Every finding on record at Hillview Health Care CTR

Based on interview, record review, and policy review, the facility failed to ensure a care plan was developed to provide effective and person-centered care and services that meets the professional standards of quality of care for 5 of 22 sampled residents (R1, R2, R9, R27, and R30). Findings include: 1. Review of R9's Face Sheet, located in the electronic medical record (EMR), revealed R9 was admitted on [DATE] with diagnoses of urine retention, schizoaffective disorder, adjustment disorder, borderline personality disorder, and obsessive-compulsive disorder. Review of R9's quarterly Minimum Data Set, located in the EMR and with an Assessment Reference Date (ARD) of 11/11/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R9 was cognitively intact. The MDS also indicated R9 received non-invasive ventilator (ventilator or respirator) treatment. Review of R9's Physician Orders, located in the EMR, revealed the following order dated 01/13/26: CPAP [continuous positive airway pressure] settings 5-12 [centimeters of water pressure] H20 to be applied for sleep and/or naps AM (morning) shift PM (night) shift. Further review of this document revealed the following order dated 01/13/26: Albuterol sulfate HFA (Hydrofluoroalkane) 108 (90 base) mcg (microgram)/ACT (actuation) dose: (2 puff) inhalation every 4 hours as needed for wheezing. Review of R9's Care Plan, located in the EMR, revealed the resident care plan did not address the needs noted above in the physician orders or address the residents' respiratory needs. 2. Review of R27's Face Sheet, located in the EMR, revealed R27 was admitted on [DATE] with an admission to hospice. Review of R27's Physician Orders, located in the EMR, revealed the following order dated 10/22/24: Admit to hospice 10/22/2024 . Review of R27's quarterly MDS, located in the EMR and with an ARD of 01/02/26, revealed the resident had a BIMS score of 15 out of 15, which indicated R27 was cognitively intact. The MDS also indicated R27 was receiving hospice services. Review of R27's Care Plan, located in the EMR, revealed the resident care plan did not address the needs or use of Hospice services. 3. Review of R30's Face Sheet, located in the EMR, revealed R30 was admitted on [DATE] with admission to hospice. Review of R30's Physician Orders, located in the EMR, revealed the following order dated 01/02/26: risperidone 0.5 mg (milligram) tablet disintegrating dose (1 tablet/0.5mg) by mouth daily for dementia with behavioral disturbances Review of R30's quarterly MDS, located in the EMR and with an ARD of 01/12/26, revealed the resident had a BIMS score of 15 out of 15, which indicated R30 was cognitively intact. The MDS also indicated that R30 received antipsychotic medication. Review of R30's Care Plan, located in the EMR, revealed no plan to address psychological needs and antipsychotic medication side effects. During an interview on 02/11/26 at 9:50 AM, Registered Nurse (RN) 2 stated that all the nurses can add to the care plans. She stated that antipsychotic medications and CPAP should both have a care plan. The information on the care plans feeds into the KARDEX (care summary) to help care for the residents. During an interview on 02/10/26 at 12:18 PM, the Director of Nursing (DON) stated care plans were started by the nurse supervisors, and the nurse would take the CAA (care area summary) and create a care plan. During a follow-up interview on 02/12/26 at 10:49 AM, the DON stated care plans let staff know what was needed to care for the residents. She stated antipsychotic medications and breathing treatments should have a care plan. She stated she was unaware there needed to be a specific hospice care plan. 4. Review of R1's Face Sheet, located in the EMR, revealed R1 was admitted to the facility on [DATE] with a diagnosis of long-term use of anticoagulants and a prosthetic heart valve. Review of the annual MDS, located in the EMR and with an ARD of 12/03/25, revealed R1 had a BIMS score of 15 out of 15, which indicated R1 was cognitively intact. The MDS recorded R1 was administered an anticoagulant during the seven-day observation period. Review of the 01/26/26 Physician Order, located in the EMR, revealed, Coumadin [Warfarin-an anticoagulant medication] 5 mg [milligram] Dose: (1tablet/5mg) by 03/08/2026 for Anticoagulant Therapy Administration daily. Recheck INR [international Normalized Ratio-a standardized lab test that measures how long it takes for blood to clot] on 03/09/26. Review of the Comprehensive Care Plan, located in the EMR, revealed no focus/problem, goal, or approaches for the use of R1's anticoagulant medication. During an interview on 02/09/26 at 10:02 AM, R1 stated, I have been on Warfarin since 2014 for my heart condition. During an interview on 02/10/26 at 9:17 AM, the DON stated, The admission nurse will start the baseline care plan and within 48 hours it becomes more comprehensive. The DON was asked why the Warfarin was not care planned due to being a significant medication. The DON stated, We did not care plan it because it was on the MAR [medication administration record]. 5. Review of R2's Face Sheet, located in the EMR, revealed R2 was admitted to the facility on [DATE] with a diagnosis of Type 1 Diabetes and long-term insulin use. Review of the quarterly MDS, o located in the EMR and with an ARD of 11/17/25, revealed R2 had a BIMS score of 14 out of 15, which indicated R2 was cognitively intact. It was recorded R2 had received insulin during the seven-day observation period. Review of the Physician Orders located in the EMR, revealed: a. 06/27/25: Blood Glucose Check: every 4 hours. If Dexcom [a specialized glucose monitor that checks glucose levels 24 hours a day] reading is <70 or >450, obtain finger stick to confirm reading.b. 06/27/25: Insulin Aspart [short-acting insulin] three times a day for type 1 diabetes sliding scale: 150-199 give 2 units; 200-249 give 3 units; 250-299 give 4 units; 300-349 give 5 units; 350-399 give 6 units; 400-499 give 7 units; greater than or equal to 450 give 8 units.c. 07/14/25: Insulin Aspart: Give 5 units daily at supper.d. 07/21/25: Insulin Aspart: Give 13 units daily at breakfast.e. 10/12/25: Insulin Aspart: give 3 units daily at lunch. Review of the Comprehensive Care Plan did not show a focus/problem, goals, or approaches related to R2's type 1 diabetes. During an interview on 02/11/26 at 9:13 AM, RN1 stated, I am sorry, he should have a care plan for his diabetes. Review of the policy titled Care Plan - Development and Updating, dated 12/31/25, revealed, Care plans include instructions needed to provide effective, person-centered services, which should include the individual's strengths, needs, goals, meds, social services, . Care plans will be updated as changes occur and as often as needed. This is to include things like changes to level of function, treatments, and skin care.

Based on interview, record review, and facility policy review, the facility failed to obtain a signed declination which contained education on the risks/benefits of the influenza vaccine for 2 of 5 Residents (R18 and R30) reviewed for vaccines. Findings include: Review of the facility policy titled, Acute Respiratory Illness Protocol, dated 11/30/25 revealed, . Consent will be obtained from the resident or his/her responsible person prior to administration of vaccine. A declination form will be completed by resident or his/her responsible person if they choose to decline the vaccine . 1. Review of the Face Sheet, located in the electronic medical record (EMR), revealed R18 was admitted to the facility on [DATE] with a diagnosis of cancer with metastasis to the bone. Review of the annual Minimum Data Set (MDS), located in the EMR and with an assessment reference date (ARD) of 01/20/26, revealed R18 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated R18 was cognitively intact. It was recorded R18 was offered and declined the influenza vaccine. Review of the EMR and the Hard Chart at the nursing station revealed no documented evidence of a signed declination for the influenza vaccine, including that education on the risks and benefits of the vaccine was provided to R18. 2. Review of the Face Sheet, located in the EMR, revealed R30 was admitted to the facility 10/25/24 with diagnoses that included a personal history of mental and behavioral illnesses. Review of the quarterly MDS, located in the EMR and with an ARD of 01/12/26, revealed R30 had a BIMS score of 15 out of 15, which indicated R30 was cognitively intact. It was recorded R30 was offered and declined the influenza vaccine. Review of the EMR and the Hard Chart at the nursing station revealed no documented evidence of a signed declination for the influenza vaccine, including that education on the risks and benefits of the vaccine was provided to R30. During an interview on 02/12/26 at 10:50 AM, the Director of Nursing (DON) confirmed that she was not aware that a declination of a vaccine needed to be in the medical record with the documentation to show that the risks/benefits were explained to the resident.

Based on interviews, record review, and review of facility policy, the facility failed to provide a notice of hospital transfer and appeal rights for one resident (R28) in a total sample of 22. Findings include: Review of the 07/31/25 facility policy titled, Discharge/Transfer Documents revealed, Transfer Form/Patient Care Plan-Any resident being transferred to the hospital shall have a Resident Transfer Form filled out by Nursing Service and the Hospital Transfer Checklist completed. A copy of the transfer from (original) shall be sent with the resident and a copy will be filed in the medical record. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R28 was admitted to the facility 10/07/25 after sustaining a fracture arm/wrist from a fall at home. Review of the quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR and with an assessment reference date (ARD) of 12/31/25 revealed R28 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated R28 was moderately impaired in cognition. Review of the Nursing Notes of the EMR revealed, On 10/17/25 R28 complained of nausea with yellowish brown liquid emesis x 1. Continues to [NAME] with fluid intake. Resident was positioned on her left side with HOB [head of bed] elevated at 45 degrees. Nursing interventions were continued and at 10:54 AM, [R28] requested to go back to hospital due to continued emesis and abdominal pain. Resident was admitted for ileus [a cessation of normal intestinal movement]. R28 returned to the facility on [DATE]. During an interview on 02/11/26 at 11:57 AM, the Director of Nursing and Administrator was asked if the resident and/or her representative was notified in writing of the hospital transfer and appeal rights when she was admitted to the hospital on [DATE]. The Administrator stated, I don't think we have done this. During an interview on 02/12/26 at 10:30 AM, the Support Systems Manager (SSM) stated, We used to have a transfer form for residents/representatives which included their appeal rights. The SSM confirmed that the transfer form was not provided to R28 and/or her representative at the time of the transfer to the hospital.

Based on observations, interview, record review, and policy review, the facility failed to ensure the urinary catheter drainage bag was covered for privacy and dignity for 1 of 2 Residents (R9) reviewed for urinary catheters out of a total sample of 22. Findings include:A review of the policy titled Resident Rights, dated 06/30/25, revealed Respect, Dignity, and Self-Determination: you have the right to be treated with respect and dignity.Review of R9's Face Sheet, located in the electronic medical record (EMR), revealed R9 was admitted on [DATE] with diagnoses of urine retention.Review of R9's quarterly Minimum Data Set (MDS), located in the EMR and with an Assessment Reference Date (ARD) of 11/11/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R9 was cognitively intact. The MDS revealed R9 used an indwelling catheter.Review of R9's Care Plan, located in the EMR and dated 01/13/26, revealed R9 had a catheter for urinary retention. A goal for this was to have R9's dignity remain intact.Review of R9's Physician Orders, located in the EMR and dated 01/27/26, revealed the following order dated 01/27/26: Foley catheter 18 fr [French foley]/5 ml [milliliter] silicone only. An observation on 02/09/26 at 10:43 AM revealed R9 wearing a urinary catheter bag with no privacy cover. The bag was attached to her left calf. R9 was wearing a skirt that covered just past her knees, and urine was noted in the bag. R9 was observed in her room; however, the bag could be seen from the hallway.During an interview on 02/09/26 at 12:14 PM, R9 stated the bag and exposed urine bothered her. She stated she wished there was something to cover it with.During an observation on 02/10/26 at 9:25 AM, R9 was observed propelling in her wheelchair in the hallway. R9's urinary catheter bag was observed attached with a strap to her left calf. The catheter bag was exposed, and the urine could be seen in the bag.During an interview on 02/10/26 at 9:26 AM, Certified Nursing Assistant (CNA) 6 confirmed R9 did not have a privacy cover on her catheter bag.During an interview on 02/11/26 at 9:50 AM, Registered Nurse (RN) 2 stated all catheter bags should have a privacy cover on the bag. She then confirmed that R9 did not have a privacy cover on her bag.During an interview on 02/12/26 at 10:49 AM, the Director of Nursing stated R9 should have a privacy cover on her catheter bag to ensure her dignity was respected.

Based on interviews, record reviews, and facility policy reviews, the facility failed to follow infection control and prevention guidelines for environmental cleaning of floors in resident areas for 34 sampled residents. Findings include:Review of the Centers for Disease Control (CDC) Environmental Cleaning Procedures dated 03/19/24 revealed, spills of bodily fluids. Regardless of an area's risk level, spills or contamination from blood or body fluids (e.g., vomitus) must be cleaned and disinfected immediately using a two-step process. She said she expected staff to use detergent and then sanitize the floors after cleaning. Review of the Centers for Disease Control (CDC) Environmental Cleaning Procedures dated 03/19/24 revealed, spills of bodily fluids. Regardless of an area's risk level, spills or contamination from blood or body fluids (e.g., vomitus) must be cleaned and disinfected immediately using a two-step process. Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules (if available) that are spread over the spill to solidify the blood or body fluid (all should then be disposed of as infectious waste). Clean thoroughly, using neutral detergent and a warm water solution. Disinfect by using a facility-approved intermediate-level disinfectant. Typically, chlorine-based disinfectants at [PHONE NUMBER]ppm free chlorine (1:100 or 1:10 dilution of 5% chlorine-bleach; depending on the size of the spill) are adequate for disinfecting spills (however, do not use chlorine-based disinfectants on urine spills). See Appendix E - Chlorine disinfectant solution preparation. Take care to allow the disinfectant to remain wet on the surface for the required contact time (e.g., 10 minutes), and then rinse the area with clean water to remove the disinfectant residue (if required).During an interview on 10/21/25 at 12:58 PM, Certified Nurse Aide (CNA) 1 stated that CNA staff are responsible for the daily cleaning of resident rooms. She stated the residents' rooms are cleaned once a week. CNA1 stated that when they mop the floors, they use only water and do not use any cleaning solution or disinfectant. If there were a bowel movement on the floor, she would use a peroxide wipe. She stated their Support System Manager was supposed to be getting something that disinfects without harming the floors. There have been people who have complained and were concerned. She said she felt there were contaminants on the floor since no disinfectant was used. She did say the mop head was changed after each use. During an interview on 10/21/25 at 1:27 PM, CNA2 stated that when they mop the residents' floors, they only use water. She said the floors were generally dirty, and water did not clean them. She felt it only spread the dirt and germs around the floor. During an interview on 10/21/25 at 2:15 PM, CNA3 said they mop the resident floors with only water and were told not to use cleaning products on the floors due to the warranty. She said they have been told the approved products were too expensive due to tariffs. But she felt water could not clean or disinfect. If there were a bowel movement, she would use the hydrogen wipes, but they were not supposed to; she felt it was morally wrong, and you can't just clean poop with water. She said she has voiced her concerns to management, and she felt she was told to quiet down about it. She said water just pushes dirt and grime around but did not clean.During an interview on 10/21/25 at 3:38 PM, the Supportive Systems Manager (SSM) said staff have been using only water to mop resident rooms. She said they have found a cleaning and disinfecting product that will be here tomorrow. When staff cleaned, they were to use a hydrogen wipe, then mop it with water. She said the facility had new floors and required a product with a low pH, but did not feel the floors necessarily needed to be disinfected. She spoke with the flooring manufacturer, who said you don't need to disinfect the flooring. During an interview on 10/21/25 at 4:15 PM, the Director of Nursing (DON) said it was not appropriate just to use water to clean the floors because it did not kill germs. She said she expected staff to use detergent and then sanitize the floors after cleaning.

Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for observations of mishandled laundry, having the potential to affect all 51 residents, and 1 of 1 (R) resident observed for catheter care while on Enhanced Barrier Precautions (R11). This is evidenced by: Example 1 Facility policy titled Transmission Based Precautions, last reviewed and revised 04/30/24, states, Standard precautions are used by staff and residents at all times. Standard precautions are the primary strategy for control and prevention of infections. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the facility. Under section titled Contact Precautions - Gowns states in part, Remove gown and discard of gown appropriately, after gown removal, staff should ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other residents or environment. On 11/12/24 at 10:54 AM, Surveyor observed Activities of Daily Living cares (ADL) followed by wound care on R4. On 11/12/24 at 11:20 AM, Surveyor observed Certified Nursing Assistant (CNA) C complete ADL cares on R4. CNA C placed dirty linens in a plastic bag, removed PPE gown, rolled up into a ball, and without placing in a bag, exited into hallway and discarded in hamper situated in hallway two doors down. On 11/12/24 at 11:57 AM, Surveyor observed Registered Nurse (RN) E, after completing R4's wound care, remove gown and without putting PPE gown into a bag, exited into hall and discarded in hamper situated in hallway two doors down. On 11/12/24 at 11:59 AM, Surveyor observed Nurse Manager D after assisting with R4's wound care, remove gown and without putting PPE gown into a bag, exited into hall and discarded in hamper situated in hallway two doors down. On 11/13/24 at 10:59 AM, Surveyor interviewed RN E regarding procedure of discarding PPE after use. RN E stated in the past we would toss linens down a laundry chute, but since laundry services are no longer at facility every day, we use the two hampers in the hallway that separate linens from PPE and staff are to bring cart outside resident room. Surveyor shared observation of RN E on 11/12/24 removing contaminated PPE after assisting R4 with ADLs and wound care and exiting room with contaminated gown and discarding in hamper down hall without bagging. RN E stated we should be putting them in a plastic bag before leaving a resident's room. On 11/13/24 at 11:06 AM, Surveyor interviewed Nurse Manager D (who is the facility's Infection Preventionist) regarding processes and observations on 11/12/24 of R4's ADL and wound care, performed by Nurse Manager D, CNA C, and RN E. Nurse Manager D stated they probably should place contaminated PPE in a plastic bag before exiting a resident room or have bins in the room. On 11/13/24 at 11:59 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation and expectations with discarding contaminated PPE. DON B stated expectation would be for all laundry items to be bagged before leaving the resident's room per facility's policy of remove gown and discard of gown appropriately. 40590 Example 2 On 11/13/24 at 9:47 AM, Surveyor observed CNA M coming out of resident room [ROOM NUMBER] with a bath blanket tucked under her left arm. CNA M was observed standing in the hallway talking to a volunteer who had brought in three small dogs for pet visits. There was an Enhanced Barrier Precautions (EBP) sign on the door of room [ROOM NUMBER]. CNA M was then observed going to a dirty laundry bin in the hallway and putting the bath blanket in the dirty laundry bin. At 10:15 AM, Surveyor observed CNA M coming out of resident room [ROOM NUMBER] with linen tucked under her left arm. At 10:34 AM, CNA M was in resident room [ROOM NUMBER]. There was a sign on the door of room [ROOM NUMBER] for EBP. At 10:49 AM, Surveyor observed CNA M exit room [ROOM NUMBER] with several linen items in her hands. CNA M was also holding a pair of goggles in her right hand. In CNA M's left hand was a clear bag with washcloths and towels. A PPE gown was draped over CNA M's left forearm and two dark blue cloth napkins were on top of the PPE gown. These items were up against her body to hold them. CNA M then switched these linens to be held with her right arm up against her body to use her left arm to place the linen in the dirty linen bins. The PPE gown was placed in the bin labeled SOILED LINEN HILLVIEW ONLY (all residents personal items) personal clothing, personal bedding, PPE gowns, gripper socks. The PPE gown was not contained in a clear plastic bag. The clear plastic bag and blue cloth napkins were placed in the bin labeled, SOILED LINEN (BANDBOX ONLY) (all bedding & linens) bedspreads, flat/fitted sheets, pillowcases, bath towels, hand towels, wash clothes, blue pads, bath blankets, blue linen clothing protectors. At 11:12 AM, Surveyor interviewed CNA M who stated that the soiled linen bins are supposed to be next to the door of the room or in front of door so linen can be placed in them. At 11:50 AM, Surveyor observed CNA M walking down the 600 wing hallway past Surveyor with a large amount of dirty linens in her hands/arms. Linens were not contained and open to the air. CNA M disposed of linens in a dirty laundry bin in the hallway. CNA M sanitized her hands and entered a clean linen room. CNA M was observed coming out of the linen room a few minutes later with a clean, folded flat sheet tucked under her left armpit. 31086 Example 3 R102 was admitted to the facility with diagnoses of displaced fracture of shaft of left clavicle, Parkinson's disease, dementia, and nephrostomy. On 11/12/24 at 9:57 AM, Surveyor observed RN D provide care to R102's nephrostomy tube site. RN D sanitized hands, applied a gown, and set up supplies with a barrier on the over the bed tray table. RN D removed the nephrostomy site dressing and noted the dressing had a little serosanguineous drainage. RN D removed gloves, sanitized hands, applied gloves, and cleaned the site with gauze and saline. RN D removed gloves, sanitized hands, and applied clean gloves. RN D dried area with a clean gauze. RN D removed gloves, sanitized hands, removed gown, sanitized hands, and left the room with the gown not contained in a bag, to gather supplies of split gauze. RN D returned and sanitized hands, applied a gown, washed hands, and applied clean gloves. RN D cleansed the site again using the same process. RN D removed gloves, sanitized hands, applied clean gloves, and applied the split gauze to the nephrostomy site. RN D removed gloves, sanitized hands, applied clean gloves, and applied medipore over the split gauze. RN D removed gloves, sanitized hands, gathered supplies and garbage. RN D washed hands and removed gown by keeping the gown inside out and left R102's room with the gown in hand and not contained in a plastic bag. RN D walked down the hallway past two resident rooms, placed the gown in the laundry bin, and sanitized hands. On 11/13/24 at 12:00 PM, Surveyor interviewed DON B about her expectation of Surveyor's observation of RN D removing gown in R102's room and walking down the hallway with gown not contained in a bag. DON B stated the expectation is to bag the dirty linen before bringing out of the room. 49353 Example 4 Facility policy titled, Transmission Based Precautions with a most recent revised date of 04/30/24 states in part: .Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the facility. Enhanced Barrier mirrors Contact Precautions though are used in specific care activities .designated high contact activities include dressing, bathing, hygiene, transferring, linen change, toileting/brief change, indwelling line care, wound care. Enhanced Barrier Precautions will be used, in addition to Standard Precautions, for a resident who is known to be colonized with MDROs, has a chronic wound, or has an indwelling medical device. Examples of indwelling medical devices include central lines, urinary catheters, feeding tubes, or tracheostomies. .Enhanced Barrier Precautions-PPE use: Glove, gown, mask and eye protection as stated in Contact Precautions [Mask and eye protection used when activity likely to generate splashes or spray of blood, body fluids, secretions, and excretions.] Findings: R11 was admitted to the facility on [DATE] with pertinent diagnoses of obstructive uropathy (urine unable to drain normally) and the presence of a chronic suprapubic catheter. R11's care plan included Enhanced Barrier Precautions (EBP) due to the presence of a catheter. On 11/13/24 at 9:53 AM, Surveyor observed Licensed Practical Nurse (LPN) G enter R11's room to clean R11's suprapubic catheter site and apply a split gauze. LPN G completed hand hygiene, donned gloves after entering, and placed catheter care supplies on covered bedside table. LPN G did not don a gown before beginning cares for R11. Surveyor observed LPN G lean against the side of R11's bed to reach R11's catheter and completed catheter cares. On 11/13/24 at 9:55 AM, Surveyor asked LPN G why R11 was on EBP. LPN G stated because he had a catheter and for providing cares during catheter cares. Surveyor asked LPN G what PPE should be used for EBP. LPN G stated gown and gloves.

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 51 residents who reside in the facility. Facility staff did not conduct appropriate hand hygiene and were observed touching ready to eat foods with contaminated gloved hands. This is evidenced by: Facility's policy Hand Hygiene-Kitchen with the revised date of 08/31/22 read in part, 2. How to wash hands: .c. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of 10 to 15 seconds within the 20 second hand washing procedure. Apply vigorous friction between the fingers and fingertips. Rinse with clean, running warm water. d. Rinse thoroughly. e. Dry hands with paper towel. f. Use a clean paper towel to turn the faucet off and open the door if needed, and then discard towel. On 11/12/24 at 7:37 AM, Surveyor observed Culinary Services Assistant (CSA) H washing hands. When CSA H completed washing hands, CSA H turned the faucet off with clean hands then dried his hands. On 11/12/24 at 7:39 AM, Surveyor observed CSA I was preparing a salad and removed gloves. CSA I touched the lid of the garbage can and threw gloves away. CSA I, with contaminated hands, picked up a cover and placed on the salad container. CSA I dated the salad and put it into the refrigerator. On 11/12/24 at 7:42 AM, Surveyor observed CSA I completed hand washing and turned the faucet off with their clean hands. CSA I dried hands, applied gloves, and started the meal tray line. CSA I wore the same gloves during the service of the meal trays. CSA I touched the cart with fruit cups, moved a butter container from another counter, and touched a cake pan. CSA I was cutting a cake in a pan and touched the pieces. Multiple times during tray line CSA I touched the cake, the bread bag, placed the bread in the toaster, and held the toast to butter. On 11/12/24 at 8:35 AM, Surveyor observed CSA K with gloved hands bring a tray cart to the unit and came back to the kitchen with the same gloves on. CSA K then touched the napkins, moved the silverware tray to another table, and brought the tray cart to the dish room. CSA K removed gloves, washed hands, turned the faucet off with clean hands and then dried hands. On 11/12/24 at 11:45 AM, Surveyor observed Food Service Supervisor (FSS) L ask CSA J to remove gloves and wash hands after touching hair net and face. CSA J washed hands for approximately 5 seconds and turned the faucet off with her clean hands. CSA J applied gloves and continued with meal tray line. On 11/13/24 at 9:37 AM, Surveyor interviewed FSS L about hand hygiene within the kitchen. Surveyor reviewed with FSS L of Surveyor's observations of staff's hand hygiene process. FSS L indicated the proper procedure is to wash hands and dry with the water still running and take a new paper towel to turn the faucet off. FSS L indicated staff during tray line should not be wearing gloves and should be using tongs and spatulas to serve the ready to eat foods. FSS L indicated they had training on Relias within the last year and written audits have not been completed but do daily visual audits of staff. FSS L indicated hand hygiene training will begin.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. This affected 14 of 55 residents (R) in the building. (R4, R36, R33, R25, R7, R20, R32, R37, R44, R31, R34, R49, R1, and R30) Staff did not sanitize mechanical lift between use for residents R33, R36 and R4. Staff did not provide hand hygiene for residents prior to meals for 12 residents. (R33, R25, R4, R7, R36, R20, R32, R37, R44, R31, R34, and R49) Staff did not perform hand hygiene when changing gloves during wound care for R1. Staff administered nasal spray to R30, that was stored without a cap and comingled with other resident medications. Findings include: Example 1 Facility policy titled Mechanical Lift Cleaning/Maintenance last reviewed/revised on 07/31/23, stated in part, .When transfer is completed, clean all contact areas with disinfectant wipe. All lifts should have a vinyl bag attached to hold cleaning wipes. Notify Central Supply if the lift is missing a bag . On 09/25/23 at 11:43 AM, Surveyor observed Certified Nursing Assistant (CNA) J bring a mechanical lift out of a resident room after using the lift to transfer a resident. CNA J did not wipe down the lift with a sanitizing wipe after use. CNA J brought the lift down the hall and placed it beside the bed in room [ROOM NUMBER]. There were no sanitizing wipes in the bag on the lift. On 09/25/23 at 12:42 PM, Surveyor observed CNA K take the mechanical lift from room [ROOM NUMBER] and take it to R33's room to transfer R33 from their chair. CNA K did not wipe down the lift with a sanitizing wipe before taking it into R33's room. At 12:53 PM, Surveyor observed CNA K bring the mechanical lift out of R33's room. CNA K did not wipe it down with a sanitizer wipe. CNA K brought the lift into room [ROOM NUMBER] and placed it beside the bed. On 09/26/23 at 7:35 AM, Surveyor observed CNA K bring a mechanical lift out of a resident's room after using the lift to transfer a resident. CNA K took the lift to room [ROOM NUMBER] and placed it beside the bed and left the room. CNA K did not sanitize the lift after using it to transfer a resident. On 09/26/23 at 9:15 AM, Surveyor observed CNA J take the mechanical lift out of room [ROOM NUMBER] and bring it to R36's room to transfer R36 out of bed. CNA J did not wipe down the wipe with a sanitizer wipe before taking it into R36's room. At 9:46 AM, Surveyor observed CNA J bring the mechanical lift out of R36's room and place it in room [ROOM NUMBER] beside the bed. CNA did not wipe down the lift with a sanitizer wipe prior to placing it in room [ROOM NUMBER]. On 09/26/23 at 1:05 PM, Surveyor observed CNA J bring the mechanical lift from where it had been stored in room [ROOM NUMBER] into R4's room. CNA J did not wipe the lift with sanitizer wipes before bringing it into the room. There were no sanitizer wipes in the bag on the lift. CNA J and CNA K transferred R4 from wheelchair to toilet and then from toilet into bed using the mechanical lift. Immediately following the transfer, Surveyor asked CNA J and CNA K if they sanitized the mechanical lift before or after use of the lift. CNA K stated they were supposed to wipe it down between residents, and there were supposed to be sanitizer wipes on each lift. Both CNAs said they didn't have any wipes on the lifts on the 600 hall, so they had not been wiping them down after each resident use. On 09/26/23 at 1:26 PM, Surveyor observed none of the mechanical lifts on the 600 unit and none of the lifts in the hallway on the 800 unit had sanitizer wipes in the bags on the lifts. On 09/26/23 at 2:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C about facility policy for cleaning and sanitizing multi-use lifts between residents. ADON C stated they were supposed to wipe down the lifts after each use, and each lift should have a container of sanitizer wipes in a bag on the lift. Surveyor explained the observations of lift use on the 600 hall over the past two days with no sanitization after use. ADON stated they should have been sanitizing the lifts after each use. Example 2 On 09/25/23 at 12:35 PM, Surveyor observed a lunch tray delivered to R33's room. The staff member set up the tray in front of R33 and R33 began feeding self. No hand hygiene was offered to R33 prior to eating. At 12:37 PM, Surveyor observed a staff member deliver a lunch tray to R25's room. No hand hygiene was offered to R25 prior to feeding self. On 09/26/23 at 7:51 AM, Surveyor observed R4 brought to a table in the 600 dayroom and served breakfast. R4 began feeding self. No hand hygiene was offered to R4 prior to eating. 09/26/23 at 7:59 AM, Surveyor observed R7 sit down at a table in the 600 dayroom. A staff member served R7 breakfast and R7 began feeding self. No hand hygiene was offered to R7 prior to eating. On 09/26/23 at 8:53 AM, Surveyor observed R36 served breakfast in resident room. No hand hygiene was offered to R36 prior to feeding self. 46694 R20 was admitted to the facility on [DATE] with a BIMS of 14 indicating that R20 was cognitively intact. Diagnoses include cerebral infarct (disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysphagia (swallowing difficulties). On 09/25/23 at 12:35 PM, Surveyor observed R20's tray delivered to room by Certified Nursing Assistant (CNA) E. CNA E placed tray on bedside table. CNA E assisted R20 to an upright position. No hand hygiene offered to R20 before the meal. On 09/26/23 at 8:31 AM, Surveyor observed R20's breakfast tray delivered to room by CNA F. CNA F removed the plate cover, sat R20 upright from a reclining position, placed clothing protector on R20 and no hand hygiene offered to R20. CNA F left the room. 47284 The facility did not provide hand hygiene to the residents before eating meals for residents R32, R37, R44, R34, R31, and R49. Findings include: The facility policy, entitled Resident Care General Approaches, dated 5/31/23, states: .Encourage or assist resident to wash their hands before eating or handling food . On 9/25/23 at 11:52 AM, Surveyor observed lunch served in the 800-hall dining room. Staff did not offer hand hygiene to the residents (R32, R37, R44, R34, R31, and R49) prior to eating. On 9/26/23 at 7:05 AM, Surveyor observed residents (R37, R32, R44, R34, and R31) in the 800-hall dining room waiting for breakfast to be served. Staff did not offer hand hygiene to the residents. On 9/26/23 at 7:49 AM, staff started to serve breakfast to the residents (R37, R32, R44, R34, and R31) in the dining room. No hand hygiene offered to the residents prior to eating. On 9/26/23 at 11:10 AM, Surveyor observed Certified Nursing Assistant (CNA) H bring in R44 and then R34 into the 800-hall dining room. No hand hygiene was offered to the residents. On 9/26/23 at 11:21 AM, Surveyor observed CNA H bring in R37 into the 800-hall dining room with no hand hygiene offered to the resident. On 9/26/23 at 11:25 AM, Surveyor observed CNA H bring in R49 into the 800-hall dining room with no hand hygiene offered to the resident. On 9/26/23 at 11:27 AM, Surveyor observed CNA I bring in R31 into the 800-hall dining room with no hand hygiene offered to the resident. On 9/26/23 at 11:32 AM, R32 came into the 800-hall dining room. Staff did not offer R32 hand hygiene. On 9/26/23 at 11:59 AM, Surveyor observed the residents R44, R34, R37, R49, R31, R32 served lunch. No hand hygiene was offered to the residents before eating. On 9/26/23 at 12:14 PM, Surveyor asked CNA H if the residents were offered hand hygiene before eating meals. CNA H said we should be offering hand sanitizer to the residents before they eat meals. Example 3 R1 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) of 04 indicating that R1's cognition was severely impaired. Diagnoses include pressure injury right heel, chronic buttock ulcer and diabetes. R1's doctor's orders include skin cleanse the left inner buttocks ulcer, apply calmoseptine to buttocks and coccyx twice a day. On 09/26/23 at 10:41 AM, Surveyor observed wound care completed by Registered Nurse (RN) D. RN D performed hand hygiene using Alcohol Based Hand Rub (ABHR) and put on single use gloves. RN D pulled R1's incontinent product down to R1's knees and positioned R1 onto the right-side lying position in bed. RN D then removed the gloves and put on new gloves without performing hand hygiene. The rest of the wound care observation was appropriate with standards of care. 48793 Example 4 On 09/26/23 at 7:55 AM, Surveyor observed Registered Nurse (RN) M administrate ipratropium bromide nasal spray to R30. RN M pulled R30's nasal spray out of another resident's medication compartment on the medication cart. Surveyor did not observe a top on the nasal spray bottle nor was it in a contained zip lock bag. Surveyor interviewed RN M about what normally occurs when a medication is found in another's compartment opened or not in its own bag. RN M indicated this usually does not happen and unsure why it's in there. RN M proceeded into R30's room with the uncapped bottle and administered the nasal spray. Surveyor did not observe any cleaning of the tip of the nasal spray actuator before administering two puffs into each nostril for R30. RN M placed a clear bag over the tip of the nasal spray bottle and placed into R30's correct compartment in med cart when finished. On 09/26/23 at 9:50 AM, Surveyor interviewed DON B about what the expectation/process is for infection control measures pertaining to the medication cart/storage, and medication administration. DON B indicated that medication carts and storage rooms are to be kept clean, labeled correctly, and stored in each resident's individualized compartments. DON B indicated that the nasal spray without a top should have been tossed in trash as the facility is unaware what the tip has touched or been exposed to prior to administration. DON B indicated that a new nasal spray bottle should have been obtained prior to administering the medication.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, did not ensure only authorized personnel had access to medication carts, and did not ensure expired medications were removed from stock supply. This occurred for 3 of 4 medication carts/storage rooms observed. During the three-day survey, 4 of 7 observations were made of medication carts left unlocked when unattended and out of view of staff. One observation was made of resident (R) medications left on top of the medication cart when the cart was unattended and out of view of staff. (R8) One observation was made of a stock bottle of Maalox 3/4ths empty not labeled with an open or expiration date stored in the stock supply room. One observation was made of R30's ipratropium bromide nasal spray not labeled with an open or expiration date. Findings include: Surveyor requested and reviewed the facility policy titled Medication Administration-oral dated August 31st, 2023. The policy in part reads: The medication cart is to be kept in clear view and in reach of administering medications at all times . Surveyor requested and reviewed the facility policy titled Storage of Medications dated April 2012. The policy in part reads: ~Outdated, contaminated, deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, and disposed of. ~The nurse will check the expiration date of each medication before administering it . On 09/25/23 at 12:05 PM, Surveyor observed Registered Nurse (RN) L administer medications to R28. Upon entering room RN L left cart outside the room unlocked. On 09/26/23 at 8:27 AM, Surveyor observed RN L administering medications to R46. Upon entering the room, RN L left cart outside the room unlocked. Surveyor did not observe RN L lock medication cart before leaving it outside R46's door. On 09/26/23 at 8:32 AM, Surveyor observed RN L administering medications to R36. Upon entering room, RN L left the cart outside the room unlocked. Surveyor did not observe RN L lock medication cart before leaving it outside R36's door. On 09/26/23 at 9:21 AM, Surveyor observed RN L walk into R8's room with cart outside the room unlocked. Surveyor observed medications in a cup on top of medication cart outside R8's door. RN L was behind R8's curtain speaking with R8. Surveyor did not observe RN L lock medication cart. Surveyor never observed RN L lock medication cart during medication passes from 4 of the 7 observations. On 09/26/23 at 9:30 AM, Surveyor interviewed RN L about the process of medication administration when going in and out of resident rooms. RN L indicated that normally I minimize computer and lock the medication cart when entering a resident's room to give a medication. On 09/26/23 at 7:55 AM, Surveyor observed RN M administrate ipratropium bromide nasal spray to R30. Surveyor did not observe a top or open date/expiration date on the nasal spray bottle. Surveyor interviewed RN M about what normally occurs when a medication is found with no open date. RN M stated it's usually good for 28 days, but I would have to check the sheet located in the med room. RN M still administered nasal spray and placed into R30's compartment in med cart when finished. RN M also found an empty nasal spray in R30's compartment which RN M stated she was unsure how long that's been there as it doesn't have a label, and RN M tossed it in trash. On 09/26/23 at 9:30 AM, Surveyor observed med storage room on Hall 900 with Assistant Director of Nursing (ADON) C. Surveyor observed an opened Maalox bottle with sticky substance running down about 3/4ths empty without an open date or expiration label. ADON C indicated that the Maalox bottle should not be in the cabinet opened without an open date label. ADON C specified that usually once a stock bottle is opened it is taken to a medication cart not stored in the stock supply cabinet. On 09/26/23 at 9:50 AM, Surveyor interviewed Director of Nursing (DON) B about what the expectation/process is for the medication cart/storage, and medication administration. DON B indicated that medication cart and storage rooms are to be kept locked and all medications safely stored. DON B indicated that all medications such as liquids like the Maalox, any sprays, and insulins are to be labeled with an open date so that the expiration rule can be followed. DON B indicated that this is not in the policy verbiage, but it is expected from the nursing staff.

