Every finding on record at Holly Care Center

Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control practices when cleaning resident rooms; -Ensure nursing staff followed appropriate infection control practices when providing wound care; and, -Ensure clean items, such as medications and body soap, were stored in a sanitary manner. Findings include: I. Failure to ensure housekeeping staff followed appropriate infection control practices when cleaning resident rooms A. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the quality mentor (QM) on 8/27/24 at 2:43 p.m. It read in pertinent part, Use heavy duty gloves and other personal protective equipment (PPE) as indicated for housekeeping tasks. Perform hand hygiene after removing gloves. B. Observations On 8/27/24 at 9:06 a.m. housekeeper (HSK) #2 was cleaning room [ROOM NUMBER]. HSK #2 was not wearing gloves when she discarded the dirty mop pad. After handling the dirty mop pad, and without performing hand hygiene, HSK #2 obtained a clean mop and squeezed the end of the mop with her ungloved hands. HSK #2 finished mopping the resident's floor, then proceeded to use her ungloved hands to pull off the dirty mop pad. -HSK #2 did not perform hand hygiene after touching the soiled mop pad. On 8/27/24 at 9:15 a.m. HSK #2 entered room [ROOM NUMBER], she cleaned the high touch surfaces with disinfectant and then took out the trash without wearing gloves. HSK #2 did not perform hand hygiene after removing trash. C. Staff interviews The housekeeping supervisor (HSKS) was interviewed on 8/27/24 at 10:04 a.m. The HSKS said the housekeepers should wear gloves if they were removing trash or handling a soiled mop pad. HSK #2 was interviewed on 8/27/24 at 10:10 a.m. HSK #2 said she should have worn gloves when she was handling the soiled mop pad. She said she should use hand sanitizer and wear gloves when she removed trash from a resident's room. The infection preventionist (IP) was interviewed on 8/27/24 at 1:39 p.m. The IP said HSK #2 should have worn gloves and sanitized her hands while handling dirty and clean mop pads. The IP said HSK #2 should wear gloves and use hand sanitizer to prevent the spread of infection and germs. II. Failure to ensure nursing staff followed appropriate infection control practices when providing wound care A. Facility policy and procedure The Wound Care policy, undated, was provided by the director of nursing (DON) on 8/28/24 at 2:20 p.m. It read in pertinent part, Steps in procedure: -Place disposable cloth next to the resident (under the wound) to serve as a barrier and to protect bed linen; -Put on exam gloves. Loosen tape and remove dressing; and, -Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. B. Observation On 8/27/24 at 9:25 a.m., registered nurse (RN) #2 was changing Resident #5's wound dressing. RN #2 removed the soiled dressing and placed it on the clean disposable cloth that was less than six inches from the resident's uncovered wound. RN #2 then washed his hands for 10 seconds, donned (put on) new gloves, cleaned the wound and performed the remainder of the dressing change. -RN #2 did not discard the soiled dressing (which remained less than six inches from the wound on the clean field) prior to applying the new dressing. C. Staff interviews RN #2 was interviewed on 8/27/24 at 10:00 a.m. RN #2 said his hands needed to be washed for at least 20 seconds. RN #2 said he should have discarded the soiled dressing into the trash can immediately after removing it. The IP was interviewed on 8/27/24 at 1:39 p.m. The IP said the staff should wash hands for at least 20 to 30 seconds to ensure germs were removed effectively. III. Failure to ensure clean items, such as medications and body soap, were stored in a sanitary manner A. Facility policy and procedure The Medication Storage policy, revised February 2024, was provided by the DON on 8/28/24 at 2:20 p.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication room according to manufacturer recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. B. Observations and staff interview On 8/26/24 at 1:56 p.m licensed practical nurse (LPN) #1 was observed during medication administration. LPN #1 used a key to unlock the medication storage room. She walked through a bathroom, which was located inside the medication storage room, to get to a second medication storage area contained in the room. The following items were observed in the bathroom less than two feet from the toilet: -An emergency medication kit which contained 35 medications; and, -An emergency intravenous (IV) kit which contained 18 medications. LPN #1 said the toilet in the bathroom located inside the medication storage room was sometimes used by nurses, who were the only staff members who had a key to the medication storage room. LPN #1 said the emergency medication kits should not be stored in the bathroom. LPN #1 moved the emergency medication and IV kits from the bathroom to the outer storage area of the medication room. On 8/27/24 at 10:40 a.m., the two shower rooms were observed with the HSKS. There was an opened one gallon container of body soap on the floor in each of the shower rooms. C. Additional staff interviews The IP was interviewed on 8/26/24 at 2:05 pm. The IP said the emergency medication and IV kits should not be stored in the bathroom in the medication storage room. The IP said it was an infection control risk to store them in the bathroom. The IP was interviewed again on 8/27/24 at 2:04 p.m. The IP said the body soap should not be stored on the floor of the shower rooms as it could spread infection.

Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two (#23 and #25) of six residents out of 16 sample residents. Specifically, the facility to: -Ensure a care plan and interventions were developed for Resident #23's use of a hypertensive medication; and, -Ensure a care plan and interventions were developed for Resident #25's use of insulin, an anticoagulant medication and for dialysis treatments. Findings include: I. Facility policy and procedure The Comprehensive Care Plans policy, revised on 2/28/24, was provided by the quality mentor (QM) on 8/28/24 at 12:27 p.m. The policy revealed this facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives, timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the resident's comprehensive assessment. Person-centered care meant the facility would focus on the resident as the locus (specific position) of control, support the resident in making their own choices and having control over their daily lives. The care planning process would include an assessment of the resident's strengths and needs and would incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, would be culturally competent and trauma-informed. The comprehensive care plan would be developed within seven days after the completion of the comprehensive minimum data set (MDS) assessment. All care assessment areas (CAAs) triggered by the MDS assessment would be considered in developing the plan of care. Other factors identified by the interdisciplinary team (IDT), or in accordance with the resident's preferences, would also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning would be evidenced in the clinical record. The comprehensive care plan would be prepared by the IDT. The comprehensive care plan would include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives would be utilized to monitor the resident's progress. Alternative interventions would be documented, as needed. II. Resident #25 A. Resident status Resident #25, age 78, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis and multiple fractures of the ribs on the resident's right side with an initial encounter for closed fractures. The 8/13/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) score of 10 out of 15. For the seven-day assessment period, the resident received injections everyday. The resident also received insulin injections all seven days. The resident was taking antiplatelet and hypoglycemic (including insulin) medications. The MDS assessment did not reveal the resident was on dialysis. B. Record review A physician's order, dated 2/5/24 at 1:18 p.m., revealed routine dialysis once a day every Monday, Wednesday and Friday. Staff were to check the graft site (access site for dialysis) for bleeding after the resident returned from dialysis. If bleeding occurred, staff were to apply direct pressure until the bleeding was controlled. Staff were to notify the medical provider if the bleeding lasted longer than 30 minutes or was severe. The June 2024, July 2024 and August 2024 medication administration records (MAR) revealed the resident went to dialysis as the physician ordered. -The resident's electronic medical record (EMR) did not contain a care plan for dialysis. -The facility developed a care plan for dialysis during the survey, on 8/27/24. A physician's order, dated 2/5/24 at 4:07 p.m., revealed Resident #25 was to be administered Eliquis (an anticoagulant medication) tablet 2.5 milligrams (mg) orally once a day for the use of a fistula (surgical connection between an artery and a vein in the arm that was used to access a resident's blood flow for hemodialysis treatments. The June 2024, July 2024 and August 2024 MARs revealed the resident was administered the Eliquis tablet 2.5 mg per the physician's ordered. -The resident's EMR did not contain a care plan for the use of the anticoagulant medication. -The facility developed a care plan for anticoagulant use during the survey, on 8/27/24. A physician's order, dated 6/15/24 at 10:21 p.m., revealed Resident #25 was to receive an injection of Basaglar KwikPen Subcutaneous Solution 100 units/milliliter (Insulin Glargine); 12 units subcutaneously twice a day and hold if the resident's blood sugar was less than 60 milligrams per deciliter (mg/dl). Staff were to call his physician if the resident's blood sugar level was above 500 mg/dl. The June 2024, July 2024 and August 2024 MARs revealed the resident was administered the Basaglar KwikPen Subcutaneous Solution per the physician's order. -The resident's EMR did not contain a care plan for the use of insulin. -The facility developed a care plan for insulin use during the survey, on 8/27/24. C. Staff interviews The nursing home administrator (NHA), the director of nursing (DON) and the QM were interviewed together on 8/28/24 at 1:30 p.m. The NHA, the DON and the QM said that Resident #25's EMR did not contain care plans for dialysis, the use of insulin nor the use of an anticoagulant medication. They agreed that care plans should have been developed for these three areas, according to the facility's policy. They agreed care plans for insulin, an anticoagulant and dialysis were developed during the survey. The DON said the IDT developed the resident's comprehensive care plans. She said the MDS coordinator and the IDT reviewed their disciplines' specific sections for accuracy or the need for further development. The DON said during the seven-day MDS assessment period, the coordinator should have developed care plans for these three areas. The DON said the care plans provided direction for the plans of care for a resident. She said the care plans listed the problem/concerns, goals and interventions to address the issues with the resident. She said the care plans were fluid and could be developed or updated as the resident changed. III. Resident #23 A. Resident status Resident #23, age 67, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 CPO, diagnoses included essential hypertension, hemiplegia, vascular dementia, anxiety and depression. The 7/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview of mental status (BIMS) score of four out of 15. For the seven-day assessment period, the resident received an antipsychotic, antidepressant and opioid medications. B. Record review The physician's order, dated 12/1/24 at 8:31 p.m., revealed to administer a hydrochlorothiazide 25 mg tablet orally once a day for hypertension. The physician's order, dated 12/1/23 at 8:34 p.m., revealed to administer two losartan potassium 25 mg tablets orally once a day for hypertension. The June 2024, July 2024 and August 2024 MARs revealed the resident was administered the hydrochlorothiazide 25 mg tablet and the two losartan potassium 25 mg tablets for hypertension as physician ordered. -The resident's EMR did not contain a care plan for hypertension. -The facility developed a care plan for hypertension during the survey, on 8/27/24. C. Staff interviews The NHA, the DON and the QM were interviewed together on 8/28/24 at 1:30 p.m. They said that Resident #23's EMR did not contain a care plan for hypertension. They agreed that a care plan should have been developed for hypertension, according to the facility's policy. They agreed the care plan for hypertension had been developed during the survey. Registered nurse (RN) #2 was interviewed on 8/28/24 at 2:14 p.m. RN #2 said the care plans were developed to ensure staff provided the appropriate and consistent care for the residents' concerns/issues.

