchair. Cleanse bilateral hands with soap and water every shift when removing palm guards/protectors and assessing skin. Review of the resident activities of daily living (ADL) care kardex revealed the section for ADL/Restorative Care included to remove palm protectors/guards and wash hands every shift with soap and water. The Special Needs section included bilateral palm protectors/guards. Review of the undated care plan revealed Resident #105 had an alteration in musculoskeletal status related to contractures with interventions to assist the resident to change position frequently and to educate caregivers on joint conservation techniques, bilateral palm protectors/guards as ordered, monitor skin integrity every shift, remove palm protectors/guards and wash hands every shift with soap and water. Review of the (MONTH) 2019 ETAR revealed 63 documentations that folded washcloths were placed in bilateral hands, the palm guards/protectors were on at all times, removed every shift, and the skin assessed. There were 74 documentations there was a pillow under both arms for protection at all times while up in wheelchair. Review of the January, February, and (MONTH) 2019 nursing progress notes revealed no documentation that the palm protectors and the splints were not applied or that the resident refused application of these devices. Review of the 5/27/18 OT discharge communication form revealed the resident was to continue PROM to her upper extremities during ADLs and to have a pillow between her knees when she was up in a wheelchair. Training was provided to eight staff members. Review of the 5/27/18 OT discharge summary revealed the resident was to sit upright in a chair with use of adaptive equipment to facilitate correct anatomical alignment for four hours using positioning devices. She was to safely wear a palmar guard on her left and right hands for up to eight hours and to wear a resting hand splint on her right hand for up to six hours when she was able to tolerate the palm guard and PROM. C. Observations On 2/27/19 at 12:12 p.m. Resident #105 was observed in a geri chair with her legs hanging over the sides with constant movement of her arms, legs, and head. There were no pillows under her arms and no palm protectors or splints on her hands. On 2/28/19 at 12:01 p.m., the resident was seen in the activity room on the 300 hall in a geri chair, dozing. She had slid down in the chair with her right leg off the chair near the floor. Her left leg was extended over the end of the foot rest with the back of her ankle resting on the raised end of the foot rest. She did not have a pillow under her head or under her arms. She did not have palm protectors or splints on her hands. On 3/4/19 at 8:47 a.m., the resident was sitting in the dining room in a different wheelchair. She did not have her feet on the footrests. She was flailing her arms around and sliding out of the chair. An unknown CNA entered the dining room, approached the resident and exited the dining room with her. She transported the resident to her room and assisted her to lie flat in her bed. The resident did not have palm protectors or splints on her hands. - At 8:57 a.m., the resident was sitting up in her bed with her legs over the side of the bed. CNA #7 entered the room and was overheard speaking to an unknown CNA and said the other geri chair she had was when she was on hospice but she is not on hospice now so they took the chair away. LPN #5 said she would contact therapy to evaluate her for a different chair. The two CNAs readjusted her in the bed, covered her up, raised the head of the bed, and exited the room. - At 12:05 p.m., staff transported the resident to the dining room in her wheelchair. Her legs were straight out and were not resting on the foot rests. She had slid down in the chair and was not sitting up straight. She did not have palm protectors or splints on her hands. On 3/5/19 at 10:29 a.m., the resident was in the activity room in her wheelchair seated at a table. The back of the wheelchair was reclined, the foot rests of the wheelchair were up but her feet were not on the foot rests. Her right leg was hanging off the right side. She would repeatedly raise herself up toward the table. She did not have a pillow behind her head or under her arms and she was not wearing palm protectors or splints on her hands. D. Staff Interviews Hospitality aide (HA) #1 was interviewed on 3/5/19 at 11:00 a.m. She said ROM for the residents did not get done by the CNAs because there was not enough time because they did not have enough staff. She said, Even if it was marked as done on the task section of the resident's chart, it did not mean it was done. LPN #3 was interviewed on 3/5/19 at 11:07 a.m. She said the staff was responsible for doing the ROM exercises for a resident that did not have therapy for ROM. Those exercises included moving their arms, hands, fingers, legs, feet, and head. She said the CNAs were to do the exercises when they were assisting residents with dressing. She said Resident #105 was supposed to have a rolled up washcloth in her hands for the contractures but she often did not have them in place. The DR was interviewed on 3/5/19 at 3:39 p.m. She said, As far as I know, (Resident #105) was using a chair provided by her hospice company. She had not been notified the resident needed a different wheelchair and was unaware of what wheelchair the resident was using now. CNA #12 was interviewed on 3/5/19 at 5:09 p.m. She said they were unable to get anything between the resident's contracted fingers/hands so they don't try anymore. The nursing home administrator was interviewed on 3/6/19 at 10:05 a.m. He said the facility did not have a restorative program even though they had policies and procedures for a program, and there was no plan to create a restorative program. He said it had not been identified as a problem. He said the CNAs had been informed they were to do ROM for the residents and they would re-educate the CNAs on doing ROM. VI. Resident #51 A. Resident status Resident #51, age 81, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The annual MDS dated [DATE] documented a severe cognitive impairment with a BIMS score of four out of 15. She required supervision to walk with encouragement and cuing. She was not steady and able to stabilize without human assistance while moving from a seated to standing position, walking with assistive device (walker), and turning around and facing the opposite direction while walking. The quarterly MDS assessment dated [DATE] documented severe cognitive impairment with a BIMS score of two out of 15, a decrease of two points in three months. Her need for staff assistance while walking had increased. The assessment documented the resident was highly involved in the activity and required staff to provide guided maneuvering of limbs and other non weight bearing assistance. She was not steady and only able to stabilize with human assistance while moving from a seated to standing position, walking with assistive device (walker), and turning around and facing the opposite direction while walking. The MDS assessment dated [DATE] was completed 3/5/19. The MDS documented severe cognitive impairment with a BIMS score of two out of 15. She required extensive assistance for bed mobility, toileting and personal hygiene and dressing; limited assistance with transfers, limited assistance to walk, and supervision for eating. Hospice services began 2/14/19. B. Observations Resident #51 was observed from 2/27/19 to 03/4/19. The observations revealed the resident was not supervised or provided assistance to walk. -At 12:55 p.m. she was observed in the activity room seated in her wheelchair. She sat on a bolster cushion to prevent her from falling from her wheelchair. She was observed to push the bolster in an attempt to remove it. She attempted to stand from the wheelchair but was unable to due to the bolster cushion. While she pushed the bolster again she stated, I can't get it. The staff were in the dining room and were alerted she wanted to go somewhere. The staff pushed her in her wheelchair down the hall and into her room. The staff did not provide the resident an opportunity to walk. -On 2/28/19 at 8:54 a.m. she was observed in the activity room watching an old movie. She was seated upright and attempting to stand from the wheelchair. -At 4:55 p.m. The resident was observed seated in her wheelchair at her dining room table. She faced the wall and her back was to the dining room and other tables. She scooted backward from her table with her feet. Her shoes slipped on the linoleum and she moved approximately two feet from the table. She stood from her wheelchair, unsteadily turned around and began to push the wheelchair towards the table behind her. CNA #5 was alerted. He sat her back into her wheelchair and pushed her a few feet to the table behind her. The staff did not give her an opportunity to walk. -At 9:09 a.m. she was observed to scoot the wheelchair with her feet but her shoes were observed to slip on the carpet, only moving her a few inches. During the survey, the resident was not observed using her walker to walk with one staff assistance in order to prevent loss of functioning. C. Record review 1. Care plan The resident's care plan, initiated 12/6/16 and last revised on 2/22/19, documented she(TRUNCATED)