Based on observation, interview and record review, the facility did not maintain confidentiality of resident medical record information for 4 of 7 sampled and supplemental residents (R) reviewed. During the three-day survey, Surveyor had four observations of computer screens left open and unattended on medication carts with resident identifiable information visible for R28, R46, R36 and R8. This is evidenced by: Surveyor requested and reviewed the facility policy titled HIPAA-Notice of Privacy Practices dated February 2023. The policy in part reads: ~Hillview Health Care Center is required by law to maintain the privacy of your health information. ~We will not use or disclose your health information without your authorization in this notice. ~We will share your protected health information with members of your treatment team . On 09/25/23 at 12:05 PM, Surveyor observed Registered Nurse (RN) L administer medications to R28. Upon entering room RN L, left cart outside the room unlocked with patient identifier on computer. Surveyor did not observe RN L close computer or close out of the patient identification. RN L administered medications, exited room and charted on computer. RN L went to next resident for medication administration. On 09/26/23 at 8:27 AM, Surveyor observed RN L administering medications to R46. Upon entering the room, RN L left cart outside the room unlocked with patient identifier on computer. Surveyor did not observe RN L close computer or close out of the patient identification. RN L administered medications, exited room and charted on computer. On 09/26/23 at 8:32 AM, Surveyor observed RN L administering medications to R36 . Upon entering the room, RN L left cart outside the room unlocked with patient identifier on computer. The door to the room was not closed after RN L entered. R47, who is R36's roommate, was sitting on edge of bed eating breakfast looking outside the door where R36's information was up on computer on cart outside the door. Surveyor did not observe RN L close computer or close out of the patient identification. RN L administered medications, exited room and charted on computer. On 09/26/23 at 9:21 AM, Surveyor observed RN L walk into R8's room with cart outside the room unlocked with patient identifier on computer. Surveyor observed medications in a cup on top of medication cart outside the door. RN L was behind R8's curtain speaking with R8. Surveyor did not observe RN L close computer or close out of the patient identification. On 09/26/23 at 9:30 AM, Surveyor interviewed RN L about the process of medication administration when going in and out of resident rooms. RN L indicated that normally I minimize computer and lock the medication cart when entering a resident's room to give a medication. On 09/26/23 at 9:50 AM, Surveyor interviewed Director of Nursing (DON) B about what the expectation/process is for the medication cart, and HIPAA practices during medication administration. DON B indicated that medication cart and any patient identifiers/health information are to be kept locked and out of sight for anyone else to see. DON B indicated that all computers are supposed to be minimized or locked if not present and medication cart locked.

Based on interview and record review, the facility did not ensure the resident's environment remained as free of accident hazards as possible, and residents received adequate supervision and assistive devices to prevent accidents. This occurred for 2 of 4 residents (R) who were reviewed for falls (R29 and R37) and 1 of 1 Resident (R37) who was reviewed for wandering. R29 and R37 had falls while at the facility and both residents did not have fall risk assessments completed at the required frequency. R37 was identified as an explorer but had never had an elopement risk assessment completed. Findings include: The facility policy, entitled Falls Prevention and Assessment, dated 2/28/23, states: Recognition of risk .Complete fall (safety) assessment reviewing physical abilities and activity level upon admission, quarterly and with change of condition . Example 1 On 9/26/23, Surveyor reviewed R29's record and identified R29 was admitted to the facility on [DATE] with diagnoses including, in part, diabetes, anxiety, deep vein thrombosis, long term use of anticoagulants, atrial fibrillation, mental and behavioral disorders, and dementia. R29's care plan stated resident was at risk for injuring self due to fall risk with appropriate interventions in place. R29's fall risk assessments were completed in August 2022 and November 2022. No further fall risk assessments were completed for R29. The fall risk assessments should have been completed at least quarterly. On 9/26/23 at 10:10 AM, Surveyor interviewed the Assistant Director of Nursing (ADON) C to see if there was a recent fall risk assessment completed on R29. ADON C said they do not have any fall risk assessments completed this year for R29. Surveyor asked ADON C what the expectation was for completing fall risk assessments on the residents. ADON C said fall risk assessments are to be completed upon admit, quarterly, and if any changes of condition or concerns. Example 2 On 9/26/23, Surveyor reviewed R37's record and identified R37 was admitted to the facility on [DATE] with diagnoses including, in part, dementia, Alzheimer's, vascular dementia with anxiety, restlessness and agitation, unsteadiness on feet, repeated falls and diabetes. R37's care plan stated resident was at risk for injuring self due to fall risk and wandering with appropriate interventions in place. R37's fall risk assessments were completed in August 2022, February 2023, and August 2023. No further fall risk assessments were completed for R37. The fall risk assessments should have been completed at least quarterly. R37 did not have an elopement risk assessment completed. R37's minimum data set (MDS) assessment completed 7/19/23 stated R37 had behavior of wandering daily. R37's orders indicated .Explorer: remind staff to check whereabouts every 30 minutes. Check every AM to ensure bracelet is on to identify as an explorer . On 9/26/23 at 11:32 AM, Surveyor interviewed Certified Nursing Assistant (CNA) H about if R37 had ever eloped out of the building. CNA H said no, R37 had not left the building or attempted to leave. CNA H said R37 did wander the hall and was easily redirected. On 9/26/23 at 11:50 AM, Surveyor interviewed CNA I about if R37 had ever eloped out of the building. CNA I said R37 had not left the building. R37 usually just wanders in the hall. CNA I said about 1 year ago R37 was found looking out the outside door at the end of the hall, so R37 was placed on the wandering list. R37 was also on every 15-minute checks for falls/wander risk. On 9/27/23 at 10:00 AM, Surveyor asked Registered Nurse (RN) G for R37's fall risk assessments and elopement risk assessments. On 9/27/23 at 10:25 AM, RN G provided R37's fall risk assessments that included only August 2022, February 2023, and August 2023. No other fall risk assessments provided for R37. RN G said R37 does not have an elopement risk assessment completed.

Based on interview and record review, the facility did not ensure 2 of 16 residents (R) R29 and R16, reviewed for comprehensive care plans had a developed care plan specific to the resident. R29 had a diagnosis of deep vein thrombosis (DVT) and atrial fibrillation, requiring the use of anticoagulation medication (Eliquis). R29 did not have a comprehensive care plan to include the risk of bleeding due to the use of Eliquis. R16 has a Suspected Deep Tissue Injury (SDTI). R16 did not have a comprehensive care plan to address the SDTI. This was evidenced by: Example 1 On 9/26/23, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] with diagnoses in part to include DVT, atrial fibrillation, long term (current) use of anticoagulants, and dementia. R29's orders indicated R29 was prescribed Eliquis 5mg (milligram) twice per day for deep vein thrombosis starting on 6/13/22. Review of R29's care plan showed there was nothing written concerning anticoagulation use and the risk of bleeding. On 9/26/23 at 10:17 AM, Surveyor asked Assistant Director of Nursing (ADON) C if there was anything in R29's care plan concerning anticoagulation use and the risk of bleeding. ADON C could not find anything in R29's care plan that included anticoagulation use or bleeding risk. 40590 Example 2 Braden scale, completed on 07/19/23, shows a score of 15 indicating mild risk for pressure injury development. Nurses' notes, dated 07/28/23, states that a SDTI was noted to R16's right great toe. Initial assessment, dated 07/28/23, states that R16 tends to slide down in bed at which point R16's toes touch the footrest. R16 wears pressure relief boots but these will slide up as she slides down exposing her toes due to foot drop. Interventions in nurses' note state to remove the Velcro padding from the footboard as this was touching R16's toes. The padding between the foot board and mattress was moved upward above the foot board to keep R16's toes from touching the foot board. R16's Activated Durable Power of Attorney (ADPOA) refused the pressure relieving boots and heels up cushion stating that it did not look very comfortable for R16. The physician was updated on 07/28/23 and an order was received to apply betadine to right great toe two times a day. R16 does not have a care plan in place for the SDTI on the right great toe. On 09/26/23, Surveyor requested the care plan for R16's SDTI from ADON C, who is also the facility wound care nurse. R16's care plan for SDTI was received from ADON C with a creation date of 09/26/23, after Surveyor requested the care plan.

Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for fall concerns, out of a total sample of 3 (R1). On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without waiting for a second person to assist as directed in R1's care plan. R1 rolled off the bed and fell approximately 4 feet to the floor. R1 suffered multiple fractures and a secondary fat emboli secondary to multiple fractures. This created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was informed of the Immediate Jeopardy on [DATE] at 1:50 PM. On [DATE], the facility recognized the deficient practice by the CNA and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed and corrected on [DATE]. This is being cited as past noncompliance. Evidenced by: The facility policy entitled Fall Prevention and Management, revised [DATE], includes, in part: . Policy: The policy of this facility to minimize or avoid resident falls. All residents will be observed and assessed for fall risks with a preventative intervention implemented (as applicable) on admission, quarterly and with a condition change or fall. Staff will reduce fall risks and risk of fall related to injuries while maximizing quality of life. Process: All residents will be monitored for safety. Staff will identify and report all safety concerns to their supervisor or administration. [Facility Name] will collect data regarding falls to share with QAPI committee for review and recommendations. Procedure: All residents in the facility are potentially at risk for falls. Staff will recognize and/or identify who is at risk so they may appropriately assess, treat, and monitor for fall prevention . According to For Elderly, Even Short Falls Can Be Deadly: Adults 70-Plus Three Times as Likely to Die Following Low-Level Falls (Science Daily [DATE]), .ground level falls, essentially falls from a standing position, with feet touching the ground prior to the fall, have traditionally been considered minor injuries. But the new study found elderly adults - [AGE] years of older - who experience ground-level falls are much more likely to be severely injured and less likely to survive their injuries compared to adults younger than [AGE] years. Elderly patients are three times as likely to die following a ground-level fall compared to their under-70 counterparts .approximately 4.5 percent of elderly patients ([AGE] years and above) died following a ground-level fall, compared to 1.5 percent of non-elderly patients. Elderly patients remained in the hospital and the intensive care unit longer and only 22 percent were able to function on their own after they left the hospital, compared to 41 percent of non-elderly patients. https://www.sciencedaily.com/releases/[DATE].htm According to the Center for Disease Control (CDC), Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. According to the CDC, falls are the most common cause of traumatic brain injuries; traumatic brain injury accounts for 46% of fatal falls among older adults (those 65 or older). Among older adults, falls are the leading cause of injury death and are the most common cause of nonfatal injuries and hospital admissions for trauma. The CDC notes that in 2008, over 19,700 older adults died from unintentional fall injuries. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. R1, who was [AGE] years old, was admitted to the facility on [DATE] with diagnoses including in part, CVA (cerebral vascular accident), Hemiplegia and Hemiparesis following intracerebral hemorrhage affecting left non-dominant side, aphasia, and dementia. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] indicates R1 has a BIMS (Brief Interview for Mental Status) score of 6 out of 15, indicating she has moderate cognitive impairment. R1's MDS indicates she is dependent of two staff for bed mobility and transfers, is extensive assist of two staff members for dressing and toileting, and extensive assistance of one staff member for hygiene. R1's Comprehensive Care Plan, dated [DATE], includes in part: . I: can't complete my cares on my own. Because I: have left sided paralysis due to a stroke, have left sided neglect following stroke, confusion/anxiety following stroke. I Show This By: needing assistance with cares, unable to move left arm and leg independently, occasional refusals with cares, ADL (activities of daily living) restorative program discontinued due to lack of participation (,d+[DATE]). I: need help transferring and repositioning. Because I: have left sided paralysis due to a stroke, weak muscles, have a right femur fracture (non-surgical). I Show This By: being unable to move left arm and leg independently, prefer to stay in bed. I Reposition in Bed: with the help of 2 people, I use bilateral grab bars (Per POA request), I get up late morning and to bed around 1830 (6:30 PM). Provide clear instructions and reassurance with repositioning. R1's Comprehensive Care Plan, dated [DATE], includes in part . I am at risk for injuring myself. Because I had a stroke with left sided paralysis, confusion/anxiety following stroke. I Show This By: poor balance, no longer safely transferring with the EZ stand requiring Medi lift transfer, recent fall with right femur fracture, unable to use a wide mattress as she requires an air mattress due to high risk of skin breakdown, need two people to assist with repositioning and bed mobility. In The Past: I have fallen in facility, I have a PT (physical therapy) evaluate for transfers (,d+[DATE]), a sign was used to use call light for assistance-no longer needed as I am physically unable to transfer independently and have not made attempts to self-transfer. I need my aides to--- Left side tray table up and foot pedals on w/c (wheelchair) when in wheelchair and tuck left arm in while transferring (now a Medi lift transfer ,d+[DATE]), reposition and provide cares with assist of 2. R1's Certified Nursing Assistant (CNA) Care Card, includes, in part: . Bed mobility: Turn side to side, two staff assist with bed mobility and cares. R1's Incident Report, dated [DATE] at 5:30 AM, includes in part . Describe Event: Resident was having incontinent care done at 5:15 AM. She slid down the left side of bed and she hit left side of forehead on floor. In assessment, her right leg and hip were externally rotated, and her right leg was a little shorter than the left. Root Cause Analysis: she was turned during cares towards window with assist of 1. 5 Why: Resident is assist of 2 for repositioning. Injury: Completed skin check and Inspection of head injury. Complaints Of: pain with the right hip. Range of Motion: Shortening/Lengthening of limbs present: shortening of right leg. Rotation: external rotation of the right leg. Pain: complaints of pain right hip. Actions: transferred to emergency room . Hospital Notes dated [DATE] at 6:52 AM, state the following in part . [AGE] year-old female nursing home resident with an activated POA (power of attorney) here with RLE (right lower extremity) deformity after a fall OOB (out of bed). On exam, she has evidence of head trauma with a left frontal cephalohematoma as well as an RLE (right lower extremity) external rotation and shortening. Concern for hip fracture. Will CT head and C-spine given her inability to provide much history and previous deficits ,d+[DATE] (secondary to) CVA as well as right hip and chest given anticipated OR as well as questionable hypoxia. Without pain now, but fentanyl prn (as needed) to facilitate imaging. 1. I independently reviewed the pt.'s (patients) x-rays and CT scans and my personal interpretation shows no acute fx (fracture). Results d/w (discussed with) POA/brother (Power of Attorney) and pt. is non-ambulatory at baseline and agrees w/not (with not) pursuing further imaging for definitive fx (fracture) identification. Pt dc'd (discharged ) for PCP (primary care physician) f/u (follow up) and fall safety precautions. Pt's brother verbalized understanding and denied further questions. Return precautions given verbal and written. Head CT without contrast: 2. Extensive encephalomalacia (softening or loss of brain tissue) in the right cerebral hemisphere in the region of prior hemorrhage seen in 2017. Nurses Note, dated [DATE] at 13:24 (1:24 PM), states in part . Family/Guardian Contact The resident's guardian was again contacted as the resident has noted tachycardia (fast heart rate), and tachypnea (fast breathing) with low O2 sats. This writer explained to him what was happening and the options that were available to him, of keeping her here, and keeping her comfortable, or to send back to the emergency room , for further evaluation. He stated to send her back over to be sure they did not miss something else. Nurses Note, dated [DATE] at 15:39 (3:39 PM), states in part . follow-up: fall / ER return (emergency room ): R1 returned from ER at approximately 0930 (9:30 AM). She appeared per her usual upon return, denied any pain, and was transferred with the Medi lift without difficulty. She was lying in bed and CNA stated that she was diaphoretic (cool, clammy skin) and pale at approximately 1100 (11:00 AM). Stated that the 'bump on her head hurt' give ice pack and Tylenol. At 1100 she was tachycardic with pulse with 111 and respirations of 36. At this time, she had just finished talking with staff and laughing. CMA (certified medication aide) was asked to get another set of VS (vital signs) in an hour. At 1200 she remains tachy at P: (pulse) 108 and R: (respirations) 32. Staff attempted to assist her in eating her lunch but, she only had a couple of bites. Nurse came in to do full assessment at 1215 (12:15 PM): R1 remained diaphoretic, pale, denied pain. She has L (left) sided hemiplegia; staff was assisting to apply her hand splint. Resident typically has a contracture to this hand and cannot open it fully. While applying the brace it was noted that her fingers were flaccid (loose, floppy fingers) and were not contracted at all. Her hands are warm to the touch, radial pulse is equal bilaterally. She cannot feel sensation per her usual. Apical heart rate was regular and 110 bpm (beats per minute), respirations were shallow and 40 per minute. She remained afebrile and O2 sat remained at 90% since return to [facility name]. Her O2 sat is typically in the mid 90's, heart rate in the low to mid 80's, and respirations at ,d+[DATE]. R1 appeared comfortable and was alert and talkative. She was unable to follow directions to take a deep breath for lung auscultation. She has no cough, and her lungs were clear with her shallow breaths. Her L great to [sic] was also observed to have a large bruise at the base. PA (Physician's Assistant) was called and informed of the above information along with fall and ER visit from this AM (morning). She stated to call the POA to find out his wishes: 1) to keep at [facility name] and monitor as well as keep her comfortable or 2) send her to the ER for eval again. POA-HC (Power of Attorney for Health Care), was called and wished for her to be sent in. Hospital Notes dated [DATE] at 5:11 PM, states in part . R1 is a 77 y.o. (year old) F (female) w (with) PMH (past medical history) of severe dementia with activated POA resides at SNF (skilled nursing facility), osteoporosis with fractures in the past who presents after a fall out of bed with a L hip fracture. I called and spoke with her POA. Orthopedic surgery wasn't sure she was a surgical candidate given her debility but will review tomorrow. When I see her she is very confused and doesn't know where she is at. Per POA this is her baseline. Most of her history is obtained via chart review. She in the ER was given 2 L (liters) NC (nasal cannula). CT was negative for PE (pulmonary embolism). Assessment and Plan: Pathologic Osteoporotic L hip fracture/moderate L knee effusion/R tibial plateau fracture. Acute hypoxic respiratory failure: suspect fat emboli syndrome, CTA (clear to auscultation) negative for PE or infiltrates. Hospital Notes dated [DATE] at 10:50 AM, states in part . Principal Diagnosis: Closed left hip fracture. Hospital Course: Diagnosis . Closed left hip fracture; fracture of right tibial plateau - likely acute on chronic - non-weightbearing. Medication List: enoxaparin (Lovenox-blood thinner) 40 mg (milligrams)/0.4 mL (milliliters), inject 0.4 mL (40 mg) under the skin daily. Closed Hip Fracture - Pt was seen by orthopedic team and surgical vs nonsurgical options were discussed and both surgery and the POA felt a nonoperative approach was appropriate. Pt is tolerating transfers w/o excessive pain and has pain meds available as well. Pt will discharge back to SNF (skilled nursing facility) with non-weightbearing status. She f/u with Ortho (Orthopedics) on a prn (as needed) basis. We are treating her with Vit D (Vitamin D) supplementation and 30 days of DVT (deep vein thrombosis) prevention dose LMWH (low molecular weight heparin). Pt will see PT/OT (physical and occupational therapy) at SNF, and they can decide if and how long to continue therapies. Fracture of right tibial plateau - Likely acute on chronic. Non-weightbearing Nurses Note, dated [DATE] at 10:54 AM, states in part . Late Entry for: [DATE] R1 was admitted with a left hip fracture-family deciding on surgery or non-operative management. Nurses Note dated [DATE] at 15:36 (3:36 PM), states . R1 returned from the hospital with diagnosis of closed L hip fx. She is verbal but, does not always answer appropriately. She has pain when repositioning or moving any extremities, unable to tell nurse where the pain is located. Oxycodone was administered and seemed to be helpful. Heart is regular but, remains tachycardic with Pulse 115. She continues with O2 sat of 91% on RA (room air) and she typically runs about ,d+[DATE]%. She does not appear to be SOB (short of breath), Respirations are 24 per minute. Lungs: intermittent wheezing noted but, mostly clear with auscultation. Her L fingers are once again contracted. She has a 12 x 6 cm bruise to her left inner upper arm. No crepitus noted to the shoulder but, she does have intermittent pain with movement of that arm. PA (Physician Assistant) was here and ordered an x-ray to be done prior to OT working with her. She continues with a dry scab to her left occipital area where she had bumped her head during the fall - almost healed. R1 has what appears to be a fractured left great toe as it is bruised on both sides and medical [sic] aspect with retraction of the toe - she is non-weight bearing - PA is aware and looked it, no new orders. There are bruises to her R posterior knee, R lateral malleolus, R hip has a very faint bruise with a firm area measuring 8 x 12 cm around this - PA aware with no new orders. Her R elbow has a dry scabbed area due to her fall also. Nurses Note dated [DATE] at 17:30 (5:30 PM), states, X-RAY: x-ray left humerus shows a mildly displaced fracture involving the surgical neck of the proximal left [sic] humerus. Remainder of the humerus is intact. PA reviewed with new orders. Nurses Note dated [DATE] at 17:37 (5:37 PM), states, The resident's POA and his wife were updated on recent x-ray results of the left upper extremity and new orders by PA. Updated that the hospital failed to recognize concerns of the left upper extremity while hospitalized , but when the resident returned to facility, we continued to have concerns due to bruising and mild pain. During today's conversation I was able to update the family on the facilities investigation, education that was provided with the CNA involved and the facilities continuous monitoring/auditing. Offered ombudsman contact information if they felt like facility was not following through appropriately, but the family declined this information. They stated they felt they know mistakes can happen and continued to communicate understanding of the situation. A review of hospital notes and facility notes indicate R1 experienced the following related to the fall . Left hip fracture Left frontal cephalohematoma (is an accumulation of blood under the scalp, specifically in the sub-periosteal space.) Left proximal humerus fracture Suspected fat emboli (is the presence of fat particles within the microcirculation, while fat emboli syndrome is the systemic manifestation of fat emboli within the microcirculation. Common systemic manifestations include respiratory distress, altered mental status, and a rash. Fat emboli syndrome is most often associated with orthopedic trauma.) Acute on chronic right tibial plateau fracture (is a break of the larger lower leg bone below the knee that breaks into the knee joint itself.) Note: During the facility annual survey in ,d+[DATE], Surveyor identified a deficient practice related to R1. It was noted on that survey that R1 was having cares performed with 1 staff member instead of the 2 which her plan of care indicated. R1 fell from the bed, sustaining right femur and right tibial plateau fractures. This is the second incident of a fall with fracture for R1 related to the facility's noncompliance with following the plan of care. On [DATE] at 9:02 AM, Surveyor interviewed R1. Surveyor asked R1 how she was doing and if she had any recent falls or concerns. R1 stated, Oh my god, yes! I fell off the bed, it was awful. I am scared to fall out of bed again. On [DATE] at 10:00 AM, Surveyor interviewed Nurse Tech D. Surveyor asked Nurse Tech D if she had a recent education? Nurse Tech D stated, Recent education done in Relias on what can do and what can't do. The nurse provides direction also. This was all within the last month. Surveyor asked where CNAs can find the information on transfers or staff needed for cares for a residents. Nurse Tech D stated, It will indicate on Kardex (CNA care plan) if one or two staff is needed, located in the nurse charting, and on the care plan. On [DATE] at 10:00 AM, Surveyor interviewed CNA E. Surveyor asked CNA E if she had a recent education? CNA E stated, Recent training in Relias and from manager. Surveyor asked where CNAs can find the information on transfers or staff needed for cares for residents? CNA E stated, It will indicate on Kardex (CNA care plan) if one or two staff is needed, located in the computer, and on the care plan. On [DATE] at 10:00 AM, Surveyor interviewed CNA F. Surveyor asked CNA F if she had a recent education? CNA F stated, Recently education provided in Relias and by manager. Surveyor asked where CNAs can find the information on transfers or staff needed for cares for a residents? CNA F stated, It will indicate on Kardex (CNA care plan) if one or two staff is needed and on the care plan. On [DATE] at 10:10 AM, Surveyor interviewed ADON C (Assistant Director of Nursing). Surveyor asked ADON C if she has received any recent training on accidents, falls, and care plans? She stated, All supervisors completed the training which included audits on how they know where to find information, ,d+[DATE] assist transfers, made observations of transfers and bed positioning. Audit was completed on all shifts. Relias training was completed on care plans and what's in the MARs (medication administration record), staff were to read and sign immediately. Facility started a PIP (performance improvement plan) that morning to ensure CNAs know where to find the information. On [DATE] at 10:30 AM, Surveyor interviewed CNA G. Surveyor asked CNA G if she has had any recent education? CNA G stated, Yes, recent education done in Relias and by the manager. Surveyor asked where CNAs can find the information on transfers or staff needed for cares for residents? CNA G stated, It will indicate on Kardex (CNA care plan) if one or two staff is needed and on the care plan. On [DATE] at 12:50 PM, Surveyor interviewed IDON B (Interim Director of Nursing), NHA A (Nursing Home Administrator), and ADON C. ADON C immediately stated that CNA I was known to study resident care plans while working even prior to this event. NHA A stated, This was CNA I's first day off her 10-day training. CNA I was previously a CNA in another facility before coming to work in this facility and prior to that she worked in a local Assisted Living Facility. She worked last night so we have not been able to get ahold of her. The night of the incident she was able to indicate that she did not look at R1's care plan prior to doing cares. CNA I had stated to NHA A that during her training it was always her and another staff member and she did not realize she was the second person for cares. NHA A states, the night of the incident she immediately came into work and began education with CNA I. CNA I has been really upset about this incident and we have been trying to provide support as needed. CNA I also completed 3 additional days of training and she completed the new hire checklist that was inadvertently missed when she first started. We believe this was missed due to having a new HR (human resources) employee. On [DATE] at 1:20 PM, Surveyor interviewed RN H (Registered Nurse). Surveyor asked RN H about the events of the day [DATE]. RN H stated, I am the night Supervisor and was called to R1's room. During my exam of R1 I noted shortening of the leg, along with internal and external rotation of the leg. Surveyor asked RN H if RN H had spoken with CNA I following the incident. RN H stated that he had started education with CNA I following sending R1 to the hospital on following the care plan and that R1 was an assist of 2 staff for bed mobility and cares. Surveyor asked RN H if he had ever witnessed CNA I not following the care plan when assisting residents prior to this event. RN H indicated he had not witnessed anything else. The facility's failure to follow R1's Care Plan resulted in R1's fall with multiple fractures. These failures created a situation of immediate jeopardy that began on [DATE]. On [DATE], the facility recognized the deficient practice by the CNA and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed on [DATE] and corrected on [DATE] when the facility implemented the following: On [DATE]: 7:00 AM CNA I was removed from the floor. It was the end of her shift. 7:00 AM Audits began immediately to capture nights and day shift on Kardex locations and purpose. And how individuals transfer/reposition. 8:00 AM Reported to La [NAME] Police dept 8:30 AM Reported to DHS MIR [NAME] 10:00 AM Reviewed CNA I's file immediately that morning. Asking HR for her file to view background check, BID, DOJ, application, references. CNA I previously a CNA at another local nursing home for over a year. CNA I worked prior to a CNA as an RCA for a local CBRF All information reviewed was good and no concerns 10:00 AM Reviewed our orientation process. At the time, all Relias training and competencies were to be completed before hitting the floor for on-the-job orientation. This was completed specifically for CNA I. 10:30 AM Interviewed residents available about the care they receive from our staff. No concerns 11:30 AM Interviewed staff that have worked with CNA I. Asked how she works with residents as a caregiver. No concerns Noon Reviewed CNA I's orientation check off list while on the floor. This was not found in CNA I's file. It was identified CNA I did not receive this tool. It was identified she completed 10 days of orientation it was her first night off orientation. PIP 1 12:30 PM called staff who orientated CNA I. Asked if they trained her on understanding person centered care and knowing what and where the Kardex/care plan is located for this information. ?All staff who we talked to agreed they did review what and where the Kardex is located with CNA I. Staff did not identify using the checklist during her orientation. Trainers will be provided additional guidance on our expectations. Will investigate Wis Caregivers process to model after. PIP 2 2:00 PM began team work on creating PIP 1 pulled information and assessed interventions/changes to improve process. 3:00PM began team work on creating PIP 2 4:30PM Reviewed Wi Caregivers Mentor training program material and saved to internal drive. Will use information to assist in creating a new process for us. In the meantime, education current trainers on using checklist in their orientation process will be created. Train using tools and ensure competencies. 4:30 PM Staff development uploaded and assigned education to all direct care staff regarding care plans and Kardex. 11:00 PM NHA came into follow up with CNA I. Interview questions: see interview write up. It is clear CNA I felt she had a thorough orientation in her 10 days. Comments made that it could have been more structured, Kardex clipboard could be labeled for better identification, Kardex could be simplified for easier means to identify important info that is necessary quickly when reviewing. She confirmed she was trained on what the Kardex is and its location. Confirmed she did not receive orientation checklist. PIP 3 Prior to CNA I working the floor she completed additional Relias Education Care plan and Kardex policy was reviewed explaining expectations of CNAs to use with all cares provided. completed and signed by CNA I. Orientation checklist was issued and discussed with [NAME], the trainer to review and orientate over the next few nights that she works to use the Kardex in all trainings. I explained our expectations of [NAME] as a trainer. On [DATE]: 7:00 AM Kardex and repositioning audits including education continued days 7:00 AM Completed a Performance Improvement Plan with CNA I defining our goals for her, extending her orientation for 3 days, review orientation checklist and admin staff being available to her for any questions. 7:30 AM Kardex clipboards were labeled as suggested by CNA I that evening. 9:00 AM Educated HR staff regarding the importance of utilizing and providing the orientation check off list 10:00 AM education provided to all agency staff on care plans and Kardex Audits of all New Orientation Check off Lists since [DATE]st show that CNA I, not receiving her checkoff list, was an isolated event. All other new staff received their checkoff list. This was an isolated event. We would ensure mentor training and/or trainer expectations would be completed prior to any new staff starting. 1:00 PM Identified which staff perform training on new hires. List compiled by Staff Scheduler. NHA was creating the education. 2:30 PM Kardex and repositioning audits continued p.m. 4:30 PM Training was developed and set for staff scheduler to review in person as many staff as she could. Material was printed and signature sheet once reviewed ready for first thing, Monday morning to capture nights staff and days immediately on Monday 11:00 PM Kardex and repositioning audits continued nights On [DATE]: 6:30 AM Began 1:1 training of trainers and reviewed expectations 7:30 AM Discussed Audits and the benefits of ongoing audits. Reached out to staff development to work on creating? PIP 4 Nursing Audit Form is being created; monthly audits brought back to QAPI with no end date. This will be seen as a triple check to ensure continued compliance. Audit to include: b. Handwashing, foley and peri care, repositioning, Kardex identification and knowing residents and their specific care PIP 1 includes new process to ensure orientation checkoff list is given to all new employees. This list MUST be completed and turned into staff scheduler prior to being scheduled to hit the floor. This would include the new employee signing off that they understand and the trainer signing off that they are competent. A completed copy will be turned into HR for personnel file. HR will audit to ensure completion of checklist prior to scheduled solo and filed in new staff's personnel folder. PIP 2 Mentor Program. All new staff working with a mentor for an entire year. Current staff will be offered this as an opportunity. They would apply for this position. The mentor would be trained to be a mentor and ensure new staff are competent. In the meantime, all trainers will be trained on expectations of them as a trainer. Audits after implemented new PIP include ensure all new staff are trained with use of individualize care plan directions, referring to them upon care with each resident. PIP 3 Kardex is being assessed how we can ensure important information stands out for CNAs to read. Font color in blue of any 2 person for repositioning and/or transfer. In addition, a new process is being created. Nurse will print CNA assignment sheet for each CNA on their hall. The assignment sheet will include repositioning and transfers. Each aid will have their own copy and can refer to it in those immediate need moments. PIP 4 Nursing Audits monthly to ensure continued compliance in nursing tasks such as handwashing, foley care, peri care, repositioning, Kardex identification and knowing each resident and the care they need. Findings will be brought to and reviewed by QAPI each month.