Based on observations, record review and interviews, the facility failed to ensure one (#3) of two residents reviewed for ancillary services out of 16 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to ensure Resident #3 was provided dental services for timely replacement of her upper denture. Findings include: I. Facility policy and procedure The Ancillary Services policy, revised February 2024, was provided by the director of nursing (DON) on 8/28/24 at 2:20 p.m. It read in pertinent part, Any resident needing or requesting ancillary services such as dental, vision, audiology and podiatry will have their needs met timely. Social services/Designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner. II. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included intracranial shunt (surgical procedure to place a tube in the brain), bipolar disorder (mental illness that causes extreme behavior swings), severe obesity and chronic pain. The 5/16/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #3 was independent with oral hygiene, eating, dressing and transferring self and required set-up assistance with showering. The MDS assessment revealed the resident had no dental issues. -However, Resident #3 did not have any upper teeth (see resident observation and interview below). B. Resident interview and observation Resident #3 was interviewed on 8/25/24 at 6:02 p.m. Resident #3 said her top set of dentures was left in a transportation vehicle. She said she was not sure how long ago the incident occurred, but thought it was at least a year ago. Resident #3 said she told the facility when the top denture was lost. Resident #3 said the former social worker did not assist her with obtaining new upper dentures and Resident #3 did not know if the current social worker was aware the upper denture was needed. Resident #3 said she was limited in her ability to eat because she did not have her upper denture. During the interview, Resident #3 did not have any upper teeth or dentures in place. Resident #3 was interviewed again on 8/28/24 at 9:53 a.m. Resident #3 said she could not eat hamburger or bacon, lettuce and tomato sandwiches without her top denture. She said it was difficult to chew without her top denture. She said a social worker told her she could only have replacement dentures once every three years. C. Record review The dental care plan, revised 7/11/24, revealed the resident had upper dentures. The interventions included coordinating arrangements for dental care and providing transportation as needed. -A review of the resident's care plan did not indicate the resident's upper dentures were missing. A facility consultation sheet was provided by the DON on 8/28/24 at 2:53 p.m. The consultation sheet revealed Resident #3 was at a dental clinic on 3/11/24 to get upper dentures and the dentist documented they provided Resident #3 with the price of new dentures. A progress note, written by the previous social services director (SSD) on 3/12/24 at 11:51 a.m., revealed Resident #3 was seen by the dentist on 3/11/24 for top denture replacement. The progress note documented the resident's insurance would not cover dentures for seven years and the resident was not able to financially cover the cost of dentures herself. The progress note indicated the SSD was researching other options. A progress note, written by the current SSD on 3/13/24 at 10:15 a.m., revealed the SSD reviewed with Resident #3 that insurance would not cover dentures and one alternate payor would not cover it. The note documented Resident #3 said she did not have the means to pay privately or set up a payment plan fo the dentures. -A review of the resident's electronic medical record (EMR) did not reveal any additional documentation indicating the facility had assisted the resident in finding her dentures or replacing them. A progress note, written by the DON on 8/28/24 at 1:26 p.m. (during the survey), revealed a dental appointment had been scheduled for Resident #3 in September 2024 (exact date to be determined) for x-rays and impressions for the denture to be replaced. The DON indicated the bill for services would be sent to the facility and the facility would pay for the denture if an alternate payor was not possible. D. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 8/27/24 at 1:09 p.m. CNA #5 said Resident #3 had dentures at one time, but did not know if Resident #3 still had them. CNA #8 was interviewed on 8/27/24 at 1:20 p.m. CNA #8 said Resident #3 had told her in the past that her dentures did not fit. CNA #8 said she was not aware the resident had lost her upper denture. Licensed practical nurse (LPN) #1 was interviewed on 8/27/24 at 1:15 p.m. LPN #1 said she was not aware Resident #3 had lost her top dentures. The DON, the SSD and the nursing home administrator (NHA) were interviewed together on 8/28/24 at 11:28 a.m. The SSD said she knew the process for assisting residents with the replacement of dentures. The DON said Resident #3 had a dental appointment to replace her top dentures on 3/11/24. The DON said the denture had not been replaced as of 8/28/24. The DON said she would have expected the SSD to work with the business office and the NHA to arrange funds to obtain the upper denture replacement. The DON was interviewed again on 8/28/24 at 3:02 p.m. The DON said it was the facility's responsibility to ensure timely replacement of dentures for a resident. The DON said the current SSD was not aware when she documented her 3/13/23 progress note that she had alternative means for obtaining new dentures for residents.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Food was stored and labeled properly Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, in part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations Observation of meal service was conducted on 3/29/23 at 10:45 a.m. Dietary aide (DA) #1 was observed preparing hamburger meals for lunch. DA #1 put on a pair of gloves and walked into the walk-in freezer and removed a box of frozen hamburger patties and placed them next to the stove. She retrieved a large pan and placed it on the oven and turned on the gas burner. She opened the box with her gloved hand and removed five frozen hamburger patties with her gloved hand and placed them into the pan. She proceeded to seal up the box of hamburger patties and returned to the walk-in freezer. She opened the freezer door with her gloved hand and walked into the freezer placing the box into the freezer. She returned to the stove to check the hamburger patties. She then walked over to the walk-in refrigerator and opened the door with her gloved hand. She placed three plastic containers of tomatoes, onions and lettuce on the counter top in front of the walk-in refrigerator. She then returned into the walking refrigerator grabbing the door handle with her gloved hand. She exited the walking refrigerator with a jar of mayonnaise and placed it in the preparation area next to the stove. She checked the hamburger patties on the stove and proceeded to grab four plates. She then grabbed a bag of buns from the top counter. She reached in with her gloved hand and removed the hamburger buns placing them on the plate. She wiped her hands on the side of her pants as she reached up to get a pair of tongs. She took two plates with the hamburger buns over to the counter in front of the walk-in refrigerator and proceeded to grab a slice of tomatoes, a handful of lettuce and onion and place them onto the hamburger bun. She returned to the preparation area with the plates and put them on the counter. She walked over to the small refrigerator, opened the door with her gloved hands and retrieved a package of cheese. She opened the package of cheese and grabbed two slices with her gloved hand and placed them on the hamburger buns. She grabbed the tongs and grabbed two hamburger patties placing them onto the buns. She then opened the bag of chips and proceeded to use the same tongs she used to grab the hamburger patties and grabbed potato chips from the bag placing them on the plate. She then walked over to the serving line and placed plastic wrap over the plate of hamburger and chips. She leaned forward over the plate which allowed her badge to rest on the hamburger patty. The cutter on the box of plastic wrap was broken so she grabbed a pair of scissors and cut the plastic wrap with the scissors. She then placed the hamburgers on to the top of the serving line. She grabbed two more plates and proceeded the same process of preparing the other hamburgers. This time she used the same tongs to place the tomatoes, lettuce and onions onto the hamburger buns. She replaced the lids on the plastic containers and placed the tomatoes, lettuce and onions back into the walk-in refrigerator. She exited the walk-in refrigerator and proceeded to take the plates over to the preparation area. She again grabbed two slices of cheese and placed them on the bun. She then took the tongs and placed the hamburger patties onto the buns. She used the tongs again and removed chips from the bag, placing them onto the plate with the hamburger. She followed the same procedure of wrapping the plate with the plastic wrap and placing it onto the serving line. She then grabbed the tongs and other utensils and took them to the dishwashing area and placed them onto the dirty dishes side. She returned to the preparation area removing and discarding her used gloves and putting one new glove on without performing hand hygiene. She then proceeded to prepare peanut butter and jelly sandwiches. She grabbed four slices of bread with her one gloved hand and a plate and proceeded to spread the peanut butter onto the bread while holding the bread with her ungloved hand. She did this for two slices of bread. She walked over to the small refrigerator and removed a jar of jelly. She opened it with her gloved hand and proceeded to spread the jelly onto the bread holding one side of the bread with her ungloved hand. She placed the peanut butter and jelly sandwich on the cutting board and cut the sandwich in half. She grabbed the sandwich with her gloved hand and placed it on to the plate and placed it on the top of the serving line. She repeated the same process for one more sandwich of peanut butter and jelly. DA #1 did not perform hand hygiene during this process. The cook was observed serving meals on the service line. She would constantly grasp her hand together while she was waiting for the next meal order. She left the serving line and proceeded to go to the dirty dish side of the dish room. She proceeded to rinse some utensils and returned to the serving line. She was observed grabbing several slices of bread to put on the plate. She did this twice and then proceeded to use tongs to grab the bread. The cook grabbed four assistive devices for bowls for a resident order. She had her thumbs inside the bowl while she was serving the pureed meals. The cook did not perform hand hygiene during this process. C. Staff Interview The dietary manager (DM) was interviewed on 3/29/23 at 2:05 p.