Based on interview and record review, the facility failed to ensure a safe transfer of one (#3) of three residents reviewed for transfers. Specifically, the facility failed to ensure Resident #3 received a timely and an appropriate level of transportation to the hospital. The resident waited for several hours for transfer, during which time he demonstrated a decrease in his ability to communicate and additional lethargy. The resident was transferred via non-emergent, non-medical transport, during which time he further decompensated; he was found unconscious and non-responsive by hospital personnel outside at the ambulance bay. Following the incident, the facility initiated a performance improvement plan (PIP) to address the concerns. The facility had fully implemented corrective action prior to the onsite investigation. The deficiency is cited as past non-compliance. Findings include: I. Transportation Contract A review of the facility ' s contract with its non-emergent transportation service provider, dated 5/26/17, revealed in pertinent part, that the facility assumed administrative responsibility for ensuring that services provided met professional standards, and the service provider was responsible for ensuring that staff had appropriate training. The contract did not specify the professional qualifications of the transport personnel or type of medical training, if any, of the personnel conducting the transport. The nursing home administrator (NHA) was interviewed on 5/23/18 at 1:30 p.m. He said the contract had been signed by the previous NHA, and he was not certain what qualifications or medical training, if any, were held by transport personnel employed by the non-emergent transportation service provider. II. Resident #3 A. Resident status Resident #3, age 60, was admitted to the facility on [DATE]. According to the 3/18/18 physician orders, [DIAGNOSES REDACTED]. The 3/13/18 minimum data set (MDS) assessment revealed the resident displayed severe cognitive impairment with a brief interview for mental status (BIMS) of 7 of 15. He did not display any signs of [MEDICAL CONDITION]. Licensed practical nurse (LPN) #1 was interviewed on 5/23/18 at 2:50 p.m. She said she had worked with the resident during his stay at the facility. She said the resident was confused and did not understand he was in a nursing home. However, she said he was able to communicate his needs and was alert. The director of nurses (DON) was interviewed on 5/23/18 at 1:20 p.m. She said on 3/15/18 (date of the resident's hospital transfer - see below), she had been at the facility only a few weeks. She said the resident had been in the facility for a rehabilitation stay after hospitalization . She said he had [MEDICAL CONDITION] of the liver and had presented on admission with severe jaundice (a yellow discoloration of the skin caused by a buildup of bilirubin from liver failure) and ascites. She also described the resident as being alert and able to advocate for his needs, although he was somewhat disoriented. B. Decline and Hospital Transfer Record review and interview revealed the resident's condition worsened on 3/15/18. Although observed by the nurse practitioner (NP) mid-morning with instruction to send the resident to the hospital for testing and treatment, the resident was not transported until after 2:00 p.m. by a non-emergent, non-medical transport service. 1. Record review A physician note dated 3/15/18 at 9:52 a.m. indicated the resident was seen that morning for worsening ascites from [MEDICAL CONDITION] of the liver. The note revealed the resident had not been eating, but at the time of the visit, he had normal speech and affect. The note revealed the resident was to be sent to the emergency department for testing and treatment. A nursing note dated 3/15/18 at 2:28 p.m. indicated the resident had been noted with a change in speech and had not been able to communicate his needs. The note documented the resident's abdomen was distended and was larger than the day before, and the resident was not drinking or eating and had verbalized feeling sick. The physician had been notified and had ordered to send the resident to the emergency department for evaluation and treatment. The note read the DON had been notified and report had been called in to the emergency department. Although there was no transportation sheet documenting the resident's transfer from the facility, a transfer assessment, dated 3/15/18 at 2:28 p.m., documenting changes in the resident's condition (see nurses' note above) was signed by Licensed Practical Nurse (LPN) #1. The physician/nurse practitioner (NP) was not notified of these changes and the resident was not assessed by a registered nurse at the time of discharge (Cross reference F657). 2. Interview LPN #1, during her interview on 5/23/18 at 2:50 p.m., said she had been the resident ' s cart (medication) nurse 3/15/18. She said when she did rounds that morning, the resident was more lethargic than usual and was weaker. She said his ascites (a fluid retention due to liver failure) was also worse, and that his abdomen was swollen. -She said she called the resident ' s physician and the NP came to assess him. She said the NP said he needed to go to the emergency department for some tests and potential paracentesis (the manual draining of fluid from the abdominal cavity). She said she asked the NP if it would be okay to use non-emergent transport, and told the NP it could take an hour or two. The NP said this would be okay. -She said the NP left the faciity on [DATE] at around 10 to 10:30 a.m and she contacted a non-emergent transport company the facility used to transport residents to doctors' appointments. She said she did not know if the transport service used medical personnel. She said she contacted this service because they had previously been helpful with last minute transportation. She said she called them for transport at approximately 11:00 a.m. -She said the transport company arrived at approximately 11:45 a.m., but told her they needed to make another trip before taking Resident #3. She said she had contacted them twice after that to see where they were, but they did not return to the facility until approximately 1:45 or 2:00 p.m. -She confirmed the resident's change in condition as documented in the nursing note above but said the resident had been awake when he left the building. The DON, during her interview on 5/23/18 at 1:20 p.m., said the morning of the transfer, the resident had presented with worsened ascites and the physician ' s office had been contacted to determine the appropriate course of treatment. She said the NP had given the order to send the resident to the emergency department for a computed tomography (CT) scan of his abdomen, and potentially for paracentesis. She said approval had been given to use a non-emergent transport, although she was not sure if the NP and physician were aware the transport service did not have paramedics on board. -The DON confirmed the nursing notes by LPN #1 at 2:28 p.m. (see above) indicated a change in the resident ' s communication and cognitive status and said she had not been made aware of this. She said she and the physician's office should have been notified of these changes. She also said the resident had sustained a fall the day before and was currently on monitoring for post-fall concerns. -The DON said