Based on interview, and record review, the facility did not ensure each resident received staff assistance to prevent accidents for 1 of 4 residents (R48) reviewed for incidents/accidents out of a total sample of 19. R48 has severe cognitive impairment, left sided paralysis due to stroke, and requires extensive assist of two staff with bed mobility and transfers. Staff determined that R48 was a 1 assist vs. a 2 assist without a nursing assessment and attempted to perform cares on R48 with 1 staff member rather than with the assistance of 2 staff members per R48's MDS (minimum data set) assessment. R48 was rolled away from the staff rather than towards staff resulting in a fall with a fracture of the right femur and tibial plateau. This is evidenced by: The facility Policy, titled, Falls Prevention and Assessment, updated 05/2022, states in part: . Policy: The policy of this facility to minimize or avoid resident falls. All resident's (sic) will be observed and assessed for fall risks with a preventative intervention implemented (as applicable) on admission, quarterly and with a condition change or fall. Staff will reduce fall risks and risk of fall related injuries while maximizing quality of life. Process: All residents will be monitored for safety. Staff will identify and report all safety concerns to their supervisor or administration. Procedure: All residents in the facility are potentially at risks for falls. Staff will recognize and/or identify who is at risk so they may appropriately assess, treat and monitor for fall prevention. - Document risk factors for falling in resident's care plan and discuss at care conferences. - Complete fall (safety) assessment reviewing physical abilities and activity level upon admission, quarterly and with change of condition . Per Turning patients over in bed: MedlinePlus Medical Encyclopedia it is indicated that you should stand on the opposite side of the bed the patient will be turning towards, and lower the bed rail. Move the patient towards you, then put the side rail back up. Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you. This will be the direction in which the person is turning. It is indicated that you're to turn residents towards you and not away from you when providing care/repositioning in bed with just one care giver.) R48 was admitted to the facility on [DATE] with diagnoses that include in part . anxiety disorder, [CONDITION(S)] with behavioral disturbance, delusional disorders hallucinations, personal history of other mental and behavioral disorders [CONDITION(S)] (Post Traumatic Stress Disorder), and dysphagia following nontraumatic intracerebral hemorrhage. R48's Annual Minimum Data Set (MDS) dated [DATE] indicates R48's Brief Interview of Mental Status (BIMS) is 03, indicating severe cognitive impairment. R48 has an Activated Health Care Power of Attorney (HCPOA). Section G0110, Functional Status, bed mobility extensive assistance of two staff, transfers dependent of two staff, and dressing, toileting, and hygiene extensive of one staff. Section G0400, Functional Limitation in Range of Motion: Upper Extremity - Impairment on one side. Lower extremity - Impairment on one side. Section H0300, always incontinent of urine. Section H0400, always incontinent of bowel. R48's Comprehensive Care Plan, dated 6/13/22, states in part . Problem: I: can't complete my cares on my own. Because I: have left sided paralysis due to a stroke, have left sided neglect following stroke, confusion/anxiety following stroke. I Show This By: needing assistance with cares, unable to move left arm and leg independently, occasional refusals with cares. I Reposition in Bed: with the help of 1-2 people, I use bilateral grab bars (per POA request), I go to bed about 2000 [8:00 PM] and up about 0700 [7:00 AM] but usually get up late morning and to bed around 1830 [6:30 PM]. I Transfer: with the help of 2 people and a Medi lift [full body lift]. I Toilet: (no male staff please), wear incontinent brief, check/change with cares, repositioning, mealtimes, HS [bedtime] and as needed. (R48's MDS assessment on 6/1/22 indicates she needs extensive assistance from 2 staff for bed mobility (moving to/from lying position, turning side to side, and positioning of the body while in bed or alternate sleep furniture.) and R48's care plan dated 6/13/22 indicates 1-2 for repositioning in bed. R48's care plan does not address when it's appropriate for staff to use 1 vs. 2 for bed mobility. CNA staff are not able to determine if a resident is safe for 1 vs. 2 assist, due to CNA's cannot assess a Residents mobility status as it is not in their scope of practice. R48 according to her MDS functional status assessment is to be a 2 person assist with bed mobility/positioning.) The facility document, titled, Fall Risk Assessment, dated 3/24/20, states in part: . Total Score: 6. Risk: Resident is not at risk. (Note: Per facility policy staff will recognize and/or identify who is at risk so they may appropriately assess, treat, and monitor for fall prevention. A fall risk assessment has not been completed for R48 since 3/24/20, indicating staff have assessed R48's fall risk potential in the last 2 years.) The facility document, titled, Fall Report, dated 6/20/22 at 15:10 [3:10 PM], states in part: . Location: resident's room. Describe Event: Staff member was changing residents brief/cleaning her up, resident was holding the grab bar wit [sic] her good hand, resident then began to slip and lean off the bed. Staff member, CNA D attempted to pull her back but couldn't hold her weight up as she rolled off the bed onto the floor. 5 Why's: Resident has poor balance, resident has had a stroke and has left sided paralysis, resident is confused, resident is unable to assist with transfer/rolling. Injury: Inspection of head for injury - superficial abrasion/bump to crown of head and left occipital area. Ice applied to areas. Actions: Continue to observe, continue with neurochecks per protocol, ice applied to bumps on head. Risk education: Necessary that resident is an assist of 2 for any/all cares/repositioning. Clinician Notified: PA-C H (Physician Assistant-Certified). Date: 6/20/22. Time: 15:40 [3:40 PM]. (Fall report indicates that R48 is unable to assist with transfer/rolling, the CNA rolled R48 without a 2nd person to assist with R48's cares. ) On 7/13/22 at 2:51 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D if she could describe what happened on 6/20/22 when R48 fell while she was completing cares. CNA D stated, I was in doing her cares and I had her turned on her left side. R48 reached over and was trying to grab something on her nightstand and moving her feet. I reached over her waist to stop her from rolling out of the bed it didn't work and she rolled out of bed. I got the nurse and all that good stuff. I don't know for sure what assist she needed I always did her with one assist, but I usually work the 800 wing or float. The Nurses assessed her and did her vitals. R48 did not complain of pain she was mostly scared, and I would be too. The bed was at waist level when she fell . We got a medi lift to get her up and put her back into bed. Surveyor asked CNA D if R48 was noted to have any injury after the fall. CNA D stated, When she fell , she rolled under bed and hit her head. She needed to ice her head, then we just monitored her the rest of the night. Surveyor asked CNA D if she ever received any education following the fall. CNA D stated, After the fall they didn't really talk with me about it, but I have been asking for more help lately. I just am using two from now on. She won't roll in her bed unless someone is there to console her, she gets very paranoid and scared, just since the fall. (Note: Subsequent nursing assessments indicate there is only movement in the right arm. Cross reference F580.) Nurses Note from 6/21/22 at 10:02 AM, states, Musculoskeletal Status: Recent incident where the resident fell from bed during repositioning. Neuro checks have been initiated. During repositioning today, resident was fearful and having discomfort along the right lower extremity. No shortening or lengthening of the extremity noted. No bruising or redness noted. Discomfort with bending of her knee and lifting the leg up. Due to cognitive deficits, she was unable to describe where the pain was exactly. She would rub her right thigh with movement of the leg. PA-C H was updated with new orders provided. Nurses Note from 6/21/22 at 13:20 [1:20 PM], states, X-Ray: Findings: AP and lateral views are obtained. Visualization is limited. There is a fracture of the medial aspect of the distal metaphysis of the femur, seen best on the AP view. Milk impaction is present. Detail is poor in the lateral view. There appears to be a joint effusion. Impression: Fracture medial aspect of the distal metaphysis of the femur with mild impaction and an associated hemarthrosis. MD [Medical Doctor] Updated. Action: Family notified POA [Power of Attorney] was updated by DON B [Director of Nursing]. Reported xray results that MD stated she would need to be evaluated in the EW [sic] to see if surgery was needed. POA requested that she be sent over for evaluation. Nurses Note from 6/21/22 at 14:13 [2:13 PM], states, Resident has been kept on bedrest waiting for x-ray. When asked, resident will admit to pain/discomfort, and states, it's my right leg. VSS [vital signs stable]. Neuro checks WNL [within normal limits]. Resident appeared to be having discomfort vs anxiety when turned in bed. Resident was given Tylenol PRN [as needed] which was not effective in reducing pain, per the resident. X-ray present and complete. X-ray results back and POA called. Ambulance here and resident taken via stretcher to [Hospital Name]. Hospital Admission History and Physical from 6/21/22, states in part . R48 is a 76 y.o. [year old] female with PMH [personal medical history] of dementia with activated POA, history of hemorrhagic stroke with left-sided [CONDITION(S)], left-sided visual neglect, [CONDITION(S)], depression, delusions. She resides at [facility name] where per report she fell today. Xray was obtained showing distal fracture of her right femur. Transferred to ED [emergency department] for additional eval. In the emergency department CT R [right] knee was obtained showing: 1. Impacted and minimally displaced right distal femur fracture, which extends from the medial cortex of the distal femur metaphysis into the intercondylar notch. 2. Minimally depressed lateral tibial plateau fracture. 3. Moderate knee joint effusion. Distal right femur fracture: -CT obtained in ED - orthopedics consulted, per report will discuss management options with POA. - [MEDICATION(S)] for pain control. - NPO given uncertainty of possible intervention. Hospital Discharge Summary from 6/23/22, states in part . Non-weight bearing: Non-weight bearing right lower extremity. CPB [controlled position brace] brace to be work [sic] full-time; remove only for hygiene. CPB brace must be locked straight at all times with the exception of knee range of motion. When seated, unlock the brace to work on unrestricted motion a minimum of 3-5 times per day. Lock brace when exercises are finished. Hospital Course: R48 was admitted to the inpatient unit in stable condition on 6/21. Orthopedics was consulted. She was not felt to be a surgical candidate and non-operative management was pursued. It was felt that she her [sic] injury did not warrant anticoagulation she was not in rigid immobilization and the fracture would not change her previous level of mobility. She was discharged back to nursing home on 6/23. R48's MAR includes the following medications and changes since admission . Order 6/23/22: Tylenol 325mg, give 2 tabs [650mg] by mouth every 4 hours as needed for pain, discontinued on 6/26/22. Order 6/23/22: [MEDICATION(S)] 5mg, give 1 tablet by mouth every 6 hours as needed for pain x [times] 3 days, discontinued 6/26/22. Order 6/26/22: [MEDICATION(S)] 5mg, give 1 tablet by mouth every 6 hours as needed for pain x3 days, discontinued 6/29/22. Order 6/26/22: Tylenol 325mg, give 2 tabs (650mg) by mouth three times per day 0800 [8:00 AM], 1300 [1:00 PM], 2000 [8:00 PM] for pain, discontinued 7/08/22. Order 6/26/22: Tylenol 325mg, give 2 tabs (650mg) by mouth daily prn [as needed] for pain, discontinued 7/08/22. Order 6/29/22: [MEDICATION(S)] 5mg, give 1 tablet by mouth every 6 hours as needed for pain through 7/12/22, discontinued 7/11/22. Order 7/08/22: Tylenol 500mg, give 2 tabs (1000mg) by mouth three times per day 0800 [8:00 AM], 1300 [1:00 PM], 2000 [8:00 PM] for pain. Order 7/11/22: [MEDICATION(S)] 5mg, give 0.5 tablet/2.5mg by mouth every 6 hours as needed for pain, discontinued 6/29/22. On 7/13/22 at 11:10 AM, Surveyor interviewed Nurse Tech E. Surveyor asked Nurse Tech E if she could describe what happened with R48's fall on 6/20/22. Nurse Tech E stated, Basically what happened is, I got called by the staff to come into R48's room. A single staff was doing cares and she was doing cares alone. The CNA said R48 must not have had a good grip on the grab bar. R48 was on her left hip holding the grab bar with right hand while cares were being done. The CNA also said that she was leaning forward, she couldn't pull her back, and she fell off the bed. I called the Supervisor, then we got her up off the floor with the medi lift and 3 staff assist. Further assessment was completed once R48 was in bed. Neuro assessment showed, bumps in two spots but no bleeding. Surveyor asked Nurse Tech E if she was aware of what the care plan said for R48's assistance need prior to the fall. Nurse Tech E stated, I believe in the chart she was a two staff assist but with staffing shortages people started doing her 1 assist, she usually rolls really well, and we never had issues before this. She is now always two assist, and we try to give her PRN pain medication before moving her for pain control. She has been anxious since this happened, so we always do two assist. Surveyor asked Nurse Tech E if any discussion was had with the CNA following the fall. Nurse Tech E stated, We discussed how it should be two assist after the fall with the CNA and she would need to wait for assistance. Surveyor asked Nurse Tech E who is able to decide if a resident is one or two assist. Nurse Tech E stated, I am not sure if therapy decides or the nurse/CNA. We talk amongst ourselves. (Nurse Tech E indicated that R48's chart indicated R48 is a two staff assist and due to staff shortages, staff started providing cares as 1 assist.) On 7/13/22 at 3:22 PM, Surveyor interviewed DON B. Surveyor asked DON B if she could describe what happened on 6/20/22 when R48 fell . DON B stated, On the PM shift the aides were going into to do cares and the resident grabs the grab bar when rolled on to the side. R48 did not grab the grab bar and fell to the floor. Surveyor asked DON B if R48 complained of pain following the fall. DON B stated, She was not having very bad pain and (was) not weight bearing. She had no pain that was different for her until morning. When went to get up or sometime in the morning she complained and that is when they noted pain was more than expected. Staff called for Xray, called MD and asked about sending to ER versus not. PA-C H said ortho needed to sign off and the POA was updated. The POA wanted R48 to be sent and have her evaluated. R48 was considered a nonsurgical candidate. She came back with the brace and non-weight bearing. Since R48 has been back her anxiety vs pain control has been a challenge. R48 has history of [CONDITION(S)], and she is scared now but unable to get exactly what she is scared of. Surveyor asked DON B if R48 takes anything for pain related to the fracture. DON B stated, Recently R48 was switched to [MEDICATION(S)] to keep her comfortable. Surveyor asked DON B what staff can determine if a resident is a one or two assist. DON B stated, The CNA cannot decide if a resident can be 1 or 2 assist. That needs to come from the Nurse or therapy. (R48's care plan indicates 1-2 for bed mobility, where her MDS indicates she needs extensive assistance of 2. The CNA determined R48 could be assisted by 1 instead of 2 for her cares, when a CNA is not able to assess or determine a residents care needs or fall risk potential.) On 7/13/22 at 2:58 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F if she could describe what happened with R48's fall on 6/20/22. RN F stated, So what happened was just came on duty and I walked out, and they said they needed me in R48's room. CNA D was doing her cares and her weight shifted and she fell out of bed onto the floor. Surveyor asked RN F if she was aware what the care plan said for staff assistance for R48. RN F stated, Initially one person would do her cares but after that I changed the care plan to two assist. The care plan did say 1-2 assist and ADON G (Assistant Director of Nursing) was in building still and I talked with her, and she said two assist at all times. Surveyor asked RN F who is able to decide if a resident is one or two assist. RN F stated, Any nursing staff can make that decision. When there is an incident, we have to put an intervention in place. It depends on if they are able to reposition or the resident is cooperative then could use one. CNA D has done it before in the past with one assist. The CNAs are able to determine if a resident is one or two assist. They let us know if something needs to be assessed. We go by what the CNAs think, they are the ones that are doing the cares and they can come to us if something is going on and more assistance is needed. Surveyor asked RN F if any education was given to CNA D following R48's fall. RN F stated, Told CNA's that R48 was to be a two assist at all times that is all. The facility failed to ensure R48 received adequate staff assistance, due to CNA D assisting R48 alone, without having a nurse assess her ability to be a 1 vs. a 2 assist at that time, and despite R48's MDS indicating she needed 2 assist with bed mobility. The CNA did not roll R48 towards her when assisting R48 alone, as she rolled R48 away from her, which resulted in R48 having a shift in her gravity point and body weight that resulted in R48 falling out of the bed and sustaining a fracture.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 59 residents. The sanitizing solution in the kitchen's three compartment sink did not meet manufacturer parts per million (PPM) requirements. An ice machine was observed with rust-looking residue on the interior. Hood vents were observed with clumping dust. Findings include Example 1 The facility's main kitchen uses a three compartment sink to wash larger pots and pans as a supplement to the dishwashing machine. One of these compartments uses a sanitizing agent to complete the dishwashing process. Sanitizer dispenses from a machine through a hose into the sink basin. On 7/13/22 at 10:11 AM, Surveyor observed multiple kitchen staff using the three-compartment sink to wash dishes. On the wall above the sink and on a nearby wall, Surveyor observed signs prepared by: 1) the sanitization manufacturer, 2) the company that services the facility's dishwashing equipment, and 3) the facility. Each sign stated the sanitization of the three-compartment sink was to be tested at a temperature of 75 degrees Fahrenheit and was to reach 200 PPM (Parts Per Million). Additionally, the posting by the sanitization manufacturer states, Testing sanitizer solution above or below recommended temperatures may result in inaccurate reading. Surveyor then tested the temperature of the sanitizer siting in the sink and found it to be 92 degrees. Surveyor then put sanitizer in a cup and waited for the sanitizing solution temperature to cool. At 10:30 AM, Surveyor, along with DM I (Dietary Manager), tested the solution at a temperature of 77 degrees Fahrenheit. The manufacturer recommended test strips were used to test the solution and did not change color, indicating the solution's PPM was 0. DM I observed and agreed the test strip did not change color. On 7/14/22 at 9:24 AM, DM I stated to Surveyor that the water that comes from the sanitizer hose is a perfect blend of sanitizer and water. Additional water does not need to be added from the faucet that sits over the sink, but staff were adding water to the sanitizing solution because the solution was coming out so hot. Therefore, when staff were attempting to cool the solution, they were inadvertently diluting it. Example 2 On 7/11/22 at 10:46 AM, Surveyor observed, in the main kitchen's ice machine, a rust-looking residue on the ceiling of the ice machine. Surveyor was able to wipe the residue off, which had a sand or dust-like consistency to it. At 10:48 AM, DM I stated to Surveyor that the ice machine needed cleaning and was missed. Example 3 On 7/11/22 at 10:31 AM, Surveyor observed clumps of dust on the hood vents in the facility's main kitchen. The visible clumps of dust were located above a stove top that was currently being used by facility staff to prepare food. DM I acknowledged the clumps of dust on the hood vent and stated that the hood vents are deep cleaned twice per year, but may need to be cleaned more regularly on an as-needed basis.

Based on observation, interview, and record review the facility did not ensure that each resident and his/her family member received a written summary of the baseline care plan for 2 of 19 (R43 and R52) sampled and 3 of 3 supplemental residents (R3, R45, and R47) reviewed. The facility had no evidence that they provided a written summary of the resident baseline care plan for R3, R43, R45, R47, and R52. Evidenced by: Facility policy titled Care Plan-Development and Updating, last revised 3/31/22, states in part: .Procedure: Initial Care Plan: The initial care plan will be started on the day of admission by nursing and social services if necessary. Residents have the right to participate in the development and implementation of his or her person-centered plan of care initially and as updates occur. Updates to this will continue until the finalized care plan is finished on day 21. Care plans are developed by the care conference interdisciplinary team. The resident/representative must be included in this process. The resident/representative shall be provided a summary of the care plan including initial goals, meds, treatments, and diet. The initial care plan is finalized on day 21. Example 1 R3 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R3's care plan with R3 or her representative within 48 hours of admission. Example 2 R43 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R43's care plan with R43 or her representative within 48 hours of admission. Example 3 R45 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R45's care plan with R45 or her representative within 48 hours of admission. Example 4 R47 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R47's care plan with R47 or his representative within 48 hours of admission. Example 5 R52 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R52's care plan with R52 or his representative within 48 hours of admission. On 7/13/22 at 3:06 PM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C who completes the residents' initial care plan. RN C stated, The Nursing staff does. The yellow sheet is completed on admission by the admission nurse which varies. Surveyor asked RN C if anyone reviews the initial care plan with the resident or their representative. RN C stated, I know someone does but I am not sure who, maybe the social worker or the MDS [Minimum Date Set] Nurse. On 7/13/22 at 3:24 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B process for completing the initial care plan. DON B stated, Initial care plan are completed in the first 48 hours on the yellow sheet of paper. In the first care conference the care plan is reviewed by the resident and/or their representative and signed then. On 7/14/22 at 11:32 AM, Surveyor again spoke with DON B. DON B stated, I did not realize there was a difference between the initial care plan and the comprehensive care plan.

Based on interview, and record review, the facility did not ensure each residents physician was notified of a change in condition for 1 of 4 residents (R48) reviewed for incidents/accidents out of a total sample of 19. R48 fell on [DATE], resulting in a fracture of the femur and tibial plateau. R48 is indicated as not being able to move her RLE (right lower extremity). R48's PA-C H (Physician Assistant) was not informed of R48's change in ROM (range of motion) to her RLE until 6/21/22. This is evidenced by: The facility Policy, titled, Falls Prevention and Assessment, updated 05/2022, states in part: .Process: All residents will be monitored for safety. Staff will identify and report all safety concerns to their supervisor or administration. Procedure: .When a resident falls, the nurse needs to immediately evaluate head, neck spine and extremities to determine evidence of significant injury, need for emergency assistance or first aid. - Preform head to toe skin assessment, assess further range of motion of extremities, determine by inspection or report of resident or witness if resident hit their head, if so begin neurochecks per facility protocol and notify provider immediately. - Transfer resident to the hospital if they exhibit; uncontrolled bleeding, probable fracture, deformity of limbs, acute change of neurological status or condition or changes in functional status after discussing findings with provider and resident and/or POA-HC-A (Power of Attorney - Healthcare - Activated). R48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (R48 has left sided parlysis due to a stroke) R48's Annual Minimum Data Set (MDS) dated [DATE] indicates R48's Brief Interview of Mental Status (BIMS) is 03, indicating severe cognitive impairment. R48 has an Activated Health Care Power of Attorney (HCPOA). Section G0110, Functional Status, bed mobility extensive assistance of two staff, transfers dependent of two staff, and dressing, toileting, and hygiene extensive of one staff. Section G0400, Functional Limitation in Range of Motion: Upper Extremity - Impairment on one side. Lower extremity - Impairment on one side. Section H0300, always incontinent of urine. Section H0400, always incontinent of bowel. R48's Comprehensive Care Plan, dated 6/13/22, states in part . Problem: I: can't complete my cares on my own. Because I: have left sided paralysis due to a stroke, have left sided neglect following stroke, confusion/anxiety following stroke. I Show This By: needing assistance with cares, unable to move left arm and leg independently, occasional refusals with cares. I Reposition in Bed: with the help of 1-2 people, I use bilateral grab bars (per POA request), I go to bed about 2000 [8:00 PM] and up about 0700 [7:00 AM] but usually get up late morning and to bed around 1830 [6:30 PM]. I Transfer: with the help of 2 people and a Medi lift [full body lift]. I Toilet: (no male staff please), wear incontinent brief, check/change with cares, repositioning, mealtimes, HS [bedtime] and as needed. The facility document, titled, Fall Report, dated 6/20/22 at 15:10 [3:10 PM], states in part: . Location: resident's room. Describe Event: Staff member was changing residents brief/cleaning her up, resident was holding the grab bar wit [sic] her good hand, resident then began to slip and lean off the bed. Staff member, CNA D attempted to pull her back but couldn't hold her weight up as she rolled off the bed onto the floor. 5 Why's: Resident has poor balance, resident has had a stroke and has left sided paralysis, resident is confused, resident is unable to assist with transfer/rolling. Injury: Inspection of head for injury - superficial abrasion/bump to crown of head and left occipital area. Ice applied to areas. Actions: Continue to observe, continue with neurochecks per protocol, ice applied to bumps on head. Risk education: Necessary that resident is an assist of 2 for any/all cares/repositioning. Clinician Notified: PA-C H (Physician Assistant-Certified). Date: 6/20/22. Time: 15:40 [3:40 PM]. (There is no indication that the PA-C H was updated on R48's change in ROM to her RLE at this time. ) Nurses Note dated 6/20/22 at 16:55 [4:55 PM] states in part . Date: 6/20/22. Time: 15:30 [3:30 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 157/89, P 104, R28, Temp. 98.1. Nurses Note dated 6/20/22 at 20:48 [8:48 PM] states in part . Date: 6/20/22. Time: 15:45 [3:45 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 138/89, P 108, R22, Temp. 97.5. Nurses Note dated 6/20/22 at 20:49 [8:49 PM] states in part . Date: 6/20/22. Time: 16:00 [4:00 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 139/85, P 101, R20, Temp. 97. Nurses Note dated 6/20/22 at 20:50 [8:50 PM] states in part . Date: 6/20/22. Time: 16:15 [4:15 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 140/84, P 104, R18, Temp. 97.9. Nurses Note dated 6/20/22 at 21:06 [9:06 PM] states in part . Date: 6/20/22. Time: 16:30 [4:30 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 128/81, P 103, R17, Temp. 98.1. Nurses Note dated 6/20/22 at 21:07 [9:07 PM] states in part . Date: 6/20/22. Time: 17:30 [5:30 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 125/79, P 104, R18, Temp. 97.7. Nurses Note dated 6/20/22 at 21:08 [9:08 PM] states in part . Date: 6/20/22. Time: 18:30 [6:30 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 132/79, P 107, R18, Temp. 98.1. Nurses Note dated 6/20/22 at 21:09 [9:09 PM] states in part . Date: 6/20/22. Time: 19:30 [7:30 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 118/71, P 113, R17, Temp. 98.3. Nurses Note dated 6/20/22 at 21:10 [9:10 PM] states in part . Date: 6/20/22. Time: 20:30 [8:30 PM]. Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 112/75, P 110, R19, Temp. 98.0. Nurse Note dated 6/21/22 at 5:25 AM, states, Recent fall: Resident has denied pain related to recent fall this shift. Nurses Note dated 6/21/22 at 6:08 AM, states in part . Level on Consciousness: full conscious (awake, aware, oriented). Movement: right arm only. Hand grasps: equal and strong left weakness. Speech: clear. Vital Signs: BP 143/82, P 106, R16, Temp. 98.0. (Note: All assessments up to this point indicate there is only movement in the right arm and no indication that a medical provider was updated.) Nurses Note from 6/21/22 at 10:02 AM, states, Musculoskeletal Status: Recent incident where the resident fell from bed during repositioning. Neuro checks have been initiated. During repositioning today, resident was fearful and having discomfort along the right lower extremity. No shortening or lengthening of the extremity noted. No bruising or redness noted. Discomfort with bending of her knee and lifting the leg up. Due to cognitive deficits, she was unable to describe where the pain was exactly. She would rub her right thigh with movement of the leg. PA-C H was updated with new orders provided. Nurses Note from 6/21/22 at 13:20 [1:20 PM], states in part, X-Ray: Findings: AP and lateral views are obtained .Impression: Fracture medial aspect of the distal metaphysis of the femur with mild impaction and an associated hemarthrosis. MD [Medical Doctor] Updated. Action: Family notified POA [Power of Attorney] was updated by DON B [Director of Nursing]. Reported xray results that MD stated she would need to be evaluated in the EW [sic] to see if surgery was needed. POA requested that she be sent over for evaluation. Nurses Note dated 6/21/22 at 13:59 [1:55 PM] states in part . Date: 6/21/22. Time: 11:00 AM. Level on Consciousness: full conscious (awake, aware, oriented). Movement: no/unusual movement. Hand grasps: left weakness. Vital Signs: BP 124/82, P 100, R20, Temp. 97.4. Hospital Admission History and Physical from 6/21/22, states in part . R48 is a 76 y.o. [year old] female with PMH [personal medical history] of dementia with activated POA, history of hemorrhagic stroke with left-sided [CONDITION(S)], left-sided visual neglect, [CONDITION(S)], depression, delusions. She resides at [facility name] where per report she fell today. Xray was obtained showing distal fracture of her right femur. Transferred to ED [emergency department] for additional eval. Hospital Discharge Summary from 6/23/22, states in part . It was felt that she her [sic] injury did not warrant anticoagulation she was not in rigid immobilization and the fracture would not change her previous level of mobility. She was discharged back to nursing home on 6/23. On 7/13/22 at 3:22 PM, Surveyor interviewed DON B realted to R48's fall. Surveyor asked DON B if she would be able to locate any pain or range of motion charting following the fall. DON B stated, I would expect they would have done a pain and range of motion assessment. The nurse needed to complete those before she got R48 up off the floor and pain should have been documented every shift. On 7/13/22 at 2:51 PM, Surveyor interviewed CNA D related to R48's fall. Surveyor asked CNA D if R48 was noted to have any injury after the fall. CNA D stated, When she fell , she rolled under bed and hit her head. She needed to ice her head, then we just monitored her the rest of the night. On 7/14/22 at 8:31 AM, Surveyor interviewed RN C. Surveyor showed RN C Neuro Assessments completed on R48. Surveyor asked if the documentation of movement in only the right arm would have been a normal finding for R48. RN C stated, 'Looking at the neuro sheet I would say that is a change. If you ask her to lift her leg she could, and you could move it. On 7/14/22 at 8:33 AM, Surveyor interviewed ADON G (Assistant Director of Nursing). Surveyor asked ADON G if prior to the fall on 6/20/22, R48 would be able to lift her right leg. Yes, resident was able to move right side prior to fall. Surveyor showed ADON G neuro assessments completed on R48 and asked if this would be a normal finding for R48. ADON G stated, When you look at the Neuro sheets on paper and in the computer, they indicate no movement RL (right leg), LA (left arm), LL (left leg) and she should have had movement on the RL. This would have been a change for the resident. On 7/14/22 at 9:42 AM, Surveyor interviewed PA-C H. Surveyor asked PA-C H if she can describe what was reported to her following R48's fall on 6/20/22. PA-C H stated, The staff said cares were being done with bed in raised position when R48 rolled her feet off the bed, causing her to fall off the bed falling onto knee and then onto side. She was then Medi lifted to bed to complete assessment and there were no concerns at that time. Surveyor asked PA-C H if the Nurse stated she did a pain or range of motion assessment. PA-C H stated, The Nurse stated she did a full assessment and had no concerns at that time. Pain and range of motion should have been included in that assessment. Surveyor asked PA-C H if no movement in R48's right leg would have been a change that she would have expected to have been notified of. PA-C H stated, she has [CONDITION(S)] on the L (left) but no movement in the right leg would have been abnormal for her. I would have more questions for the nurse on what that statement meant. It is not clear to me what she was saying by R (right) arm movement only as she has movement in the right leg. If they are documenting a change from baseline I would expect to be notified. If they are documenting a change from prior baseline I would want to be notified of that change. That would be a change and then yes I would want to be notified of that. The facility failed to ensure a medical provider was notified on 6/20/22 that R48, was unable to move her right lower extremity/right leg.

Based on interviews and record review, the facility did not ensure the right of a resident to receive visitors at the time of their choosing for 1 Resident (R128) of 2 residents reviewed for end of life visitation. The facility restricted R128's spouse, 6 children, and her Priest access to R128 when she was showing signs of decline and then actively dying. R128, a lifelong Catholic, did not receive her last rites due to the facility's visiting restrictions. Using reasonable person concept, the facility's restricted visitation policy caused R128 actual harm when her family was put in a position to choose between the two things that brought R128 comfort, her faith (receiving last rites) or her family. Evidenced by: R128 was admitted to the facility on [DATE] with diagnoses, including: [CONDITION(S)] without behavioral disturbance, anxiety disorder, depressive episodes, and pain in arm, [CONDITION(S)], and Dysthymic disorder. She is a lifelong member of St. Mary's Catholic Church. She and her husband of [AGE] years had seven children (six of which are still living). R128's Minimum Data Set, with Assessment Reference Date of [DATE], indicates it is very important for R128 to participate in religious services or practices and to have a close friend or her family involved in discussions regarding her care. R 128's Recreation Therapy Assessment, dated [DATE], includes, in part: Resident was admitted after a fall at home and an arm injury. Resident is on hospice . Former occupation: Cook . Marital status: married (named spouse) . # of children: 7 (listed them) . Religion: Catholic, St. Mary's . Current Interests: . religious shows, religious music . Group Programs: bible Study, church- Catholic Mass . Recreation Therapy Goals: To go to Mass, visit with my family, and watch TV.-quoted by R128 . Her Catholic faith and going to church is very important to her. R128 and her husband were asked if R128 would like to receive Catholic Communion while she was at (facility) as a doctor order for Communion would be needed as she is on a pureed diet. They responded, Yes. A doctor's order for Communion has been approved. R128's Progress Notes, include, in part: [DATE] . crying and emotional behavior continues with episodes that are somewhat inconsolable. Episodes of crying generally occur every day and can be disruptive to others . often these emotional times begin after resident has a visit from her family. They are attentive to her and often visit outside her window and with a phone call. She does enjoy these interactions with family, but can be tearful afterwards . Resident does find comfort in her faith and spends time reading her Bible/daily devotional . Family has found visits on the phone difficult at times, because she does not hear well. Staff do try to encourage her to wear her hearing aides at these times. Resident's husband remains her health care power of attorney . Staff reported this resident was especially tearful and weepy today. They had been trying to console her but were not successful . While we were visiting, her husband came to the window. This writer assisted with holding the phone for the resident and helping relay conversation back and forth as she does have a hard time hearing . Following the visit from the husband, this writer spent more time with resident as she often becomes tearful when family leaves. She was redirected to looking at her Catholic Calendar . [DATE] . Resident's speech was very difficult to understand, but she readily repeated herself when asked . [DATE] received a call from (hospice agency) they have once again admitted R128 to their service . [DATE] this writer informed by staff resident's condition is declining. According to staff, she was seen by the Physician Assistant who feels that it may be time to allow family members to visit. This writer visited with R128. She was lying comfortably in bed, but offered no response to verbal or physical touch . 5:47 PM this writer attempted to call R128's power of attorney today. Because we were unable to reach him, R128's daughter was called. Discussion held regarding R128's declining condition and signs she is nearing end of life. The hospice nurse reviewed R128's eating, drinking, skin concerns, and other areas which indicate that resident's condition is failing. The nurse also explained R128's medications and the benefits of discontinuation of medications by mouth which can be burdensome/impossible to take at this time. Compassionate Care Visits were offered with specific COVID parameters explained. Daughter was informed the facility will allow up to four visitors per day, one at a time, for up to one hour each. The visitor must check in/out and wear personal protective equipment while visiting. Family has been quite active in resident's life, and have had difficulty adjusting to her placement . During the conversation noted above, it was also suggested resident may want a Priest visit. A Priest does count as one of R128's four allowed visitors. Resident's faith is of great importance to her and family does feel this would be desirable . Facility policy, entitled End of Life Visits, dated [DATE], includes, in part: .End of Life Visits: -There can be a total of four people visit in one day- only one visitor at a time - Each visit can be one hour long - Ask the visitor to arrive to the 700 door Upon arrival: -Meet visitor at 700 door -Have visitor sign in/temp prior to bringing to room -Have visitor don (wear) surgical mask and face shield -Escort visitor to room -Let visit for one hour -Escort visitor back out 700 door According to Wikipedia, Last Rites, in Catholicism, are the last prayers and ministrations given to an individual of the faith shortly before death. Last rites cannot be performed on people who have already died . These are the final prayers and blessings a person receives that give spiritual comfort and a renewed faith that they will walk with Christ to meet their maker. A letter, from R128's family representative (FR U), addressed to facility staff leaders, dated [DATE], includes, in part: . Our family's nightmare began on [DATE]. Our mother had fallen and broken her arm . On [DATE] the pandemic started . As time passed summer and fall came, we thought at least there would be outside visits with our mother. All of my visits since [DATE] have been through a window, on a phone, or on an iPad we brought to the home. Because we needed to rely on staff to handle the iPad, virtual visits didn't happen often. As time went on at (facility), our mother progressively had more difficulty speaking so conversations were mostly one sided . I can't count the number of times I walked away from the window sobbing myself as I know my father and siblings also did. There were times we were both sobbing so much we had to hang up the phone . I couldn't hug her, read to her or just be with her to help her at the end of her life. Do you have any idea what that feels like? On [DATE] we were informed our mother was rapidly declining. I told the social worker I wanted to bring her home so she could spend her final days with her family . we were told compassionate care visits could finally happen, but restrictions placed on the family were unbelievable. Only four people could visit per day, they had to come alone, and they could stay no longer than one hour. My father hadn't been with his wife of [AGE] years for eleven months, and he was only allowed one hour a day to sit with her. There are six children in our family so three would come on Saturday and three on Sunday. Our priest never did make it in to give her last rites because he would have counted as one of the four each day, and he wanted to make sure the children saw her first. She opened one eye partially for one family member during those eight hours of visits. She was already that far gone. That was extremely difficult for my father. Then we got the call at 7:50 AM on Monday morning to say she had died . No one was there! She died alone! She didn't have COVID-19 and some of our family members had already received both doses of the vaccine, but that didn't matter . Allow at least the spouse to spend as much time as they want with their spouse as they are dying. If you can't allow the whole family, at least allow the spouse. If you are going to have limits on the number of people who can visit in a day don't count the Priest/Pastor as one of those visitors. The dying resident should be able to have his/her religious person be available to help them during the dying process . Remove the snow in front of the windows. The only way families can see their loved ones is by standing outside their windows. Why hasn't the snow been removed around the building to make paths for family members to safely get to these windows? On [DATE] at 10:06 AM during an interview, CNA R and CNA S indicated faith and family is what was really important to R128 and those two things brought her comfort. CNA R and CNA S indicated they recalled R128 crying inconsolably after visits with her family and stated, It was hard on her to be here without them. On [DATE] at 10:20 AM during an interview, RN P indicated R128 had a very close family consisting of her husband and seven kids. RN P stated, Someone from her family came every day. It was very hard on her husband. R128's speech got bad, she cried when he came. We took her to window visits, zoom meetings, all she would do is cry. Was very stressful for them and her. I would try to assist by interpreting. We were able to bring the whole family in to say goodbye to Mom. They came one at a time. It was hard her husband. He didn't have any of his kids to lean on. Prayers brought her comfort, mass on TV, bibles, Green Bay Packers, and seeing her family/children. Her boys were Mama's boys. Family brought her the most comfort. She was Catholic. Her faith was really important. On [DATE] at 11:13 AM during an interview, R128's Husband/Power of Attorney for Health Care (POA Q) indicated he was married to R128 for [AGE] years and they did everything together. When R128 fell at home and injured her arm, he was no longer able to care for her so they made a family decision to bring her to the facility. POA Q indicated their family was close. When COVID-19 hit, the facility closed everything up. We were only allowed to visit from the window. Was not able to get last rites by Priest. This was very important to her. I could only go in for one hour and only 4 of us per day. We have 6 kids trying to visit Mom before she passes and the priest couldn't come or one of the kids would miss out or me. I couldn't get in to hold her hand when she died or nothing. They wouldn't let us in. We would all cry after visits. They had a hallway empty. Why couldn't they use one of those rooms for us? Family and faith was her comfort. She or we for her shouldn't have had to choose in the end between them. She was gradually getting worse, we saw the changes through the window and asked for in person visits over and over. We thought we could be by her. I feel like I let her down, because I couldn't hold her hand through this. We went through everything together for [AGE] years/until this last year when we were separated. We don't want other families to go through this. My daughter wrote a letter regarding our concerns. On [DATE] at 1:21 PM during an interview, NHA A and Support Services Manager W indicated R128 was having a hard time not being able to be with family. Family was having a hard time too. NHA A indicated R128's daughter wrote a letter to the facility leaders and expressed she was unhappy with the visitation time restrictions, unhappy R128 did not receive last rites by the Priest before passing due to visitation restrictions, and unhappy R128 passed away alone. NHA A stated, We were hesitant to allow visitors. When we got more comfortable, we allowed them to do compassionate care visits. Compassionate care visits were allowed at all times and we could have allowed a compassionate care visit for the family (R128's family). NHA A also stated, family was everything to her. (R128) or her family should not have had to choose between her children seeing her and receiving last rites. NHA A indicated the family spoke with her about R128 not having that last visit with the Priest where her [NAME] would be forgiven and she would be saved. NHA A indicated after receiving the letter and having this discussion, she organized the Priest to meet with R128's family to discuss this and provide reassurance. On [DATE] at 3:42 PM during an interview, ADON V indicated only two people can come at a time for compassionate care visits and they can stay up to one hour. Surveyor asked ADON V if she has had any training/education on the most current visitation policy. DON B joined the interview. DON B indicated visits have to have a time limit. Surveyor asked about compassionate care visits and DON B indicated compassionate care visits are limited, but not end of life visits. Surveyor asked what is the definition of compassionate care visit. DON B indicated it was if a resident was to lose weight or have a change in sleep. Surveyor asked what the definition was for end of life visits and DON B indicated it is when a resident has ,d+[DATE] hours left to live. Surveyor asked if end of life was a reason for a compassionate visit. DON B indicated yes. On [DATE] at 12:16 PM during an interview, NHA A and DON B indicated that compassionate care visit is when there is a change in resident's status like weight loss or change in sleep patterns. NHA A and DON B indicated end of life visits were for residents who staff deemed had only ,d+[DATE] hours left of life. DON B indicated staff just know when a resident is within this window. Surveyor asked if an end of life visit could be a compassionate visit. Both indicated yes. Surveyor reviewed facility's updated visitation policy with NHA A and DON B. NHA A indicated the policy was not up to date with Center for Medicare and Medicaid Services recommendations and they need to look at it closer. NHA A stated, Our definition of compassionate care visits has evolved. Now, compassionate care visits will be allowed at all times for any resident regardless of outbreak, or a residents vaccination status, or the county's COVID-19 positivity rate. Surveyor asked if staff have received training regarding this evolved definition. NHA A and DON B indicated they had talked to some of the staff about this change. Facility policy, dated ,d+[DATE], includes in part: We recognize that physical separation from family and their loved ones has taken a physical and emotional toll on residents/tenants and their loved ones. Preserving family presence during this pandemic will continue to be accomplished by: . compassionate care visits, end of life visits (,d+[DATE] hours left of life) . Visits will be deemed appropriate using our best clinical judgement, the pandemic status within our community and within our home . End of life visits: will be arranged with Director of Nursing/Administrator/Community Living Supervisor or designee .Compassionate Care Visits: will be arranged with Director of Nursing/Administrator/Community Living Supervisor or designee . Those that would not be eligible for an in person visit: unvaccinated residents if the nursing home's COVID-19 county positivity rate is greater than 10% and less than 70% of the residents . are fully vaccinated, current COVID -19 positive residents or those with symptoms, residents in quarantine, when facility is in outbreak, visitation will be restricted until outbreak is characterized, and/or 14 days have passed from last positive case and/or as directed by NHA A, DON B, Medical Director, and/or Health Department. (It is important to note the facility did not provide proof of staff training regarding the new definition of compassionate care visitation and the facility policy spoke to end of life and compassionate care as two separate categories being deemed appropriate using clinical judgement.) On [DATE] at 4:05 PM during a phone interview, R128's daughter/ family representative (FR U) indicated she wanted the facility and others to know firsthand the impact the facility's visitation restrictions had on her family. She also indicated she wanted them to change it so others are not left looking through a window as their mom sits alone deteriorating or actively dying. R128 indicated she and her siblings would have wanted to be in the room with their father, to hold him up, as he supported their mother through the dying process. FR U indicated the family has always been close and needed each other through this time, but were not allowed to be together with Mom. FR U emphasized to Surveyor that her mother died alone, stating, She died alone without last rites. Do you know how that makes us feel? FR U indicated what has been done is done with her mom, but closure would come from knowing her letter reached the right people and changes were made to prevent other families from experiencing this. On [DATE] 2:06 PM during an interview, RN P indicated if a family member showed up at the facility asking for a compassionate care visit, RN P would have to contact NHA A or DON B to arrange the visit. RN P indicated if she could not get ahold of NHA A or DON B, she would have to tell the family member to come back a different time or to conduct a window visit. RN P stated, We have a visitation policy, but it has not been updated since COVID hit. On [DATE] at 2:30 PM during a phone interview, RN T indicated when a resident is receiving end of life care they may have up to four visitors a day come in, one at a time. RN T indicated he would get report to see how many visits the resident has already received in the 24 hour time frame. RN T also indicated clergy and/or family members count as one visit and may come one at a time. RN T indicated if a family member came to the door and asked for a compassionate care visit and their resident was not on the list to have compassionate care visits he would have to call DON B or NHA A. If he was unable to get in touch with them, he would have to refer the family member to the visitation policy and ask that they come back another time. RN T indicated the facility has visiting hours and they are during the day time, not at night. R128 was not allowed a visit from her Priest thus R128 did not receive her last rites. Family and faith were very important to R128. Due to the facility visitation policy R128 was not allowed visitation from her Priest thus did not receive her last rites. Using the reasonable person concept not being allowed your last rites a person may have fear, anxiety and anger not being allowed their last rites, forgiveness of [NAME] and passage to eternal life.