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. She said staff should never touch ready to eat foods with their bare hands. She said they should use serving tongs even if they have gloves on. Staff should also wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash their hands between tasks to avoid cross contamination. II. Labeling food A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) 3-602.11, 4 a-d. pg. 103, 4 a-d. in part, A date marking system that meets the criteria stated .using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Using calendar dates, days of the week, color coded marks or other effective marking methods. B. Observation On 3/27/23 at 7:30 a.m. during the initial tour of the kitchen items stored in the walk in freezer that were not labeled included: one box of hamburger patties, a bag of ravioli, box of fish filets, box of green peas, chicken breasts in a clear plastic bag, hotdogs in a clear plastic bag. On 3/29/23 at 11:00 a.m. items stored in the walk in freezer that were not labeled included: one box of hamburger patties, a bag of ravioli, box of fish filets, box of green peas, chicken breasts in a clear plastic bag, hotdogs in a clear plastic bag. C. Staff interview The DM was interviewed on 3/29/23 at 2:05 p.m. She said all food should have been labeled to include the item and date. She said by doing so, it identified the product, so staff knew what they were grabbing and it was the correct product. She said it was important to date the items so the staff knew when to discard them. She said the proper time frame was seven days from the day the item was prepared, opened or pulled out of the freezer to thaw. She said the potential risk of not labeling was serving an incorrect food item and serving food past seven days from the day the item was prepared, opened or pulled out of the freezer to thaw.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on a hose in the kitchen maintenance closet and on the hand held shower on the west hall shower, increasing the risk of contamination to the facility's main water supply. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Cross-Connection Control, updated on 11/2/22, retrieved on 3/29/23 from: https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection, which can result in a potentially serious public health hazard. A cross-connection control and backflow prevention program helps prevent contaminants from entering a drinking water distribution system. This fact sheet is part of EPA's (Environmental Protection Agency) Distribution System Toolbox developed to summarize best management practices that public water systems (PWSs), particularly small systems, can use to maintain distribution system water quality and protect public health. B. Observation Observations of the resident living environment conducted on 3/29/23 at 8:47 a.m. revealed: The kitchen maintenance closet had a hose which was utilized to fill the mop bucket. The hose in the kitchen maintenance closet did not have a backflow prevention valve on it. The sink was approximately 20 inches long by 20 inches wide and six inches deep. The sink was set on the floor with a long hose approximately 48 inches long sitting at the bottom of the yellow mop bucket. The mop bucket had visible water on the bottom. The hand held shower in the west shower room was positioned on the floor of the shower pan and was constantly running. The backflow prevention valve was nonfunctional as it was leaking. The hand held shower was long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pan and the hand held shower had a continuous flow of water coming out of the end of it. II. Staff Interview The maintenance supervisor (MS) was interviewed on 3/30/23 at 9:15 a.m. He acknowledged he was familiar with the backflow valve protocol. The MS observed the hand held shower in the west shower room and the kitchen maintenance closet. The MS stated the hose in the kitchen maintenance closet was used to fill the mop bucket, and it should have had a backflow prevention valve on it. He said the hand held shower hose on the west shower room should have had a functioning backflow prevention valve as it was visibly leaking. He said he would have to investigate why the water was constantly running. He said the west shower room did not have a functioning backflow preventer valve on the hand held shower head, and the hose in the kitchen maintenance closet should have had a backflow prevention valve on it. He said she would place the backflow valves on them immediately.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 14 of 25 resident rooms in two hallways. Specifically, the facility failed to ensure walls, halls, ceilings, floors, and doors were repaired, painted and properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 3/29/23 at 8:47 a.m. revealed: room [ROOM NUMBER]A: There were four nickel sized holes underneath the resident's shelf next to his bed. The wall next to the resident's bed had an area 24 inches by 24 inches which had not been painted. The outlet box did not have a cover on it with the cable wire exposed. The lament in front of the sink had an area approximately eight inches long by two inches wide which was lifted. room [ROOM NUMBER]B: The resident's call light was wrapped around the grab bar in the restroom which made it inaccessible. room [ROOM NUMBER]B: There was a large chip of sheet rock approximately four inches in circumference next to the resident's door. room [ROOM NUMBER]B: The wall in the restroom had a section of peeling sheetrock approximately seven inches long by three inches wide. room [ROOM NUMBER]B: The restroom wall had four nickel sized holes from the wall mount toilet paper holder, which had been moved. The restroom door had a hole approximately seven inches long by three inches wide. There was a metal bracket where the television brackets had been removed. The wall behind the door had damage from the door knob hitting the wall which was approximately five inches long by four inches deep. room [ROOM NUMBER]B: The wall next to the sink had peeling and chipped sheetrock approximately six inches long by three inches wide. The wood frame next to the sink had three areas where the wood had peeling and splintering scraps. The wall above the bed had a section approximately eight inches by four inches where a light fixture had been removed. The wall had pea-sized holes. The restroom's call light was wrapped around the grab bar which made it inaccessible. room [ROOM NUMBER]B: The wall above the resident's headboard had three areas of unpainted patch work approximately 10 inches by six inches, five inches by four inches, and four inches by four inches. room [ROOM NUMBER]B: The ceiling had water damage approximately five feet by five feet and another area approximately four feet by four feet. The restroom did not have a call light. room [ROOM NUMBER]A: The wall at the end of the resident's bed had damaged sheetrock approximately six inches in circumference. room [ROOM NUMBER]B: The corner piece next to the sink had an area approximately three feet high by three inches wide of chipped and damaged sheetrock. The metal corner bracket was exposed. The wall in the restroom had peeling and damaged sheetrock approximately 12 inches long by three inches wide. The fire doors next to room [ROOM NUMBER]A had chipped and splintering wood approximately four feet high by three inches wide on the corner. room [ROOM NUMBER]B had a metal piece approximately 24 inches by 24 inches where the old air conditioner had been replaced. There was an air gap on the right side of the metal piece. room [ROOM NUMBER]A: The wall in the restroom was damaged from the wheelchair hitting the wall. The wall behind the commode had a hole approximately nine inches long by five inches wide. The bathroom door had the bottom lament peeling away from the bottom of the door. The wood frame next to the sink was chipped and splintering from the wheelchair hitting the corner. The entrance door had chipped and splintering wood approximately three feet high by three inches wide. The wall next to the air conditioner had a metal piece approximately 24 inches by 24 inches where the old air conditioner had been replaced. There was an air gap on the right side of the metal piece. room [ROOM NUMBER]B: The wood frame next to the entrance had chipped and splintered wood from the wheelchair hitting the wood frame. The laminate on the sink had an area approximately three inches in circumference. There was a metal bracket from a missing towel rack next to the sink. The shower room on the north east end of the hall had 16 dime sized holes in bottom of the wall close to the shower surround. The caulking around the base of the shower was black and peeling. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) and nursing home administrator (NHA) on 3/30/23 at 9:15 a.m. The above detailed observations were reviewed. The NHA documented the environmental concerns. The MS said the facility utilized a computer system to identify environmental issues. The MS said he did not have any repair requisition requests for the above-mentioned items. The MS said he missed these repairs and the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (#1 and #26) of three residents reviewed for accidents/hazards out of 15 sample residents. Specifically, the facility: -Failed to ensure a medication in Resident #1's room had a current order and was not kept at bedside; -Failed to ensure Resident #26 had fall interventions in place; and, -Failed to ensure an oxygen concentrator was plugged into an appropriate electrical supply. Findings include: I. Resident #1 A. Resident status Resident #1, age 70, was admitted on [DATE]. According to the March 2023 computerized physicians orders (CPO), diagnoses included intracranial injury (brain injury), bipolar disorder, and acute kidney failure. The 3/6/23 minimum data set (MDS) assessment did not assess the brief interview for mental status. No behaviors were noted. B. Observation and interview Resident #1 was interviewed on 3/27/23 at 10:00 a.m. During the interview the resident stated he was discouraged that the nursing staff did not apply the medicine I need for my legs. The resident was keeping a tube of Diclofenac gel in the nightstand. He said he had to apply the cream when he needed it. C. Record review The resident did not have a care plan for self-administration of medications. The