the only time she had received a phone call about Resident #3 was when LPN #1 called her while with the NP to let her know the resident was going to be sent to the hospital. Then, much later in the day, she received a call from the facility staff letting her know the resident had been admitted to the intensive care unit and the hospital had called with concerns about the manner in which the resident had been transported to the hospital. The DON was interviewed a second time at 4:00 p.m. She stated a non-medical and non-emergent transportation service was not an appropriate choice to transport Resident #3 due to his clinical instability and additional change in condition. D. Resident status upon arrival at the hospital A caseworker from the hospital was interviewed on 5/22/18 at 4:17 p.m. She said the emergency department personnel had sent her an alert because they were concerned about the resident's condition on arrival on 3/15/18. She said he had arrived in a non-medical vehicle and had been left outside the hospital with no assistance. She said he had been unconscious and unresponsive on arrival with a obtunded abdomen and a low blood sugar. The hospital intake documentation, dated 3/15/18 at 2:58 p.m., revealed the resident arrived at the hospital in a non-medical transport. The resident was unconscious with severe ascites to his abdomen. His blood glucose was well below normal at 30 milligrams per decaliter (mg/dL) (normal range 70 to 100 mg/dL), he was hypotensive with a blood pressure was 59/47 millimeters of mercury (mmhg), his heart rate was 65 beats per minute, and his respiration rate was 15 respirations per minute. III. Facility correction A. Corrective Action for Resident #3 Corrective action was not possible for Resident #3. He did not return to the facility following the transfer. B. Identification of other residents The DON was interviewed on 5/23/18 at 1:20 p.m. She said after the incident, the facility had identified that any resident who went to the hospital could potentially be impacted by the practice of using non-emergent, non-medical transport. C. Systemic Changes 1. New non-emergent transportation service provider and staff training The DON and NHA were interviewed on 5/23/18 at 1:30 p.m. They said that following the incident, the facility had terminated its contract with the transportation service agency involved in Resident #3's transport, and had initiated contracts with two non-emergent ambulance services, both of which were staffed with emergency medical technicians (EMTs) or paramedics. A letter dated 3/16/18 confirmed the facility terminated its contract with the transportation service agency effective 4/16/18. The NHA said they had created updated contact lists at each nursing station identifying the transportation service providers the facility now uses. The NHA said the facility had conducted an all staff training on 3/16/18 about which transportation provider (non-emergent or emergent) to use in which situation. Staff were instructed to use the facility van for routine (non-emergent) appointments, and to use the ambulance services (emergent) for transportation to the hospital. The staff were instructed to document the transfer and the mode of transportation in the nursing notes. D. Monitoring The DON was interviewed on 5/23/18 at 4:00 p.m. She said the facility reviewed each transfer to the hospital (if applicable) on a daily basis during morning meeting. She said there had been no additional transfers to the hospital without a trained EMT or paramedic. The DON was interviewed on 6/1/18 at 2:41 p.m. She said the unit managers had been assigned to review the documentation for each transfer to the hospital and to communicate with her if a note did not indicate that an ambulance was used. She said that although the termination of the transportation contract with the transportation service provider was not effective until 4/16/18, the management team had monitored transfers on a daily basis to ensure documentation was in place regarding the use of an ambulance. She said that following 4/16/18, the facility no longer had any transportation contracts that were not ambulances; however, the management team would continue to monitor transfers as a part of their standing quality assurance efforts. E. Interviews and observations confirming facility correction Interviews and observations conducted on 4/17/18 and 5/23/18 confirmed staff had received training on transportation to the hospital during a change in condition, knew to contact an ambulance or to call 911, and had access to a list of providers used for transportation that included only transportation providers staffed with EMTs or paramedics. 1. Interviews LPN #2 was interviewed on 4/17/18 at 10:50 a.m. She said if she received orders to send a resident to the hospital for evaluation and treatment, she would contact the hospital to let them know the resident was coming and to give a report about the situation. She said for transportation, she would use one of the ambulances with whom the facility had a contract, or would call 911. She said she would tell the ambulance provider what the resident needed for support so they would be prepared. She said she would call the hospital a few minutes later to see if the resident had arrived and again after a few hours to see how they were doing. Registered nurse (RN) #1 was interviewed on 4/17/18 at 11:02 a.m. He said if the resident needed to go to a hospital, he called the hospital to notify them of the situation, and sent paperwork with them. He said the transportation to the hospital always required paramedics. He said if the resident required immediate support, they called 911. If not, they had a list of two other ambulance companies that they could use. He said the staff communicated the resident's medical status to the ambulance provider too, so they were aware what care and support would be needed during the transfer. RN #2 was interviewed on 5/23/18 at 10:59 a.m. She said when a resident needed to be sent to the hospital, the facility had a list of ambulances to use. She said the two ambulances were for non-emergent transport, but that they would give the facility an estimated arrival time, and had paramedics on board in case the resident required medical assistance on the way to the hospital. She said for more emergent cases, the staff had been instructed to call 911. LPN #3 was interviewed on 5/23/18 at 12:56 p.m. He said if a resident was being sent to the hospital, the facility had a list of providers that could be used for transport. He said all of them were ambulances with paramedics or EMTs on board. He said the ambulances would give them an estimated time of arrival, and the staff were to stay with the resident to continue to monitor their status while they were waiting. The LPN said if the resident had a situation, such as a stroke, that required immediate attention, the staff would not use one of the ambulance providers from the list, but would instead call 911. RN #3 was interviewed on 5/23/18 at 12:56 p.m. She said if a resident needed to be sent to the hospital, the level of transportation needed was based on the resident ' s condition. She said if the resident had an urgent need, such as oxygen desaturation, abnormal neurological checks, a fracture, or uncontrolled bleeding, the facility called 911. If not, the facility had a list of ambulance services that they could use for transport. She said if there was a long estimated time of arrival, she called 911. She said she or another nurse would stay with the resident until the ambulance arrived to monitor their condition, and if there were a change prior to the transport, she would also call 911. LPN #4 was interviewed on 5/23/18 at 2:38 p.m. He said if he needed to send a resident to the hospital, he would use 911 if the resident required urgent care, or if they deteriorated while he was waiting for one of the non-emergent ambulances. He said if the resident did not require urgent support, he would contact one of the ambulances from the list of transportation providers. 2. Observations The nursing station on the rehab hall was observed on 4/17/18 at 11:02. A list of transportation options was taped to the desk. It listed two ambulance providers, along with their phone numbers. Neither agency was the non-emergent and non-medical provider that had been used for Resident #3 ' s transfer. The nursing station on one of two long term care stations was observed on 5/23/18 at 10:59 a.m. A list of transportation options was present at the desk. It listed two ambulance providers along with their phone numbers to use when transferring a resident to the hospital. Neither agency was the non-emergent and non-medical provider that had been used for Resident #3 ' s transfer. The nursing station for the second of two long term care halls was observed on 5/23/18 at 12:56 p.m. A list of transportation options was present at the desk. It listed two ambulance providers along with their phone numbers to use when transferring a resident to the hospital. Neither agency was the non-emergent and non-medical provider that had been used for Resident #3 ' s transfer.