Based on observation, interview and record review, the facility failed to label and date food and drinks, remove dented cans of food to ensure resident safety from foodborne illness and ensure dishes were not wet stacked. This has the potential to effect 80 of 80 residents. According to the Wisconsin's Food Code Fact Safety Sheet, from the Department of Consumer Trade, Agriculture and Consumer Protection, dated 8/16 .refrigerated, ready to eat foods that were prepared in whole or part in a food establishment .must be marked to indicate when to be consumed, sold or discarded, not to exceed 7 total days at 41 degrees Fahrenheit (F) or less .at 41 degrees F for 7 days if removed from the freezer. The facility policy dated Dietary Supplies created 12/83 and reviewed on 8/20, indicates .food items, beverages, supplements etc. are to be labeled and/or dated when opened. All items that are stored in a container other than the original container need to be labeled and dated. All leaking, bulging, dented or corroded cans of food will be destroyed. Per the Unites States Food and Drug Administration's Food Code of 2017, Chapter 4-901.11, After cleaning and sanitizing equipment and utensils they shall be air-dried. Chapter 4-903.11, Clean equipment and utensils shall be stored in a self-draining position that allows air drying and covered or inverted. This is evidenced by: On 5/3/21 at 6:20 PM, Surveyor noted two cans in dry storage to be dented; one mandarin oranges and one fruit mix. On 5/3/21 at 6:24 PM, Surveyor interviewed DA K (dietary aide), What do you do with dented cans? DA K replied, If the seal is dented we remove from the shelf. While pointing to the dented can of fruit mix, Surveyor asked DA K, should this one should be removed? DA K responded, I don't know. On 5/3/21 at 6:28 PM, Surveyor observed in a refrigerator, an open gallon of 2% milk, approximately 2/3 gone, an open container of cranberry thickened liquid, approximately 1/3 gone and a glass of Glucerna (diabetic milk shake); all without open or discard dates or labels. One Magic Cup (frozen protein supplement) that was thawing with no date. In the juice machine, there was a box of fruit punch and apple juice that were open, being used and undated. On 5/3/21 6:47 PM, Surveyor observed drink ware glasses upside down on a tray in the storage area with condensation in them. On 5/3/21 at 6:50 PM, Surveyor interviewed DA X. Surveyor, tell me your process for removing items from the dish washing tray line? DA X stated, I pull them off, allow them to dry and then move them to a tray on the storage rack. Surveyor pointed to upside down glasses on the storage rack with condensation and asked DA X, should these glasses have condensation in them? DA X stated, I don't know why that is there, it must be from lunch or breakfast, I didn't put them there. Surveyor asked DA X, are these glasses dry? DA X, The cups won't be fully dry before I put them on the tray. On 5/5/21 at 11:40 AM, Surveyor interviewed DM J (dietary manager). Surveyor, when should dented cans be removed? DM J indicated, Dented cans, should be pulled from shelf as soon as noticed. Surveyor asked DM J, should items be dated when opened? DM J, Yes, all items should be dated when opened. The facility failed to ensure proper food storage and labeling and disposal of dented cans of food to safe guard all the residents of the facility. On 5/4/21 at 9:50 AM, Surveyor interviewed DM J regarding wet stacking of glasses and condensation present. Surveyor asked DM J, should there be condensation on tableware? DM J, No, there should not be condensation, they should be dry.

Based on observation, interview and record review the facility did not ensure drugs and biologicals used were stored in accordance with currently accepted professional principles for 1 of 2 medication rooms observed with the potential to affect 6 (R279, R280, R57, R281, R64 and R63) of 6 new admissions served from this medication room. An expired PPD (Purified Protein Derivative) vial was observed in the medication room refrigerator. On 5/5/21 at 1:54 PM, Surveyor observed the medication room located by the 400 wing with RN D. Surveyor observed a PPD (Purified Protein Derivative-used for [MEDICATION(S)] skin testing) vial, in the refrigerator, with an open date of 3/15/21 and no expiration date listed. Surveyor asked RN D how long after the open date the PPD vial is good for. RN D referenced an information sheet, titled Expiration Dates for Medications, on a cupboard door in the medication room and stated 30 days. Surveyor asked RN D if this vial should still be used. RN D stated, no and disposed of the vial. Surveyor asked RN D which residents the medication in this refrigerator are used for. RN D stated, residents on the 100, 300, and 400 wings. Surveyor asked RN D if there is a process for checking for expired medications. RN D stated, the nurse would be responsible for checking the expiration date prior to administration. On 5/5/21 Surveyor requested a policy on medication expirations and a list of residents on the 100, 300, and 400 hall that received a TB ([MEDICATION(S)]) skin test since 4/16/21. A copy of the Expiration Dates for Medications that was on the cupboard door, as referenced above, was provided to Surveyor, noting that [MEDICATION(S)]/[MEDICATION(S)] [MEDICATION(S)] PPD vials expire 30 days after opening. A hand written resident list was provided by the facility, with the following information: PPD (Purified Protein Derivative) since 4/16: 100 - 0 300 - R279 (5/3); R280 (5/3); R57 2nd TB on (4/21); R281 (4/28); R63 (4/28); R64 (4/19) (4/27). On 5/6/21 at approximately 1:30 PM Surveyor interviewed DON B and asked when she would expect staff to stop using an open PPD vial. DON B stated, she would have expected the staff to throw the PPD after 30 days and not to have used it. Surveyor asked DON B what the policy is for checking for expired medications. DON B stated, pre-COVID, the pharmacy came in monthly and did a clean out of cart and med rooms and would pull that and we would dispose of it. Nurses are expected to check prior to administration.

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 3 of 7 residents (R34, R14, and R40) reviewed for fall concerns out of a total sample of 37. R34 sustained a closed non-displaced fracture of right (R) femur after multiple previous self-transfer attempts. Interventions were not always placed on her Falls Care Plan, which were related to the root cause of the falls. R34's care plan indicates to redirect her, however, R34 has dementia and cannot remember to use her call light or wait for assistance. R14 sustained a clavicle fracture from a fall, after multiple previous self-transfer attempts and interventions weren't always placed on her Falls Care Plan, which were related to the root cause of the fall. R14's care plan did not address need for supervision or specific action related to self-transferring. Risk and benefits of R14's falls/self-transfers were not reviewed with R14's POA (Power of Attorney). The facility did not always place interventions to prevent reoccurrence of R40's falls, which were related to the root cause of the fall. R40's care plan did not address need for supervision or specific action to take if R40 is seen transferring or ambulating independently on her own. Risk and benefits of R40's falls/self-transfers were not reviewed with R40's POA, until after Surveyor asked about it. Evidenced by: The facility's Fall Prevention and Assessment policy, dated 12/16, includes, in part, the following: Policy: The policy of this facility to minimize or avoid resident falls. All residents will be observed and assessed for fall risks with a preventative intervention implemented (as applicable) on admission, quarterly and with a condition change or fall. Staff will reduce fall risks and risk of fall related injuries, while maximizing quality of life. All residents will be monitored for safety. Staff will identify and report all safety concerns to their supervisor or administration. Assessment. When a resident falls complete an incident report, update falls (safety) assessment and implement a NEW preventative intervention and add it to the care plan. Perform head to toe skin assessment, assess further range of motion of extremities, determine by inspection or report of resident or witness if resident hit their head, if so begin neuro checks per (Facility) protocol. Document benefit vs risks of interventions with residents or their representatives and document refusals of suggested interventions. Post Fall Assessment: The Post Fall Assessment tool was created to investigate further the factors leading up to the fall, it is designed to focus on ROOT CAUSE, assist in management of further falls, enhance quality of life, achieve maximum potential of physical functioning, minimize injuries related to falls, enhance dignity, rehabilitate residents to their fullest potential function and review causal factors to assist with individualized plans of care. Care Planning: Develop a plan for managing falls and fall risks, if resident is admitted and determined to be a fall risks, immediate measures must be put in place and documented. The care plan should include: Goals to prevent falls, decrease falls and decrease risk and severity of injury. Determine, implement and document interventions to manage and prevent falls. Review individual risks to reduce the number of falls and number of fallers. If fall occurs (or reoccurs) despite interventions, add additional or different intervention after a fall to minimize risk to fall again. Update plan of care, make referrals to therapy for seating, positioning, balance, strengthening etc. Example 1 R34's [DIAGNOSES REDACTED]. R34 has a Guardian and is not her own decision maker. R34's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/30/17, indicates R34 has severe cognitive impairment, has no physical or verbal behaviors, does exhibit wandering behaviors and rejection of care behaviors. Transfers with limited assistance of one person and ambulates with supervision of one person. Uses toilet with extensive assistance of one person and is frequently incontinent of bladder and is continent of bowel. R34's Care Plan Problem, Self-Care Deficit, dated 1/8/18, includes, in part, the following approaches: See S(NAME) (Standards of Care) for ADLS (Activity of Daily Life). No paper products on meal trays, prefers female care providers, segment tasks, enc (encourage) choice, barrier to buttocks with cares, notify nurse if refuses cares, prompt to toilet standard times and between 0500 AM and 0530 AM. Glass items or anything breakable that can be filled with water should not be left in room. Make sure Dycem is taped to seat of 4WW (wheeled walker). Resident is to sit in straight back chair for all meals, not in bed. Provide reassurance if anxious/upset. Toilet before and after breakfast. Keep walker on left side of bed, night light on. If restless bed/HS (bedtime) asst (assist) into w/c (wheelchair). Prompt/offer to assist resident to obtain items from drawers, shelves, etc with interactions and when observed up. Often removes Dycem from w/c cushion, ensure placement. Transferring: I am independent with no setup. Ambulation: I am independent with no setup - remind prn (as needed) to use walker. R34's Care Plan Problem, Falls/Mobility, dated 1/13/18, includes, in part, the following approaches: See S(NAME) for Falls/Mobility. Fall Interventions: other: Redirect if wandering, encourage use of walker with ambulation. Sign in room use walkers with transfers. Redirect resident to use walker, w/c not tray table for ambulation. Self-locking brakes to wheel chair. Assist resident to 800 day room monitor/safety for breakfast meal pass. Place Dycem in recliner. Keep headboard at line on wall for bed height. Need of hi-low bed due to short stature. (It is important to know the care plan interventions do not reflect the date they are put into place.) R34's Fall Risk Assessment, dated 10/9/17, indicates R34 doesn't understand safety risks, attempts to carry objects, which she cannot hold. Has poor recall, judgement, and safety awareness. Is ambulatory and incontinent, has jerking or unstable when making turns. Has had falls, is on [MEDICAL CONDITION] medication, has dementia anxiety and is at risk for falls. Interventions: Continue plan of care. (It is important to know the 10/9/17 is the only Fall Risk Assessment completed, until 1/8/18, when R34 was readmitted to the facility following a hospitalization .) R34's Incident Reports are as follows: Date: 11/8/17, Time: 15:00 (3:00 PM), Incident Type: fall. Description of the incident: Resident was pushing tray table and rolled out from beneath her and she fell landing on buttocks. Resident did not hit head and no apparent injuries noted. Root Cause: other: Using tray table as assisted ambulation device. Measure put in place to prevent reoccurrence directly related to Root Cause: Redirect resident that the tray table is not an assisted ambulation device redirect resident to use walk or wheelchair (w/c) for assisted ambulation device. Date 11/16/17, Time: 13:10 (1:10PM), Incident Type: fall. Description of the incident: A staff member entered the nurse charting room stating she needed assistance in repositioning the resident in her w/c. As this writer entered the hallway to assist, resident had already slid out from her w/c and her buttocks landed on the floor. She was propping herself up with her left upper extremity. Feet were extended out in front of her. She did not hit her head. There was a folded blanket that was on top of the cushion of her w/c that makes her position in the w/c unsafe. Resident was unable to state what she was doing. Resident has been noted to be anxious today, wandering, weeping and restless. Root Cause: slid from the chair - restless, unaware of safety concerns. Measure put in place to prevent reoccurrence directly related to Root Cause: 1:1 time was provided x (times) 20 minutes, prn [MEDICATION NAME] (an anti-anxiety medication) was administered for her weeping, agitation and restlessness. Date: 11/22/17, Time: 14:35 (2:35 PM). Incident Type: fall. Description of the incident: Resident was found by writer sitting in front of her w/c in her room. Resident stated that she was trying to sit down in w/c as it was moving backwards, in which she fell on her buttocks. Resident stated that she did not hit her head when asked. Root Cause: other: Wheelchair brakes were not applied. Measure put in place to prevent reoccurrence directly related to Root Cause: Self-locking brakes to w/c. Date 12/15/17, Time: 17:40 (5:40 PM). Incident Type: fall. Description of the incident: Resident was sitting on side of bed for supper, attempted to move tray and slipped from the bed. Resident was found sitting on her buttock, legs stretched in front of her. Her tray table had moved away from her, spilling all her beverages. Root Cause: other: slid from bed. Measure put in place to prevent reoccurrence directly related to Root Cause: Will have resident sit in straight back chair for all meals. Date 12/17/17, Time: 10:00 (AM). Incident Type: fall. Description of the incident: Resident was heard hitting the door to her bathroom against the wall. By the time staff attempted to assist, resident had slid from the w/c to the floor. Resident was incontinent of bowel at this time. Resident was assisted off of the floor and incontinence cares were provided. Resident had been assisted from the bathroom approximately 10 minutes prior to fall. Root Cause: slid from chair. Measure put in place to prevent reoccurrence directly related to Root Cause: Resident was assisted off of the floor and incontinence cares were provided. Resident has an extensive care plan. Resident has advanced dementia, cannot make her needs known appropriately, or does she understand safety risks. Date 12/22/17, Time: 12:55 PM. Incident Type: fall. Description of the incident: . Upon entering room, resident was observed laying on R side attempting to sit self-up with hands. Staff reports resident was seen safe in room minutes before this. Resident reports she does not know what she was attempting to do. Root Cause: Without (w/o) assist device. Measure put in place to prevent reoccurrence directly related to Root Cause: Resident was assisted to nurse charting room and 1 on 1 was provided, until calm, due to increased anxiety/agitation this AM. Date: 12/26/17, Time: 19:40 (7:40 PM). Incident Type: fall. Description of the incident: CNA (Certified Nursing Assistant) staff was in hallway and heard resident scream. Upon entering doorway, resident was found to but (sic) sitting upon next to the foot of her recliner. Root Cause: w/o assist device. Measure put in place to prevent reoccurrence directly related to Root Cause: Resident was assisted to bed for incontinence cares and then assisted back into w/c, due to increased combativeness. Resident was provided one on one by nurse, until calm, in 800 hallway then went into 800 day room with CNA staff. Date: 12/27/17, Time: 09:40 (AM). Description of incident: resident was found lying on her R side between her recliner and the bathroom. Resident stated she was trying to get to the bathroom. Measure put in place to prevent reoccurrence directly related to Root Cause: Resident will be toileted before and after breakfast. Date: 12/28/17, Time: 08:22 (AM). Description of the incident: This nurse was walking down 800 hallway towards 800 Dayroom. This nurse heard yelling/calling out from end of hallway. This nurse immediately walked toward the end of hall and observed resident to be semi-laying on her R side .flat. Resident was reaching toward this nurse with both hands saying, Help me. Root Cause: w/o assist device. Measure put in place to prevent reoccurrence directly related to Root Cause: Resident was very upset while on floor. She was assisted into her w/c and one on one was provided by this nurse at breakfast / diversional activities. If resident is asleep during breakfast meal pass, staff will assist resident into the 800 Dayroom to monitor/safety. Date: 1/1/18, Time: 04:00 AM. Description of the incident: Resident was found lying on her R side with head near foot board of bed. Resident was on the door side of bed and was facing room door. Resident noted to be incontinent of bladder when found. Plant was lying on the floor and dirt was noted to be in resident's mouth, nose and on hands. Resident not able to answer what she was doing out of bed. Call light was not on, but was within reach. Root Cause: w/o assist device. Measure put in place to prevent reoccurrence directly related to Root Cause: Resident's walker was on the R side of her bed and resident got out of the L side of her bed. Care plan was changed so that walker would be placed on the L side of resident's bed. Clinician Notification: clinician notified (Physician's Name) orders received. Send to ER (emergency room ) for evaluation. R34's Nurses Notes include, in part, the following note: 1/1/18, 7:38 (AM), Follow up of incident: fall. Injury: (Hospital Nurse) from (Hospital) called at 0650 AM on 1/1/18. (Hospital Nurse) stated that resident has a non-surgical crack on the ball of her R hip and that resident should be non-weight bearing to her R leg as much as possible, until it heals itself. Date: 1/8/18, Time: 21:59 (9:59 PM). Incident Type: fall. Description of the incident: Resident was awake, but lying in bed and was visualized 5 minutes prior to incident. Staff saw (sic) heard noise, saw her shoes were thrown into the hall and then saw resident sitting on floor on buttocks scooting herself on floor in her room to doorway to room. Root Cause: Lack of safety awareness, attempts to transfer, ambulate w/o assist. Measure put in place to prevent reoccurrence directly related to Root Cause: will get hi-low bed. Date: 1/10/18, Time: 13:45 (1:45 PM). Incident Type: fall. Description of the incident: Resident was found sitting upright between her bed and her recliner. Resident states, I was organizing my things. Resident does admit to R hip and thigh pain. Root Cause: Resident got up w/o using her call light or asking for assistance, and fell between her recliner, and resident failed to use it. Resident states, I won't do that again, and immediately started crying. Measure put in place to prevent reoccurrence directly related to Root Cause: Place Dycem in her recliner. Date: 1/10/18, Time: 18:30 (1:30 PM). Incident Type: fall. Description of the incident: CNA staff had just assisted resident to bed per request. Cares were provided and resident was assisted into bed. Minutes later, staff walked by and found resident was assisted into bed. Minutes later, staff walked by and found resident sitting upright between her bed and recliner. Resident did not hit head. Resident stated to CNA staff that she was trying to get back into her w/c . Root Cause: w/o assist device, w/o staff assist. Measure put in place to prevent reoccurrence directly related to Root Cause: Change resident to a low bed. Date: 1/12/18, Time: 20:30 (8:30 PM). Incident Type: fall. Description of the incident: Resident was being provided with 1:1 and was sitting in her w/c near my med (medication) cart. She requested to lie down as she was tired. This nurse assisted her to lie in bed. Less than 10 minutes later, she was heard calling out for help. CNA was first to respond and found her sitting on the floor between her bed and the window. She was unable to state what she was trying to do. Root Cause: Confused, restless patient. Lacks awareness that she needs assistance for transfers and ambulation. Measure put in place to prevent reoccurrence directly related to Root Cause: close monitoring. Date: 1/13/18, Time: 10:15 (AM). Incident Type: fall. Description of the incident: Housekeeper alerted nurse that resident was on floor. Nurse noted resident just outside her doorway sitting on the floor with legs extended in front of her with her w/c by her feet. She was sitting upright calling out for help. Resident has advanced dementia and [MEDICAL CONDITION]; she has an extensive fall history and a recent fractured R femur in which she is currently WBAT (weight bearing as tolerated). She was transferring herself and fell on to her buttocks. She was unable to state what she was doing, due to her dementia. Staff reported that they walked by her room a few minutes before the fall and resident was resting in bed, not noted to be restless. Root Cause: Transferred w/o assist. Measure put in place to prevent reoccurrence directly related to Root Cause: Staff will continue to monitor for unsafe behaviors. Due to her dementia and inability to understand safety needs, she will remain high fall risk. Date: 1/14/18, Time: 2:10 (AM). Incident Type: fall. Description of the incident: Resident was found sitting next to bed. Root Cause: Resident is confused and tried to get up w/o asking for assistance. Measure put in place to prevent reoccurrence directly related to Root Cause: Brought to hub to monitor. On 1/30/18 at 5:32 PM, Surveyor interviewed ADON C. ADON C is a Unit Manager. ADON C stated staff tried to get R34 out of her room for activities, dining, dementia programming, however, R34 would take herself back to her room. ADON C stated with R34's dementia it was difficult to redirect her. ADON C stated staff were to put a new intervention on the care plan after each fall, however, this did not always happen. ADON C stated the staff fills out the Incident Report, then it goes to the Unit Manager, who reviews it, and it then goes to DON B (Director of Nursing) for further review. ADON C stated she was not aware of anyone reviewing all of R34's Incident Reports regarding falls to track any similarities. ADON C stated that would have been a good idea. R34 was known to be at risk for falls. R34 has dementia and is impulsive and had multiple falls, while attempting to self-transfer, prior to sustaining a closed non-displaced fracture of R femur. New interventions were not always placed on her falls care plan, which were related to the root cause of the falls. R34 continued to fall even after she was diagnosed with [REDACTED]. Example 2 R14 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R14's Quarterly MDS, dated [DATE], indicates the following: BIMS 10, indicating moderate cognitive impairment. Requires extensive assist of two with bed mobility and transfers. Ambulates with extensive assist of one between locations in room, and requires extensive assist of two for toileting. R14 is occasionally incontinent of stool and frequently incontinent of bladder. Section J indicates R14 has had 2 or more falls since admission or prior MDS assessment. R14's care plan, dated 10/18/17, states, in part: (SIC) impaired physical mobility, falls. Related to: cognitive impairment, generalized weakness .Nurses see S(NAME) for fall/mobility .Nurse Aide see S(NAME) for falls/mobility - refer to ADL Care Plan. Fall interventions: pick items off floor, clear blankets/clutter from room, no small pieces. When asleep in Broda, give warm blanket. Frequent checks when in recliner/low bed. When up earlier in AM, put in Dayroom more visible. When resident is restless, prompt her to stay in common areas where she is more observable. Keep mail/cards, commonly used items, in reach. Offer toileting at the start and end of N(NAME) shift. If resident refuses, re-approach 15 mins / offer again. R14's care plan, dated 1/30/18, states, in part: . potential to fall down and hurt myself .I need my aides to follow the S(NAME) fall/safety interventions: give me non-skid footwear so I don't slip. Keep my bed low to the ground and keep the wheels locked. Place a mat on the floor beneath my bed in case I roll out. Stay with me during toileting, frequently check on me - try to keep me in line of sight when I am restless. When restless, please have me work on coloring projects and sew cards in the Dayroom with support tech . R14's CNA Guidelines for Daily Care, dated 1/30/18, states, in part: Fall/Safety interventions: give me non-skid footwear so I don't slip. Keep my bed low to the ground and keep the wheels locked. Place a mat on the floor beneath my bed in case I roll out. Stay with me during toileting. Frequently check on me, assist me with transfers. When restless, please have me work on coloring projects and sew cards in the Dayroom with support tech. Toileting/pericare: I use the bathroom with the help of 2 people, I wear incontinence briefs, I wear nighttime undergarments, I need help to wash my peri-area and buttocks. I need help wiping, I need help adjusting my clothes, I will ask for toileting as desired. Toilet. (Please note, this guideline does not indicate CNA's are to try to keep R14 in line of sight when she is restless per her care plan. This also does not indicate CNA's are to stay with R14 during toileting.) 10/26/17 at 4:46 AM, Incident Report indicates the following: unwitnessed fall in resident's room. Resident was found sitting on the floor between beds. She did not hit her head. Root Cause: w/o staff assist. Measure put in place to prevent occurrence directly related to Root Cause: offer toileting if wake at 04:00 (SIC). (Please note this intervention is not placed on R14's care plan until 12/12/17, based on care plans provided to Surveyor from 10/18/17 through 1/30/18.) 10/26/17 at 8:04 AM, Progress Note indicates R14 fell at 4:46 AM, it was unwitnessed, and neuro (neurological) checks were not applicable. There is no indication neuro checks were initiated at this time. 10/30/17 at 3:00 PM, Incident Report indicates the following: unwitnessed fall in 700 Dayroom, staff found resident on hands and knees on the floor. Root Cause: w/o staff assist. When asked, resident stated she was trying to fill the holes to make it look better. No indication neuro checks were initiated. 10/31/17 at 9:51 PM, Follow-up on Incident Note states, in part: .Resident observed walking in Dayroom independently. Resident had gotten up from Broda chair after resident was checked on by staff 5 minutes prior to this . 11/1/17 at 12:50 PM, Incident Report indicates the following: fall in the 700 Dayroom - seen from across the hall by staff trying to lower herself to knees, when approached, laid on her stomach. When asked what she was doing she stated she wanted to go home and was very anxious. What was the Root Cause: w/o staff assist. Intervention to continue to provide 1 on 1 as much as possible. 11/2/17 at 8:15 AM, Incident Report indicates the following: unwitnessed fall in resident's room. CNA heard a noise in the 700 Dayroom and ran in to see resident sitting on floor with head back on fridge. She was trying to get her stuff out of the cupboard. Root Cause: w/o staff assist. Measure put in place: continue to try to keep resident in site and offer magazines and coloring pages to color as she enjoys these. 11/2/17 - Care plan intervention added: Offer reading materials or coloring books if restless, as she likes to sit and do them. 11/5/17 at 10:50 PM, Incident Report indicates the following: unwitnessed fall in resident's room; got out of bed unassisted and was found lying on floor, next to her bed, with head near head of bed and feet near foot of bed. Res. (Resident) was holding her head off floor with hands as if attempting to do a sit up . Root Cause: w/o staff assist restlessness. 11/14/17 at 10:05 AM, Incident Report indicates the following: unwitnessed fall in activity room. Resident was found on floor, when asked what she was trying to do she stated, Looking for something. Restless to use bathroom. Root Cause: W/o staff assist. Measure put in place to prevent reoccurrence directly related to Root Cause: Resident was toileted, put back in Broda chair, given warm blanket, and made comfortable. Actions: continue to observe. There is no indication that neuro checks were initiated on the Incident Report or Progress Notes. Post Fall Assessment for this fall indicates that R14 was last toileted at 7:00 AM. 11/17/17 at 11:40 AM, Incident Report indicates the following: unwitnessed fall, CNA walked past resident's room and seen her sitting on the floor with her back against her bed. Legs straight out and toes up and denied hitting her head. When asked how she fell , as CNA and nurse had just been in there, and attempted to get her up she was resistive. Resident said she was looking for socks. Root Cause: w/o staff assist. Measure: Resident assisted to Broda chair and one to one for 15 minutes and snack offered until resident is less anxious. This report indicates resident did not hit her head, fall was unwitnessed, and no indication that neuro checks were initiated. Post fall assessment indicates R14 was last toileted on PMs or N(NAME), and it's been 8 hours since her last meal. (Please note time of Incident Report is 11:40 AM.) 11/17/17 - Care plan intervention added: if awake, must be in line of sight at night. If resident is anxious, offer snack and one to one for 15 minutes until relaxed. 11/18/17 at 12:50 PM, Incident Report indicates the following: unwitnessed fall in Dayroom. Found curled up in a fetal position next to her chair on her left (L) side. Root Cause: resident is unaware of safety risks secondary to her dementia. Measures: Resident was 1:1 for 15 minutes and put to bed. Indicated R14 received [MEDICATION NAME] at midnight and it was slightly effective. Neuro checks indicated as not applicable, and no indication that neuro checks had been initiated for R14's unwitnessed fall. R14's care plan, dated 11/18/17, states, in part: impaired physical mobility risk for falls .Fall Interventions: high/low bed in lowest position when in bed. Gripper socks on at all times. Other: frequent checks on resident, 1:1 when resident requires, when awake must be in line of sight, keep resident busy with folding wash clothes, coloring, writing. (Discontinued 12/14/17) 11/19/17 at 11:00 AM, Incident Report indicates the following: unwitnessed fall in 700 Dayroom. R14 was found sitting at end of her Broda chair, moves all extremities. Root Cause: slid from chair w/o staff assist. Measure put in place to prevent reoccurrence directly related to Root Cause: monitored with 1:1 for 15 minutes until resident was calm. Neuro check is indicated as not applicable. (Please note that R14's care plan, on 11/18/17, (see above) indicates when awake must be in line of sight. In addition, there is no evidence that neuro checks were initiated related to this unwitnessed fall.) Post fall assessment indicates, Resident scooted to end of Broda resulting in Broda tipping forward. 11/20/17 at 7:12 AM, Progress Note titled Follow up of incident: Fall: the resident did have ice placed to L shoulder a few times this shift. She accepted prn [MEDICATION NAME] 5 mgs (milligrams) at 5:10 AM for L shoulder discomfort. There is some swelling that remains. No increase in bruising noted during the night. Resident did not attempt to move her arm at all actively at 12:00 AM, but at 5:00 AM, she kept arm straight out and raised it up to near shoulder height w/o grimacing. 11/20/17 - (Clinic name) L shoulder X-ray - minimally displaced fracture of distal L clavicle. 11/21/17 at 1:50 PM, Progress Note titled Follow up of incident: Fall: the resident continues to have L shoulder pain and noted bruising to this area.she has made no attempts to stand or self-transfer this shift. The X-ray results have been reported to (Physician Assistant & Doctors name) awaiting return call . 11/21/17 at 1:54 PM, Progress Note titled Follow up of incident: Fall: resident has made no attempts to stand of (SIC) self-transfer this shift.awaiting a call from (physician name) reguarding (SIC) the X- ray results. 11/21/17 at 9:15 PM, Progress Note titles Follow up of incident: Fall: she was sleepy all shift and made no attempts to get up w/o assistance. 11/22/17 at 10:02 PM, Progress Note titled Follow up of Incident: Fall: no other latent injuries noted from recent fall, continuing to monitor L clavicle fracture . 11/23/17 at 7:12 AM, Progress Note titled Follow up of Incident: Fall: the resident made no attempts to get out of bed unassisted . 11/29/17 at 11:08 PM, Incident Report indicates: unwitnessed fall in resident's room and was found sitting. Last assisted to bathroom just before 10:30 PM as given report by CNA staff at 11:00 PM. Resident lying in bed asleep. 11:08 PM when walked past resident's room they noted resident out of bed and on floor. Res sitting with her knees bent with the incontinence pad partially under her. When immediately asked what happened the resident stated she slid out of bed. When asked if she hit her head, said no. Gripper socks on. Root Cause: slid from bed. Measure put in place to prevent: assist to Broda chair when awake in bed. Again, no indication that neuro checks were initiated for this unwitnessed fall, as it says not applicable. Actions: offered assist to the bathroom, but resident denied needing to go . (Please note there is no indication of neuro checks being initiated for this unwitnessed fall, report indicates neuro checks are not applicable.) R14's Impaired Physical Mobility Falls Care Plan, dated 11/30/17, states, in part: .Fall Interventions: Hi/low bed in lowest locked position, gripper socks. Pick items off floor, clear blankets/clutter from room, no small pieces. Frequent checks recliner/low bed. When up earlier in AM, put in Dayroom, more visible. If restless to stay in common areas, more observable. Keep mail/cards in reach. Offer reading material of coloring books if restless as she likes to sit and do them. If awake, must be in line of sight at night. If resident is anxious, offer snack and one to one for 15 minutes until relaxed. 12/6/17 at 11:55 PM, Incident Report indicates: unwitnessed fall in resident's room. Resident was found sitting on her buttocks in front of her TV and her legs underneath her buttocks. Root Cause: went to bed at 10:40 PM. She got up from her bed w/o staff assistance and was looking for jam. Measures: observe for wakefulness of res in addition to asking res if they are ready for bed, due to inability to stay asleep. Neuro checks not applicable. (Please note this intervention/action is not indicated on the care plans given to Surveyor. Also, there is no indication that neuro checks were initiated related to this unwitnessed fall) 12/9/17 at 4:25 AM, Incident Report indicates the following: unwitnessed fall in resident's room. Was sitting on floor next to bed, on window side facing foot of bed. Resident stated, I didn't fall far. Root Cause: other: Resident attempted to stand and get out of bed, sat on floor. Measure put in place: Resident transferred to Broda chair and supervised by staff while awake in bed. Neuro checks indicated as not applicable, and there is no indication that neuro checks were initiated for this unwitnessed fall. (Please note that resident is to be offered toileting at 4:00 AM if awake, per Incident Report intervention from 10/26/17.) 12/9/17 at 7:20 PM, Incident Report indicates the following: unwitnessed fall in dining room/ activity room on 700 Hall. Resident found on floor near her Broda chair. She was lying on her back with knees bent and feet on the floor. She reports she sat down on her buttocks and then laid down, because she couldn't get up. When asked what she was trying to do, I was going to go over to (name) and then we were going to go get a paper. Root Cause: dementia, Resident tries to get up on her own as she cannot remember that she is unable to transfer and walk independently. Measure put in place: Resident to be in hall (TRUNCATED)