resident did not have an order for Diclofenac gel. The resident did not have a self-medication evaluation completed for Diclofenac gel. D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 3/27/23 at 10:53 a.m. She said for a resident to have their own medications, the resident must complete an evaluation to ensure they were safe to administer the medication on their own. She said Resident #1 did not have an evaluation for self-administration for any medications. She said she could not locate a current order for Diclofenac gel. She said it was important to make sure the resident could administer the medication safely. The director of nursing (DON) was interviewed on 3/29/23 at 1:18 p.m. She said after LPN #1 notified her of the Diclofenac gel, the facility began an investigation to find out where the Diclofenac gel came from. She said the facility reached out to the physician about the Diclofenac gel. The provider wrote an order for Diclofenac gel, and the DON and nursing home administrator (NHA) completed a self-administration evaluation. She said it was important to ensure all medications residents took had a current order and residents who wanted to self-administer medications had an evaluation completed for safety. She said the pharmacy would send a new tube of Diclofenac gel. 31821 II. Resident #26 A. Resident status Resident #26, age under [AGE] years old, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included cirrhosis (severe scarring) of liver, alcohol dependence, fracture of left patella (knee cap), adjustment disorder with mixed anxiety, and post-traumatic stress disorder. According to the 3/7/23 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The resident had disorganized thinking and had difficulty focusing attention. She required limited assistance for bed mobility, transfers, grooming and toilet use. The MDS assessment revealed the resident had a fall prior to admission. The MDS asssessment revealed no wander guard. B. Observation and interview On 3/27/23 at 9:13 a.m. the resident was observed lying flat in bed sleeping and the bed was left in a high position. The resident did not have a fall mat next to her bed. The resident's call light was wrapped around the repositioning bar. LPN #1 was interviewed on 3/27/23 at 9:20 a.m. LPN #1 said she was familiar with the resident's care plan. LPN #1 observed the resident while she was sleeping. LPN #1 said the bed was supposed to be in a low position and she should have had a fall mat next to her bed per her care plan. LPN #1 said the negative outcome of care plan not being followed would be the resident could have another fall or a major injury. C. Record review Fall risk evaluation dated 3/13/23 identified the resident as being at a high risk for falls. The care plan, initiated 3/1/23, identified the resident was at risk for falls. Interventions include: The resident needs a safe environment such as the bed in low position at night, personal items within reach, fall mats next to bed while the resident is in bed. The resident needs prompt response to all requests for assistance. The resident has a fluctuating ability to utilize call light. Provide consistent rounding and offer redirection as indicated. D. Interview The director of nursing (DON) was interviewed on 3/29/23 at 1:18 p.m. The DON was told of the observation above. She said it would be her expectation the care plan should have been followed and the bed would have been at the lowest position and the fall mat would be next to the bed. The DON said when staff assist the resident to bed they should place the bed in the lowest position. Staff should use the fall mat and keep her call light cord within reach. The DON said failing to provide care planned interventions could contribute to further falls for this high-risk resident. III. Failed to ensure oxygen concentrator was plugged into a medical grade power surge protector On 3/27/23 at 11:18 a.m., room [ROOM NUMBER]B had an oxygen concentrator, which was plugged into a regular power strip. It was not a medical grade power surge. The environmental tour was conducted with the maintenance supervisor (MS) and nursing home administrator (NHA) on 3/30/23 at 9:15 a.m. The above detailed observations were reviewed. The NHA said the oxygen concentrators should not have been plugged into the power strips. She said the oxygen concentrator was plugged directly into the room outlet after the environmental tour.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in the plan of care for two out of two registered nurses (RN) and one out of one licensed practical nurses (LPN) reviewed for competencies. Findings include: I. Resident census and conditions According to the resident census and conditions provided by the nursing home administrator (NHA) on 3/27/23, the facility had: -Two residents with an indwelling catheter; and, -One resident with a pressure ulcer. II. Record review RN #1, RN #2, and LPN #2 did not have competencies completed for identified conditions in the facility specifically catheter care and wound care. III. Interviews The director of nursing (DON) was interviewed on 3/29/23 at 1:18 p.m. She said nursing competencies were important to ensure the residents were not put at risk and skills were performed safely. She said she had observed some of the skills performed by the nurses from standing afar, but did not have a formal return demonstration recorded.

Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (#23 and #15) of three residents reviewed for oxygen therapy out of 16 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Professional reference According to Potter/Perry, Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Facility policy The Medication Administration policy, revised 11/26/19, provided by the director of nursing (DON) on 12/14/21 at 9:49 a.m. included, Medications are administered in accordance with written orders of the attending physician or physician extender. III. Resident #23 A. Resident status Resident #23, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/6/21 minimum data set (MDS) assessment revealed the resident had no impairment with a brief interview for mental status (BIMS) score of 14 out of 15. He had no behaviors or rejections of care. He was identified as using oxygen. B. Record review The care plan, initiated on 8/24/21 and revised on 10/26/21, identified altered respiratory status and difficulty breathing related to shortness of breath with exertion. Interventions included oxygen settings at 4 liters (L) via nasal cannula (NC) continuous use and to administer medications as ordered. The care plan, initiated 8/24/21 and revised on 10/16/21, identified the resident receiving oxygen therapy. The intervention was oxygen via nasal cannula at 4L continuous use. The November 2021 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The remaining days not indicated above, the documentation was not clear on the liter flow. The December 2021 eMAR (from 12/1-12/13/21) failed to document 4L via NC. Review of the progress notes revealed that the resident refused on several occasions to wear the ordered oxygen. The progress notes failed to reveal communication with the physician notifying the provider about the resident refusing to wear the physician ordered oxygen. Review of the recorded oxygen levels revealed the resident maintained a safe oxygen level on room air (between 90% and 98%) without supplemental oxygen. C. Observation and interview Resident #23 was interviewed on 12/13/21 at 11:34 a.m. He had a concentrator in his room. He said he stopped wearing oxygen a couple of months ago. He said he did not need oxygen. D. Interviews Certified nurse aide (CNA) #1 was interviewed on 12/14/21 at 2:55 p.m. She said he would only wear his oxygen when he was low. She said he did not wear his oxygen all the time. Licensed practical nurse (LPN) #1 was interviewed on 12/14/21 at 3:03 p.m. said oxygen was a medication and could only be given by physician order. She said the order for 4L of oxygen had been discontinued that day. She said prior to 12/14/21, he had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the nurse should encourage the resident to wear the oxygen and document the refusal. Registered nurse (RN) #1 was interviewed on 12/14/21 at 3:13 p.m. She said oxygen was considered a medication and required a provider's order. She said the resident had been refusing to wear the oxygen. She said he had told staff he did not like the noise the concentrator made. She said the provider had not been notified. She said she had notified the provider today (12/14/21) and had the order discontinued. She said he consistently refused to wear his oxygen for her. She said the provider should have been notified of the refusals. The DON was interviewed on 12/14/21 at 4:13 p.m. She said oxygen was considered a medication and an order was needed for administration. She said he would wear his oxygen when he felt like he needed it. She said the facility reported the refusals on 12/14/21 to the provider. She said the provider should have been notified of the continuous refusals (prior to 12/14/21, during the survey). She agreed the oxygen saturation levels were within normal limits. IV. Resident #15 A. Resident status Resident #15, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/16/21 minimum data set (MDS) assessment revealed the resident had no impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He had no behaviors or rejections of care. He was identified as using oxygen. B. Record review The care plan, initiated 3/15/16 and revised 11/16/21, identified oxygen therapy related to ineffective gas exchange. Interventions included: -Oxygen at 2L via NC continuously. -Give medications as ordered by physician. C. Observation and interview On 12/14/21 at 11:09 a.m. licensed practical nurse (LPN) #1 identified the room concentrator was set at almost 4L. She checked Resident #15's order for oxygen and said his order was for 2L. She adjusted the concentrator to the correct setting at 2L. She said oxygen was considered a medication and required an order to administer. She said she would continue to monitor him and notify the provider of the incorrect dosage administered. Resident #15 was asked by LPN #1 if he adjusted the concentrator and he said he did not adjust it. The DON was interviewed on 12/14/21 at 11:16 a.m. She said oxygen was a medication ordered to specific liter flows for specific resident's needs. She said education would be provided to the residents regarding only allowing nursing staff to adjust the concentrator. She said she would provide education to the staff to ensure the concentrators were set to the correct settings when the staff were providing care in the resident's rooms.

Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for [CONDITION(S)] drugs were evaluated by a physician within 14 days for use and duration for one (#8) of five residents reviewed for unnecessary medication use out of 16 sample residents. Specifically, the facility: -Failed to re-evaluate the use of PRN [CONDITION(S)] medication by a physician within 14 days; and, -Failed to have individualized person centered interventions to utilize prior to the administration of PRN [CONDITION(S)] medication. I. Facility policy The Psychopharmacological policy, revised 1/10/19, was provided by the director of nursing (DON) on 12/14/21 at 3:35 p.m. included, The licensed nurse or Social Services Director will initiate behavior monitoring within the first twenty-four hours of admission. Behavior monitoring is mandatory for residents who take [CONDITION(S)] medications. The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate. Consideration should be given to potential underlying causes of the behavior symptoms to assure appropriate treatment. II. Resident #8 A. Resident status Resident #8, age 83, was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO), diagnoses included adult failure to thrive and generalized anxiety disorder. The 11/24/21 minimum data set (MDS) assessment revealed the resident had moderate impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He had no behaviors or rejections of care. He was not identified utilizing an anti-anxiety medication. B. Record review The care plan, initiated 12/9/21, identified the use of a [CONDITION(S)] medication for anxiety. Interventions included behavior monitoring for the target behaviors of feeling anxious, agitated, and irritable. -The care plan did not include person-centered individualized non-pharmacological interventions to attempt prior to the use of the PRN medication. -The resident did not have any behaviors documented on the behavior monitoring forms for the past 30 days with use of anxiety medication (see order below). The December 2021 CPO listed the order for [MEDICATION(S)] tablet 0.5 milligrams (mg), give 0.5 mg by mouth every six hours as needed for anxiety ordered on 11/12/21. The November 2021 (11/12/21-11/30/21) electronic medication administration record (eMAR) documented that [MEDICATION(S)] was given on three occasions. The behavior monitoring form did not identify behaviors. The December 2021 (12/1/21 - 12/11/21) eMAR documented that [MEDICATION(S)] was given on nine occasions. The behavior monitoring form did not identify behaviors. -The facility did not utilize non-pharmacological interventions prior to the administration of the PRN [MEDICATION(S)] in November and December 2021. -The facility failed to ensure the PRN [CONDITION(S)] medication was evaluated by the physician for use and duration within 14 days. C. Interviews Certified nurse aide (CNA) #2 was interviewed on 12/15/21 at 8:30 a.m. She said Resident #8 yelled out several times a day. She said when he yelled out she would report it to the nurse. She said she had not received resident specific training on his behaviors. Licensed practical nurse (LPN) #2 was interviewed on 12/15/21 at 8:51 a.m. She said she had never administered the medication. She looked up the order and said the original order date was 11/12/21. She said she did not know PRN [CONDITION(S)] medication needed to be evaluated by a physician for use and duration in 14 days for continued use. She said Resident #8 yelled out several times a day. She said she had not seen him display the identified target behaviors in the care plan. She said she had not received training on non-pharmacological interventions when he displayed the targeted behaviors. The DON was interviewed on 12/15/21 at 9:15 a.m. She said the resident would sometimes display anxiety. She said she would want her staff to redirect him, offer activities, offer to call his brother, talk to him about his life, and with weather permitting take him outside. She said the person-centered individualized interventions should have been in the care plan and communicated with the floor staff. She said the interventions should be attempted prior to the administration of the PRN [CONDITION(S)] medication. She said the order should have been discontinued and the provider re-evaluate for the continued need for the medication. She said going forward she would monitor the order dates for PRN [CONDITION(S)] medications more closely.

Based on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development and the worsening of pressure injuries for three (#2, #3, and #8) of three residents reviewed for pressure injuries out of 12 sample residents. Record review and interview revealed the facility had multiple systemic failures in its management of pressure injuries. These included failure to properly identify, document and monitor pressure injuries, implement interventions in a timely manner and complete ordered wound treatments to prevent the development and worsening of the residents ' pressure injuries. This contributed to deterioration of Residents #2, #3 and #8's pressure injuries. Resident #2, diagnosed with [CONDITION(S)] and diabetes, returned from the hospital on [DATE] with a stage 2 pressure injury. As a result of the facility's failure to properly identify the resident's wound, timely implement appropriate and ordered interventions, the stage 2 pressure injury worsened and progressed to an unstageable pressure wound by [DATE], five weeks after readmission to the facility. The resident required transfer to a specialty hospital for surgical debridement and wound care. The resident remains in the hospital after multiple surgeries and will require more surgeries in the future. Resident #3, diagnosed with multiple [CONDITION(S)] and dependent on staff for care, obtained an abrasion from the improper use of an adult brief. As a result of the facility's failure to properly assess and implement appropriate interventions in a timely manner, the abrasion developed into a stage 4 pressure injury within a 6-week period of time. The wound became infected and the resident required hospitalization for [CONDITION(S)] and surgical intervention of her pressure injury. The resident was subsequently readmitted to the facility on hospice due to being septic from her pressure injury and passed away a week later. Resident #8 had a pressure injury to his coccyx that healed in [DATE] and was at high risk for pressure ulcer development. He developed a stage 2 pressure area to the right buttock. Despite the resident's complaints of pain, the facility failed to timely identify the wound and implement consistent treatment to prevent the wound from worsening. According to record review, the area was first identified on [DATE] in a progress note but no assessment or treatment was put into place until [DATE], following observations during the survey. Observations on [DATE] revealed the resident's wound did not have a dressing in place and the wound had deteriorated from observations made [DATE]. Further, the nurse did not perform the wound care appropriately. Although a performance improvement plan (PIP) was implemented on [DATE] for pressure injury and skin documentation, it failed to identify the problem of treatments not being performed appropriately as ordered by the physician. Specifically, record review and interviews revealed Resident #8 did not receive wound care and dressing changes as ordered by the physician from ,d+[DATE]-[DATE]. The facility's failure to properly identify, document, monitor, implement appropriate treatments in a timely manner and ensure treatments were being completed, created an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Resident #2, diagnosed with [CONDITION(S)] and diabetes, returned from the hospital on [DATE] with a stage 2 pressure injury. As a result of the facility's failure to properly identify the resident's wound and implement appropriate and ordered interventions in a timely manner, the stage 2 pressure injury worsened and progressed to an unstageable pressure wound by [DATE], five weeks after readmission to the facility. The resident required transfer to a specialty hospital for surgical debridement and wound care. The resident remains in the hospital after multiple surgeries and will require more surgeries in the future. Resident #3, diagnosed with multiple [CONDITION(S)] and dependent on staff for care, obtained an abrasion from the improper use of an adult brief. As a result of the facility's failure to properly assess and implement appropriate interventions in a timely manner, the abrasion developed into a stage 4 pressure injury within a 6-week period of time. The wound became infected and the resident required hospitalization for [CONDITION(S)] and surgical intervention of her pressure injury. The resident was subsequently readmitted to the facility on hospice due to [CONDITION(S)] related to the pressure injury and passed away a week later. Resident #8 had a pressure injury to his coccyx that healed in [DATE] and was at high risk for pressure injuries. He developed a stage 2 pressure area to the right buttock. Despite the resident's complaints of pain, the facility failed to timely identify the wound and implement consistent treatment to prevent the wound from worsening. According to record review, the area was first identified on [DATE] in a progress note but no assessment or treatment was put into place until [DATE] following observations during the survey. Observations on [DATE] revealed the resident's wound did not have a dressing in place and the wound had deteriorated from observations made [DATE]. Further, the nurse did not perform the wound care appropriately. Although a performance improvement plan (PIP) was implemented on [DATE] for pressure ulcer and skin documentation, it failed to identify the problem of treatments not being performed appropriately as ordered by the physician. Specifically, record review and interviews revealed Resident #8 did not receive wound care and dressing changes as ordered by the physician from ,d+[DATE]-[DATE]. The facility's failure to properly identify, document, monitor, implement appropriate treatments in a timely manner and ensure treatments were being completed, created an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. On [DATE] at 5:45 p.m., the nursing home administrator (NHA) and the nursing home administrator consultant (NHAC) were notified that the findings above created a situation of the immediate jeopardy for serious harm. B. Plan to remove immediate jeopardy On [DATE] at 2:10 p.m., the facility submitted the following plan to remove the immediate jeopardy situation: 1. Education completed with licensed nursing care for Resident #8 on how to care for his wound. RN completed reassessment of wound on [DATE] and documented findings. New Wound Physician group starting to round with the community staff weekly starting on [DATE]. Wound Physician will complete wound care and documentation training with NHA and nurse on [DATE]. It will be either via virtual tours or in-house visits. Wound care and documentation training will be provided to other nursing staff performing wound care prior to their next scheduled shift. 2. Whole house community wide audit of all residents completed by the RN on [DATE] to get baseline on skin concerns in the community. No new concerns identified. 