Based on interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that residents, including two of four sample residents (#1, #2, #3 and #4), received adequate supervision and assistive devices to prevent accidents. Specifically: --Resident #1 who had a [DIAGNOSES REDACTED]. According to the nurses notes documented yelling and cursing at residents and staff. The facility failed to implement measures to ensure resident #1's care was individualized and effective and her supervision adequate to protect the remaining 20+ residents on the secured unit, all of whom were elderly (average age 80), memory and cognitively impaired, and some of whom wandered the unit without direction. The facility's failure to keep resident safe created a situation of harm which resulted in resident #2 having a fracture to her hip and she untimely died during surgery. -Resident #3 resided on the secured unit, facility failed to implement interventions to keep resident #4 safe. The failure created a potential for harm to resident #4. Findings included: I. Resident #1 1. Resident #1, age 81 was admitted on [DATE]. According to the computerized physician orders [REDACTED]. a. Resident status: According to the ,[DATE] computerized physician orders [REDACTED]. --Zyprexa 2.5 mg one time a day with the psychological symptoms of dementia. After [DATE] the Zyprexa was increased to 5 mg one time a day. --Oxycodone HCI 10 mg one time a day for back pain at noon. --Venlafaxine HCI 187.5 mg once a day in the morning for depression. 2. [DATE] incident According to the progress note dated. [DATE] documented that on [DATE] at 2:30 p.m., resident #1 was involved with a resident to resident altercation with resident #2, age 95. Resident #1 pushed resident #2 against the restroom door causing resident #2 to fall. Resident #1 was redirected from other resident and incident site. Intervention used was a 1:1 caregiver for three days. The director of nurses (DON) was interviewed on [DATE] at approximately 4:00 p.m. The DON said that the resident #2 was confirmed with a fracture hip and had surgery, however, expired during surgery. Ultimately the resident #1 was discharged from the facility on [DATE]. 3. Failure to assess and manage resident #1 behavior The progress notes documented the resident had aggressive behavior both physical and verbal which dated back to ,[DATE]. --[DATE] progress note documented, IDT team reviewed [DATE] incident involving res (resident) and another Res. Res was wanted to speak to a female Res who was speaking to someone else at the RN station and was not able to give attention to Res. This Res slapped the other resident in the face. Res had no apparent injuries noted at this time of incident. The RN on duty attempted to separate the two residents and the resident hit the RN in the stomach .Res transferred to (name of hospital) ED (emergency department) . --[DATE] documented the resident was getting ready to give other residents coffee and CAN stopped resident, however resident started cursing, calling names, yelling, swinging arms but did not hit anybody, this behavior was disturbing to other resident in the dining room, talked to resident, redirected resident to her table --[DATE] documented, .Patient used inappropriate language to staff and resident.redirected patient, and put patient in chair . --[DATE] documented, .Patient yelling at staff, not cooperative with care. Patient not-re-directable. After several attempts patient calmed down . --[DATE] documented, Resident came to nurses station in anger rage, yelling cursing, states, I want my room back, I'm gonna kill somebody. I want her out of my room now, I cannot have a roommate, talked with resident regarding her roommate, redirected resident to her room, offered back rub but resident refused, snacks and fluids offered but resident refused. Resident swing her arms to hit, leave resident to calm down, re-approached after 5 minutes but resident still aggressive. Olanzapine (Zyprexa) 2.5 mg given . [DATE] documented, Resident became verbally aggressive X1 when her roommate kept irritating her, but she was easily redirected and finally was accepting her to sleeping in her room. [DATE] documented, Resident started evening shift pacing halls, saying she is wanting to go across the street to the dr's office and if we did not allow her she was going to start some trouble, tried 1:1 with resident and she was so aggressive and angry that she hit this writer in right shoulder, this writer jumped back and did not get the full impact of hit. Resident kept saying she needed to get some medicine for her back when this writer offered her icy hot and a pain med, pt. (patient) refused and said she did not have pain .water accepted, but continued to be aggressive and verbally abusive, threw a bedside table down . [DATE] documented, Patient had behaviors today yelling and saying inappropriate language to residents and staff. Patient was challenging to redirect [DATE] documented, Patient has expressed verbal aggression. Patient yelled, cursed, having trouble finding room and with negative attitude entire shift .staff tried to redirect patient and were unsuccessful . [DATE] documented, resident started evening shift upset, with verbal aggression towards staff and other residents. [DATE] care plan progress note documented, staff monitors res (resident) for verbal and physical aggression and attempt to calm and redirect Res as soon as symptoms are noted. [DATE] documented, Late entry for [DATE] Res became verbally aggressive on ,[DATE]=10 shift . [DATE] documented, .around 8 pm started yelling at another resident for no reason, he was in his own room, was able to re-direct pt (patient) with 1:1, food/drink which she accepted [DATE] documented, late entry for [DATE] Resident observed by this AUD (secured unit director) screaming and swinging her arms at caregivers and other Res stating, I'm trying to get out of here because nobody gives a heck about me. Staff unable to redirect res . [DATE] documented, noted verbal/physical behavior, hitting the staff and pull out clothes from Roommate's closet. Took off name box at the wall then claimed that's mine. Talking with her, distracted her then calm down hanging around with other resident's in the d/r (dining room) . [DATE] documented, .Behaviors throughout shift including yelling at staff and other residents . The facility was aware that the resident #1 had altercations with other residents. The progress notes documented the following: 4. physician progress notes [REDACTED].