Based on interviews and record reviews, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 9 residents reviewed for pain out of a total of 37 residents sampled (R34). R34 sustained a closed non-displaced fracture of right femur after multiple previous self-transfer attempts. R34 had an increase in behaviors after sustaining the fracture. R34's pain assessment showed she had an increase of pain, due to her femur fracture. Evidenced by: The facility's Standard of Care for Pain Management policy, dated 8/2016, includes, in part, the following: Nurses: Pain assessment as needed. Administer pain medication as ordered and monitor for effectiveness and for adverse effects. Consult with Clinician as needed. Promote non-pharmacological interventions to promote comfort. CNA's: Report any complaints or signs of pain to nurse. Non-verbal signs may be: fidgeting, rocking, striking out, guarding of a body part, grimacing, restlessness, pacing, and striking out. Position to improve comfort. May offer warm blanket, ice, distraction, food or fluids, etc. The facility's Standard of Care for Thought and Behavior Management policy, dated 8/2016, includes, in part, the following: Nurses: . Assess for pain and determine if there is a correlation between display of behaviors and pain. The facility's Pain Control/Monitoring Record policy, dated 1/15, includes, in part, the following: Procedure: 1) Determine the resident's level and type of pain. c) Observe for indicators of pain - moaning, crying, frowning/facial expressions, resistance to movement or cares, etc. 2) Call physician, explain need for medication, and receive input. 3) Implement Pain Monitoring Flow Sheet whenever using prn medication(s). 5) Never miss an opportunity to prevent or relieve pain. 6) We need to be proactive in treating pain, not reactive. Review the prn [MEDICATION NAME] MAR. Look for patterns and similarities. Proactively schedule and administer medication to prevent pain. This enhances the resident's quality of life. Example 1 R34's [DIAGNOSES REDACTED]. R34's most recent MDS with an ARD, of 10/30/17, indicates R34 is usually understood, can somewhat understand, has severe cognitive impairment, has no physical behaviors, no verbal behaviors, no other behaviors directed toward others, does reject cares, and does wander. It also shows R34 needs limited assistance of one person to transfer, needs supervision of one person to ambulate, is frequently incontinent of bladder and continent of bowel. R34 has received prn pain medications, however, does not have any pain at the time of the assessment. R34's Pain Assessment, dated 10/30/17, includes, in part, the following: Have you had pain or hurting at any time in the last 5 days: No. Comments: Resident does have advanced dementia and staff report that resident reports frequent headaches daily. R34's Pain Assessment, dated 1/8/18, includes, in part, the following: Resident has pain: right hip/leg. Type of pain: Pain is acute. Description of pain: sharp intermittent. Pain interferes with: ADL's, Sleep, Therapy, Mood. Alleviating factors: [MEDICATION NAME], ice, rest, position changes. Exacerbating factors: exercise, therapy, ambulation, transfers, ADL's. Resident pain goals: Will express relief with medication. Non-verbal or confused residents: Facial expression: facial grimacing. Body Language: relaxed. Activity: Squirming, shifting back and forth. Consolability: no need to console. Comment: The resident is returning with Tylenol scheduled at 500 mgs twice daily. A call was placed and a prn Tylenol order received. [MEDICATION NAME] was discontinued in the hospital. R34's Care Plan Potential for cognitive loss, dementia, includes, in part, the following approaches: See S(NAME) for Thought, Targeted Behavior #1: agitation with redirection m/b (manifested by) slamming doors, pushing walker into things, etc. Target Behavior #2: restless exploring, needing frequent reassurances during repetitive episodes. Targeted Behavior #3: crying, worried, re: health status, expressing suspicion towards staff members. (It is important to know that R34 does not have a care plan related to pain.) R34's General Medicine Discharge Summary, dated 1/8/18, includes, in part, the following: All Diagnoses: [REDACTED]. Closed non-displaced fracture of R femur - conservative management per Orthopedics. Resume PT/OT (Physical Therapy/Occupational Therapy) at SNF (Skilled Nursing Facility). Discharge medications: [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg tablet. Take 0.5 tabs (0.25 mg) by mouth every 4 hours as needed for Anxiety or Agitation. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg tablet. Take 0.5 tabs (0.25 mg) by mouth 2 times daily for Anxiety. [MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet. Take 1.5 tabs (7.5 mg) by mouth every evening for dementia with agitation. [MEDICATION NAME] (Tylenol) 500 mg tablet. Take 500 mg by mouth 2 times daily 0800 (AM) and 1600 (4:00 PM). Per the General Medicine Discharge Summary, R34's [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg tablet and [MEDICATION NAME] ([MEDICATION NAME]) 400 mg tablet were both discontinued. R34's Pain Monitoring prn MAR indicated [REDACTED] 1/8/18, 1600, Pain Level: Unable. Location: R leg. Observation Code: A (Anxious), B (Restless), G (Grimace). Medication Dose/Route: Tylenol 500 mg po (per oral). Results: 2 (no improvement). Time: 1800 (6:00 PM). Non-Med (medication) Interventions: P (positioning), R (Rest), J (Pillow), D (Distraction), E (Snack). R34's Nurse's Notes and Medication and Doctor's Order forms include, in part, the following: 1/8/18, 16:54 (4:54 PM): readmitted from (Hospital). admitted : 1/8/18. Admission Time: 14:35 (2:35 PM). Narrative: . She is in a w/c and is an assist of 2 for transfers. She continues to have pain to her R hip from previous fracture she received as the result of a fall on 1/1/18. She is at her baseline of orientation and remains confused. She is alert and pleasant, initiating conversation. She states her R leg hurts when she is moving it, and she does grimace when bearing weight to the R leg, with transfer. 1/8/18, 17:00 (5:00 PM): Pain Assessment: Location: R hip, Pain is acute. Pain interferes with ADL's, Sleep, Therapy, Mood. Pain medication received - Scheduled Tylenol 500 milligrams twice daily. Non-Pharmacological interventions - Repositioning, ice. Clinician consulted - see Physician Orders. PRN Tylenol 500 mg every 4 hours as needed. Non-Verbal/Staff Assessment: lack of facial expression, facial grimacing with movement or weight bearing. Action: physician notified of Need for PRN, orders received, continue to observe, encourage to rest, repositioned. Comments: The resident had a prn [MEDICATION NAME] for pain, which was discontinued in the hospital. 1/8/18, 17:09 (5:09 PM): Pain Assessment: Verbal or Alert Residents: Resident has pain R hip/leg. Type of Pain: Pain is acute. Description of Pain: sharp intermittent. Pain Interferes with: ADL's, Sleep, Therapy, Mood. Alleviating factors: [MEDICATION NAME], ice, rest, position changes. Exacerbating factors: exercise, therapy, ambulation, transfers. Resident's Pain Goals: Will express relief with medications. Non-Verbal Expression: facial grimacing. Body Language: relaxed. Activity: Squirming, shifting back and forth. Consolability: no need to console. Comment: The resident is returning with Tylenol scheduled at 500 mg twice daily. A call was placed and a prn Tylenol order received. [MEDICATION NAME] was discontinued in the hospital. 1/8/18, T.O. (Telephone order) (Change) Tylenol to 1000 mg BID (twice a day) and 500 BID prn, pain. 1/8/18, 2030 (8:30 PM), Pain Level: Unable. Location: R leg. Observation Code: A, B, G. Medication Dose/Route: Tylenol 500 mg po. Results: 2. Time: 2200 (10:00 PM). Non-Med Interventions: P, R, J, D, E. 1/8/18, 21:28 (9:28 PM): Musc (Muscle)/Skeletal Pain: Resident does complain of pain to R groin, hip, leg. Tylenol 1000 mg (500 scheduled and 500 prn) given at 1600, but appears to have little effect. Tylenol 500 mg given at bedtime. Resident did participate in PT assessment, but staff report grimacing and obvious pain with mobility. She appears to have inadequate pain control at this time. 1/9/18, 4:03 (AM): Musc/Skeletal Findings: has only pain with movement, no pain at rest, recognizes pain when she tries to bear weight, has non-displaced R [MEDICAL CONDITION]. 1/9/18, 4:19 (AM), Mood: trouble falling or staying asleep, more restless than normal. 1/9/18, 14:32 (2:32 PM): Musc/Skeletal Pain: Nursing continues to monitor resident's pain related to recent non-displaced fracture of R greater trochanter. She is weight bearing as tolerated. She received her scheduled Tylenol today as ordered, with some effect. Positioning and a warm blanket were given and provided some relief. (Physician's Assistant) was called and updated on pain with no new orders. Circulation movement sensation to R lower extremity is within normal limits. 1/9/18, 15:20 (3:20 PM): Telephone/Fax orders: . Aspercreme with [MEDICATION NAME] topical to painful areas BID prn. 1/9/18, T.O. Aspercreme (with) [MEDICATION NAME] topical to painful areas BID prn. 1/9/18, 21:39 (9:29 PM): Musc/Skeletal Findings: no problems noted. Resident continues to grimace and wince with repositioning. Once still, resident does appear to be near pain free as she has been able to sleep well in recliner this evening. No prn Tylenol has been required. Will continue to monitor. 1/10/18, 1:38 (AM): Behavior: . Resident is not able to say what she needs or why she walked (sic) of her room. She will eventually cry when behavior is exhibited. Cause of Behavior: non-apparent. Non-med intervention: 1:1, activity, assessed for pain, conversation, given food, left alone and re-approached, television/radio, warm blanket, behavior medication, [MEDICATION NAME] prn medication, [MEDICATION NAME]. Both medications seem to work in conjunction together and she will eventually be redirectable. Resident will be able to focus on activities and her anxiety and confusion will lessen considerably. 1/10/18, 11:30 (AM), Pain Level: Unable. Location: leg and hips. Observation Code: A, O (Other). Medication Dose/Route: Tylenol 500 mg. There are no results or non-med interventions documented, 1/10/18, 15:12 (3:12 PM): Musc/Skeletal Findings: . Resident cries out with all transfers and complains of R hip and thigh pain. Resident transfers poorly even with assistance of two and cries out stating, My leg hurts. PRN Tylenol does not appear to relieve resident of her pain or discomfort. 1/10/18, 15:28 (3:28 PM): Mood: Resident cries uncontrollably at times and will answer yes or no questions appropriately at times. Has spent all of this shift in her room. 1/10/18, 19:07 (7:07 PM): Musc/Skeletal Findings: no problems noted. Res continues to offer discomfort to R hip. Resident reports Tylenol is not effective for pain. Declines [MEDICATION NAME] balm at this time and is quite upset. 1/10/18, 19:11 (7:11 PM): Follow up of incident: Res continues to offer pain to R leg/right hip. No latent injury observed to skin. 1/10/18, 1920 (7:20 PM), Pain Level: Unable. Location: R leg/hip. Observation Code: A, B, G, E. Medication Dose/Route: Tylenol 500 mg. There are no results or non-med interventions documented. 1/10/18, 21:18 (9:18 PM): Mood: Res required additional staff attention since the start of shift this evening. Res has been throwing items given to her by staff. Res has been noted to scream at the top of her lungs with most any staff intervention. Res was in Charting Room with this nurse, while CNA staff was assisting other residents to bed. Res stood and attempted to walk 8 - 9 x in a 15 min (minute) period. When this nurse suggested to res she shouldn't stand d/t (due to) broken hip, resident responded with anger/yelling 4 - 5 x when intervening. Upon start of 2000 (8:00 PM) medication pass, res was entering other resident rooms and screaming at staff when attempting to redirect her. Res continues to throw items she had previously enjoyed. CNA staff toileted res per her request, res then became verbal/physical with transfers. At a calm moment for res this evening, an outburst (out of nowhere) happened where res grabbed the neck of her shirt with both hands in attempts to tear it down the middle, while also angrily screaming. Residents and visitors were observing these behaviors from West Hub. Res is currently with staff in attempts to keep res from standing/walking. Will continue to monitor. 1/11/18, 0220 (AM), Pain Level: Nothing documented. Location: R leg. Observation Code: A, B, G. Medication Dose/Route: Tylenol 500 mg. There are no results or non-med interventions documented. Pain Med Offered and Declined: 0230 (AM). 1/11/18, 0500 (AM), Pain Level: Unable. Location: R leg. Observation Code: A, B, G. Medication Dose/Route: Tylenol 500 mg po. Results: Unable. Time: 0600 (AM). There are no non-med interventions documented. 1/11/18, 5:23 (AM): Musc/Skeletal Findings: Complained of Musc/Skeletal pain: pain in R hip. Comments: pain with no movement, sharp aching pain in R hip, refused Tylenol at 0230 (AM), took Tylenol at 0500 (AM) for R hip, had warm blanket on hip for few minutes. 1/11/18, 5:26 (AM): Behavior: given [MEDICATION NAME] at 2325 (11:25 PM), confusion, thinking her parents were still living, anxious, restless, unable to console, redirectable for few seconds, close supervision most of the night, ineffective prn [MEDICATION NAME], no change in behavior, upset over not able to do things. 1/11/18, 7:14 (AM): . She stated that she had pain in her R leg. Res refused Tylenol and warm blankets at 0230 (AM). She was trying to stand or she was scooting herself forward in her w/c. Res vacillate between present and past. Staff performed close supervision. She did not sleep during the night. 1/11/18, 7:18 (AM): . there was no change in her pain behavior. She complained of pain at rest in her R leg. Resident would only take Tylenol at 0500 (AM) despite the pain complaints during the night. She was not redirectable from her behavior. 1/11/18, 13:22 (1:22 PM): Comment: Resident behaviors have been poor this AM shift. Resident has been crying, screaming, calling out, striking out and throwing items intermittently since the start of shift this AM shift. Res also spent a considerable amount of time with therapy/rec (recreational) therapy this AM. Will continue to monitor. 1/11/18, 13:24 (1:24 PM): Musc/Skeletal Findings: Res continues to offer pain. (Physician) in facility this AM and is making adjustments to medication regimen. Did receive 1 x dose of [MEDICATION NAME], which had some positive effect. New orders en route from MD (Medical Doctor). Will continue to monitor. 1/11/18, T.O. Give one dose [MEDICATION NAME] 5/325 mg 1 po now and let me know later if effective for pain and behaviors or not. 1/11/18, 1930 (7:30 PM), Pain Level: Unable. Location: R leg/hip. Observation Code: A, B, G. Medication Dose/Route: Tylenol 500 mg. There are no results. Non-Med Interventions: H (heat). R34's physician progress notes [REDACTED]. . For the fracture orthopedics were consulted and they recommended conservative management with PT/OT as well as pain control. She was aggressive and combative during hospitalization , which was treated with [MEDICATION NAME] 25 mg daily, [MEDICATION NAME] 7.5 mg daily and [MEDICATION NAME] 0.25 mg BID. This regimen was continued on discharge. 1/11/18, 20:55 (8:55 PM): Musc/Skeletal Findings: Res requested and received Tylenol 500 mg po for pain to her R hip. Upon follow-up, she appeared to have calmed down and stopped crying. Will continue to monitor. 1/12/18, T.O. Give one dose of [MEDICATION NAME] 5/325 mg 1 PO now and let MD know later if effective for pain and behaviors or if ineffective. 1/12/18, T.O. 1. D/C (discontinue) [MEDICATION NAME], 2. Start [MEDICATION NAME] 2.5 mg po q (every) AM, [MEDICAL CONDITION], 3. Change scheduled Tylenol to: Tylenol 650 mg po TID (Three times a day) pain. 1/13/18, 0835 (AM). Pain Level: Unable. Location: R leg. Observation Code: A, B, G. Medication Dose/Route: Tylenol 500 mg. There are no results or non-med interventions documented. 1/13/18, 2115 (8:15 PM), Pain Level: Unable. Location: R leg. Observation Code: A, B, G. Medication Dose/Route: [MEDICATION NAME] 5/325. There are no results or non-med interventions documented. 1/13/18, T.O. [MEDICATION NAME] 5/325 mg 1 now x 1 dose. Call (Physician) later today (with) an update. 1/13/18, T.O. Schedule [MEDICATION NAME] 5/325 1 po twice daily and once prn daily, pain. 1/14/18, 2150 (8:50 PM), Pain Level: Unable. Location: R leg. Observation Code: A, B, G, E (Crying), O. Medication Dose/Route: Tylenol 500 mg. There are no results or non-med interventions documented. 1/14/18, 2345 (11:45 PM), Pain Level: Unable. Location: R leg. Observation Code: A, B, G, E (Crying). Medication Dose/Route: Tylenol 500 mg. There are no results or non-med interventions documented. 1/15/18, 2340 (11:40 PM), Pain Level: 6 (Moderate). Location: R leg. Observation Code: A Medication Dose/Route: Tylenol 500 mg. No non-med interventions documented, Pain Med Offered and Declined: 2343 (11:43 PM). Since returning to (Nursing Home), her behavior has been increasingly more aggressive/combative. She is very restless in that she is constantly reaching for things and putting them down and then trying to stand up which (sic) them makes her behaviors worse. This progressed since her return and this morning she struck the RN and tore off his badge. This led to her receiving 5/325 mg of [MEDICATION NAME]. I visited with her just 10 minutes after she received the dose. She was initially very aggressive and combative with me saying things such as, You can go hang yourself. However, as I sat and tried to converse with her, she calmed down and became more tearful and lachrymose. She was unable to specifically articulate why she was crying, but did lead me to the pictures of her family and showed them all to me upon my asking her why she was so sad. It was at this time, in what was certainly an unusual moment of clarity for R34, that she told me the names of her children and grandchildren and pointed them all out in the pictures. However, just 5 minutes later she was unable to tell me her birthday, where she was, or the day, month, or year. Review of systems was thus unable to be completed, but I will note that the patient on multiple occasions, during our conversation, denied having any pain. She also specifically said that she feels fine and wants to leave. Though she couldn't tell me where she wanted to go. . I agree with (R34's Primary Physician's) past documented suspicions that this may be a frontotemporal type of dementia. That being said, I am not convinced that her behavioral disturbance is truly due to her dementia and is more likely to be due to under treated pain from her [MEDICAL CONDITION], particularly, if she is always more agitated and aggressive upon standing as the nursing staff is reporting. R34's Primary Care physician progress notes [REDACTED]. Regarding pain: We gave one dose of [MEDICATION NAME] the morning of 1/11/18 and observed; and another the morning of 1/12/18 and observed. It is unclear whether the [MEDICATION NAME] is effective or not, so will not schedule at this point. If over the weekend, when she is not receiving scheduled [MEDICATION NAME], her behaviors worsen, will assume untreated pain and proceed with scheduling [MEDICATION NAME] q AM, but not until the clinical picture is clearer . Regarding dementia: I have talked at length this week with nursing and administrative staff here at (Facility), all of whom provide a longstanding (years-decades) history of anger and impulsivity, and some history of violence (striking others) and self-mutilation (pulling out hair). This makes me wonder about a concomitant mental illness or thought from a mood stabilizer, such as Trazadone, which is also an evidenced based treatment used in [DIAGNOSES REDACTED]. On 1/30/18 at 5:22 PM, Surveyor interviewed LPN N (Licensed Practical Nurse). LPN N stated R34 was having pain behaviors, grimacing with re-positioning, she would try to stand and walk without grimacing as well, but definitely grabbing at her hip. LPN N stated when he asked R34 if she was in pain she would become verbal, aggressive, throwing things. LPN N stated when R34 returned from the hospital, on 1/8/18, she started to have more behaviors. On 1/30/18 at 5:25 PM Surveyor interviewed RN O. RN O stated after R34 went to the hospital, on 1/8/18, she was refusing to take her medications, including pain medications and was very aggressive, scratching staff, we could not control her pain or behaviors. On 1/30/18 at 5:32 PM Surveyor interviewed ADON C. ADON C is a Unit Manager. ADON C stated it is expected that staff assess and monitor all residents for pain and monitor the effectiveness of pain medications. ADON C stated R34 would grimace, get upset, be weepy, sometimes she could answer yes or no when asked about pain. R34 cannot answer accurately, most of the time, when asked about pain ADON C stated that a physician should have been called when R34's pain was unrelieved and /or her behaviors increased.

Based on observation, record review and interview, the facility did not ensure residents who are at risk or have pressure ulcers received the necessary treatment to promote healing, prevent infection and prevent new pressure ulcers from developing for 6 of 6 sampled residents reviewed for pressure ulcers (R10, R4, R6, R7, R17 and R3). R10 was admitted to the facility with a stage I pressure injury. Assessement of the pressure injury upon re-admission to the facility was not completed for five days, nutritional interventions were never implemented, re-evaluation of interventions and their effectivness were not completed resulting in worsening of R10's pressure injury. This example is cited at scope and severity level 3, isolated; all other examples are cited at the scope and severity level 2. R4 developed three pressure injuries on her bottom while in the facility. R4's nutrition interventions and repositioning interventions had not been revised to reflect the current standards of practice. R4's support surface was not upgraded until 11/29/16, after the third pressure injury was identified. R17 developed a deep tissue injury on the right heel, and one week later developed a deep tissue injury on her left heel. Preventative measures were not put into place prior to the pressure injury development. R6 and R7 are at risk for developing pressure injuries. Preventative measures were not put in place to prevent pressure injuries. R3 did not have a pillow and blanket applied to the footrests of the wheelchair and developed a blanchable red area to the left heel. This is evidenced by: The facility policy, entitled Pressure Ulcers/Pressure Injuries/Moisture Related Skin Damage: Prevention & Treatment, dated revised 9/16, states: General Guidelines of Prevention .6. A skin assessment is completed on admission, readmission, with each additional assessment, quarterly, annually and with significant changes. General Guidelines of Treatment. 1. The pressure ulcer treatment program will focus on the following strategies: a) Assessing the resident and the pressure ulcer(s) b) Managing tissue load c) Pressure ulcer care d) Managing bacterial colonization and infection e) operative repair of the pressure ulcer(s) f) education and quality improvement . General Guidelines Interventions & Preventative Measures 2. For a person in bed: a) Change position a (sic) least every 1-2 hours b) Determine if resident needs a special mattress and utilize as indicated c) Raise the head of the bed as little and as short of time as possible, and only as necessary for meals, treatments and medical necessity. 3. For a person in a chair: a) Change position every 1-2 hours-a completed position change .7. Offer and encourage resident to maintain proper nutrition and hydration. 8. Staff to monitor skin daily. Wound team to document weekly assessments as needed .10. The care process should include efforts to stabilize, reduce, and remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate . Poor Nutrition 1. Dietician will asses nutrition and hydration. Make recommendations and document in care plan. 2. Monitor nutrition, hydration, and dental status. Monitor proper dietary and fluid intake .4. Administer vitamins, minerals and protein supplements as ordered . Avoidable vs Unavoidable In order for us to determine that a wound is unavoidable all of the following criteria need to be met, even 1 or more not completed risks wound being unavoidable. Risk factors evaluated and documented. Interventions proactively implemented consistent with needs. Each area of the Braden scale evaluated with measures put in place. Monitoring and evaluating impact of interventions. Revise interventions as needed. If ALL areas were addressed wound is unavoidable. 1. R10 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R10's Minimum Data Set (MDS) assessment, with a target date of 10/27/16 indicates that R10 has a Brief Interview Mental Status (BIMS) of 10, which indicates moderate impairment; however, R10 makes own decisions. R10's care plan, dated 10/20/16 Impaired Skin Integrity .pressure ulcer on [MEDICATION NAME] spine related to protruding kyphotic spine-continue with measures. Approach Nurses - See S.O.C for Skin, has air mattress and Tri-colored cushion to wheelchair, place waffle cushion to back of wheelchair as she allows. Goal: will maintain rest of skin integrity and open area will heal. Goal Time: Three months. R10's Care plan, dated 11/07/16 Problem (Nutrition) Potential for further changes. Inadequate food intake, [MEDICAL CONDITION] on admission with elevated weight. Approach Nurses - Weights as ordered daily, Nurses Aide - Record intake of meals and fluids, Set up food as needed, receives a no added salt diet with no between meal snacks from dietary, lids with straws on meal tray, take a long time to eat. Dietary - Provide ordered diet, no added salt diet with no between meal snacks, Covered cup for fluids, Provide straws for fluids on meal trays to aid in self feeding. Goal - reduce [MEDICAL CONDITION] Goal Time: three months. R10's Braden assessments were as follows: 09/19/16 Total score 18 = Mild risk (R10 has a stage I pressure injury on this date), 09/26/16 Total score 18 = Mild risk (R10 has a stage I pressure injury on this date), 10/06/16 Total score 19 = No risk (R10 has a stage I pressure injury on this date), 10/31/16 Total score 18 = Mild Risk (R10 has an unstageable 3.0cm x 1.5cm pressure injury with a peri wound measuring 9.0cm x 6.0cm that is red in color on this date), and 11/17/16 Total Score 18 = Mild Risk (R10 has an unstageable 2.5cm x 1.5cm x 0.8cm pressure injury with undermining at 4.0cm) Surveyor reviewed R10's medical record. A Dietary Progress Note, dated 10/19/16, states, She does have a few skin conditions at the moment and nursing is monitoring those very closely. (R10 has an unstageable 2.0cm x 0.9cm pressure injury on this date.) Surveyor reviewed R10's Wound Team and Nursing Notes: Wound Team flow sheet: R10 was admitted on [DATE] with a 3.0cm x 1.5cm stage I pressure injury, R10 denies pain, intervention included a duoderm over the pressure injury to be changed weekly and as needed, a Rest Q mattress, iris cushion to sit on and a waffle cushion behind R10's back. Medical Doctor (MD) aware. 09/20/16 Nursing notes include that the duoderm was coming off pressure injury and was changed and a MD observed this area. 09/27/16 Wound Team flow sheet: 2.8cm x 1.0cm stage I pressure injury, denies pain, interventions remain the same as 09/19/16, it is marked that R10 is compliant and an MD is aware of this injury. 10/01/16 Nursing notes indicate that R10 was transferred to the emergency room (ER) at 8:45 a.m. with right sided pain. 10/06/16 R10 is readmitted at 11:45 a.m .She also continues to have the duoderm placed to the mid spine as protection. Dressing was there previous to hospital stay and RN K and the HHCC wound team are aware. No assessment of the pressure injury upon re-admission was completed. 10/11/16 Next recorded assessment of pressure injury: Wound Team flow sheet: 2.0cm x 0.9cm Unstageable pressure injury, R10 reports that the area is tender, interventions remained the same as 09/19/16, dressing was changed from a duoderm to Allevyn and to be changed weekly, it is marked that R10 is compliant and the MD is aware. (Next wound team assessment not completed until 10/20/16). 10/11/16 Nursing Notes 22:04:55 states Resident starting on Allevyn dressing to [MEDICATION NAME] open area on back. Wound appears to have yellow slough, skin around area is reddened, drainage was noted to resident's shirt while dressing was applied. Resident stated that wound area was tender, resident received her scheduled [MEDICATION NAME] at the same time of dressing application. Resident is currently using egg-crate cushion for pressure relief/comfort. 10/14/16 Nursing Notes 14:01:49 states Resident treatment to mid-[MEDICATION NAME] spine was completed as ordered. Old dressing was removed area was cleansed, dried and new Allevyn dressing applied. Wound bed is 50% yellow slough and 50% dark red. Periwound is slightly reddened with no increased warmth to it. There is a small amount of serosangious drainage to the old dressing. Resident did complain of the area hurting and bothering her, she stated she liked the additional cushion of the dressing. Wound team continues to follow up every week. Will continue to monitor. 10/15/16 Nursing Notes 10:52:30 states, Dressing to [MEDICATION NAME] spine observed scrunched and coming off this AM. Dressing removed. Area measures 2.3 cm x 1.3 cm. Wound bed is covered in 100% slough. Surrounding area is red and swollen. Area is very tender per resident. New dressing was applied after cleansing. Utilizes a waffle cushion when up in wheelchair. Will continue to monitor. 10/19/16 Nursing Notes 08:35:45 states [MEDICATION NAME] spine noted intact with dressing upon review this AM. Tender per resident. Utilizes a waffle cushion when up in chair. 10/20/16 Wound Team flow sheet: 2.5cm x 1.8cm Unstageable pressure injury with periwound that extends 4.0 cm distally, resident reports it is tender, intervention changed Rest Q mattress to an air mattress, dressing change remains the same of Allevyn changed weekly, it is marked that R10 is compliant, and an MD is aware of pressure injury. On 10/26/16, R10 falls at the facility landing on her back. At a later date it is believed that this fall may have possibly been the cause of the periwound around R10's pressure injury to become a seroma. On 10/28/16, wound team note: 13:29:46 The open area to the [MEDICATION NAME] spine measures 1.9cm X 1.5cm. Unable to determine depth due to the fact that the entire wound bed is covered in tan slough. The periwound is reddened, raised, and blanchable extending out approximately 3.5cm. No warmth or purulent drainage noted. There was a large amount of serosangious drainage to the previous dressing. The upper half of the raised reddened area is boggy as though it is fluid filled (?cyst, seroma? hematoma? tumor?). There is a raised firm ridge at the top of the circular reddened boggy area from the 9 o'clock to the 3 o'clock position. Nursing Notes 15:30:00 The reddened area surrounding the ulcer of the spine is now (at 1415) warm, painful, and a little more red than prior. She remains afebrile at this time with a temp of 36.7 .I explained that if this was an infection it is located near her spinal column and could worsen quickly, the infection could get into her blood stream (sepsis), and cause death . At 3:30 p.m., R10 was transferred to the ER and admitted to the hospital for a Incision and Drainage (I and D) of the periwound of R10's pressure injury. On 10/31/16, R10 was readmitted to the facility on oral Keflex. 10/31/16 Wound team flow sheet: 3.0cm X 1.5cm Unstageable pressure injury with the periwound red and measures 9.0cm x 6.0 cm surrounding the ulcer, resident states it is tender, intervention are the same as 10/20/16, dressing changed to Iododorb gel with a dry dressing, R10 is now marked as non-compliant and an MD is aware. 11/01/16 Wound team flow sheet: 3.0cm x 1.8 Unstageable pressure injury with the periwound measuring 9.0cm x 5 cm with undermining from 10 to 1 o'clock positions measuring 4.3cm deep. Oral antibiotics until 11/10/16, R10 reports the area as tender, interventions remain the same, dressing changed to Iodosorb ribbon packing with a foam dressing. R10 is marked as non-compliant with lying down during the day and lying side to side and stays up in recliner. MD saw R10 today. 11/08/16 Wound team flow sheet: 2.7cm x 1.5cm Unstageable pressure injury with the periwound 9.0cm x 5.0cm with decreased redness with undermining from 10 to 1 o'clock positions measuring 4.2cm deep. Oral antibiotic until 11/10/16. Resident reports area as very tender, interventions remain the same, dressing changed to mesalt with foam dressing and changed Monday, Wednesday, and Friday. Resident is marked as non-compliant with lying down during the day and MD is aware. 11/12/16 R10 fell at the facility and was admitted to the hospital with [REDACTED]. 11/18/16 Wound team flow sheet: 2.5cm x 1.5cm X 0.8cm unstageable pressure injury with a periwound that is red, raised and firm (no measurement) with undermining from 7 to 4 o'clock positions with the deepest area at 12 o'clock measuring 4.0cm. Resident reports area as tender, interventions remain the same, dressing and changing schedule remain the same. 11/22/16 Wound team flow sheet: 3.0cm x 2.0cm x 0.8cm unstageable pressure injury with a periwound that is red and extends 3.0cm with undermining for 7 o'clock to 3 o'clock that measures 1.5cm to 4.4cm deep. Bone is now palpable with a cotton swab. Resident reports pain as ok, interventions remain the same, dressing and changing schedule remains the same, Resident is marked as non-compliant with lying down during the day. MD notification is not marked. On 11/29/16 at 9:10 a.m., Surveyor observed wound care on R10's pressure injury. The pressure injury measures 3.5cm x 2.5cm x 1.2. Undermining surrounding the pressure injury in the peri wound (seroma) measures from 0.4cm to 3.8cm. The peri wound (seroma) measure 2.0cm to 4.5 in thickness, the pressure injury and peri wound (seroma) measure 10.0cm x 6.0cm. At the 7 o'clock position there is palpable bone and in the center of the pressure injury the bone of the spinal column is visible and measures 1.8cm x 0.9cm. As of this date the pressure injury is a stage IV. R10's Physician Orders, dated 11/17/16, indicate that pain needs to be treated with [MEDICATION NAME] 5/325 mg tablets every six hours as needed, orders dated 11/22/16 indicated Tylenol 650 mg every four hours as needed for pain had been added. On 11/29/16 at 9:10 a.m., Surveyor observed wound dressing change and R10 was asked if she was having any pain and R10 stated, Not too bad now but yesterday was terrible. I could not lean back or get comfortable. On 12/3/16 at 10:10 a.m., Surveyor interviewed Registered Nurse (RN) K and asked if there was any documentation showing that R10's dressing had been removed and the pressure injury assessed after readmission on 10/06/16 to 10/11/16 when the wound team assessed the pressure injury and RN K stated, No. Surveyor then asked if there was any documentation showing that nutritional interventions had been implemented at any time during R10's stay and RN K stated No. Surveyor then asked if the interventions had been reviewed for effectiveness such as changing the cushion behind R10's back and RN K stated No. RN K stated that R10 has an appointment at the surgical clinic on 12/07/16 and she is unable to move that appointment up to an earlier date. No additional documentation was provided to this surveyor. 2. R4 has dementia, immobility, incontinence, and neurological disease that put her at risk for pressure ulcers. The quarterly MDS, dated [DATE], documents the resident is at risk for pressure ulcers but has none. R4 is dependent on staff for repositioning. The braden score is 17 on 10/15/16, meaning a mild risk for developing pressure ulcers. The care plan Impaired skin integrity, related to: .history of pressure ulcer prior to admit, open areas spine .developed new pressure ulcers with new reclining w/c (wheelchair) and cushion so is no longer using. Approaches: Rest-q mattress .roho in broda chair, .reposition every 1 - 2 hours. The Certified Nursing Assistant (CNA) Access document in part: 11/19/16 .position off buttocks/coccyx when in bed. Reposition every 1 -2 hours . The NPUAP documents in Repositioning the Individual with Existing Pressure Ulcers in a Chair .3. If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less .5. Modify sitting time schedules and re-evaluate the seating surface and the individual's posture if the ulcer worsens or fails to improve. Nurses' notes in part: 10/17/16 .Resident has a stage 1 non blanchable pressure ulcer to her coccyx. Area measures 0.7 cm x 0.5 cm .Resident is repositioned every 2-3 hours .receives a large ensure daily . 10/19/16 The red area to her upper buttock remains very red .duoderm applied per new wound team orders. (The description is not of the coccyx as documented 10/17/16). 10/25/16 Inspected lateral wound across coccyx and DTI (deep tissue injury) on left ischial. The wound across the coccyx measures 1.0 cm X 7 cm within it measures an open slit at the coccyx of .8 cm X 0.1 cm .we did get her a roho cushion last week because the odd shaped wound is a result of the custom w/c cushion. Despite the different cushion she now has a faint purple mark on left ischial that measures 2 cm x 1.2 cm. Will try switching her to a broda chair . 11/01/16 Inspected wounds on coccyx and left ischial. These ulcers are from her new custom w/c. The rep was out last week and said he does the mechanical piece of the chair. He was going to get a hold of the rep who would come out and pressure map her with regards to the cushion .coccyx now measures 0.6 cm x 7 cm .the DTI that developed on the left ischial is now open and covered in slough so I would say it is unstageable. It measures 0.8 cm x 0.8 cm .resident is using broda chair and roho cushion. 11/08/16 .left ischial .measures 0.9 cm x 0.8 cm and covered in 100% yellow moist slough .will continue with the santyl and all other measures . 11/13/16 .to reposition in w/c every 1-2 hours prn, reposition off buttock/coccyx every 2-3 hours during the noc (night), as resident will allow. (There are no refusals of repositioning documented.) 11/16/16 Left ischial area cleansed .left ischial wound is covered with yellow slough . (There is no weekly measurement; the last measurement is 11/08/16.) 11/22/16 .stage 2 ulcer to the left ischial area. Ulcer measures 0.7 cm X 0.5 cm .the wound bed is 90% covered with [MEDICATION NAME] tissue and 10% covered with slough . 11/24/16 Treatment completed to left ischial area .There was moderate amount of serosanguineous drainage noted to the old dressing .Resident continues to have reddened area noted to left upper buttock, area remains intact. The next assessment of the left upper buttock is four days later. 11/28/16 Resident noted to have a darkened purple skin area with irregular border to far upper left buttock. Measures approximately 1.5 cm in length .resident is positioned off buttocks when in bed with pillows . 11/29/16 .assessed area to residents left ischial. This area is unstageable with 100 % light yellow slough .on resident is an atypical appearing DTI that presents on left of sacrum. The area measures 0.2 cm x 1 cm with 100% black skin .peri-wound has redness surrounding wound that measures 2.4 cm x 4.0 cm .a maintenance slip was put in to switch out her mattress to an air mattress .appears this area is from a wrinkle in the green pad . The NPUAP 2014 quick reference guide in part: Support surfaces; 2. Replace the existing mattress with a support surface that provides better pressure redistribution, shear reduction, and microclimate control for the individual if she or he: cannot be repositioned off the ulcer .fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care. 3. If pressure ulcers are not healing: 3.2 Intensify prevention strategies as indicated. 3.3 Consider changing the support surface . Observations On 11/29/16 at 8:25 a.m., Surveyor observed R4 on her back with the head of the bed elevated approximately 75 degrees. R4 remained in this position until 9:35 a.m. At this time, the head of the bed was lowered to 45 degrees. R4 was not offloaded of the left buttock, or coccyx. At 10:05 a.m., CNA N and CNA O went into R4's room to start the morning cares. R4 was on her back until 10:15 a.m., when CNA O assisted R4 onto her left side. Surveyor could observe indentations on R4's skin from the bedding on the thigh and buttock area. The left upper buttock had a black area surrounded by red intact skin. Surveyor asked when the area had started. CNA N replied, It was noticed yesterday. Interviews On 11/30/16, Surveyor interviewed the Director of Nursing (DON) and RN A about the above pressure injuries. The DON stated it started because of the new wheelchair and cushion R4 was using. R4 started using the wheelchair 08/23/16. Surveyor asked what standard of practice the facility uses. The DON stated NPUAP. Surveyor referred to the standard of practice (SOP) for positioning in a chair if a resident has a pressure injury. The DON replied that she did not want to be held to one hour and needed flexibility. Surveyor asked when the black area on the left buttock started. The DON replied she had no idea where that came from. (The nurses' notes document a red left buttock on 11/24/16.) On 11/30/16 at 3:00 p.m., Surveyor asked RN A for the most recent dietary interventions. The Ensure addition was dated 10/17/16; no nutritional updates since then. R4 has developed two additional pressure injuries since then. The NPUAP documents in Prevention and treatment of [REDACTED]. Screen nutritional status for each individual at risk or or with a pressure ulcer * at admission to a health care setting; * with each significant change of clinical condition; and/or * when progress toward pressure ulcer closure is not observed .2. Use a valid and reliable nutrition screening tool to determine nutritional risk .3. Refer individuals screened to be at risk of malnutrition and individuals with an existing pressure ulcer to a registered dietician or an interprofessional nutrition team for a comprehensive nutrition assessment .Protein Intake .3. Provide adequate protein for positive nitrogen balance for adults with a pressure ulcer .4. Offer 1.25 to 1.5 grams protein/kg (kilogram) body weight daily for adults with an existing pressure ulcer who are assessed to be at risk of malnutrition when compatible with goals of care, and reassess as condition changes . 3. R17 has [DIAGNOSES REDACTED]. The Care Area Assessment, dated 06/28/16, includes in part: Resident triggered for pressure ulcers due to need for assistance with be mobility, bowel/bladder incontinence and weight loss she does have assist of 2 with positional changes due to pain in hip .Resident admitted to facility with venous stasis ulcers and blisters to bilateral lower extremities she has no pressure ulcers .she has a Rest Q mattress on her bed and a pressure redistribution cushion in her wheelchair. She is diabetic which slows the healing process . The quarterly MDS with ARD of 09/21/16 documents R17 is at risk for developing pressure ulcers, but currently does not have one. The MDS documents R17 is dependent on staff for extensive assist for bed mobility and transfers. The care plan Impairment of skin integrity, 09/24/16 history of venous stasis ulcers to lower extremities, DTI to both heels .[MEDICAL CONDITION] . Approaches in part: Place pillow between feet and pillow to suspend heels when in bed to avoid pressure. Resident is to have left heel protector boot on at all times. 09/27/16. The nurses' notes in part: 08/30/16 .there is a new area of concern as we pulled back the covers by her feet were left laying over right. There is a DTI on the right medial heel that is a light purple and measures 1.2 cm x 1.2 cm. Will have staff place pillow between feet to keep separated There are no interventions put in place to prevent pressure on the left heel. 09/06/16 Wound team inspection DTI to right medial heel .1.0 x 0.9 cm and is currently intact with a dark purple color .will continue to put pillow between feet as she rests her feet against each other .Staff elevate her leg as tolerated, and suspend heel off mattress . No changes are made to the care plan for preventing pressure on the left heel. 09/08/16 Wound team inspected area on residents left lateral heel. Thee is a DTI on the left lateral heel that is purple in color and measures 2.2 cm x 2.2 cm and is intact. Area is 100% purple with no drainage .A pillow is placed between her feet to offload pressure DTI on right medial heel. Will place a heel protector on left foot at all times . The interventions are put into place after the development of two deep tissue injuries to R17's heels. On 11/30/16 at 1:40 p.m., Surveyor interviewed the DON to ask what interventions had been in place for pressure reduction on R17's heels prior to 08/30/16. The DON replied there were none. Surveyor asked if 09/08/16 was the first date for the heel protector of the left foot. The DON reviewed the care plans and replied, Yes. 4. R6 has [DIAGNOSES REDACTED]. The significant change in status MDS with ARD of 11/02/16 documents R6 is dependent on staff for position changes and transfers, and at risk for developing pressure injuries. R6's weight is 96 pounds. The nursing and CNA care plans were reviewed and do not have a skin integrity care plan. The Self Care deficit care plan instructs: Repositioning: I need limited assist of 1. Transferring: I need extensive assist of 2 or more . Observations On 11/28/16 at 12:25 p.m., Surveyor observed R6 sitting in her doorway in her broda chair eating lunch. R6 had a gripper sock on one foot, and one bare foot directly on the hard tile floor. On 11/29/16 at 6:46 a.m., Surveyor observed R6 lying in bed on her back; the heels were not floated. There were no heel boots on R6. Surveyor continued the observation of R6 lying on her back in the same position until 10:00 a.m., with the heels directly on the mattress. On 11/30/16 at 9:45 a.m., Surveyor interviewed the DON about R6's risk for pressure ulcers. The DON acknowledged R6 is at risk due to her immobility and diagnoses. Surveyor asked what the repositioning schedule should be. The DON said the care plan should address a repositioning schedule. Surveyor asked if R6 should have something in place to prevent pressure to her heels. The DON acknowledged that R6's heels should be floated. 5. R7 has [DIAGNOSES REDACTED]. The quarterly MDS with ARD of 10/24/16 documents R7 is at risk for developing pressure ulcers and that she is dependent on staff for transfers and bed mobility. The care plan, Impairment of skin integrity, 09/14/16, manifested by: stage II ulcer to left buttocks-healed 9-2016. Approaches in part: .reposition every two hours in bed as resident tolerates .needs total assist of one for all major position changes . Nurses' notes in part: 09/04/16 Braden scale: Mobility: very limited .interventions mobility .float heels . 10/17/16 At skin risk due to: [MEDICAL CONDITION], dementia, malnutrition history of pressure ulcer, impaired mobility/repositioning/friction and shear, incontinence .Braden score: 15 - mild risk Observations On 11/28/16, Surveyor observed personal cares for R7. CNA P assisted R7 with the bedpan. R7's heels were not floated. Surveyor continued the observation until 3:25 p.m., R7's heels were not floated but directly on the mattress; no heel boots were used. On 11/29/16 at 6:45 a.m., Surveyor observed R7 lying in bed on her back. R7's heels were not floated. The heels remained in the same position until 8:10 a.m., when the head of bed was raised for breakfast. No other position change was done. The heels remained directly on the mattress. R7 remained in the raised position on her back, with the heels not floated, until 10:00 a.m. On 11/30/16 at 8:25 a.m., Surveyor observed R7 with the head of the bed elevated greater than 45 degrees. R7's heels were not floated. On 11/30/16 at 9:30 a.m., Surveyor interviewed the DON and RN A about R7. The DON stated R7 had recently healed from a stage II and was at risk to develop another pressure ulcer. Surveyor asked if R7's heels are to be floated. The DON replied, Yes. 6. On 11/28/16, Surveyor reviewed R3's medical record and noted the following: - Minimum data set (MDS), dated [DATE], states R3 is severely cognitively impaired and has a history of pressure injuries. - R3 has a [DIAGNOSES REDACTED]. - CNA care plan, received 11/28/16, states a blanket and pillow are to be placed on the footrests of the wheelchair when R3 is in the wheelchair to prevent skin damage. On 11/29/16, Surveyor observed R3 in her wheelchair in the dining room from 7:00 a.m. - 8:45 a.m. R3 did not have a pillow and blanket on the footrest of the wheelchair. At 8:45 a.m., Surveyor observed CNA F and CNA G provide personal cares for R3. Upon completion of personal cares, the CNAs placed R3 in her wheelchair. The CNAs did not place pillows and blankets on the foot rest of the wheelchair. At approximately 9:00 a.m., Surveyor requested to look at R3's heels. CNA G removed R3's sock and Surveyor noted R3's heel to be red. CNA G stated she would go get the nurse because the redness to the heel was new. CNA G left the room and returned with RN E. RN E assessed R3's left heel and noted the heel was blanchable and red. On 11/29/16 at 9:10 a.m., Surveyor interviewed both CNA F and CNA G in regard to the above noted observation. Both CNAs stated a pillow and blanket should have been placed on the footrests of the wheelchair. On 11/30/16, Surveyor interviewed the DON and RN A in regard to the above noted concerns.