3. NHA/designee initiated education with nursing staff on [DATE] regarding community expectations for wound documentation. Education to be completed upon hire, annually, and PRN. Admission for all residents: The nurse will complete the Nursing Data Collection UDA (user defined assessment) - Section 3 Skin Condition - Any issues identified at the time of admission will be written on the 24 hour report for follow up by nurse management. (The 24 hour report is a paper form) The nurse will complete the PCC- Braden Risk Assessment UDA. The Braden Risk Assessment is completed on admission and per our policy will be completed quarterly, annually and with change of condition. A care plan will be implemented to identify actual skin issues or potential risk factors. Weekly for all residents: On a weekly basis the nurse will complete the Weekly Nursing Documentation (weekly skin) - Section L. Actual Pressure Ulcer: The UDA titled, Nursing - Pressure Ulcer Injury and Weekly Monitoring - V4 will be completed at time of identification or after admission. Actual Non Pressure Ulcer: The UDA titled, Nursing- Skin Condition Monitoring for Non-Pressure Ulcer Skin Condition will be used for newly identified non-pressure skin concerns. Incidents: An Incident Report will be completed for all newly identified skin issues including pressure ulcers and all non-pressure skin issues For any newly identified skin concerns, the physician will be notified and new orders inputted into the electronic health record. Upon receiving new orders, nursing staff will follow the orders as written. Once a pressure injury has healed, the area will continue to be monitored for two weeks post healing to ensure that it does not open up again. If breakdown is noted again, then the physician is to be contacted and orders followed. DON/designee to complete wound rounds weekly and ensure documentation is inputted in the electronic health record weekly. DON/designee to complete wound dressing change observations and complete chart review two times a week for one month, then weekly for two months wound documentation for two residents to ensure that orders in place and are being followed as written, that staff is following good infection control practices, that the physician is notified as needed, and that documentation is consistent throughout the chart. Identified concerns to be addressed with staff. Nurse consultant/designee to complete monthly review of three resident's wound documentation to ensure that it is consistent with documentation from the wound physician and that the physician is being contacted as necessary for the wound. Identified concerns to be addressed with DON/designee. 4. DON/designee to report on wound data monthly in QA. Identified concerns to be tracked and trended as needed. C. Removal of immediate jeopardy On [DATE] at 3:00 p.m., the NHAC was informed that the facility's plan to remove the immediate jeopardy was accepted. Based on review of the facility's plan to address systemic issues in pressure injury management, the immediate jeopardy situation was removed. However, deficient practice remained at H level, a pattern of actual harm. III. Residents #2, #3 and #8 - Failure to prevent the worsening of pressure injuries A. Resident #2 1. Resident status Resident #2, age less than 55, was admitted [DATE], discharged to the hospital on [DATE] and readmitted [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He required total assistance of two people for all of his activities of daily living (ADL) except only required set up for eating. He had one stage 2 pressure injury upon admission to the facility and used pressure reducing devices for the chair and bed and received pressure injury care. 2. Resident family interview The resident's spouse was interviewed on [DATE] at 3:57 p.m. She said her husband would have the certified nurse aides (CNAs) take pictures of his wound on his phone so he could send them to her. She said she called the director of nursing (DON) a few days after he was readmitted and asked about the wound. She said the DON told her they were treating it and it was fine. She said she asked the DON for a wound consultation multiple times and got no response. She said she finally insisted he be sent to the hospital when pictures of the wound revealed an obvious infection. She said even then it took them several days to get him transferred. She said he has had to have multiple surgeries on the area. She said he was still at the specialty hospital and would require ,d+[DATE] more surgeries and intense wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Record review The [DATE] Readmission Nursing Data Collection revealed the resident had an unstageable 18 centimeter (cm) by 18 cm dark purple area across the right buttocks going down to the top of his right thigh and an unstageable one cm diameter open area surrounded by a 4 cm diameter dark purple area over the coccyx. The [DATE] Braden Scale for Predicting Pressure Sore Risk revealed a score of 14, indicating the resident was at moderate risk for the development of pressure injuries. According to the scoring: a score of ,d+[DATE] indicates at risk, ,d+[DATE] moderate risk, ,d+[DATE] high risk and 9 or below very high risk. The care plan, last revised [DATE], revealed the resident was readmitted with a stage 2 pressure injury to the right buttock. Interventions included: -Administer treatments as ordered and monitor for effectiveness; -Uses a bariatric air mattress for pressure relief; -Monitor/document/report as needed any changes in skin status; and -Encourage small frequent position changes. The Owner's Manual for Resident #2's Air Advance Mattress and Air Advance Bariatric Mattress, distributed by Direct Supply Manufacturing in [DATE], provided by the NHAC on [DATE], read in pertinent part, This device is only a tool to assist with pressure reduction as part of an overall care plan. This product is not designed to replace good caregiving practices. a. [DATE] to [DATE] - Worsening wound - failure to properly identify the resident's wound, and implement appropriate and ordered interventions in a timely manner. The [DATE] Pressure Injury Initial and Weekly Monitoring revealed the resident was readmitted on [DATE] with a stage 2 pressure area to the right buttock that measured 24.4 cm by 18 cm by 1.0 centimeter with a scant amount of serosanguinous drainage. It indicated the wound bed had granulation tissue with necrotic tissue but did not specify what percentage of the wound had necrotic tissue. It indicated the current treatment was [MEDICATION(S)], although the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record revealed the staff was doing daily wound monitoring of the right buttock and of the coccyx (see [DATE] Readmission Nursing Data Collection above), yet the coccyx wound was not included in the pressure injury weekly monitoring; no measurement or description was given of this wound. The [DATE] Pressure Injury Initial and Weekly Monitoring revealed the stage 2 pressure area to the right buttock measured 25.4 cm by 18 cm by 1.0 cm. It indicated the wound appeared worse and the current treatment was to wash with dial soap, dry, and apply cornstarch to the area twice a day as prescribed by the physician. However, the [DATE] CPO revealed orders for daily wound care to the coccyx and left (the wound was on the right) buttock were obtained on [DATE], three days after the wound was identified as worsening and the treatment order obtained. It also was 11 days after his readmission to the facility. Review of the [DATE] treatment administration record (TAR) revealed no treatment to the coccyx and left (right) buttock was performed on the following dates and times: On [DATE] in the morning ( coded 9 which indicated to see the progress note); on [DATE] in the evening; and on [DATE] in the evening. Further record review revealed no progress note was made on [DATE]. The [DATE] physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . New orders were received that day according to the [DATE] CPO for TBC (Trypsin-[NAME] oil-[NAME] Balsam) to be applied to the right buttock two times a day. It did not indicate what the wound should be covered with and the orders for the cornstarch were not discontinued. Orders were also obtained for [MEDICATION(S)] (an antifungal) 150 milligrams (mg) one tablet daily for 10 days and [MEDICATION(S)] (an antibiotic) 500 mg one tablet four times a day for 10 days. The [DATE] TAR revealed the resident did not receive the TBC treatment to the wound on [DATE] and [DATE] in the evening. b. hospitalization The [DATE] Pressure Injury Initial and Weekly Monitoring revealed the stage 2 pressure area to the right buttock measured 23.0 cm by 7 cm by 0.3 cm. It indicated the wound had a moderate amount of foul smelling serosanguinous drainage and the wound bed had granulation tissue, slough and necrotic tissue. It did not specify what percentage of the wound had slough and necrotic tissue. The summary revealed the wound had gotten much worse and the physician ordered an antibiotic, an antifungal and ointment on [DATE]; however, the wound continued to get worse and the physician ordered the resident to be sent to the hospital on [DATE] for evaluation of an infected pressure wound. The [DATE] CPO revealed when the resident returned from the hospital on [DATE], the [MEDICATION(S)] was discontinued and the resident was started on [MEDICATION(S)] and [MEDICATION(S)] (two different antibiotics) for wound infection. c. [DATE] to [DATE] - Worsening wound - failure to timely communicate changes and implement ordered treatments and a second hospitalization for surgical intervention. The [DATE] Pressure Injury Initial and Weekly Monitoring revealed the wound continued to measure 23.0 cm by 7 cm by 0.3 cm; however, it now had ,d+[DATE] cm of tunneling. It did not indicate what direction the wound was tunneling. The wound continued to have a moderate amount of foul smelling serosanguinous drainage and the wound bed had granulation tissue, slough and necrotic tissue. It did not specify what percentage of the wound had slough and necrotic tissue. The summary indicated the resident was waiting for transport to a facility that specialized in wound care. The [DATE] daily wound monitoring progress note revealed the wound had digressed and tunneling was now present. It indicated the physician was notified and new orders were obtained. This communication was three days after the appearance of tunneling was first documented. According to the [DATE] CPO, a new order was received on [DATE] to flush the wound with Dakin's solution twice a day and pack with Iodaform with each dressing change. It did not indicate what kind of dressing to cover the wound with. The orders for the TCB were not discontinued. The [DATE] daily wound monitoring progress note revealed the wound to the right buttock was 26.0 cm by 10.0 cm by 6.0 cm deep with tunneling. It indicated the resident was being transferred to a wound care specialty hospital that day. The [DATE] TAR revealed the resident did not receive the TCB on [DATE], [DATE], [DATE] or [DATE] in the morning. On [DATE] in the evening it was coded 9 (see progress note), however; no progress note was made. The [DATE] TAR revealed the Dakin's flush was not documented as being done on [DATE] prior to the resident's being transferred out of the facility. However, it was documented as being provided on [DATE], when the resident was no longer in the facility. A [DATE] progress note from the specialty hospital revealed the resident was admitted with an unstageable sacral pressure wound that required surgical intervention. 