>The resident was originally seen by the geropsych physician on [DATE]. The resident had a primary [DIAGNOSES REDACTED]. The resident had been prescribed amitriptyline, for many years, although the risks of continuing this medication were more dangerous. She was prescribed citalopram 10 mg one time a day for depression with a start date of [DATE]. The director of nurses (DON) was interviewed on [DATE] at approximately 2:00 p.m. The DON said that the resident was not seen by the psychiatrist since [DATE], it was only a chart review. [DATE] documented the resident continued to have behaviors, usually in the morning. The note further documented the behaviors could be exacerbated by inadequate pain control. Staff reported improved behavior and pain control with icy hot and massage. [DATE] documented caregiver/nursing staff reports aggressive, difficult to redirect, does not participate in activities. [DATE] documented in the progress note the notifications which the physician received from the provider. [DATE] resident's behavior noted to be better with pain control. Per staff resident can still get in your face but not as aggressive as used to be. [DATE] geropysch signed off as resident was improved. [DATE] facility psychopharm meeting recommended to taper Effexor dose from 225 to 150 due to resident being stable. [DATE] phone call from facility that resident had knocked over plexiglass vase and got a skin tear. [DATE] phone call received that resident was screaming at others in the late afternoon. Had been using her as needed oxycodone every day. She calmed down with a back rub. Increased afternoon oxycodone to better control her pain. [DATE] phone call from the facility that resident had pushed another resident down causing the other resident to break her hip. When ambulance came to get the other resident, the resident asked what's wrong with her? Zyprexa was increased from 2.5 mg every morning to 5 mg every am to 5 am. Referred to geropsych, the resident was given a 1:1 sitter to ensure safety to other residents. The resident seemed to have a shorter fuse then in the past per staff. 5. Investigation after the [DATE] incident The investigation was immediately implemented. According to the eye witness statement dated [DATE] certified nurse aide (CNA) #1 documented, While I was charting I saw (name of resident #1) slapping in her face also yelling at her. At the same time she push her to the ground in front of the bathroom door. The statement further documented that the resident most of the time angry, yelling at everybody mainly in the evening . SW investigation statement dated [DATE], documented the resident has had escalating behaviors anger at others. 6. Interviews about the incident a. The licensed practical nurse #1 was interviewed on [DATE] at approximately 3:00 p.m. The LPN said that he was on duty when the incident (see above) occurred. He said that he was in the medication room, and he heard some yelling, when he came running out of the room, he saw that resident #2 was on the floor and one of the certified nurse aides (CNA) was leaning over her. The resident was crying and was in distress and pain. She was unable to lay flat and he knew that she had probably broke her hip. The resident was then assessed and treated. The LPN said that when he started the investigation he was informed that resident #1 had pushed resident #2 and she then fell to the ground. The resident #1 was then asking staff what had happened. The LPN said that resident #1 had dementia and that she was on oxycodone four times a day for pain. He said that the resident was not hostile per say, but she was angry with herself and was an attention seeker. He said that she was not physical to his knowledge other than that day, but that she would become angry to other residents and would yell at the other residents. When her behavior escalated then they would redirect her to an activity or to food. After the incident she had a one to one sitter, however, that was the first time that intervention was used. The resident complained about back pain and back rubs and icy hot would help. He said that the staff were all aware that they had to keep an eye on her She was sparatic with her behavior. b. CNA #1 was interviewed on [DATE] at 3:15 p.m. The CNA said he worked on the secured unit on a regular basis. He said that he was standing in the hallway completing some charting on the computer. He saw resident #1 standing in front of the bathroom in the hallway. Resident #2 was walking from the nurses' station and walked toward resident #1. The two residents were observed to be talking and then resident #1 hit resident #2 in the face, then pushed her on the shoulder. Resident #2 took a step backwards and then fell to the ground. Resident #1 was observed to walk away and then began to ask what happened. The resident #2 was then assessed by the nurses. The CNA said that resident #1 had memory issues and that some days she was moody and other days no problem. The CNA said that she had a mood disease and that she would become angry. She would yell at other residents sometimes. He said he had not seen her be aggressive physically toward another resident, however she did yell at other residents. c. The social worker (SW) for the secured unit was interviewed on [DATE] at approximately 4:00 p.m. The SW said that resident #1 had a long psychiatric history with major depression. She resided in a mental hospital for a short time as a younger adult. The resident had been prescribed an anti-psychotic medication shortly after she was admitted to the facility in 2014, she was saying things to residents that were not nice and she was transferred to the secured unit. The SW said that the resident would attention seek and she would make comments that she could not breath, and her behavior would begin to escalate. She said that the resident would yell to noone in particular, and would get angry. She was short tempered. She said that she had not observed her swing at other residents, however, had heard from other staff that the resident took swings at other residents. The SW stated that the resident was unpredictable. The SW said that the staff were aware that when she began to speak in a high pitched voice that she was becoming angry. The resident was reviewed in the psychoactive committee and her medications were changed often in order to find the right medication. The family requested amitriptyline, as that was the medication she was on in the mental hospital, however her physician did not feel that it was a good drug for her. The resident was monitored for outbursts and re-direction, or food was used for interventions. d. The director of nurses (DON) was interviewed on [DATE] at approximately 2:00 p.m. The DON said that the resident resided on the secured unit. She said that she was aware the resident cursed and yelled, she was not aware that she had this behavior almost daily. She said that the staff had not reported to her, and it had not always been documented. 7. Failures: a. Although the care plan identified the resident had behaviors, the facility failed to update or initiate any new approaches, or approaches such as back rubs, which staff said they used (see above). The care plan was as follows. The care plan dated [DATE] identified the resident had verbal, physical, agitation, aggression, including negative statement and physical aggression towards other residents related to cognitive impairment. The goal was for the resident to not harm self or others. Approaches included, allow resident time to respond to directions or requests, approach slowly and slightly to the side, evaluate for pain and administer analgesia per order, and gain resident's attention before speaking or touching. The SW was interviewed on [DATE] at approximately 4:00 p.m. The SW reviewed the care plan of resident #1. The SW said that she thought the care plan was adequate. The DON was interviewed on [DATE] at 5:10 p.m. The DON reviewed the care plan and recognized that the care plan was not customized for the resident's behavior and approaches. b. The medical record failed to show that the verbal and physical outbursts toward other residents were investigated. The DON was interviewed on [DATE] at approximately 2:00 p.m. The DON said that they did not complete investigations on verbal aggression or yelling. c. Though the investigation for the [DATE] incident, the facility found that nursing staff, both CNA and licensed nurses and the SW were aware the resident had both verbal and physical aggression toward other residents, however, failed to follow up and investigate the aggression so as new interventions could be tried. The social service director (SSD) was interviewed on [DATE] at 11:37 a.m. The SSD said that she oversaw the social service department. She said that the SW on the unit also was the coordinator of the secured unit. She said that she rounded the unit one time a week, and would hear about the resident's escalating behavior. She said that the SW should document progress notes on the resident's behavior and interventions used. The DON was interviewed on [DATE] at approximately 2:00 p.m. The DON said that prior to the investigation on the [DATE] she was aware that the resident had behaviors, as it was discussed in the Eagle room (meeting to discuss specific issues revolving around residents). However, she was not aware or the registered nurse unit manager