Based on observation, interview and record review, the facility did not provide necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 1 of 17 residents (Resident #23) reviewed for pain; 4 of 24 residents reviewed for skin integrity (Residents #23, #6, #14 and #1); and 2 of 2 residents reviewed for a decline in bowel function (Residents #16 and #10). 1. Resident #23 had experienced episodic leg/wound pain, which occurred almost daily, for a two month period. The facility did not consult with a physician after the resident experienced excruciating leg/wound pain and wanted to dial 911. The facility did not thoroughly assess or manage the resident's pain, did not routinely pre-medicate the resident to prevent pain, prior to wound care or therapy services. 2. Resident #23 developed recurrent moisture-associated skin damage to the buttocks and coccyx. No new interventions, or toileting/repositioning schedule, were implemented to prevent further skin breakdown, and to prevent the open areas from reoccurring. 3. Resident #6 has reoccurring open areas on her coccyx and buttock, diagnosed as incontinence associated [MEDICAL CONDITION]. The facility has not implemented new interventions with the reoccurrence of the open areas, to prevent further skin breakdown. 4. Resident #14 developed a alteration in skin and the facility did not complete a thorough assessment, notify the physician and did not complete an investigation as to how the skin alteration developed. 5. Resident #16 had a decline in bowel function in which the facility did not implement interventions to promote or maintain current bowel function. 6. Resident #10 had a decline in bowel function. The facility did not complete a bowel assessment to determine cause of decline. 7. Resident #1's physician order [REDACTED]. This is evidenced by: PAIN: 1. On 10/21/15, Surveyor received and reviewed a facility policy, entitled, PAIN CONTROL/MONITORING RECORD. The policy, last revised in January 2015, states the following, in part: POLICY: It is the intent of this facility to identify and monitor pain level, administer appropriate mediation(s), and to evaluate the effectiveness. Our goal is to keep the resident at his/her most comfortable state of wellbeing. Pain is not meant to be tolerate by the body. The body uses pain to let us know something is not right and needs our attention. The following scale will be used: --0= NO PAIN/COMFORTABLE --1-3= MILD PAIN/DISCOMFORT (although the resident experiences some pain, he or she is able to carry on with daily routines, including therapy, socialization or sleep) --4-6= MODERATE PAIN/DISCOMFORT (an amount of pain that does not allow the resident to comfortably participate in activities of daily living) --7-8= SEVERE PAIN/DISCOMFORT (an intense amount of pain, severely impairing activities of daily living) --9-10= EXCRUCIATING/HORRIBLE PAIN (the worst pain ever experienced) . PROCEDURE: 1) Determine the resident's level and type of pain: a) Ask him/her to describe the pain. b) Take the resident's comments seriously, if he/she says they have pain; they do. The pain experience is very subjective. Pain is whatever the resident says it is. c) Observe for indicators of pain--moaning, crying, frowning/facial expressions, resistance to movement or cares, etc. 2) Call physician, explain need for medication, and receive input 3) Implement Pain monitoring flow sheet whenever using PRN (as needed) medication(s) . 5) Never miss an opportunity to prevent or relieve pain. 6) We need to be proactive in treating pain, not reactive. Review the PRN [MEDICATION NAME] MAR (Medication Administration Record). Look for patterns and similarities. Proactively schedule and administer medication to prevent pain. This enhances the resident's quality of life. 7) Pre-medicating residents prior to therapy sessions, enables them to more actively participate in their programs and recover quicker. No pain level would be needed for these instances. On 10/21/15, Surveyor reviewed Resident #23's medical record. The resident has [DIAGNOSES REDACTED]. Resident #23 was admitted to the facility on [DATE]. Wound Team notes, dated 08/12/15, indicate the resident was admitted with a venous stasis ulcer to the right lower leg, measuring 10-12 centimeters (cm) wide which goes around the entire ankle. Resident #23 had orders to have wound care treatments completed twice a day. According to the resident's MAR, the resident received the following pain medications, upon admission to the facility: -[MEDICATION NAME] ER (Extended Release) 15 milligrams (mg), at 8:00 a.m. and 8:00 p.m. -[MEDICATION NAME] 200 mg, daily at 8:00 p.m. -[MEDICATION NAME] 5 mg, every four hours, as needed (PRN) Surveyor reviewed Resident #23's most recent Brief Interview for Mental Status (BIMS), dated 10/13/15. The resident scored 15 out of a possible 15 points, which according to the BIMS assessment, a score of 15 indicates the resident has intact cognitive function. The resident's most recent Minimum Data Set (MDS), dated [DATE], indicates the resident requires assistance with transfers, ambulation, bed mobility, dressing, and personal hygiene. Surveyor reviewed the resident's Pain Management section (J0100) on the resident's MDS, dated [DATE]. This section states the resident experiences frequent pain over the last five days and the worst pain has been a seven out of ten. Nurses and wound care notes, from 08/11/15 to 10/21/15, were reviewed. Resident #23's notes state the following, in part: -08/12/15: SLEEP PATTERN: Resident made no complaints during the night . -08/13/15: SKIN TREATMENT .resident does have tenderness to the area (venous ulcers) but mostly on the back side of the leg along the tendon area . -08/14/15: PHYSICIAN VISIT: Dr .saw resident for admission visit this morning; reviewed medical history, medication list, labs, vitals, weights, therapies. Physical exam was competed .D/C (discontinue) HS (Hour of Sleep) [MEDICATION NAME]([MEDICATION NAME]) . -08/17/15: .HAVE YOU HAD PAIN OR HURTING AT ANY TIME IN THE LAST 5 DAYS: Yes. She indicates she has had right lower leg pain 'where I have that sore' .HOW MUCH OF THE TIME HAVE YOU BEEN EXPERIENCING PAIN .OVER THE LAST 5 DAYS: Frequently. OVER THE PAST 5 DAYS, HAS PAIN MADE IT HARD FOR YOU TO SLEEP AT NIGHT: No. OVER THE PAST 5 DAYS, HAVE YOU LIMITED YOUR DAY-TO-DAY ACTIVITIES BECAUSE OF PAIN: No. PLEASE RATE YOUR WORST PAIN OVER THE LAST 5 DAYS .07 . -08/19/15: .Resident had an appointment with Dr .in the wound clinic today .[MEDICATION NAME] (antibiotic medication) 500mg .twice daily x 5 days . -08/20/15: .Skin treatment completed to right lower extremity .The [MEDICATION NAME] dressing did require soaking with normal saline to remove dressing and large amount of bloody drainage noted on the old dressing. She is currently receiving oral [MEDICATION NAME] twice daily for [DIAGNOSES REDACTED]. She did complain of increased pain to the right leg wound during treatment . -08/21/15: .The tissue to the posterior (back) aspect of the wound is a dark, moist slough with tenderness to the area with gentle cleansing . -08/23/15, 4:50 a.m.: SLEEP PATTERN .Resident requested and received prn [MEDICATION NAME] 5 mg at (11:15 p.m.) and again at (03:15 a.m.) for leg pain 8/10 that 'comes and goes.' Med was effective each time . -6:46 a.m.Resident informed this writer at (6:00 a.m.), that she got very little sleep throughout the night. Resident's leg pain was primarily in her left leg from left lateral (outer) knee to ankle, resident described the pain as a shooting nerve pain, and she stated that she has experienced pain such as this in the past. Resident received prn tylenol 1000 mg at (6:00 a.m.) and a warm blanket was wrapped around her leg which has provided her with some relief . -1:17 p.m. .PAIN ASSESSMENT: Resident states that she is not having the pain to her legs like she was last evening but has not used any (pain medications) so far this shift. Resident is concerned about the amount of pain she was in and does not want an episode like that again. She states that she had one other episode like that at home and there was 'nothing' that could be done for it. Resident describes the pain as a 'shooting pain' down her leg. She does have PRN [MEDICATION NAME] that she used with some effectiveness last night. She currently receives low dose of [MEDICATION NAME] at HS and recently her HS MSContin was discontinued. Resident continues to report that the pain is like a 'nerve' pain. Will place note in MD book to review pain control measures with resident . -7:53 p.m. .Resident up in chair, alert, oriented and conversing .Denies pain. States she had severe pain in left leg last night, sudden onset, which she rated 'more than 10.' Stated she received pain medication, repositioned herself and prayed to get through it. She has had this pain before but does not know the cause . -10:05 p.m. PRN MED GIVEN: She denied need for any pain med at (4:00 p.m.). She refused [MEDICATION NAME](sleep aid medication) when offered at bedtime but wanted [MEDICATION NAME] 5mg at (9:00 p.m.) for leg pain, 5, and sleep . -08/24/15 at 1:28 p.m.: PHYSICIAN'S ASSISTANT VISIT .Increase [MEDICATION NAME] 300 mg daily dx (diagnosis) [MEDICAL CONDITION] . -3:46 p.m.: .HAVE YOU HAD PAIN OR HURTING AT ANY TIME IN THE LAST 5 DAYS: Yes both her legs from the swelling. HOW MUCH OF THE TIME HAVE YOU BEEN EXPERIENCING PAIN .OVER THE LAST 5 DAYS: Occasionally. OVER THE PAST 5 DAYS, HAS PAIN MADE IT HARD FOR YOU TO SLEEP AT NIGHT: Yes just one night. OVER THE PAST 5 DAYS, HAVE YOU LIMITED YOUR DAY-TO-DAY ACTIVITIES BECAUSE OF PAIN: Yes. PLEASE RATE YOUR WORST PAIN OVER THE LAST 5 DAYS .10 .WORST PAIN YOU CAN IMAGINE: 05. ALLEVIATING FACTORS: States she asks for a pain pill when needed. -08/27/15: .Wound team assessed multiple ulcers to left and right shin, coccyx and left of coccyx .Back side of the leg has more discomfort . -09/02/15, 6:27 a.m.: SLEEP PATTERN: Resident complained of pain at (4:20 a.m.) and she was given 5 mg of [MEDICATION NAME]. It was effective . -09/03/15: .Wound team assessed venous ulcer to right shin this morning .Area is tender to the touch . -09/05/15: .resident had dressings changed to right lower leg ulcers as ordered, small amount of active bleeding noted .tolerated procedure ok, said she is aware hurting more and does take [MEDICATION NAME] prn more, she does realize more pain means circulation is also improving then to her right leg . -09/07/15: SLEEP PATTERN .At (11:30 p.m.), resident requested prn [MEDICATION NAME] for pain to legs 6/10. Med was effective .Administered PRN [MEDICATION NAME] 5 mg .at (9:20 a.m.) per resident's request for leg pain .Med effective . -09/14/15: .Resident continues to report increased pain to the posterior aspect of the right leg and wound. She is now receiving oral [MEDICATION NAME] 500 mg twice daily for a 7 day course for [MEDICAL CONDITION] of the right leg and resident has not noted any change in pain yet after receiving 2 doses of antibiotic. The old dressings carefully removed due to increase pain and moderate amount of serosanguineous (watery/bloody fluid) drainage . -09/17/15, 12:12 p.m.: .Wound care continues to cause increased discomfort for resident and she did receive prn [MEDICATION NAME] for increased pain . -3:30 p.m.(physician) .updated in regards to the increasing pain to the right leg as well as the continued purulent (clear) drainage from the right leg wound. New orders were given . Resident #23's medical record indicates the physician changed the resident's order for [MEDICATION NAME] once a day, to twice a day. The resident now receives the medication at 8:00 a.m. and 8:00 p.m. The resident's nurses and wound notes continue to read, in part: -09/18/15: .Requested PRN [MEDICATION NAME] for pain management during wound treatment on right leg. PRN oxycodne administered with (8:00 a.m.) med pass. At (8:00 a.m.) med pass resident denied any pain. during right leg wound treatment rated pain at a '5 or 6.' Showed facial grimacing and increased respiratory effort during the treatment. (At 9:20 a.m.) rated pain at 3; 30 minutes post treatment .Resident stated 'pain is a lot more tolerable today.' The order for Scheduled [MEDICATION NAME] from once a day to twice a day on 9/17/15. Effective pain control is in place at this time. -09/19/15: PAIN ASSESSMENT: Resident continues to have a fair amount of pain especially to the right lower leg where the ulcer is present. She has had her MSContin restarted at bedtime and she reports that it has been helpful for pain control during the night. She did request PRN [MEDICATION NAME] this morning before wound care to the right leg--which even with the pain medication was extremely tender to the touch . -09/20/15: PAIN ASSESSMENT: Resident continues to have significant discomfort to the open tissue to the medial (middle) and posterior aspect of her right leg especially during the wound treatment. She states that once the treatment is done it is 'not that bad.' During the night her legs will bother her more in which she was utilizing the PRN [MEDICATION NAME] more frequently .She feels that the current regimen is effective at this time . -09/21/15: .Wound care completed to the right lower leg venous ulcers. Old dressing carefully removed as dressing removal does cause increased pain and discomfort for resident .She received the last dose of oral [MEDICATION NAME] this AM (morning) . -09/24/15: Resident currently has 6 venous ulcers to her right lower leg . -09/26/15: .Wound care provided to the right lower extremity venous ulcers. Resident reports that she requested the outer [MEDICAL CONDITION] wraps be removed at bedtime due to pain and stated that she was able to sleep well without right leg pain during the night .Wound treatment does cause increased discomfort for a short period of time after new dressings and ointment applied then resolves. -09/27/15: .Wound care did cause mild burning discomfort for resident during and shortly after the treatment . -09/29/15: . Resident complained of leg discomfort rating 5/10 and requested [MEDICATION NAME] 5 mg at (5:00 p.m.). Resident stated that 'tylenol doesn't do anything.' -10/02/15: .Wound treatment does continue to cause mild burning and discomfort, but resolves shortly after treatment completed . -10/03/15: .Treatment completed to the right lower extremity this morning with some minor discomfort during the process .Resident did not want the [MEDICATION NAME] to the upper thigh area on either leg this morning stating that they 'roll down and cause more pain' . -10/04/15, 6:49 a.m.: .Tylenol given (at 11:10 p.m.) and oxy ([MEDICATION NAME]) given around 6 (in the morning) . -10:53 a.m.She continues to have a fair amount of pain especially to the posterior aspect of her right lower leg wounds. She has been utilizing the PRN [MEDICATION NAME] when she can for pain control . -11:24 a.m. PAIN ASSESSMENT: Resident continues to have pain to the right lower extremity especially the posterior aspect where open tissue is noted. Last evening she recalls having a large amount of pain to the left leg from the 'hip all the way down.' She reports that in the past she has had these episodes every once in a while in which she gets this pain in her leg and that no 'matter what I do nothing can get rid of the pain.' She utilized the PRN [MEDICATION NAME] and (in) time the pain did resolve . -5:31 p.m. PAIN ASSESSMENT: Resident was weepy this afternoon in regards to 'what if's.' What if she has pain like she did last evening. Resident is fearful as to 'how will I deal with the pain.' It was explained that she did not take any PRN medication last evening. She ambulated in the hallway as well as completed her exercise program (the bike) which is a lot of movement for her. With those exercises and not requesting a PRN it (is) conceivable that she would have a large amount of pain that staff would have to catch up on. The plan for tonight is to continue with the PRN every 4 hours for optimate pain control and discuss with MD tomorrow. -6:45 p.m. MOOD .Resident then stated that she'd had a bad night, her legs hurt so badly that she was thinking about calling 911. Stated she thought she took her pain meds but had been told that she refused them. Resident stated she thought that meds were given every 4 hours. Nurse confirmed with resident that she wants her pain meds every 4 hours and that she prefers staff to give them even if they have to wake her up to do it. On 10/05/15, the medical record indicates the Physician's Assistant (PA) reviewed Resident #23's lab work. There is no documentation the facility updated the physician or PA regarding the resident's increase in pain, or the resident wanting to dial 911 due to having significant pain. The resident's nurses and wound notes continue to state, in part: -10/06/15: .Resident has been sleeping well after receiving prn [MEDICATION NAME] at (11:40 p.m.) for pain to legs 8/10 .HAVE YOU HAD PAIN OR HURTING AT ANY TIME IN THE LAST 5 DAYS: Yes. HOW MUCH OF THE TIME HAVE YOU BEEN EXPERIENCING PAIN .OVER THE LAST 5 DAYS: Frequently. OVER THE PAST 5 DAYS, HAS PAIN MADE IT HARD FOR YOU TO SLEEP AT NIGHT: Yes. OVER THE PAST 5 DAYS, HAVE YOU LIMITED YOUR DAY-TO-DAY ACTIVITIES BECAUSE OF PAIN: Yes. PLEASE RATE YOUR WORST PAIN OVER THE LAST 5 DAYS .09 .LOCATION OF PAIN: Resident reported pain in left leg/thigh. States pain medications does help relieve the pain. On 10/07/15, Resident #23's primary care physician visited the resident at the facility. The progress note for this visit, states the following, in part: History of Present Illness .She is supposed to be treated with Medi Honey twice daily to the venous stasis ulcers, but oftentimes she will only allow it once a day .She still though has significant discomfort, especially in the posterior calf on the right especially when the dressing is removed. She is still requiring [MEDICATION NAME] daily and then the as-need [MEDICATION NAME]. How often she takes that is often dependent on how much she does in therapy. One day she tried to walk over 200 feet and then she had also done her stationary bike and then have a lot of pain that evening .She was seated in her wheelchair when I met with her today. She had just come back from the wound clinic. As a result, I did not undress her wraps. It is very uncomfortable for her . Impression/Plan .4. Pain management. She remains on the [MEDICATION NAME] daily and the as needed [MEDICATION NAME]. We talked about trying to ultimately wean down and off the [MEDICATION NAME] of (sic) we can get her pain controlled well enough, and then start weaning the [MEDICATION NAME]. The wound care treatment orders were changed on 10/07/15, to be completed one to two times per day. The nurses and wound notes continues to state, in part: -10/08/15: .Resident states she has mild discomfort to her RLE (Right Lower Extremity) most of the time . -10/13/15: .Resident reports that her leg is very tender and this is why she is unable to wear the [MEDICAL CONDITION] wraps during the night .She does tolerate them during the day . -10/18/15: SKIN TREATMENT .She does have some discomfort during the treatment but states that today was a 'good day' . Surveyor reviewed the resident's Pain Management, section J, on the resident's MDS, dated [DATE]. This section states the resident has had almost constant pain the last five days. The MDS identifies the pain has made it difficult for her to sleep at night and rates the worst pain a nine out of ten. The resident's Pain Monitoring flow sheets, from August 2015 to October 2015, were reviewed. The flow sheets indicate Resident #23 has received the PRN [MEDICATION NAME] almost daily, since September. The sheets identify the resident was pre-medicated prior to therapy services six times, from 08/24/15 to 10/22/15. The flow sheets do not identify if any pain medication was given prior to Resident #23's wound care. The sheets do identify PRN [MEDICATION NAME] was given for complaints of pain, between the hours of 6:00 a.m. and 9:00 a.m., approximately 15 times, from 08/13/15 to 10/22/15. The resident's morning dressing change is generally completed between 7:00 a.m. and 8:00 a.m., per the resident (see below). The pain monitoring flow sheets indicate the resident has not been given or offered PRN pain medications, every four hours, as Resident #23 requested on 10/04/15. Surveyor reviewed Resident #23's comprehensive care plan. The care plan states the following, in part: 08/31/2015. PROBLEM: Impaired physical mobility, Fall Risk, Alteration in Comfort. 10/19/2015. RELATED TO: Recent hospitalization s, Chronic low back pain. [MEDICAL CONDITION]. Multiple falls at home . MANIFESTED BY: decreased mobility, weakness, history of falls, verbalization of pain . APPROACH. 08/31/2015. Nurses--Assess ain as needed, Administer pain medication as orders .Nurse Aid--TRANSFER--limited assist of one and walker .uses wheelchair .Best mobility--assist of one upon request. Report pain to nurse. Provide clutter free environment . 08/31/2015. PROBLEM: Impairment of skin integrity RELATED TO: Right sided heart failure, [MEDICAL CONDITION] MANIFESTED BY: Poor circulation and weeping/blisters/[MEDICAL CONDITION] of lower extremities causing venous stasis ulcers .present on admission . APPROACH. 08/31/2015. Nurses--Skin assessment as needed, Treat ulcers as ordered, Consult with Wound Team and/or Clinician as needed. Followed in Wound Clinic .Nurse Aide--Monitor skin with cares and report any signs of skin breakdown to nurse, Apply lotion to skin as needed. Has air mattress on bed and iris cushion in wheelchair. Encourage fluids . The care plan does not identify the resident is having a significant amount of pain related to the presence of venous stasis ulcers, during wound care, or throughout the night. The care plan does not identify if Resident #23 should be pre-medicated prior to wound care and/or therapy services. On 10/21/15 at 9:38 a.m., Surveyor interviewed Resident #23. The resident stated she has had a lot of pain during wound care, which she rates being at a six, seven and sometimes higher. She describes the pain as sharp, and constant. The resident explained her wound will usually burn when the nurses apply the ointment during a dressing change. Surveyor asked the resident how often staff offer pain medication prior to wound care, to which Resident #23 replied, Sometimes. Resident #23 stated the pain usually comes on during the night, and once it starts it can last up to three hours, even after taking pain medication once it starts. The resident further explained the pain medication ([MEDICATION NAME]) lasts about four hours, to which the resident would prepare, and watch the clock, so she knew when the next pain medication could be taken. At approximately 3:00 p.m., Surveyor interviewed Resident #23. The resident indicated the [MEDICATION NAME] medication takes approximately 45 minutes for the medication to start working. Surveyor asked Resident #23 about the evening of 10/03/15, when the resident stated she was in so much pain, she wanted to dial 911. Resident #23 indicating the pain she experienced that evening was excruciating, and she felt as if she was going out of her mind. The resident stated she requested a pain pill that evening, but the pain was so intense she doesn't remember the events of that evening (i.e. receiving pain medication, etc.). Surveyor asked if the facility knew the resident's pain was excruciating, the night of 10/3/15, to which Resident #23 replied, she hoped they already knew. Resident #23 indicated she has more pain when working with therapy services. The resident indicated therapy has no scheduled time when they work with the resident, so Resident #23 stated she does not usually receive her pain medication prior to therapy services. On 10/22/15 at 7:19 a.m., Surveyor began an observation of Resident #23's wound care to the right lower leg. Registered Nurses (RNs) OO and PP completed the dressing change. RN PP and Resident #23 discussed the amount of drainage which has been draining from the venous ulcer. The resident stated the wound was leaking again last evening, and said, When it leaks, it hurts the most. At approximately 7:35 a.m., RN PP began to cleanse the ulcer, located on the back of the resident's right leg. At this time, Surveyor observed Resident #23's body flinch, and display facial grimacing. At approximately 7:37 a.m., RN PP applied the gauze, which was covered in [MEDICATION NAME] ointment, to the ulcer. At this time, Resident #23's body flinched, the resident had facial grimacing, and said, Eh! RN PP then stated, I'm sorry, I know it burns. After wound care was completed, RN OO asked the resident if Resident #23 was having pain. Resident #23 stated her pain was okay at that time. The nurses did not stop the wound treatment and offer any pain medications, when Resident #23 flinched, or grimaced. At this time, Surveyor interviewed Resident #23. The resident stated she experienced sharp pain in the ulcer when the wound was touched during the treatment. The resident currently rates her pain at a five or a six on a scale of ten. The resident stated her wound dressings are generally done in the mornings, between 7:00 and 8:00 a.m. Resident #23 stated she was not offered, nor did she receive any pain medication prior to the dressing change, the morning of 10/22/15. At 8:18 a.m., Surveyor asked RN PP if Resident #23 received any pain medication this morning, prior to wound care. RN PP replied the resident received a PRN [MEDICATION NAME] about 4:00 a.m., So she got something. The PRN pain medication documentation was reviewed for 10/22/15. The flow sheet indicates the resident received a PRN [MEDICATION NAME] for complaints of leg pain at 3:58 a.m. The resident was not offered and did not receive any other pain medications, prior to the dressing change. It is noted, the pain relieving effects of [MEDICATION NAME] peaks after an hour of administration, and tapers off at the end of four hours. On 10/22/12 at 8:21 a.m., Surveyor interviewed Assistant Director of Nursing (ADON) H. Resident #23's significant wound pain, as well as the wound care observation, were discussed. ADON H did not know if Resident #23 has been pre-medicated prior to wound care and therapy services. During the continued interview, the resident's significant pain, documented in the medical record on 10/04/15, was discussed. ADON H stated the resident refused the PRN [MEDICATION NAME] the previous evening, which made the pain worse. ADON H further indicated the new intervention after 10/04/15, was to provide the PRN pain medication every four hours, and would try what the facility had in place. ADON H indicated the facility does not call the wound clinic when a resident is having significant pain in a wound, but the facility physician's would be contacted. Surveyor asked if Resident #23's physician or the PA was notified and/or consulted with on 10/05/15, regarding the resident's significant pain and wanting to dial 911. ADON H stated she would have to review the resident's medical record for this information. At 9:44 a.m., ADON H reported to Surveyor , the physician and PA were not contacted on 10/05/15, regarding Resident #23's significant pain. SKIN: 2. On 10/21/15, Surveyor reviewed Resident #23's medical record. The resident has [DIAGNOSES REDACTED]. Resident #23 was admitted to the facility on [DATE], and had several open areas to the coccyx, buttock, and thighs. The medical record indicates these open areas have occurred from moisture, related to incontinence. The open areas, documented in the resident's wound team notes are as follows: -Midline coccyx: 1.2 centimeters (cm) x (by) 1 cm -Left-Upper coccyx: 0.5 cm x 0.5 cm -Left buttock: 0.8 cm x 0.5 cm, with approximately ten percent yellow slough (dead cells which have accumulated in the drainage). -Right-Upper back of thigh: 0.6 cm x 1.4 cm Upon admission, the facility placed an air mattress on the resident's bed, and an Iris cushion (has a flat, dimpled surface on top) in the wheelchair. The facility regularly used a barrier type (skin protectant) cream on the resident's coccyx and buttocks. The resident's MDS, dated [DATE], indicates the resident requires assistance with transfers, ambulation, bed mobility, dressing, toileting, and personal hygiene. The MDS indicates the resident is frequently incontinent of both bladder and bowel, and has moisture-associated skin damage. Surveyor reviewed Resident #23's BIMS scores, dated 08/20/15 and 10/13/15. The resident scored 15 out of a possible 15 points on each assessment. According to the BIMS tool, a score of 15 indicates the resident has intact cognitive function. The nurses and wound team notes indicate the following information related to Resident #23's moisture-associated skin damage: -08/18/15: The open areas to the buttocks are now healed. -08/20/15: The open area on the left side of the coccyx measures 0.4 cm x 0.5 cm, and the open area on the coccyx measures 0.1 cm x 0.5 cm. The notes indicate the resident no longer has loose stools, and receives high protein jello, daily, for wound care. -09/10/15: The open areas to the coccyx are now healed. No new interventions, or a toileting/repositioning schedule, were implemented, in order to prevent future skin breakdown, once the open areas were healed. -09/24/15: Resident #23 develops three new, reddened areas to the left buttock. They measure 1 cm x 3 cm, 1 cm x 1 cm, and 1 cm x 2.5 cm (this area has two superficial open areas, each measuring 0.4 cm x 0.4 cm). No new interventions were implemented at this time, in order to prevent further moisture-associated skin breakdown to the resident's coccyx and buttocks. -10/06/15: The notes identify the resident continues to have three superficial open areas to the left buttock. There are no measurements for these areas. Resident #23 has a new superficial open area to the right buttock, of which there are no measurements. -10/13/15: The left-upper buttock open area measures 0.3 cm x 0.1 cm; the left-lower buttock open area measures 1.0 cm x 1.3 cm, and has a layer of yellow slough in the middle of the area. The open area to the right buttock measures 0.3 cm x 0.1 cm. The notes indicate the resident continues to be incontinent and continent of urine, but the incontinent product used is usually wet, due to urinary dribbling. -10/15/15: The left buttock open areas now measures 1.5 cm x 1.2 cm, and 0.2 cm x 0.2 cm. The note does not identify the location of the open areas (upper or lower). There is no documentation related to the open area on the right buttock, indicating if the area is healed or remains open. -10/19/15: The note indicates there is one open area to Resident #23's left buttock. There is no documented measurement for this area. Resident #23's most recent MDS, dated [DATE], indicates the resident continues to be frequently incontinent of both bladder and bowel. The MDS indicates the resident currently has moisture-associated skin damage,