4. Staff interviews regarding Resident #2's pressure injury A staff member, who wished to remain anonymous, was interviewed on [DATE] at 8:48 p.m. The staff member said Resident #2 was a two-person assist and required so much time that the staff would not go into his room to care for him as often as he needed. The director of nurses (DON) was interviewed on [DATE] at 11:51 a.m. She said Resident #2 was a paraplegic and was readmitted from the hospital with a stage 2 pressure area to his buttocks that he developed there because the hospital did not have him on an air mattress. She said he was a non-compliant diabetic and non-compliant with allowing the staff to reposition him. She said the resident thought the air mattress was enough. A pharmacy consultant was interviewed on [DATE] at 2:30 p.m. With regard to the order [DATE] for cornstarch, he said he was not a wound specialist, but he had never heard of putting cornstarch on an open wound. He said he thought it would cause a breeding ground for bacteria to grow. Certified nurse aide (CNA) #3 was interviewed on [DATE] at 9:50 a.m. She said she had cared for Resident #2 when he was in the facility. She said Resident #2 was a two-person assist and if there were not enough CNAs on the floor, he was not transferred out of bed. She said he would refuse to be repositioned frequently but he was on an air mattress that changed his position for him. The nursing home administrator (NHA) was interviewed on [DATE] at 11:00 a.m. She said Resident #2 was a paraplegic from a recent car accident and had developed the wound on his buttocks while he was at the hospital. She said she had been working closely with the resident's insurance to transfer him out to a facility that could better treat him but had difficulty getting approval. B. Resident #3 1. Resident status Resident #3, age 52, was admitted [DATE], discharged to the hospital on [DATE], readmitted to the facility [DATE] and expired at the facility [DATE]. According to the [DATE] CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment revealed the resident had severe cognitive impairment and required extensive assistance of two people for her ADLs. She had one stage 3 pressure injury. No pressure relieving devices were being used. 2. Resident representative interview The resident's former medical durable power of attorney (MDPOA) was interviewed on [DATE] at 1:47 p.m. She said she was only to be contacted if the resident was mentally unable to make decisions so she had not been aware of the resident's status until she was sent to the hospital ([DATE]). She said she was told the resident had a bedsore in an awkward place and she kept messing with it and wouldn ' t leave it alone so it got infected. She said the hospital did surgery the day she arrived but had to restrain her in order to administer medications and treatment because she kept pulling out her IVs (intravenous line). The surgeon said the resident would have to have ,d+[DATE] more surgeries and that the wound may never heal because of the location. She said she contacted other family members and the decision was made to place the resident on hospice with comfort care only. 3. Record review a. [DATE] - [DATE] - Worsening wound - failure to promptly identify and document the resident's skin injury and implement appropriate and ordered interventions in a timely manner. The [DATE] Braden Scale for Predicting Pressure Sore Risk revealed a score of 14, putting the resident at moderate risk for pressure injury development. A skin injury, identified [DATE] and caused from a too tight adult brief, was noted in a [DATE] Risk management Review Note. Staff was educated to leave the resident open to air at night and assure she was wearing proper fitting attends. However, the injury was not noted until [DATE] in the daily wound monitoring progress notes. This note revealed the resident had an area at the crease on the bottom edge of the right buttock with a small amount of drainage. It indicated the area was left open to air and [MEDICATION(S)], ordered [DATE] (twice a day), was applied. A [DATE] nursing progress note revealed the resident's wound had increased in size and had developed slough on the wound bed. It indicated the provider was notified and new orders were obtained for wound care and to keep the resident in bed without an adult brief on to promote wound healing. According to the [DATE] CPO, an order was obtained on [DATE] for daily wound care to the base of the right buttock. It indicated to assess the wound daily, cleanse, dry and cover with a protective dressing. However, review of the [DATE] TAR revealed no documentation the resident received daily wound care to the right buttock on [DATE], [DATE], [DATE], [DATE] and [DATE]. A [DATE] Skin Condition Monitoring for Non-Pressure Ulcer Skin Conditions revealed the resident had an abrasion to the right buttock above the thigh that was first identified on [DATE]. It indicated the skin issue measured 4.5 cm by 3 cm by greater than 0.1 cm. This was the first documented measurement of the wound. A [DATE] daily wound monitoring progress note revealed the resident did not have a dry dressing in place and a moderate amount of serous drainage was present on the pad under her. A [DATE] daily wound monitoring progress note revealed the area was 3.0 cm round with a 3.0 cm depth. A [DATE] nurse practitioner (NP) progress note revealed the resident currently had a wound on her left buttock (wound was on the right) that measured 1.5 cm deep and was 2.5 cm in diameter (different measurements than what the nurse charted earlier in the day) and she would not leave the dressing in place. It indicated the plan was to use a calcium alginate dressing to the wound; however, this treatment was not ordered. A [DATE] Skin Condition Monitoring for Non-Pressure Ulcer Skin Conditions revealed the resident had not stayed off her buttock and the areas was now a pressure area but continued to document the same measurements as the previous week's assessment, 4.5 cm by 3 cm by greater than 0.1 cm. A [DATE] Pressure Injury Initial and Weekly Monitoring revealed the area to the right buttock was now being classified as a stage 2 pressure injury that measured 3.0 cm by 3.0 cm by 3.0 cm. It indicated the area had gotten deeper because the resident was removing the dressing and scratching the wound. According to the [DATE] CPO, orders were received on [DATE] for the wound to the right buttock. It indicated the area was to be packed loosely with a wet to dry dressing and covered with a pressure relieving dressing. It was to be changed as often as needed when soiled and replaced as soon as possible when she removed it. [MEDICATION(S)] 500 mg (an antibiotic) daily for five days was also ordered. However, according to the [DATE] TAR, the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A [DATE] daily wound monitoring progress note, written at 3:25 p.m., revealed the area to the right buttock was 2.0 cm by 2.0 cm and 1.0 cm deep with purulent drainage and slight bleeding. It indicated the area was cleansed with wound cleanser, wet gauze was placed inside the wound bed with a calcium alginate dressing and covered with a foam non-adhesive dressing taped on the sides with paper medical tape. However, there were no orders for this treatment. Another [DATE] daily wound monitoring progress note, written at 11:32 p.m., revealed the area to the right buttock was 3.0 cm round and 3.4 cm in depth (different measurements than what the previous nurse had documented) and scant gangrenous drainage that had a pungent odor. It indicated the resident was in horrible pain and yelled out when being turned if the area was touched or when she was lying directly on the area. (Cross-reference F697 for failure to manage the resident's pain) A [DATE] progress note revealed the physician was notified about the change in the wound and asked that the DON contact a wound specialist. A [DATE] daily wound monitoring progress note written by the DON revealed the licensed practical nurse (LPN) reported to the NP that the wound had worsened and the NP wanted a wound specialist to see it. It indicated this would be done on [DATE] when the offices were open. A [DATE] nursing progress note revealed the resident's wound to her left buttock (wound was on the right) had tunneling in the two o ' clock region with purulent drainage. It indicated the physician was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], five days after the NP asked the DON to contact a wound specialist, a nursing progress note revealed a call was placed to a wound consultant and recommendations were made to put Calcium alginate powder in the wound and cover with an occlusive dressing. It indicated the wound was now a stage 3 pressure area and had a very pungent odor. The NP was notified of the recommendations and orders were obtained for wound care and the NP requested the dietitian look at her protein and meal intake and possibly order a protein supplement. However, review of the record revealed no documentation of the dietitian intervening until after the resident was readmitted to the facility on hospice on [DATE]. At that time, the dietitian suggested a trial of a protein supplement or fortified milk product. According to the [DATE] CPO, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated calcium alginate powder was to be placed in the wound loosely and covered with an occlusive dressing. Yet, a [DATE] daily wound monitoring note revealed the wound was packed with calcium alginate dressing (not powder as per the order) and covered with a foam dressing cut to size. It indicated a wound culture (originally ordered [DATE]) was collected and put into the refrigerator for lab pick up. A [DATE] Pressure Injury Initial and Weekly Monitoring revealed the wound to the right buttock measured 3.0 cm by 3.0 cm by 3.6 cm. The summary indicated the area continued to decline and the wound nurse would continue to be consulted. Record review revealed no further Pressure Injury Initial and Weekly Monitoring was completed. However, a [DATE] daily wound monitoring progress note revealed the wound was 4.0 cm diameter and 4.0 cm deep. It indicated a wet calcium alginate dressing (not powder as per the order) was packed loosely into the wound then covered with a foam dressing. No further measurements were made of the wound until [DATE]. A [DATE] daily wound monitoring progress note revealed a culture of the wound would be sent that day, and a [DATE] nursing note revealed a wound specimen was collected and was being transported to the lab that night. According to the laboratory report, the specimen was collected on [DATE] and results obtained and verified on [DATE]. It indicated that the specimen was possibly contaminated and the culture and sensitivity was not completed. A [DATE] daily wound monitoring progress note revealed the wound had 4.2 cm tunneling and had purulent drainage with a foul smell. It did not indicate the direction of the tunneling. Record review of the daily wound monitoring progress notes revealed conflicting documentation. Some of the notes indicated the wound was being left open to air, others indicated the wound was being packed with calcium alginate and others indicated collagen powder was being applied to the wound. Review of the [DATE] TAR revealed the following: -The order for daily wound care to the base of the right buttock was blank on five out of 22 days, indicating treatment was not provided; -The order for daily dressing change with Calcium Alginate powder was blank on 6 out of 22 days, indicating treatment was not provided; -The order for twice daily wound care with wet gauze was blank four out of 14 times the treatment was to be provided, no refusals were documented. A [DATE] physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#1) of three residents reviewed for skin integrity issues out of 12 sample residents. The facility failed to accurately document and monitor Resident #1's skin integrity issues and implement timely treatment and interventions to prevent the worsening of these skin issues. Record review revealed the facility failed to consistently assess and document the resident's skin condition and delayed implementing treatment for [REDACTED]. It also revealed that treatment was not being delivered to the resident as ordered by the physician. The facility failures resulted in the resident having a delay in treatment which contributed to the resident experiencing unnecessary discomfort. The resident stated his rash became unbearably worse and spread to other parts of his body, the itching was so bad he could not sleep and his skin felt like on fire Findings include: I. Facility policy and procedure The Pressure Injury Prevention policy and procedure, last revised 7/22/2020, provided by the nursing home administrator consultant (NHAC) on 3/11/21 at 2:45 p.m., revealed in pertinent part, The facility will complete a