were not aware of how often the resident was having these aggressive behaviors. The DON said that the staff were provided education on how to report abuse, and working with individuals with Alzheimer's. D. The facility failed to have a mechanism to track and trend the behaviors in order to assess accurately the reason for the aggression, time of day for the aggression and what interventions which were successful. The order summary report identified alert charting for verbal aggression and swinging her arms was initiated every shift for behavior for seven days and document non-pharmacological interventions. It had a start date on [DATE] and end date of [DATE]. The same order was requested on [DATE] to [DATE]. The order was not continued or requested from [DATE] to [DATE]. The DON was interviewed on [DATE] at approximately 2:00 p.m. The DON said the CNA care tracker was not set up to have behavior tracking to have comment section. It was a Kardex of what care the resident required, which included, whether the resident had behaviors. She said that recently after the [DATE] incident the information technology department fixed it so that the CNAs could now document specific behaviors The DON said that they had not put a time line together or any mechanism in order to evaluate and assess all the verbal and physical aggression behaviors which the resident was exhibiting. II. Resident #3 1. Resident #3, age 85, was admitted on [DATE]. According to the ,[DATE] CPO [DIAGNOSES REDACTED]. According to the admission screen dated [DATE] documented the resident used a walker for ambulation. He had altered mental status. 2. Resident to Resident altercation: [DATE] at 2:40 p.m., per activities person, (name of activity) she was at the table in dining room and rsd (resident) was with her, he walked she looked over to see where he was going and resident #3 quickly walked directly to other male rsd and verbal statements were exchanged and he shoved other male rsd with 1 hand on pt's (patient) shoulder/arm, other male rsd took 2 steps back from shove and activities person ran over to separate them., other rsd just walked away . 3. Failure to assess and manage resident #3 behavior The progress notes documented the resident had aggressive behavior toward resident #4 prior to the incident on [DATE]. [DATE] documented, resident noted bothering, annoying other pt., staff redirected with 1:1 . [DATE] documented, resident at beginning of shift was noted bothering another resident in room (resident #4's room). No physical touch, but verbal aggression noted was able to redirect with 1:1, pt. (patient) was escorted out of room and shown in room .pt (patient) mumbled aggressively and cursed to this writer [DATE] documented, Resident was verbally aggressive to another male resident. CNA and activities assistant redirected resident . [DATE] documented, Resident monitored for aggression, bothering other residents . The care plan initiated on [DATE] identified the resident had verbal/physical aggression directed toward specific male resident (uses foul language, rolls eyes, holds fist up, verbally threatens when other resident is present) related to cognitive impairment. The goal was, Will not harm self or others. Approaches included, allow resident time to respond to directions, if strategies are not working, leave and re-approach, and provide diversional activity. Interviews: The activity assistant (AA) was interviewed on [DATE] at 10:57 a.m. The AA said she was assigned to the secured unit. She witnessed the altercation, between resident #3 and resident #4. She said that she was in the activity room at the table. Resident #3 was organizing items, and resident #4 was walking down the hallway and looked over, and resident #3 made a B line to resident and pushed his shoulder and the resident #4 took a step backwards. The AA said that she knew that the two needed to be separated. She said they always had a verbal exchange, and an angry tone. She informed the nurse when any incidents happened. The Activity Director (AD) was interviewed on [DATE] at 10:46 a.m. The AD said that resident #3 was aggressive verbally, mainly to another resident. She confirmed it was resident #4. He would raise his hand and say get the hell out of the way to resident #4. She witnessed it a few times, and re-directed the resident. She said when incidents happen it needed to be documented, she stated that they needed to keep the two residents apart. The DON was interviewed on [DATE] at approximately 2:00 p.m. The DON said that after the incident on [DATE] a 1:1 sitter was assigned, and the resident was going to be discharged to another facility.

Based on observation, record review, resident and staff interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well being of one (#48) of three sampled residents out of 16 residents who were interviewed about pain and for one (#16) out of seven residents reviewed for skin issues out of 35 sample residents. -Resident #48's pain was not adequately managed, contributing to the resident experiencing unrelieved shoulder pain at a level above her acceptable level of pain. -The plan of care was not followed for resident #16 to prevent skin breakdown and contracture. The findings include: I. Unmanaged Pain The facility's policy titled PAIN PRACTICE GUIDE FLOWCHART provided by the facility nursing home administrator (NHA) on 5/4/15 at 3:35 p. m., included in pertinent part: Assess: pain scale, complete pain section on admission, complete MDS (minimum data set)/Pain CAA (care area assessment). Contact physician for orders. Initiate plan. Plan: Develop/revise initial or Interdisciplinary Care Plan as applicable. Implement: Evaluate patients for pain daily and document. Evaluate: Change in condition. Resident Status: Resident #48, age 72, was readmitted to the facility on [DATE] from an acute hospital with [DIAGNOSES REDACTED]. According to the quarterly minimum data set ((MDS) dated [DATE], the resident was alert, had adequate hearing and clear vision with glasses. The Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated the resident was cognitively intact. No behavior was exhibited. She had clear speech and was able to express her needs. Resident was able to understand others and there was no mood problem. The resident required moderate assistance with activities of daily living (ADLs). The resident had a pain issue and was coded for pain management. Resident Interviews: -On 4/27/15 at 4: 47 p. m., resident #48 was interviewed. The resident complained that her right shoulder was very painful. She rated her pain level at 8/10 (with 10 being the worst pain) and said she received as needed (PRN) pain medication ([MEDICATION NAME]) at 4:00 p.m., but the PRN medication doesn't give her any relief. She said she tried to get the nurse to call the doctor for her but nothing had been done. The resident said the pain medication they were giving was not helping at all. -On 4/29/15 at 11:44 a. m., the resident complained of right shoulder pain. She said that anytime she made an attempt to raise her shoulder, it hurt. - On 4/30/15 at 9:15 a. m., the resident was interviewed in her room. She stated her right shoulder hurt badly. During the interview, the resident was observed to be unhappy and she sound frustrated and angry. The resident said she was having dry needle therapy to reprogram nerves. She said her leg went out on her last week and she fell and hurt her right side. She said had a bruise on her right thigh and, although there was no bruise on her shoulder, her shoulder hurt. The resident stated she asked a nurse at the facility to contact the in house doctor and the in-house therapist for her, but the nurses did not call either professional. The resident stated she was told they would have to put her on a waiting list to see a doctor. The resident said her right shoulder hurt when she tried to use her fingers. She said on Tuesday (4/28/15) she was without her pain medication for more than 12 hours and did not receive pain medication until 5:00 a.m. the next day. She reported the nurse told her the pain medication had run out and was not available. (According to the nurses note dated 4/19/15, the resident fell at 12:15 a.m. The note documented the resident stated her legs gave way when she tried to get up to go to the bathroom. The resident fell on her bottom and did not call