Based on observation, interview and record review, on the first day of survey, the facility's nurses' stations were not equipped to receive resident calls through a communication system for 17 residents when in their rooms, with the potential to affect all residents in resident rooms as well as toilet and bathing facilities, in a total census of 191. On the first day of survey (09/23/10), 14 residents were identified by the survey team to not have consistently functioning call lights (Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 26). The facility identified three additional residents (Residents #15, 16 and 17) on the first day of survey that also did not have consistently functioning call lights. Nine current residents complained on the first day of survey of having occasional or frequent problems with their call lights (Residents #18, 19, 20, 21, 22, 23, 24, 25 and 27). Family Member (FM) D complained that Resident #1's call light was not consistently functioning on the morning of the resident's death (09/08/10) and expressed concern Resident #1, who was at high risk for [MEDICAL CONDITION], may have attempted to call for assistance but was unable to do so because she might not have had a working call light. On the first day of the survey (09/23/10), it was evident the facility had not identified, addressed and monitored whether all residents had consistently functioning call systems in their rooms, bathrooms and bathing areas. On 09/23/10, the facility was advised to put a plan in place to monitor the call light system and it was confirmed on 09/29/10 and 09/30/10 that the facility did not have a communication system that was consistently functioning which had the potential to affect all residents. This situation created a finding of immediate jeopardy. On 10/01/10, the facility administrator was notified that immediate jeopardy regarding the call lights began on 09/23/10 when 17 residents were identified to have call lights that were not consistently functioning. The immediate jeopardy was removed on 10/05/10. Although immediate jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm, with a potential for more than minimal harm that is not immediate jeopardy). The deficient practice continued at scope/severity F (potential for harm that is not immediate jeopardy/widespread) because of numerous, continued examples of the facility's call lights working inconsistently throughout the facility. This is evidenced by: The facility consists of 199 resident beds and the physical layout consists of a west and an east side, each side consisting of four to five hallways. The nurse's station on each side is in a central location with the hallways branching outward. The call light system consisted of: -call cords at the bedside (with buttons to press to initiate the call) that were either directly plugged into a metal wall plate on the wall or "piggybacked" with approximately a 12-inch cord that plugged directly into the wall plate (sometimes these two cords were secured with black or clear tape and sometimes they were not secured with tape); -either a black or a white plug at the end of the cord; -a metal wall plate in each resident room between the two beds into which the black or white plugs at the end of the call cords were placed; -a small light on the metal plate next to each plug to indicate to the resident or someone else in the room that the call light had been activated; -a small button on the metal plate just below the small light that when pressed would deactivate the call light; -a larger light on the wall outside the resident room to indicate to staff that a call light had been activated in that room (which flashed red for the bathroom light); -a light at the end of each hallway nearest the nurses' station, on the ceiling, that lit on the top for any resident call light on that hall that was activated (a light on the bottom, usually red, lit when a resident bathroom light was activated); -no sound activation to the system when a resident bedside light was activated, but only when a bathroom or bathing room light was activated. The sound could not be heard in the middle or far end of the hallway, but came from wall panels at the end of the hallway across from the nurses' station and could be heard as one came closer to the nurses' station (two wall panels on the west wing and three wall panels on the east side). On 09/23/10, Surveyor made the following observations and conducted the following interviews: Resident #2's call light at 11:35 a.m. was not consistently functioning when the call button at the bedside was pushed. The light did not go on at the wall panel or outside the door. Surveyor summoned Surveyor and Maintenance Staff (MS) CC to confirm the call light could not be activated. Both were unable to make the call light go on when the call button was pushed. MS CC at first stated the problem might be that the two cords (the long cord and the shorter, approximately 12-inch cord) were not tightly connected as he stated this was sometimes a problem. The call light continued to be nonfunctional. MS CC pulled the black plug from the wall plate and showed how the part that plugged into the wall plate consisted of eight metal pins. MS CC stated these pins sometimes loosened and did not have a tight connection to the wall plate. MS CC used a metal tool to push against some of the metal pins and put the black plug back into the wall plate. The call light then functioned when the call button was pushed at the resident's bedside. MS CC stated this has to be done periodically with the black plugs, but added there was no scheduled maintenance to do this. Resident #2's nurses' notes were reviewed and it was stated Resident #2 used her call light on 08/01/10, 08/05/10 and 08/22/10 to call for staff assistance. Resident #3's call light at 11:55 a.m. was not consistently functioning when the call button at the bedside was pushed. The button one would push to activate the call light was noted to be sunken into the hole from which it should have protruded. The black plug that plugged into the wall plate was loose when it was touched. If one pushed hard on the sunken button, it would sometimes activate the call light and sometimes not. If the call light did activate, it was difficult to deactivate the call with the button on the wall plate (had to be pushed numerous times). Certified Nursing Assistants (CNAs) E and F were present when the call light was noted not to be consistently functioning. CNA E stated she was unaware the call light was not working properly and added that Resident #3 was unable to use the call light (this was confirmed by record review). CNA F stated she wrote a maintenance slip about the call light at approximately 11:30 a.m. (on 09/23/10). On 09/28/10, Surveyor asked DM C to provide all maintenance slips related to call lights from 04/01/10 to the present. The maintenance slips were received and reviewed by Surveyor . The only maintenance slip on 09/23/10 that was provided was for Resident #36, not Resident #3 as stated above. The maintenance request was written by CNA MM at 10:50 p.m. which stated the call light did not work. The maintenance response was signed by DM C on 09/24/10 which stated it was repaired. On 09/23/10 at 12:00 p.m., Resident #4's call light was not consistently functioning when the call button at the bedside was pushed (pushed several times by Surveyor ). Resident #4 was sitting up next to the bed at that time with the call light placed within his reach and with CNA E's prompting, was able to push the call button. The call light did not activate when Resident #4 pushed the button. CNA G stated she had paged maintenance earlier, at approximately 11:00 a.m., when she could not deactivate the call light by pushing the button on the wall plate. CNA G stated she was then able to deactivate the call light making it unnecessary for maintenance involvement. Record review for Resident #4 identified he was an insulin-dependent diabetic, placing him at increased risk if he required timely staff assistance. Surveyor interviewed Resident #18 on 09/23/10 at 12:03 p.m. Resident #18 stated that approximately five weeks ago she had a problem with her call light not working, but added she had no recent problems with it. Surveyor interviewed Resident #19 on 09/23/10 at 12:05 p.m. Resident #19 stated that approximately in the last three weeks, her call light did not work three times. Resident #19 stated the call cord came apart where it connected to the wall, especially at night if she put the head of her bed up. Resident #19 identified she had reported the problems with the call light to the nurses. On 09/23/10 at 12:08 p.m., Resident #5's call light was not consistently functioning when the call button at the bedside was pushed five times. Surveyor then gently shook the black plug at the wall plate and the call light was then activated. Resident #5's record review stated he was unable to use the call light. Resident #5's roommate's call light worked when the call button was pressed, but would turn off at times when the black plug at the wall plate was touched. It was noted there was black tape on the call cord going into the black plug. At 12:12 p.m., Resident #6's call light was not consistently functioning when the call button at the bedside was pushed. The call light would sometimes activate and other times not activate, even when the button was pushed five to ten times. Resident #6's record did not identify if she was capable of using her call light to summon staff assistance, but it was documented in the nurse's note on 08/08/10 that she was able to manage her own nebulizer treatment after it was set up. Subsequently, one could assume she had the cognitive and functional ability to use the call light. At 12:15 p.m., Resident #7's call light was not consistently functioning when the call button at the bedside was pushed. The plug in the wall socket was noted to be white and the call light did not work unless the plug was gently shaken at the wall plate. At 12:18 p.m., Resident #8's call light was not consistently functioning when the call button at the bedside was pushed. The light did not go on at the wall panel or outside the door. The plug into the wall plate was a white one and there were two cords (the long cord and the shorter, approximately 12-inch cord) that were not tightly connected. There was no tape holding them together as there was for some residents. When the two cords were pushed more tightly together, the call light continued to be nonfunctional. Record review for Resident #8 identified in the nurse's note on 09/05/10 that she "seldom" used her call light (appeared to be capable of using it on some occasions). On 09/23/10 at 12:20 p.m., Surveyor interviewed Resident #20 who stated her light sometimes went on by itself. When Surveyor checked the call light, it was functional at that time. At 12:22 p.m., Resident #9's call light was not consistently functioning when the call button at the bedside was pushed. The cord had a black socket plugged into the wall plate and the black socket was noted to be quite loose. The call light would not activate even by gently shaking the black socket. Surveyor discussed the situation with the Nursing Home Administrator (NHA) on 09/23/10 at 12:22 p.m. Surveyor asked if each resident had been assessed for safety regarding a functional call light. The NHA stated they had a system in place where staff make out a maintenance slip if they find a call light that does not work. Surveyor asked the NHA to accompany her on a tour to confirm some of the nonfunctioning and inconsistently functioning call lights. From 12:30 p.m. to 12:35 p.m., the NHA and Surveyor rechecked several of the call lights. The call lights for Residents #6 and #7 worked when the NHA activated them. The call lights for Residents #8 and #9 did not work when the NHA attempted to activate them. CNA II was feeding Resident #9 at the time and stated the resident was incapable of using the call light. The NHA stated he was not aware these call lights were nonfunctional, but added that Resident #9 would not be able to use his anyway. The NHA stated the call light system was "old." On 09/23/10 at 12:40 p.m., Resident #10's call light was not consistently functioning when the call button at the bedside was pushed. CNA JJ was asked to check the function of the call light. CNA JJ was only able to get the call light to activate when she gently shook the black socket that was plugged into the wall plate. CNA JJ stated Resident #10 was able to use his call light and confirmed the call light was "a little touchy." At 12:45 p.m., Resident #11's call light was not consistently functioning when the call button at the bedside was pushed. The cord consisted of a long and a short cord connected together and a white socket that plugged into the wall plate. Resident #11 sat in a Broda-type chair in the room and stated her call light was not working consistently and that she had reported it approximately a week ago. Surveyor gently pushed the two cords together and the call light went on when the call button was pushed. At 12:50 p.m., Resident #12's call light was not consistently functioning when the call button at the bedside was pushed. Surveyor noted the light outside the resident's room was lit and upon entering the room noted the resident and Family Member (FM) HH in the room. FM HH identified they had not activated the call light. When Surveyor checked the call light, it was noted the call light initially would not deactivate by pushing the button on the wall plate. It was finally able to be turned off and then one could only sometimes activate it again by gently shaking the black socket plugged into the wall plate. CNAs FF and GG were in the room and also observed the problem with the call light. Both CNAs stated they had reported the problem with Resident #12's call light to maintenance on other occasions. CNA FF obtained a new call cord, plugged it into the wall plate and the call light worked consistently when checked. Record review for Resident #12 identified in the nurse's note on 08/11/10 that he "rarely" used his call light (appeared to be capable of using it on rare occasions). Resident #12 was identified as an insulin-dependent diabetic, placing him at increased risk if he used his call light on a rare occasion and required timely staff assistance. On 09/23/10, during her building tour from noon-1:45 p.m., Surveyor made the following observations and conducted the following interviews: Resident #13's call light failed to activate two times when attempted by Surveyor . It was noted the call cord was stuck under the bed and the plug at the wall plate had to be pushed further into the socket. It did activate when the button was pushed the third time. CNAs NN and OO were in the resident's room at the time and witnessed the event. Resident #23 was interviewed, and stated her call light did not work at times and she knew it was not working when no staff respond. Resident #23 stated she sometimes has fixed the call cord herself by "pushing it together." Resident #24, when asked about her call light, stated, "I think a short in it...at times on, at times not on." She stated, "I holler," when asked how she gets help when needed. Resident #27 stated her call light was fixed approximately one week ago. She stated it had tape on it and it "must have been loose." At 12:07 p.m., Resident #14's call light failed to activate when attempted by Surveyor several times. Resident #21 was interviewed and stated she had call light problems "sometimes." At 1:28 p.m., Resident #25 stated that at times her call light did not work, and the previous evening she needed to go to the bathroom and could not get the light to work, "nothing happened...it wasn't on." Resident #22 stated his call cord "comes apart at times." On 09/23/10, Resident #26's call light did not activate when attempted by Surveyor and . Surveyor tried again to activate the light and the light went on. Surveyor and Surveyor interviewed the NHA on 09/23/10 at 3:30 p.m. The NHA stated Assistant NHA (ANHA) KK and Housekeeping/Laundry Supervisor (HLS) LL completed a full inspection of all the call lights on 09/23/10 and found a total of six call lights that were not working. Three of the inconsistently functioning call lights belonged to residents already identified by surveyors. The other three call lights belonged to Residents #15, #16 and #17. The NHA insisted there were only six call lights found by ANHA KK and HLS LL that were not working (not including those previously found by surveyors) and added the facility had a policy in place to replace call lights when they did not function. The NHA identified the six call lights that were nonfunctional represented only 3% of the residents, adding that six was too many and he would want 0%. The NHA stated, "It's a muggy day and the system is probably sluggish." The NHA confirmed, at that time, the plan was to "have weekly checks if not daily" for resident call lights. On 09/23/10, Surveyor initiated the review of Resident #1's closed record and the facility investigation following her death (09/08/10). There was no evidence that it included the immediate assessment and ongoing monitoring of all residents' call lights which might have alerted the facility to the fact some residents had call lights that did not work or only intermittently worked. Surveyor and Surveyor interviewed the NHA on 09/23/10 at 3:30 p.m. The NHA stated the facility had completed a full investigation related to Resident #1's death with no concerns identified. The NHA was unable to provide any evidence the facility had immediately assessed resident call lights for all residents immediately following the concern expressed by Resident #1's family on the morning of the resident's death. Surveyor and Surveyor interviewed the NHA on 09/23/10 at 4:30 p.m. and informed him they had observed at least 13 call lights that did not properly function and with the 3 additional the facility had identified, there were a total of at least 16 improperly functioning call lights (over 8%). The NHA stated he obtained an estimate for a new call light system two to three years earlier and the cost was over $150,000. The NHA stated he would rather give his employees raises than to put the money into a new call light system. On 09/28/10, Surveyor reviewed the facility's audits for resident call lights from 09/23/10 through 09/27/10. The audits identified there were 8 resident call lights on the west side of the facility and 5 resident call lights on the east side, a total of 13, that did not work at all or were not consistently functional. On 09/28/10, Surveyor requested all maintenance slips from 04/01/10 through 09/27/10. These were received and reviewed. Maintenance slips identified only 1 resident on 09/23/10 with a nonfunctional call light even though there were 17 call lights not consistently functional that were identified on 09/23/10 by surveyors and by the facility. The facility's maintenance slips identified only 3 call lights that did not work or did not consistently work from 09/23/10 to 09/27/10, even though there were 13 call lights not consistently functional that were identified by facility audits during that time period. Surveyor and Surveyor interviewed the NHA and Director of Maintenance (DM) C on 09/28/10 at 11:00 a.m. DM C identified the call light system was installed by the "Johnson Service Company" over [AGE] years ago. DM C stated the system included an 8-pin plug that fit into a wall plate in the residents' rooms. DM C stated new additions such as bed alarms increased the problem because another cord had to be attached to the original cord (found during surveyor observations above to not always fit tightly together whether the connection was taped or not taped) due to the fact the 8-pin system could not accept another addition any other way. DM C identified the plugs, with wear and tear, were sometimes not tight enough (to fit tightly into the wall plates). DM C confirmed, "The system is weak from the wall." On 09/28/10, from 12:15 p.m. to 12:35 p.m., Surveyor and DM C toured the facility, focusing on the facility call light system and the following was observed. When touring the west wing, the call light for Room 911 was noted to have been activated with the observation that the light outside the room and the light at the end of the 900 wing were both lit, however, the two wall panels at the end of the hallway across from the nurses' station did not light up to show which resident room light had been activated. DM C stated the bulb on the wall panel must have been burned out. To check another light on the panel (to ensure the wall panel was functioning), DM C went to the bathing room on the 800 wing and activated the call light there. The light on the wall panel associated with the bathing light on the 800 wing lit up; however, no sound was activated to alert staff of the bathing room light. DM C activated a toggle switch on the wall panel and the "chiming" sound of the bathing light could then be heard from the wall panel. When touring the east wing, it was observed that bathroom/bathing room lights had a chiming sound when they were activated. Surveyor and Surveyor interviewed the NHA on 09/28/10 at 2:40 p.m. The NHA stated it was "unnecessary" to have an electronic call system according to any codes he was aware of. The NHA stated "some" residents currently had hand bells that had been provided at the residents' request. On 09/29/10, from 10:05 a.m. to 10:35 a.m., Surveyor , Surveyor and the NHA initiated a facility tour, focusing on the facility call light system, and the following was observed. The tour began on the "west" wing. The call light for Room 614 was activated with the observation that the light on the wall plate in the room, the light outside the room and the light at the end of the 600 wing all appropriately lit, however, the two wall panels at the end of the hallway across from the nurses' station did not light up to show which resident room light had been activated. The NHA stated the light would probably be transferred over to the "east" side of the facility and would light up on the panel there. Surveyor , Surveyor and the NHA went to the "east" side of the facility and found there was no light lit up on the wall panel for Room 614 (verified by Surveyor that the call light for Room 614 remained activated). At 10:15 a.m. on 09/29/10, DM C joined the above group who was observing the facility call light system on the "east" side. DM C confirmed there was a third wall panel on the "east" wing and added he thought the system had the "capability" to transfer the lights over from the "west" wing, but to the best of his knowledge, it was never connected. DM C described all the wires related to the call light system as "a rat's nest" and stated it would be difficult to know if something from the west wing would get through. At approximately 10:20 a.m., a "chiming" sound was heard from one of the three wall panels. There was no light lit up on the wall panel, no light lit up at the end of any of the hallways and no light lit up outside any resident room or resident area. DM C stated that if a call light did not light up on the wall in the room or outside the resident room, it would not light up at the end of the hallway. It was unclear what room or area activated the call sound and after a few short minutes, the sound ceased. During the above tour, DM C confirmed the switch on the wall panel on the "east" side could be toggled, but toggling it did not silence the chiming sound when a bathroom/bathing room was activated. DM C confirmed the incident on 09/28/10 when touring with Surveyor , when he was able to activate a toggle switch on the "west" wing's wall panel. DM C identified he thought the system might have been set up in that fashion because, if it had been designed to do so, it could have had the potential to relay "west" wing call lights to the "east" wing. DM C stated that because the "east" wing was always considered the main wing (also containing the facility security system), the system was apparently not designed to have the ability to silence alarms on that wing. On 09/29/10 at 2:15 p.m., during the daily exit meeting, DM C stated the chance was "miniscule" that the sound would be activated if a bathroom call light did not light up. DM C stated the facility counted on the system as a "visual system." The NHA confirmed staff depended on "visual" to know that a resident required assistance. Both confirmed that somehow sound was built into the system, but staff did not rely on it. Surveyor interviewed CNA G on 09/29/10 at 11:15 a.m. CNA G identified there was no sound heard if a resident's call light at the bedside was activated, only if the bathroom light was activated. CNA G stated that when staff were in another resident's room, they were unaware if any call lights were on (unless it was a bathroom call light). CNA G confirmed she has found call lights not working which included things like the button sticking, the two cords that were sometimes put together coming apart and the plug at the wall plate not making a good connection. CNA G stated that if she cannot get the call light to work, she contacts maintenance. On 09/29/10, the NHA provided Surveyor a copy of the facility's policy/procedure related to the call light system, dated March 2002. The policy/procedure included the following: the purpose was to respond to resident requests and needs; equipment consisted of a "Functioning call bell system;" the procedure included to report immediately to maintenance if a call system was defective; and essential points included, "Unless indicated in the care plan, each resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of resident ability to use it. Should the call light system be defective...a manual bell will be substituted..." On 10/05/10, Surveyor continued with the review of Resident #1's closed record and the facility investigation following her death (09/08/10). It was identified facility staff did not immediately and thoroughly investigate Resident #1's death, which would have included the immediate assessment and ongoing monitoring of all residents' call lights. On 10/05/10 at 4:40 p.m., Surveyor interviewed the NHA. The NHA stated the concern with Resident #1's call light, reported by her family on 09/08/10, was investigated and "it checked out ok." The NHA stated the investigation included a copy of the maintenance slip for Resident #1's call light and confirmed that since it was the only call light in question at that time, it was the only one checked. On 10/05/10 at 5:10 p.m., Surveyor interviewed the DON and ADON A. Both identified all resident call lights were checked once each shift. Both confirmed "residents" were also checked more frequently based on their critical needs, but added that the "call lights" were not necessarily checked at those times. On 10/21/10, all maintenance slips from 09/28/10 through 10/20/10 related to call lights not consistently functioning were requested. The maintenance slips were received and reviewed. It was identified that 19 call lights were found to be nonfunctional or not consistently functional (10 call lights not working, 1 call light not working all the time, 1 bathroom call light not working, 1 with electrical tape not holding up and exposed wires, 1 with plug in wall loose, 1 call light broken due to button pushed in, 1 worked when pressed back to wall but fell out easily and then didn't work, 1 would go on only by pressing black shut off button (on the wall plate) not the red button at the bedside, 2 call lights would not turn off). On 10/21/10, during the final exit, DM C stated the call light system was mechanical and that anything mechanical could have glitches. The NHA identified the facility had 314 call lights in the building (counting the approximately 191 call lights for each resident at their bedside and adding a bathroom light for each resident room as well as other miscellaneous call lights such as those from bathing areas). The NHA stated counting the actual number of call lights would decrease the percentage of improperly functional call lights to approximately 1% (instead of the nearly 9% that was identified on 09/23/10). The failure to have a reliable communication system created an immediate jeopardy situation. The facility removed the immediate jeopardy on 10/5/10 when the facility identified there was a problem related to call lights that were not consistently functional, adequately assessed all residents and prioritized high risk residents related to the seriousness if their call light failed and was adequately monitoring all residents' call lights according to their individual needs. They also contacted an outside company to check their current call light system.