for help and got herself up.) Observations: At 3:50 p. m. on 4/29/15, resident was observed in the activity room using an impromptu sling (a yellow non-skid sock with the toe area cut out) to lift her right hand during the activity. The resident was observed sitting in the activity room listening to the activity director. -At 8:55 a.m. on 4/30/15, the resident was observed lifting her right shoulder with the same impromptu sling and said her right shoulder still hurt. She was observed holding a [MEDICATION NAME] and coloring with her right hand on the table, she was not lifting the right shoulder at all. Record Review: 1. Pain Management Plan -Review of Computerized Physician order [REDACTED]. - [MEDICATION NAME] HCl Tablet 10mg (milligram): Give 1 tablet by mouth every 6 (six) hours as needed (PRN) for breakthrough pain 1-5 AND give 2 (two) tablets by mouth every 6 hours PRN for breakthrough pain 6-10 AND give 2 (two) tablets by mouth every 4 (four) hours as ordered for pain. - Tylenol Tablet 325mg ([MEDICATION NAME]). Give 2 tablets by mouth every 6 hours PRN for fever greater than 100.3 not to exceed 3 grams in 24 hours from all sources. -[MEDICATION NAME] Tablet ER (extended release) 30mg: Give 30 mg by mouth three times a day for pain. - [MEDICATION NAME] 5 % (percent) ([MEDICATION NAME]): Apply to L (left) side of neck and L (left) hip topically two times a day for pain, on at HS (hour of sleep) for (12hrs) and off in am for (12hrs). -Bengay patch (menthol, topical [MEDICATION NAME]): Apply to neck/shoulder topically PRN for pain may have once a day. Leave on for up to eight hours. -Ice to the neck and upper back PRN every shift 10-20 min (minutes) each. -Dry needle therapy on 4/22/15 at 1:20 p.m., 4/28/15 at 11:40 a.m., and 5/6/15 at 1:00 p. m., for shoulder pain and joint region. 2. Care Plan The care plan (CP), dated 4/23/15, revealed the resident had pain-generalized as evidence by continued ache related to orthopedic decline. -The resident's goal was to express that pain management was within acceptable limits, identified as 4/10 (on a scale of 0-10) or less. -Approaches included in pertinent part: administer pain medication per physician order, implement non-drug therapies to assist with pain, monitor for effectiveness and notify physician if pain frequency/intensity was worsening or if current [MEDICATION NAME] regimen has become ineffective. 3. Pain Assessment -Pain Assessment last reviewed on 3/21/15 revealed the resident experienced pain in her neck and lower back. The resident pain was rated as 4/10 and, at worst, 5/10. The resident described visceral pain as hurting all over and neuropathic pain as the sensation of pins/needles. Relieving factors included medications. The assessment also revealed the resident's pain affected her participation in activities. 4. Change of Condition -The pain evaluation sheet was reviewed and revealed the resident was experiencing an increase in her level of pain since the pain assessment 3/21/15. The pain evaluation sheet, which documented the resident's pain level each shift, revealed documentation between 4/1/15 and 4/29/15 of pain levels 88 times at 7/10, 8/10 and on 4/22/15 10/10, all above the resident's acceptable level of 4/10 (and at worst 5/10). -The eMAR (electronic medication administration record) dated April 2015 also revealed the resident's pain level was increasing. According to the eMAR from 4/2/15 to 4/29/15, the resident experienced pain level 10/10 (on 4/23/15), pain level of 8/10 (29 times) and pain level of 7/10 (26 times). The eMAR for [MEDICATION NAME] HCL Tablet 10mg (milligram) Give 2 (two) tablet by mouth every 4 (four) hours for pain revealed: --4/2/15, the resident received pain medication for pain level 8/10 at 12:00 p.m. and 4:00 p.m. --4/6/15, the resident received pain medication for pain level 7/10 at 4:00 p.m. and 8/10 at 8:00 p.m. --4/7/15, the resident received pain medication for pain level 7/10 at 12:00 p.m. 8/10 at 4:00 p.m. and 8/10 at 8:00 p.m. --4/9/15, the resident received pain medication for pain level 8/10 at 4:00 p.m. and 8:00 p.m. --4/10/15, the resident received pain medication for pain level 7/10 at 4:00 p.m. and 8/10 at 8:00 p.m. --4/11/15, the resident received pain medication for pain level 7/10 at 8:00 a.m. and 8/10 at 12:00 p.m. --4/12/15, the resident received pain medication for pain level 8/10 at 8:00 a.m. 12:00 p.m., 4:00 p.m. and 7/10 at 8:00 p.m. --4/13/15, the resident received pain medication for pain level 7/10 at 4:00 p. m. and 8:00 p. m. --4/15/15, the resident received pain medication for pain level 7/10 at 12:00 p.m., 4:00 p.m. and 8/10 at 8:00 p.m. --4/16/15, the resident received pain medication for pain level 8/10 at 8:00 a.m. and 12:00 p.m. --4/17/15, the resident received pain medication for pain level 8/10 at 4:00 p.m., and 8:00 p.m. --4/19/15, the resident received pain medication for pain level 7/10 at 4:00 p.m. and 8:00 p.m. --4/20/15, the resident received pain medication for pain level 7/10 at 4:00 p.m. and 8/10 at 8:00 p.m. --4/21/15, the resident received pain medication for pain level 7/10 at4:00 p.m. and 8:00 p.m. --4/23/15, the resident received pain medication for pain level 10/10 at 12:00pm and 7/10 at 4:00 a.m., 4:00 p.m. and 8:00 p.m. --4/24/15, the resident received pain medication for pain level 8/10 at 4:00 p.m. and 7/10 at 8:00 p.m. --4/25/15, the resident received pain medication for pain level 7/10 at 8:00 a.m. and 8/10 at 12:00 p.m., 4:00 p.m. and 8:00 p.m. --4/26/15, the resident received pain medication for pain level 8/10 at 8:00 a.m., 12:00 p.m. and 8:00 p.m. and 7/10 at 4:00 p.m. --4/27/15, the resident received pain medication for pain level 8/10 at 12:00 a.m., 4:00 p.m. and 8:00 p.m. --4/28/15, the resident received pain medication for pain level 7/10 at 8:00 a.m. and 7/10 at 4:00 p.m. and 8:00 p.m. --4/29/15, the resident received pain medication for pain level 7/10 at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. Facility Failures: The facility failed to assess and manage the resident's pain. The resident's physician was not notified of frequency/intensity of the resident's pain or that, beginning on 4/22/15, the resident's pain medication was not administered as ordered due to lack of availability. Furthermore, there was no record regarding the effectiveness of pain medication administered to the resident. The resident had an order to apply Bengay Patch (Menthol Topical [MEDICATION NAME]) to neck/shoulder as needed for pain, there was no documentation in the eMAR or NN to indicate the topical [MEDICATION NAME] was administered as ordered. (1) eMARs The eMAR completed between 4/1/15 and 4/29/15 failed to reveal the efficacy of pain medication was documented or monitored. Additionally, electronic progress notes completed between 4/1/15 and 4/29/15 failed to reveal the physician was notified regarding management of the resident's pain. The eMAR completed between 4/1/15 and 4/29/15 failed to reveal the Bengay patch was administered as ordered, if at all. (2) Pain Assessment Nothwithstanding the documentation between 4/1/15 and 4/29/15 of elevated pain levels (see above), there was no evidence staff completed a new, comprehensive pain assessment either after the resident began reporting higher levels of pain or after her fall on 4/19/15 at 12:15 a.m. (3) Nurses' Notes (NN) -The review of NN from 4/1/15 through 4/29/15 failed to reveal the effectiveness of the [MEDICATION NAME] administered to the resident was monitored. -NN completed between 4/1/15 and 4/29/15 failed to reveal the Bengay patch was administered to address the resident's reported pain at levels well above her acceptable pain level. -The NN, dated 4/22/15, documented [MEDICATION NAME] HCL Tablet 5 MG. Give 2 (two) tablet by mouth every 4 (four) hours for Pain med not available and pharmacy notified. The resident's pain level was not documented on the eMAR. On the eMAR, scheduled administration was coded X (medication not given) and 9 (other/see Nurse Notes) at 4:00 p.m. 8:00 p. m. There was no documentation the physician or nurse practitioner was notified. - The NN for 4/23/15 documented at 12:25 a.m. [MEDICATION NAME] HCL Tablet 5 MG. Give 1 (one) tablet by mouth every 6 (six) hours as needed for breakthrough pain 1- 5. Requested and received PRN (as needed) dose of [MEDICATION NAME] for complaints of pain and catching up to tolerable level. The NN failed to document if the medication was effective. -On 4/29/15 at 12:10 a. m., the NN documented, Resident received 10mg (milligram) of [MEDICATION NAME] at 12:10 a. m., as that was what was left from e-kit removal. Waiting on pharmacy for more supply of medication. The NN failed to document if the medication was effective. -The NN was reviewed for 4/1/15 through 4/29/15 failed to reveal documentation that the physician was notified of the increase in resident's pain level or the unavailability of pain medications. (3) Therapy notes -The dry needle therapy notes, dated 4/22/15, documented the resident continues to benefit from FDN for muscle tension. She was instructed in additional shoulder AROM (active range of motion) and PROM (passive range of motion) exercises today for the right (R) secondary to some slight ROM and strength deficits noted today. Staff Interviews: The director of nursing (DON) was interviewed on 5/1/15 at 4:42 p.m. She stated she spoke with the resident about her pain during a recent care conference. She said the resident indicated she was nearly done with dry needle treatment therapy but she was still having trouble moving her shoulder. The DON stated she was not sure if the resident needed additional dry needle therapy and was not sure if the therapist was going to extend the therapy. The DON said the resident was not a great historian but confirmed the resident had real pain. The DON agreed the resident did not receive PRN [MEDICATION NAME] 4:00 p. m. She said staff should have administered the PRN pain medication and attempted non-pharmacological interventions when the resident experienced breakthrough pain. The DON agreed that every intervention should be documented in the progress note and the nurse should have checked back with the resident to see if the medication was effective. At 2:46 p.m., the DON said she was unable to find documentation the physician was notified when resident's pain medication had run out and was unavailable. The DON said the facility had an alarm system to address the resident pain rated as 4 and above. She said, when experiencing pain of 4 and above, the resident should receive PRN pain medications and non-pharmacological interventions in addition to scheduled pain medication. She said the goal was to keep the resident's pain level at 5/10 but thought the rating was unrealistic. She said the resident needed a consistent regimen of pain control medication. II. Failure to follow physician orders Resident Status: Resident #16, age 86, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented the resident was unable to complete the BIMS which indicated the resident was severely cognitively impaired and never or rarely made decisions. The MDS also documented the resident needed extensive assistance for all activities of daily living (ADL). The MDS documented the resident had a functional limitation in range of motion (ROM) to the upper extremity that resulted in an impairment on one side. The resident resided on the secure unit. Record review: The resident's care plan dated 10/22/09 documented the resident .risk for alteration in skin integrity related to normal disease progression with unavoidable decline . An intervention was to use soft towel for left hand to prevent contractions. The nurse's note, dated 2/6/15 documented .informed nurse .hole in the middle of patient's palm .hole seems to be a result of patient's nail redundantly being pressed into the palm by holding fist tightly. The telephone order dated 2/6/15 documented .cleanse right palm with wound cleanser .put clean cloth between palms, one time a day. Another telephone order dated 2/6/15 documented monitor right palm open area every shift, put clean towel every shift . -The nurse's note dated 2/8/15 documented .hand roll in right hand . -The nurse's note dated 2/11/15 documented .palm of right hand treatment as ordered area healing . -The nurse's note dated 2/22/15 documented .cloth in right palm of hand . -The nurse's note dated 2/24/15 documented .cloth in right palm of hand . -The nurse's note date 3/5/15 documented .cloth in right palm of hand . -The nurse ' s note dated 3/8/15 documented .cloth in right palm of hand . -The nurse's note dated 3/15/15 documented .put clean cloth between palms . -The care conference note dated 4/18/15 documented .resident hand treated for [REDACTED]. The telephone order (TO) signed by the doctor on 2/20/15 and dated 2/25/14 documented occupational therapy (OT) evaluation times one treatment for [REDACTED]. The OT evaluation dated 2/20/15 and plan of treatment documented a [DIAGNOSES REDACTED]. The short and long term goals documented in the plan of treatment were patient will tolerate right soft hand splint without evidence of pain, decreased skin integrity and development of contractures. The OT evaluation documented patient referred to occupational therapy for evaluation of right hand functional decline, weakness, contracture management and skin integrity and the patient exhibits new onset of decrease in range of motion (ROM), decreased skin integrity and pain placing patient at risk for contractures. The OT evaluation documented the right and left hands were impaired and at .high risk for decline in skin integrity of left hand due to atrophy and rigidity . The OT assessment summary documented .patient presents with muscle weakness, rigidity and atrophy to right hand .evidence of functional decline .patient at risk for skin breakdown due to decreased use of hand .patient would benefit from right soft hand splint to help decrease rigidity, skin on skin contact, minimize pain and assist with prevention of contractures. The OT evaluation discharge summary, dated 2/20/15 documented .patient will tolerate right soft hand splint .without development of contractures. There was no telephone order from the recommendations of the OT evaluation found in the record review. However, review of the resident's care plan and nurses' notes above revealed an expectation for a soft towel in the resident's right and left palm. Observations: 4/28/15 -At 11:17 a.m. two rolled washcloths were laying on the table in front of the resident. 4/29/15 -At 3:11 p.m. two rolled washcloths were laying on the resident's chest; neither washcloth was in the resident ' s palm. -At 3:37 p.m. two rolled washcloths were laying on the resident's chest; neither washcloth was in the resident's palm. -At 3:55 p.m. a certified nurse aide (CNA) interacted with the resident, however the two rolled washcloths (see above) remained on the resident's chest. The CNA did not place washcloths in either of the resident's palms. -At 4:25 p.m. the washcloths were not in the resident's palms; they remained on resident's chest. -At 5:01 p.m. the washcloths were not in the resident's palms; they remained on resident's chest. 5/1/15 -At 8:14 a.m. the washcloths were not in the resident's palms and were not visible. -At 9:30 a.m. the washcloths were not in the resident's palms and were not visible. -At 10:13 a.m. the washcloths were not in the resident's palms and were not visible. -At 11:48 a.m. the washcloths were not in the resident's palms and were not visible. -At 11:57 a.m. the washcloths were not in the resident's palms and were not visible. 5/4/15 -At 8:10 a.m. the washcloths were not in the resident's palms and were not visible. -At 11:46 a.m. the washcloths were not in the resident's palms and were not visible. Interviews: Certified nurse aide (CNA) #3 was interviewed on 4/30/15 at 9:10 a.m. and stated in the morning, during cares with the resident, the CNA would put rolled washcloths in both of the resident's hands so she didn't cut her hands with her nails. The CNA also reported that during cares she would occasionally attempt to open the resident's hands but the resident would call out. Registered nurse (RN) #3 was interviewed on 4/28/15 at 11:17 a.m. She reported the resident had a right hand contracture and the resident's left hand was almost contracted. She stated the staff was using rolled washcloths in the resident's palms to prevent the contractures from getting worse. As the nurse walked by the resident, it was observed the two rolled washcloths were setting on the table. The RN pointed to the washcloths and stated those are the washcloths she uses. The RN did not attempt to place them back into the resident's hands.