Based on observation, interviews and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing to 2 of 2 sampled residents (Resident #1 on eight of eight days she resided at the facility and Resident #28 over a four day period) who utilized portable respiratory ventilators, out of 6 sampled residents who had a significant condition change. Resident #1 was admitted to the facility on [DATE] for therapy and a short-term stay following hospitalization related to a fracture complicated by some acute respiratory problems. She required continuous oxygen and, at night, also required the use of a specific type of NIV, a bi-level positive airway pressure ([MEDICAL CONDITION]) machine (provides airway pressure on inspiration as well as airway support during expiration), related to a previous [DIAGNOSES REDACTED]. Facility staff did not: ~Adequately assess and/or monitor the resident's oxygen administration, oxygen saturation, [MEDICAL CONDITION] usage, and/or vital signs on 09/01/10, 09/02/10, 09/03/10, 09/04/10, 09/05/10, 09/06/10, 09/07/10 and 09/08/10; ~Notify the physician in a timely manner on 09/06/10 when she was found to be lethargic with an abnormally low oxygen saturation (45%) requiring an increase in oxygen to keep her oxygen saturation above that ordered by the physician; ~Provide complete and accurate information to the pulmonologist on 09/07/10; Subsequently, Resident #1 was found without vital signs at approximately 4:30 a.m. on the morning of 09/08/10 and with part of the [MEDICAL CONDITION] machine on the floor (preventing the machine to function). Death was pronounced by a physician via a phone call. Resident #28 required continuous oxygen to keep her oxygen saturation greater than 88% as ordered by the physician. She also utilized a [MEDICAL CONDITION] machine at night related to chronic respiratory problems and was a full code. She was evaluated at the hospital on [DATE], returning the same day with [DIAGNOSES REDACTED]. On 09/23/10, x-ray results identified [MEDICAL CONDITION] disc disease and pain medication was increased due to the resident's complaint of severe pain. Facility staff did not: ~Adequately assess the amount of Oxyfast, [MEDICATION NAME], and/or [MEDICATION NAME] to be administered from 09/22/10 - 09/27/10 in relation to the level of the resident's pain and/or anxiety; ~Adequately assess and/or monitor the resident's pain, changes in medication/oxygen, oxygen saturation, [MEDICAL CONDITION] usage, nutritional/hydration status, and/or vital signs on 09/24/10, 09/25/10, 09/26/10 and during the night shift on 09/27/10; ~Provide immediate assessment by a Registered Nurse (RN) on 09/25/10 (day and evening shifts with increased lethargy) and on 09/26/10 (day and evening shifts with increased pain); ~Notify the physician in a timely manner on 09/25/10 and 09/26/10. Subsequently, the resident was found at approximately 7:30 a.m. on the morning of 09/27/10, ashen in color, with shallow respirations and a decreased oxygen saturation of 61% while still on the [MEDICAL CONDITION], diminished lung sounds and complaints of increased shortness of breath and severe unrelieved lower back pain. Resident #28 was transported to the hospital via ambulance and hospitalized due to [MEDICAL CONDITION] and hypercapnia secondary to narcotics for back pain. Findings include: 1. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] after being hospitalized for [REDACTED]. The record identified two discharge summaries, one dated 08/30/10 and the other dated 09/01/10 (identified as an addendum to the discharge summary of 08/30/10). According to the hospital discharge summaries, the resident underwent [REDACTED]. She was then weaned to using a [MEDICAL CONDITION] which she used over the next several days, being dependent on it both day and night and then was able to use it primarily at night. At home the resident was previously on an auto regulating [MEDICAL CONDITION], only at night, related to obstructive sleep apnea, identified in the hospital discharge summary as an average volume ensured pressure support (AVAPS) machine, "an auto-regulating [MEDICAL CONDITION]." The resident was also diagnosed with [REDACTED]. Other [DIAGNOSES REDACTED]. Both discharge summaries included orders for [MEDICATION NAME] twice a day and [MEDICATION NAME] ([MEDICATION NAME]) 5 milligrams (mg) every four hours as needed for pain. The discharge summary of 08/30/10 included oxygen as needed to keep the resident's oxygen saturations above 90% and also specific settings for the [MEDICAL CONDITION]. The discharge summary of 09/01/10 included orders for oxygen at two to three liters per nasal cannula during the daytime to keep saturations above 88-90%, continued use of the [MEDICAL CONDITION] at night and [MEDICATION NAME] nebulizer every six hours and every two hours as needed. A separate physician order sheet, dated 09/01/10, identified an order for [REDACTED]. Resident #1's record identified she was a full code. Surveyor interviewed FM D on 09/22/10 who identified Resident #1 was admitted to the facility on [DATE] and utilized her own personal [MEDICAL CONDITION] machine with a full face mask. On 09/01/10, facility recommendations placed on the admission order sheet and on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Surveyor 's review of the AARC Clinical Practice Guideline, "Oxygen Therapy in the Home or Alternate Site Health Care Facility-2007 Revision and Update," identified the following: " Oxygen therapy should be administered in accordance with the physician prescription...Some patients...will be hypoxemic during ambulation, sleep or exercise...Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction in home oxygen therapy...Patients and/or their caregivers may operate and maintain oxygen delivery devices after they have been instructed and have demonstrated the appropriate level of skill..." On 09/01/10, Resident #1's nurse's note at 6:57 p.m. by Registered Nurse (RN) H identified the resident arrived at the facility at 3:20 p.m. It was noted the resident had oxygen at two to three liters to keep saturation above 88-90% and she utilized a [MEDICAL CONDITION] machine at night. It was stated upon admission the resident's vital signs (temperature in degrees Fahrenheit, pulse, respirations and blood pressure) were, respectively, 96.8, 89, 18 and 114/64. It was stated the resident "had what appeared to be a small [MEDICAL CONDITION], her full body involved with some noted shaking and eye rolling...lasted about 20 seconds..." One of the hospital physicians was notified who stated to "continue to monitor" the resident. It was stated there were no further [MEDICAL CONDITION] episodes. A detailed [MEDICAL CONDITION] summary (obtained after her death) identified the resident's [MEDICAL CONDITION] was applied at 3:50 p.m. on 09/01/10 and she utilized it (with four breaks of approximately ? to 1 hour) for the next 15 hours (until approximately 6:50 a.m. on the morning of 09/02/10). On 09/01/10, it was not identified if the rate of the oxygen administration continued at four liters (above the rate ordered). Oxygen saturation and vital signs were not adequately monitored on the evening shift and there was no evidence in the record why the overnight oximetry was not initiated. Surveyor interviewed RN H on 10/05/10 at 3:10 p.m. RN H identified she had worked at the facility for approximately one year as a Licensed Practical Nurse (LPN) and one year as an RN. RN H stated she had training on respiratory equipment in school including [MEDICAL CONDITION], but had no facility training on the [MEDICAL CONDITION] and was not familiar with the type of [MEDICAL CONDITION] Resident #1 had with the oxygen "bled" into the [MEDICAL CONDITION] tubing. RN H stated that on the evening of 09/01/10, FM D was present who identified herself as a Respiratory Therapist (RT) and who then "set up" Resident #1's [MEDICAL CONDITION]. RN H stated she was not familiar with the [MEDICAL CONDITION] settings and counted on FM D when she showed up and said she was an RT. RN H stated FM D obtained a different mask for Resident #1, per the resident's request (this was identified as a full face mask per documentation provided by FM D on 10/05/10). Surveyor interviewed FM D on 10/16/10 at 11:55 a.m. FM D stated that on 09/01/10, she went over things such as how the mask worked with the facility nurse who was on at that time. FM D confirmed the [MEDICAL CONDITION] settings had been done by the hospital staff. Surveyor interviewed RN H on 10/20/10 at 2:00 p.m. RN H stated she could not say "for sure" if the oxygen was continued at four liters on 09/01/10. RN H stated she measured Resident #1's oxygen saturation when she was first admitted (3:20 p.m.) and added she was sure she measured it again, but "did not put it down." RN H stated Resident #1's [MEDICAL CONDITION] occurred soon after admission when she was being transferred into bed with the medilift. RN H stated that following the [MEDICAL CONDITION], she took the admission vital signs (recorded in the nurse's note) and called the physician. RN H stated that when a resident had [MEDICAL CONDITION] activity "you would monitor vital signs," but added she got very busy with the admission and other things going on and did not take any further vital signs. RN H stated the physician ordered to "monitor" for any further [MEDICAL CONDITION] activity and as she documented, the resident had no further [MEDICAL CONDITION] activity that evening. Regarding the overnight oximetry that was ordered to be initiated on the evening of 09/01/10 if possible, RN H stated she was unaware of the order at that time. On 09/02/10, Resident #1's nurse's note at 3:00 a.m. by RN I identified the resident took off her nasal cannula (apparently following a nebulizer treatment) and reapplied the [MEDICAL CONDITION] machine but did not "hook up the oxygen." It was identified the resident's oxygen saturation was low at 78% but climbed to 82% in 20 minutes. Attending Physician (AP) W was called who ordered to titrate oxygen to five liters to keep oxygen saturation greater than 90%. The note also stated staff titrated the resident's oxygen up to five liters "and she only climbed to 84%." An order was obtained to transport the resident to the hospital, but this was discontinued when ambulance personnel identified the resident's oxygen saturation had increased up to 88-94%. The subsequent record, however, did not identify if the rate of the oxygen administration continued at five liters, and the resident's vital signs were not part of the assessments during the night shift on 09/02/10. Surveyor interviewed RN I on 10/20/10 at 2:50 p.m. RN I stated he did check the resident's blood pressure and respirations at the time he was planning to transfer the resident. RN I stated these would have been documented on the transfer form, but he was unsure if the transfer form was kept or whether it was thrown out because, even though the resident was assessed by ambulance personnel, she wasn't transferred out of the facility (the facility was unable to provide the transfer form). RN I stated Resident #1's oxygen was continued at five liters throughout the night on 09/02/10. On 09/02/10, a respiratory assessment was documented at 11:46 a.m. by RN J. The assessment included that Resident #1's oxygen saturation was being maintained between 87-88% on five liters of oxygen and that when the resident became anxious, her respiration rate would increase and her respirations would become more shallow. It was stated that this would drop her oxygen saturations into the low 80s. It was also stated that when she did not have the nasal cannula in place, the oxygen saturation would drop "quickly" into the upper 60s and that once the nasal cannula was in place, the oxygen saturation would come up "slowly." It was identified lung sounds were clear but diminished at the bases. The nurse's note stated the resident was currently on seven liters of oxygen with an oxygen saturation of 87% (the order was to keep the oxygen saturation "greater than" 90%). "She is sleepy at this time and she is also breathing through her mouth more than through her nose. This is contributing to the decrease in O2 sats (oxygen saturations)." It was stated the resident did not appear short of breath or anxious and oxygen would be continued at seven liters using "oxymizing tubing" (special oxygen tubing that increases the volume of oxygen, approximately doubling that being given). Surveyor interviewed RN J on 10/21/10 at 10:30 a.m. RN J stated she initiated the oxymizer tubing "sometime after 7:00 a.m. and before noon." AP W had given orders "may use oxymizer" as documented by RN J at 11:52 and 11:53 a.m. Additional orders included that Resident #1 could self-administer her nebulizer after set-up, [MEDICATION NAME] 0.5 mg three times a day as needed for anxiety and two separate oxygen orders with the last one to keep oxygen saturation greater than 87 %. The detailed [MEDICAL CONDITION] summary (obtained after her death) identified the resident's [MEDICAL CONDITION] was applied at 12:22 p.m. on 09/02/10. The rate of the oxygen administration, oxygen saturations (none after 11:46 a.m. to ensure the resident's oxygen saturation increased to greater than 87% as ordered by the physician) and vital signs were not adequately monitored on the day shift. Surveyor interviewed RN J on 10/21/10 at 10:30 a.m. RN J stated the oxygen continued at seven liters during her shift on 09/02/10. When asked if there were any further oxygen saturations measured after 11:53 a.m. on 09/02/10, RN J answered, "Not to my recollection," adding she would have documented them had she done them. Surveyor interviewed RN J on 09/29/10 at 11:30 a.m. at which time RN J identified that when she assessed a resident related to their respiratory status, she did not generally obtain a full set of vital signs. Surveyor 's review of the Sarasota Memorial Hospital Department Policy titled "Non-Invasive Positive Pressure (NPPV) Ventilation ([MEDICAL CONDITION]/[MEDICAL CONDITION])," last reviewed by the Director of Respiratory Care Services November 2009, identified the following: "NURSING CARE...Obtain an order from the physician...Assess...every four hours and PRN (as needed) for...Vital signs...Keep the head of the bed elevated at least at a 30-40 degree angle, in order to reduce the risk of aspiration...POTENTIAL COMPLICATIONS...Decreased blood pressure. The continuous positive pressure results in an increase in the [MEDICATION NAME] pressure, placing mechanical pressure on the heart, which decreases venous return. Decreased blood to the right atrium causes [MEDICAL CONDITION]. Decreased heart rate is caused by the effect of the [MEDICAL CONDITION] on cardiac sympathetic nervous system; DOCUMENTATION...Vital signs...Initiation of NPPV procedure...Assessment/Reassessment...Minimum reassessment of mental, respiratory, cardiac, GI (gastrointestinal) and skin systems every four hours..." On 09/02/10 at 11:04 p.m., a nurse's note written by RN K stated Resident #1 had the [MEDICAL CONDITION] on "all shift, has anxiety with removal of mask to administer nebulizer treatment or to ear (sic (eat)) or drink anything." The nurse's note stated the resident's oxygen saturation was 88% on that shift and the "overnight saturation machine" (overnight oximetry pouch) was applied at 10:00 p.m. (a Thursday night). The rate of the oxygen administration, the oxygen saturation and vital signs were not adequately monitored on the evening shift. Surveyor interviewed RN K on 10/15/10 at 1:00 p.m. RN K stated she did not remember what Resident #1's oxygen rate was set at on 09/02/10, but she added she did not ever remember it being up to seven liters (as was documented on the day shift). RN K stated that for a resident such as Resident #1, she would have checked the oxygen saturation at least twice during the shift. RN K stated Resident #1 usually "hovered" between 88 and 90% and added she probably did not document both of the oxygen saturations she took. RN K stated vital signs are usually only checked upon admission, readmission, if there were changes in medication or if there was a problem. RN K identified routine vital signs were taken monthly on all residents. On 09/03/10 at 7:05 a.m., a nurse's note written by RN I stated Resident #1 was constantly on her call light and she received a nebulizer treatment at midnight. It was stated she was anxious and restless at 1:30 a.m. and was given [MEDICATION NAME] and [MEDICATION NAME]. It was stated she slept three hours and then started to be constantly on the call light, receiving [MEDICATION NAME] at 5:59 a.m. The detailed [MEDICAL CONDITION] summary (obtained after her death) identified there was an approximately two hour break at 6:30 a.m. and then was discontinued at approximately 9:22 a.m. The rate of the oxygen administration, oxygen saturation and vital signs were not adequately monitored during the night shift. Surveyor interviewed RN I on 10/20/10 at 2:50 p.m. ADON A was present during the interview. RN I stated Resident #1 had the [MEDICAL CONDITION] on the entire shift and oxygen would have been continued at seven liters (as on the day shift) because he would have had no physician order to change it. RN I stated Resident #1's oxygen saturation checks were "fine" and identified he normally checked Resident #1's oxygen saturation every two hours because the resident often requested it be checked. RN I stated he could not remember exactly what the oxygen saturation checks were. RN I confirmed he did not monitor Resident #1's vital signs on 09/03/10. RN I stated that if there was a problem, then it would be a nursing judgment to check or monitor the vital signs. RN I stated there was no order to do them every shift, but if there was a change, "something different, an aspect of not doing well," then he would do vital signs. On 09/03/10 at 2:41 p.m., a nurse's note written by RN J stated Resident #1 continued to require continuous oxygen throughout the day, becoming "quite anxious" if she did not have either her [MEDICAL CONDITION] or the oxygen on (the [MEDICAL CONDITION] summary showed it was not utilized from approximately 6:30 a.m. to approximately 8:30 a.m. and was then discontinued for the day at approximately 9:22 a.m.). It was identified the resident's oxygen saturation varied from 87-93% on five liters of oxygen, depending on her level of anxiety. Vital signs were not adequately monitored on the day shift. Surveyor interviewed RN J on 10/21/10 at 10:30 a.m. RN J stated she checked Resident #1's oxygen saturation at least twice as the range of 87-93% she had documented identified she at least had a reading of 87 and of 93. Surveyor interviewed RN J on 09/29/10 at 11:30 a.m. at which time RN J identified that when she assessed a resident related to their respiratory status, she did not generally obtain a full set of vital signs. On 09/03/10 at 11:02 p.m., a nurse's note written by RN L identified Resident #1 became easily agitated when she had to wait for anything and on one occasion when her call light was not answered immediately, she called out "HELP, HELP" and wanted her notebook she was unable to reach on her table. The detailed [MEDICAL CONDITION] summary (obtained after her death) identified the resident's [MEDICAL CONDITION] was applied at 5:13 p.m. and she utilized it (with one break of approximately ? hour) for the next 11 hours (until approximately 4:00 a.m. on the morning of 09/04/10). The rate of oxygen administration, oxygen saturation and vital signs were not adequately monitored on the evening shift. Surveyor interviewed RN L on 10/14/10 at 12:35 p.m. RN L stated Resident #1 utilized her oxygen the entire shift on 09/03/10 and the rate of the oxygen was probably continued at five liters. RN L stated she can't be certain she checked Resident #1's oxygen saturation on 09/03/10, but added it was a routine thing the staff did for Resident #1. RN L stated she thinks she checked it, but did not document it. RN L stated that if there were no vital signs documented, then she didn't check them. RN L stated that as far as she knew, there was no facility policy/procedure for when vital signs should be taken. RN L stated she would normally check vital signs on admission, with any change in condition and once a week per the standing orders. On 09/04/10 at 6:59 a.m., a nurse's note written by RN M identified Resident #1 had slept poorly with many requests throughout the night for little things and was encouraged "to help herself a little more..." It was stated she slept with the head of the bed elevated with a soft roll behind her neck and no pillow. It was identified the oxygen saturation was 88% on six liters of oxygen with the [MEDICAL CONDITION] running. It was not identified that the [MEDICAL CONDITION] was removed at approximately 4:00 a.m. (as evidenced later by the [MEDICAL CONDITION] summary), nor if the resident still required six liters of oxygen with the "oxymizer" tubing after being switched from the [MEDICAL CONDITION]. The rate of oxygen administration and vital signs were not adequately monitored during the night shift. Surveyor interviewed RN M on 10/21/10 at 10:50 a.m. RN M stated she knew she measured Resident #1's oxygen saturation more than the one time she documented at 88%, but added that if the oxygen saturation did not change, she didn't always document she took it again. RN M identified Resident #1 was totally alert and oriented during the night shift on 09/04/10 and stated she didn't recall if she took any vital signs that night. On 09/04/10 at 12:41 p.m., a nurse's note written by RN J identified Resident #1 had been tolerating the oxymizer nasal cannula at six liters of oxygen with oxygen saturations in the low 90s. A note at 12:43 p.m. identified the resident had not been sleeping well at night and had been using her [MEDICATION NAME] as much as she could due to anxiety and shortness of breath. It was identified the attending physician gave the following new orders: schedule [MEDICATION NAME] 0.5 mg twice a day and continue the "as needed" order; discontinue the scheduled nebulizer treatment but continue with the "as needed" treatment. The MAR indicated [REDACTED]. Vital signs were not adequately monitored on the day shift. Surveyor interviewed RN J on 10/21/10 at 10:30 a.m. RN J stated she checked Resident #1's oxygen saturation on 09/04/10 at least twice and every time she checked it, "it would vary." RN J confirmed she did not document the specific oxygen saturation readings after 7:30 a.m. Surveyor interviewed RN J on 09/29/10 at 11:30 a.m. at which time RN J identified that when she assessed a resident related to their respiratory status, she did not generally obtain a full set of vital signs. On 09/04/10 at 10:47 p.m., a nurse's note written by RN N identified Resident #1 had frequent requests for various things and was given [MEDICATION NAME] at 4:00 p.m., [MEDICATION NAME] at 6:30 p.m. and [MEDICATION NAME] again at 8:00 p.m. The detailed [MEDICAL CONDITION] summary (obtained after her death) identified the resident's [MEDICAL CONDITION] was applied at 8:30 p.m. and she utilized it (with two breaks of approximately ? to 1 hour) for the next 10 hours (until approximately 6:30 a.m. on the morning of 09/05/10). The rate of oxygen administration, oxygen saturation and vital signs were not adequately monitored on the evening shift. Surveyor interviewed RN N on 10/14/10 at 8:00 p.m. RN N stated she would have no way of remembering what the rate of Resident #1's oxygen was at during her shift, but would have thought she would have documented it if she had changed it from the previous shift. RN N stated she did check the resident's oxygen saturation and would have documented it on a flow sheet (not documented on Resident #1's vital sign flow sheet). RN N stated she probably did not check the resident's vital signs and would have only done so if there had been a change in her condition or another reason to do so such as oxygen saturation less than that ordered by the physician. RN N stated [MEDICAL CONDITION] are used primarily at night to keep the airway open and if Resident #1 was using her [MEDICAL CONDITION] during the daytime, "she shouldn't have been there" (at the facility). On 09/05/10 at 7:20 a.m., a nurse's note written by RN M identified Resident #1 had been on her call light "at least 40 times this shift. Very needy...asking for many things that she could do for herself such as give her a drink of water." It was stated the resident was able to unhook her [MEDICAL CONDITION] to take a drink and reconnect it when done and was encouraged to do things such as that for herself. It was also stated Resident #1 had also been frequently pulling off her [MEDICAL CONDITION] mask, away from her face, to make sure it was working. It was stated, "When she feels the rush of air she seems to believe she is getting a larger dosage of oxygen than with the concentrator and nasal cannula." The vital sign flow sheet identified an oxygen saturation of 88% on five liters of oxygen at 1:00 a.m. with no further monitoring of the oxygen saturation for that shift. The [MEDICAL CONDITION] summary later identified the [MEDICAL CONDITION] was discontinued at approximately 6:30 a.m. and it was not identified if the rate of the oxygen administration was changed at that time. The rate of oxygen administration, oxygen saturation and vital signs were not adequately monitored during the night shift. Surveyor interviewed RN M on 10/21/10 at 10:50 a.m. RN M stated she did not change the oxygen flow rate on 09/05/10 and she recalled only that the oxygen saturation was checked at 1:00 a.m. as documented on the flow sheet. RN M confirmed she was in Resident #1's room many times that night and would not have checked the resident's vital signs unless she had been in respiratory distress. On 09/05/10 at 1:53 p.m., a nurse's note written by RN J identified Resident #1 was on six liters of oxygen via the oxymizer nasal cannula and oxygen saturations were 90%. It was stated the resident was anxious when cares were provided and she did not reposition well in bed. It was identified respirations increased during cares and she became more short of breath. Oxygen saturation and vital signs were not adequately monitored on the day shift. Surveyor interviewed RN J on 10/21/10 at 10:30 a.m. RN J stated that according to her documentation, she checked Resident #1's oxygen saturation "at least once" on 09/05/10. Surveyor interviewed RN J on 09/29/10 at 11:30 a.m. at which time RN J identified that when she assessed a resident related to their respiratory status, she did not generally obtain a full set of vital signs. On 09/05/10 at 11:16 p.m., a nurse's note written by RN K identified Resident #1 was on six liters of oxygen and oxygen saturation was at 89%. The detailed [MEDICAL CONDITION] summary (obtained after her death) identified the resident's [MEDICAL CONDITION] was applied at 9:27 p.m. The MAR indicated [REDACTED]. Surveyor interviewed RN K on 10/15/10 at 1:00 p.m. RN K stated she would have checked at least two oxygen saturations and added she must have forgotten to document one of them. RN K confirmed she did not check Resident #1's vital signs that evening. On 09/06/10 at 8:11 a.m., a nurse's note written by RN O identified Resident #1 had difficulty falling asleep and appeared to only sleep at intervals, utilizing the call light 10 times during the night with requests that included medication ([MEDICATION NAME] give at 11:40 p.m.), positioning, water and food. The rate of oxygen administration, oxygen saturation and vital signs were not adequately monitored during the night shift. Surveyor interviewed RN O on 10/21/10 at 9:35 a.m. RN O stated she did not change the rate of Resident #1's oxygen on 09/06/10 and she did not recall checking an oxygen saturation. RN O stated she checked the oxygen rate and looked at the resident noting she had no color change and no shortness of breath. RN O stated she did not take vital signs because the resident was not restless other than when she woke up and, since she had been at the facility for five days, she felt the initial admission criteria had been met. RN O stated that for a new admission, she would probably check vital signs every shift for 72 hours. RN O stated she worked with another nurse on 09/06/10 who stated she had cared for Resident #1 the night before and felt she was "the same." RN O stated she checked on the resident multiple times that night. RN O identified it would be on the care plan or in a facility policy/procedure as to how often a resident's oxygen saturations should be done. On 09/06/10 at 11:58 a.m., a nurse's note written by RN J identified Resident #1 had been sleepy most of the shift and had her oxymizer nasal cannula on since the start of the shift. Oxygen saturations were identified at 88-90% on five liters of oxygen. It was stated the resident became more restless and was coughing up clear phlegm at approximately 11:50 a.m. with a nebulizer treatment given. The vital sign flow sheet identified an oxygen saturation of 88% on five liters of oxygen on the a.m. shift with no further monitoring of the oxygen saturation for that shift. Vital signs were not adequately monitored on the day shift. Surveyor interviewed RN J on 10/21/10 at 10:30 a.m. RN J stated she checked Resident #1's oxygen saturation at least twice as the range of 88-90% she had documented identified she at least had a reading of 88 and of 90. Surveyor interviewed RN J on 09/29/10 at 11:30 a.m. at which time RN J identified that when she assessed a resident related to their respiratory status, she did not generally obtain a full set of vital signs. On 09/06/10, the detailed [MEDICAL CONDITION] summary (obtained after Resident #1's death) identified the resident's [MEDICAL CONDITION] was applied at 5:38 p.m. On 09/06/10 at 10:08 p.m., a nurse's note written by Nurse Tech (NT) P identified Resident #1 was found at 9:00 p.m. to be asleep in her bed with the head of the bed elevated and the [MEDICAL CONDITION] machine on, with the oxygen rate at five liters. The resident's oxygen saturation was found to be low at 45%. The oxygen was titrated up to six liters, still with the [MEDICAL CONDITION] on and the resident's oxygen saturation increased to the upper 70s. Vital signs were obtained which identified a pulse of 96, respirations at 16 and a blood pressure of 119/66. It was stated the resident was lethargic and only arousable to physical stimuli. It was identified RN Q assessed the resident and "found her to be in a hypoxic state." Oxygen was titrated up to eight liters and the resident was placed on her nasal cannula "with re-breather." An [MEDICATION NAME] nebulizer treatment was also administered at that time. The resident became more alert and oxygen saturation increased to 93%. She was placed back on the [MEDICAL CONDITION] machine with supplemental oxygen continued at eight liters (bled into the [MEDICAL CONDITION] tubing). "Will continue to monitor resident's oxygen saturations throughout the night to monitor for hypoxic episodes. Resident continues to be slightly anxious at this time. She has many demands from staff present in the room and was noted to call out when her call light was not answered within a few minutes." It was stated the twice a day [MEDICATION NAME] continued to be given (8:00 a.m. and 8:00 p.m.). It was stated oxygen continued at eight liters with the [MEDICAL CONDITION] on and the plan was to wean the oxygen down. The vital sign flow sheet identified oxygen saturations of 45% on five liters of oxygen at 9:00 p.m. and 93% on eight liters of oxygen at 10:00 p.m. The above noted vital signs were also recorded on the vital sign flow sheet. On 09/06/10 at 10:36 p.m., a nurse's note written by RN Q confirmed

Based on standards of practice for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), review of a user manual for noninvasive ventilators, review of respiratory guidelines, review of the facility's policy and procedure for oxygen, observation, interviews and record review, the facility did not provide or arrange for services that met professional standards of quality for 1 of 2 sampled residents who utilized noninvasive ventilators (NIVs). Resident #1 was admitted to the facility on [DATE] for therapy and a short-term stay following hospitalization related to a fracture complicated by some acute respiratory problems. She required continuous oxygen and at night also required the use of a specific type of NIV, a bi-level positive airway pressure ([MEDICAL CONDITION]) machine (provides airway pressure on inspiration as well as airway support during expiration), related to a previous [DIAGNOSES REDACTED]. This did not occur and resulted in a medication error related to the oxygen rate with the [MEDICAL CONDITION] on [DATE] and [DATE]. Subsequently, Resident #1 died unexpectedly at the facility on [DATE]. This is evidenced by the following: Chapter N6, Standards of Practice for Registered Nurses and Licensed Practical Nurses, states: "N6.03 Standards of practice for registered nurses... "(2) PERFORMANCE OF DELEGATED MEDICAL ACTS. In the performance of delegated medical acts an R.N. shall: "(a) Accept only those delegated medical acts for which there are protocols or written or verbal orders; "(b) Accept only those delegated medical acts for which the R.N. is competent to perform based on his or her nursing education, training or experience..." Surveyor 's review of the Sarasota Memorial Hospital Department Policy titled, "Non-Invasive Positive Pressure (NPPV) Ventilation ([MEDICAL CONDITION]/[MEDICAL CONDITION])," last reviewed by the Director of Respiratory Care Services in [DATE], identified the following: "NURSING CARE...Obtain an order from the physician..." Surveyor reviewed the "Respironics" [MEDICAL CONDITION]/AVAPS user manual which included the following information: "-Warning...the entire manual should be read and understood before using the device." Surveyor 's review of the "Administration of Oxygen Policy," by the South Staffordshire and Shropshire Healthcare NHS Foundation Trust, with an implementation date of [DATE], identified the following: "The aim of oxygen therapy is to maintain tissue oxygenation at a functional level, to eliminate detrimental compensatory responses to hypoxaemia (reduced oxygen concentration in arterial blood), which may cause serious or irreparable damage to vital organs and tissues...; The amount of O2 (oxygen) to be administered must be prescribed clearly, with full instructions, including any variations allowed in the amount to be administered and under what circumstances these variations may be made...; It is the responsibility of individual managers to ensure all members of staff who are likely to be administering O2 therapy have received appropriate training and are fully aware of the prescription and instructions for use of oxygen for that patient..." Surveyor 's review of the policy/procedure for the "Continuous Positive Airway Pressure ([MEDICAL CONDITION])/Bi-level Positive Airway Pressure ([MEDICAL CONDITION]) Support," written by 2001 MED-PASS, Inc. (revised [DATE]), identified the following: "Documentation "1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; "2. Time [MEDICAL CONDITION] was started; duration of the therapy; "3. Mode and settings for the [MEDICAL CONDITION]/IPAP/EPAP; "4. Oxygen concentration and flow, if used; "5. How the resident tolerated the procedure; "6. Oxygen saturation during therapy...; "Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a [MEDICAL CONDITION] mask..." Surveyor 's review of the American Association of Respiratory Care Clinical Practice Guideline, Training the Health-Care Professional for the Role of Patient and Caregiver Educator, reprinted from the [DATE] issue of Respiratory Care, identified the following statement, "Inadequate training of the HCP (health-care provider) can lead to harm to the patient or result in the patient's inability to participate in his/her health-care management." The facility's policy/procedure for oxygen, dated as last revised [DATE], included the following: Page 1... "-Oxygen shall only be administered by physician order, except in an emergency; "-Oxygen shall be administered to residents only by a capable person trained in its administration and use;" Page 2... "-Oxygen is a medication and will be administered by professional nursing staff as ordered by a physician." Page 4 was not dated separately and contained only the following: "Care of [MEDICAL CONDITION]/[MEDICAL CONDITION] "-Residents may be admitted to (facility name) with [MEDICAL CONDITION] or [MEDICAL CONDITION] therapy; "-If a resident's machine needs adjustment or is not working the Charge Nurse needs to call the supplier of the machine to have it adjusted; "-Exterior of machine will be washed off with soap and water as needed; "-The humidifier is emptied daily and left open to air; "-Head gear is hand washed with soap and water and air dried as needed." Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] for therapy and a short-term stay after being hospitalized for [REDACTED]. [DIAGNOSES REDACTED]. Resident #1's discharge summary of [DATE] included orders for oxygen at two to three liters per nasal cannula during the daytime to keep saturations above ,[DATE]%, continued use of the [MEDICAL CONDITION] at night (the resident had her own [MEDICAL CONDITION] machine) and [MEDICATION NAME] nebulizer every six hours and every two hours as needed. The resident arrived at the facility with the [MEDICAL CONDITION] she utilized at home which was identified in the hospital discharge summary as an average volume ensured pressure support (AVAPS) machine, "an auto-regulating [MEDICAL CONDITION]." Resident #1 was a full code status. There was no evidence in the record of an adequate initial nursing care plan to ensure the [MEDICAL CONDITION], with the supplemental oxygen, was utilized as per physician orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The computer system utilized by the facility included a respiratory section nurses could "click" on to document their assessments/monitoring data, but there was no specific plan in place for Resident #1 as to what data was expected to be assessed and/or monitored (such as how often it was expected vital signs and oxygen saturations should be done). It was not identified how the utilization of the resident's [MEDICAL CONDITION] was to be monitored and documented (when it was started, the duration of the therapy, the mode and settings, rate of oxygen used). It was not identified who was responsible for the maintenance and cleaning of the machine. (Reference F309) Facility nurses did not adequately assess and/or monitor the resident's oxygen administration, oxygen saturation, [MEDICAL CONDITION] usage, and/or vital signs on the following dates: [DATE] - RN H [DATE] - RNs I, J and K [DATE] - RNs I, J and L [DATE] - RNs M, J and N [DATE] - RNs M, J and K [DATE] - RNs O, J and Q, and Nurse Tech P [DATE] - RNs I, J and K [DATE] - RN I RN Q did not notify a physician in a timely manner on [DATE] when Resident #1 was found to be lethargic with an abnormally low oxygen saturation (45%) requiring an increase in oxygen to keep her oxygen saturation above that ordered by the physician. RN J did not provide complete and accurate information to the pulmonologist on [DATE]. RNs K and I did not clarify new orders received from the pulmonologist to include how much oxygen should be administered with the [MEDICAL CONDITION] on [DATE] and [DATE]. (Reference F-157 and F-309 both cited at immediate jeopardy/isolated, which resulted in substandard quality of care.) On [DATE] at 3:10 p.m., Surveyor interviewed RN H, the nurse who admitted Resident #1 to the facility on [DATE]. RN H identified she had worked at the facility for approximately one year as a LPN and one year as an RN. RN H stated she had training on respiratory equipment in school including [MEDICAL CONDITION], but had no facility training on the [MEDICAL CONDITION] and was not familiar with the type of [MEDICAL CONDITION] Resident #1 had with the oxygen "bled" into the [MEDICAL CONDITION] tubing. RN H stated that on the evening of [DATE], FM D was present and identified herself as a Respiratory Therapist (RT). FM D then "set up" Resident #1's [MEDICAL CONDITION]. RN H stated she was not familiar with the [MEDICAL CONDITION] settings and counted on FM D when she showed up and said she was an RT. RN H stated FM D obtained a different mask for Resident #1, per the resident's request. RN H stated that what the facility wrote to the pulmonologist on [DATE] did not clearly say if five to six liters of oxygen was used both day and night, and the way the physician wrote the order looked like he meant for the oxygen to be at two liters both with the cannula and with the [MEDICAL CONDITION]. RN H stated she could not recall a time when orders for a resident's daytime oxygen and the nighttime oxygen was different, but being a new nurse and having no "detailed" training on [MEDICAL CONDITION] in school, she stated she would have called the physician to have the order clarified. Surveyor interviewed FM D on [DATE] at 11:55 a.m. FM D expressed concern as to whether all facility nurses knew how to connect the oxygen correctly to Resident #1's [MEDICAL CONDITION]. FM D stated she recalled Resident #1's oxygen was set up with separate oxygen tubing for the oximyzer and another for the [MEDICAL CONDITION] (the tubing would have had to have been switched at the concentrator each time the [MEDICAL CONDITION] was initiated and again when the [MEDICAL CONDITION] was discontinued and the oximyzer was initiated). On [DATE] at 1:55 p.m., Surveyor interviewed RN J, the nurse who worked the day shift and cared for Resident #1 on six out of the six day shifts the resident resided at the facility. RN J identified she had worked at the facility for 4? years and had cared for Resident #1 during her stay at the facility. RN J stated there were "not too many" residents she cared for who had a [MEDICAL CONDITION]/[MEDICAL CONDITION]. RN J stated it had been approximately two months since she had cared for such a resident prior to caring for Resident #1, but added that all the [MEDICAL CONDITION]/[MEDICAL CONDITION] machines were "relatively" the same. RN J stated the only training she had related to [MEDICAL CONDITION]/[MEDICAL CONDITION] was from what she had in school. RN J stated Resident #1 was the only resident she had ever cared for that had oxygen connected to the machine. RN J stated that had she been working on the evening of [DATE], she would have decreased the oxygen to two liters via the [MEDICAL CONDITION] because "the order came from the pulmonologist." RN J identified there were books at the nurses' desk with information related to [MEDICAL CONDITION]/[MEDICAL CONDITION] and stated she would get me a copy of the material. On [DATE] at 1:40 p.m., Surveyor interviewed RN Q, the nurse who worked on [DATE] when Resident #1 had a significantly low oxygen saturation (45%). RN Q confirmed he did not notify the physician of Resident #1's low oxygen saturation. RN Q stated he would have "probably" clarified the oxygen order of [DATE]. RN Q stated that upon reviewing Resident #1's record, he noted there were often incomplete assessments that did not include vital signs, and sufficient oxygen data and information provided to physicians was not always complete and accurate. RN Q stated the two sets of vital signs (on [DATE] and [DATE]) during Resident #1's stay were not adequate. RN Q stated a new "Symptom Pursuit Manual" was made available at the nurses' stations since the start of the survey, but added it would require some changes. RN Q confirmed a standard of practice was needed. Surveyor interviewed RN K on [DATE] at 5:30 p.m. RN K worked the evening shift and cared for Resident #1 on three out of the seven evening shifts the resident resided at the facility, and was the nurse who worked the evening shift on [DATE] (when the oxygen order was not clarified). When asked if the facility had guidelines for assessment and monitoring, RN K stated she did not know. Surveyor interviewed RN K on [DATE] at 12:30 p.m. RN K stated it was her understanding the [MEDICAL CONDITION] was preprogrammed. RN K identified she had worked with [MEDICAL CONDITION] in hospitals in other states, but they were maintained by respiratory staff. RN K stated there was nothing written on the quick slip that would have made her question the oxygen order. RN K stated she was aware the function of the oximyzer tubing was to "get the oxygen better," but when asked if she was aware it approximately doubled the amount of oxygen received, she confirmed she was not. Surveyor interviewed RN N on [DATE] at 8:00 p.m. RN N identified she was a "contract nurse" and worked at the facility approximately once every two weeks. RN N stated her primary job was as a critical care nurse in a hospital. RN N recalled Resident #1 was a carbon [MEDICATION NAME] "retainer," adding that the oxygen saturations might then have not been accurate (no evidence in the record Resident #1 had problems with carbon [MEDICATION NAME] retention until her appointment with the pulmonologist on [DATE]). RN N stated Resident #1's biggest issue was not respiratory, but rather anxiety, adding she had numerous requests and "wanted somebody in the room at all times." RN N stated [MEDICAL CONDITION] are used primarily at night to keep the airway open and if Resident #1 was using her [MEDICAL CONDITION] during the daytime, "she shouldn't have been there" (at the facility). RN N stated she would have clarified the oxygen order on [DATE] so those following her would know for sure what the physician had intended. Surveyor interviewed RN O on [DATE] at 9:35 a.m. RN O stated she did not change the rate of Resident #1's oxygen on [DATE] and she did not recall checking an oxygen saturation. RN O stated she checked the oxygen rate and looked at the resident noting she had no color change and no shortness of breath. RN O stated she did not take vital signs because the resident was not restless other than when she woke up, and since she had been at the facility for five days, she felt the initial admission criteria had been met. RN O stated that for a new admission, she would probably check vital signs every shift for 72 hours. RN O stated she worked with another nurse on [DATE] who stated she had cared for Resident #1 the night before and felt she was "the same." RN O stated she checked on the resident multiple times that night. RN O identified it would be on the care plan or in a facility policy/procedure as to how often a resident's oxygen saturations should be done. Surveyor interviewed LPN R on [DATE] at 2:40 p.m. LPN R identified she had worked at the facility for [AGE] years and was currently in nursing school to become a RN. LPN R stated she worked throughout the facility, but had never worked with Resident #1. LPN R stated there were other residents in the facility who utilized [MEDICAL CONDITION]/[MEDICAL CONDITION], but added they were usually not utilized when she worked the day shift. LPN R stated the training for [MEDICAL CONDITION] was "vague" in LPN school, but she knew how to "hook them up." LPN R stated she did not recall any "live" inservice at the facility related to [MEDICAL CONDITION]/[MEDICAL CONDITION]. On [DATE] at 2:50 p.m., Surveyor interviewed RN I, the nurse who worked the night shift and cared for Resident #1 on four out of the seven night shifts the resident resided at the facility (including the night she died unexpectedly). RN I identified he had worked at the facility for eight years and the only training he had received related to [MEDICAL CONDITION] was what he had in school. RN I stated he had received report from the evening nurse who reported the oxygen had been decreased to two liters and identified the [MEDICAL CONDITION] was already on when he arrived. RN I stated he had seen the "quick slip" order form that identified the resident as a carbon [MEDICATION NAME] retainer, thus assuming the oxygen should be decreased also with the [MEDICAL CONDITION]. On [DATE], Resident #1 died unexpectedly at the facility, allegedly, with part of her [MEDICAL CONDITION] machine that normally sat on the bedside stand, found on the floor. It was subsequently confirmed from a card that monitored the resident while she was on the [MEDICAL CONDITION], that the [MEDICAL CONDITION] machine was disconnected for approximately 2? hours from the mask she still had attached to her face. Resident #1's family expressed concerns to the facility administration and to the State office regarding Resident #1's death which included that a medication error with the oxygen had occurred. Surveyor interviewed Physician V on [DATE] at 9:25 a.m. Physician V stated Resident #1's oxygen rate currently being used was higher than it needed to be and she was using an increased amount of sedatives. Physician V stated the oximyzer used by the resident nearly doubled the amount of oxygen she received during the daytime (if the rate was set at 6 liters she would be getting approximately 12 liters via the oximyzer, but at night via the [MEDICAL CONDITION], without the oximyzer, she would be getting only the 6 liters). Physician V stated his order was to decrease the "daytime" oxygen to two liters (she would still be getting approximately four liters via the oximyzer) and his intention was to keep the night oxygen as it was, at ,[DATE] liters. Physician V confirmed facility staff did not call to clarify the order. Surveyor again interviewed Physician V on [DATE] at 5:30 p.m., who again identified that on [DATE], he ordered the "daytime" oxygen to be decreased due to the resident's carbon [MEDICATION NAME] retention. Physician V stated the resident could still tolerate a higher dose of oxygen with the [MEDICAL CONDITION]. Physician V stated the order was "not well written after reviewing it," but added he would have expected the facility nurse to get it clarified. Physician V confirmed a nurse would need enough knowledge of [MEDICAL CONDITION] to know to call for clarification. Surveyor received a letter from Physician V on [DATE], as clarification regarding the oxygen order he gave to facility staff for Resident #1 on [DATE]. The letter included the following information related to Resident #1 on [DATE], "...noted to be more somnolent and her levels of carbon [MEDICATION NAME] were increased. (Resident #1) had been on 5 liters of oxygen via an Oximyzer at the time of our visit. Her oxygen levels were reassessed and she was found to adequately oxygenate on 2 liters via the Oximyzer. To that end, I did write an order to decrease her supplemental oxygen via the Oximyzer to be decreased to 2 L (liters)/min (minute). My intention was that her oxygen delivery, while using the [MEDICAL CONDITION], would remain the same at 5 liters. Unfortunately that was not written as clearly as I would have liked. There were two reasons behind the decision to keep the oxygen levels at 5 liters with [MEDICAL CONDITION]. Higher levels of supplemental oxygen are often required for patients with respiratory disease during sleep. Additionally, added ventilation from the [MEDICAL CONDITION] would help to reduce hypercarbia associated with those higher levels of supplemental oxygen." Surveyor interviewed Assistant Director of Nursing (ADON) A and the NHA on [DATE] at 1:55 p.m. When asked what standard of practice was being utilized related to assessments and monitoring, ADON A stated the nurses' training should be enough and there was no need for a standard. This was confirmed by the NHA who added the facility had "stabilized" nurses and their ratio of RNs to LPNs was at the 98th percentile. Surveyor interviewed Medical Director (MD) JJJ on [DATE] at 7:45 a.m. MD JJJ identified she had just started the role of Medical Director at the facility in [DATE]. MD JJJ identified her role as a consultant. MD JJJ identified she has reviewed some of the facility's policies/procedures, but was unsure what standards of practice were being utilized by the facility. MD JJJ stated she thought the facility might use multiple standards and identified AMDA has been recently discussed. When asked what training she would expect the facility to provide related to new equipment or an unfamiliar diagnosis, MD JJJ stated it would depend on the situation and added that the nurse could discuss it with the physician.