thorough comprehensive evaluation in the electronic record on all residents weekly. Skin evaluation may be completed more frequently if deemed necessary by nursing management or plan of care. II. Resident #1 A. Resident status Resident #1, age 71, was admitted on [DATE], discharged to the hospital on [DATE] and was readmitted [DATE]. According to the March 2021 computerized physician orders [REDACTED]. The 2/4/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision with set up or physical assistance of one person for his activities of daily living (ADLs). B. Resident interview and observation Resident #1 was interviewed on 3/4/21 at 1:20 p.m. He said he had a rash on one part of his body or another for the last nine months and the facility would not do anything about it. He said in October 2020 and November 2020, the rash was on his legs with severe itching that became unbearably worse and spread to other parts of his body. He said he had sores on both of his elbows that became infected in December 2020 and others on both of his legs. The resident had pictures on his phone of large, yellow, crusty sores on his elbows at that time. He said he ended up in the hospital with a [MEDICAL CONDITION] but while he was there they opened up all the sores on his arms and legs and they tested positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus), a drug resistant bacteria. He said he had to stay in the hospital for a week so he could get high powered intravenous (IV) antibiotics and then came back to the facility on oral antibiotics. Resident #1 said he was prescribed [MEDICATION NAME] for the itching but whenever he would ask for it the nurse would tell him he did not need it. He said the itching was so bad at night that he could not sleep and requested [MEDICATION NAME] be given before he went to bed and six hours later. He said even if he was sleeping, he wanted to be woken up for it because it would help him get through the rest of the night. He said the dermatologist prescribed him something at night, he could not remember the name, that really helped with the itching and helped him sleep. Resident #1 said the rash was now on his upper arms, thighs, and upper back. Observations at that time revealed he had small scattered scabs on both of his upper arms and dry, patchy red areas on his upper back across his shoulders. He had a red rash to the top of his thighs and red scratch marks on the inside of the right thigh. No open areas or drainage was observed. He said all of the areas were very itchy. He said the cream, the dermatologist ordered, really helped when he could get the nurse to put it on. He said he would have to ask the nurse and sometimes she would bring it and sometimes she would not. C. Record review The November 2020 CPO revealed the following orders: -[MEDICATION NAME] Lotion apply to arms, hands and legs bilaterally one time a day for dry skin, may have at bedside and apply himself, ordered 9/18/2020; -[MEDICATION NAME] 25 milligrams (mg) twice a day at 2:00 a.m. and 7:00 p.m. for itching, wake him up per his request, ordered 9/18/2020; and -[MEDICATION NAME] 25 mg every six hours as needed for itching. Give six hours from scheduled doses at 2:00 a.m. and 7:00 p.m., ordered 9/18/2020. An 11/1/2020 weekly skin documentation revealed the resident had been scratching that week and had areas of scabs on both hands, legs and arms. It indicated he had a good shower with [MEDICATION NAME] soap followed by lotion. An 11/21/20 weekly skin documentation revealed the resident continued to scratch his legs, arms and hands and lotion was applied. An 11/28/2020 weekly skin documentation revealed the resident had dry scabs to his hands, arms and legs from scratching and lotion was applied. An 11/30/2020 nursing progress note revealed the resident had very itchy skin and complained that the medications were not working. It indicated the nurse practitioner (NP) was notified and new orders were obtained for a [MEDICATION NAME] dose pack (a steroid) and the NP requested the resident see a dermatologist, so an appointment was made for 12/10/2020. A 12/1/2020 nursing note revealed the resident stated his skin felt like it was on fire. It indicated the [MEDICATION NAME] dose pack had been started that morning. A 12/3/2020 NP progress note revealed the resident had a persistent rash over multiple parts of his body and reported the use of [MEDICATION NAME] cream helped but the itching was constant. It indicated he was on [MEDICATION NAME] and started a [MEDICATION NAME] dose pack three days ago but reported it was not helping much. The plan was to continue the current plan of care and wait for the dermatology appointment on 12/10/2020. A 12/6/2020 nursing note revealed the resident had red, warm and swollen sores on both elbows from scratching and both of his arms were red and swollen around the elbows and into his forearms. The NP was notified and orders were obtained to start Bactrim DS for seven days for [MEDICAL CONDITION] and to obtain a wound culture if the wounds started draining. A 12/8/2020 SBAR (Situation, Background, Assessment, Recommendation) summary revealed the resident started vomiting bright red blood and had coffee ground diarrhea with sudden increase in weakness. It indicated the resident was sent out to the hospital. A 12/9/2020 nursing note revealed the resident's dermatology appointment was rescheduled for 1/7/21 since he was in the hospital. A 12/9/2020 nursing note revealed the facility called the hospital for an update on the resident and learned that he had [MEDICAL CONDITION] of both elbows that developed into boils and were draining. It indicated cultures of the wound were positive [MEDICAL CONDITION]. The 12/15/2020 nursing readmission data collection revealed the resident was admitted with skin issues. It indicated the resident had scabbed over [MEDICAL CONDITION] areas on both elbows. No measurements or description was provided and the areas were being left open to air. According to the December 2020 CPO, the resident returned from the hospital on [DATE] with the following orders: -[MEDICATION NAME] (antibiotic) 100 mg BID for seven days for infection; -[MEDICATION NAME] (an anti-anxiety medication) 0.5 mg every 12 hours as needed for anxiety; and -[MEDICATION NAME] 25 mg every 6 hours as needed for itching. The routine order for the [MEDICATION NAME] and the [MEDICATION NAME] lotion were discontinued. The resident was not prescribed a topical treatment to apply to the rash and no treatment orders were obtained from the resident's provider. A 12/18/2020 skilled nursing note revealed the resident's skin had open areas that were being treated with an antibiotic. No location or description was given of the open areas. A 12/20/2020 nursing note revealed the residents wounds were healing slowly. It indicated the resident was offered [MEDICATION NAME] for the first time on 12/19/2020 and the resident stated he finally didn ' t itch like crazy and got some sleep. A 12/22/2020 skilled nursing note revealed the resident had several rash areas present that were being treated with an antibiotic. It indicated the rash to the right arm measured 18 centimeters (cm) length by 9 cm width, the left leg measured 18 cm length by 7 cm width with reddish flaky skin and bumps where the boils had been present. It indicated the resident had been getting as needed (PRN) doses of [MEDICATION NAME] with increased sleep, decreased itching and decreased nerve pain. The 12/28/2020 weekly skin documentation indicated the resident's skin was clean, dry and intact. There was no mention of the resident's rash that was still present. A 12/30/2020 skin/wound progress note revealed the resident continued to have redness and healing rashes on all four extremities and upper back. It indicated the resident complained of itching and pain in all four extremities and his back, being treated with [MEDICATION NAME] and Tylenol for pain and itching. The 1/5/21, 1/6/21, 1/7/21 and 1/9/21 skilled nursing notes revealed the resident had sores to several areas and had an appointment with dermatology scheduled. No description was given of the location or appearance of the sores. A 1/7/21 nursing note revealed the dermatology appointment was rescheduled for 2/14/21 due to a mix up in addresses. Review of the skilled nursing notes from 1/10/21 to 1/13/21 revealed the resident's skin either had dried scabs on arms and legs from scratching or his skin was intact. Review of the record revealed no weekly skin documentation for the month of January 2021 or the first week of February 2021. There was no mention of the resident's skin issues until 2/9/21 in care conference progress note where it was reported the resident did not have any open weeping sores but continued to sometimes scratch, especially his legs. On 2/6/21 an order for [REDACTED]. The 2/11/21 dermatology consult note revealed the resident had nummular [MEDICAL CONDITION] (a type of skin disorder that causes itchy, oozing patches on the skin) and was prescribed a steroid, an oral antibiotic, a topical antibiotic and an [MEDICATION NAME] for the itching. It indicated the resident was to return in a month. According to the February 2021 CPO, the resident received the following orders on 2/11/21: -[MEDICATION NAME] (an [MEDICATION NAME] that helps with itching) 25 mg/milliliter (ml) inject 25 mg intramuscularly at bedtime; -[MEDICATION NAME][MEDICATION NAME] (steroid) 4 mg dose pack, give per titrating orders; -Bactrim DS (an antibiotic) 800-160 mg twice a day; and -Mupirocin (a topical antibiotic) kit 2% apply to affected areas topically two times a day. Review of the February 2021 Medication Administration Record [REDACTED] -The [MEDICATION NAME] injectable was not available from the pharmacy and was not documented as being administered on 2/12, 2/13, 2/14, or 2/17/21. It was documented as being given on 2/15 and 2/16/21 even though the medication was not available for the other days. The medication was changed to an oral solution on 2/18/21 and the resident got the first dose a week after it was ordered. -The Mupirocin cream was scheduled at 6:00 a.m. and it was documented the resident did not receive the treatment because he was sleeping so he only received the cream once a day instead of twice a day as ordered. A 2/13/21 weekly skin documentation revealed the resident had sores that were being treated by the dermatologist. No description was given of the location or appearance of the sores. A 2/14/21 weekly skin documentation indicated the resident had a skin irritation on his right upper back and right thigh. No other description was given. A 2/18/21 nursing progress note revealed the resident had redness and irritation noted to his low back area. A 2/19/21 nursing note revealed the resident stated skin was still itchy. It indicated the areas were clearing up but there were noticeable red marks from the resident recently scratching. A 2/21/21 nursing progress note revealed the resident had redness on his right lower back, bilateral lower extremities and elbows with scratches in the right front thigh area. It indicated the resident expressed itchiness to all areas where rash was present. A 2/22/21 nursing progress note revealed the resident had scratches to his right front thigh area, and redness with a rash to his right elbow and a slight redness to the lower back area. It indicated the resident complained of itchiness to all areas. A 2/23/21 weekly nursing progress note revealed the resident had scratch marks to his right front thigh area and right elbow, and redness and irritation to his right lower back and left elbow. It indicated the resident complained of pain to the skin irritation areas. A 2/23/21 NP progress note revealed the resident was being seen because the staff was concerned about the resident's skin. It indicated the resident had a rash/irritation to his right elbow and right thigh with mild redness, itchiness and multiple scabs and had little improvement with the treatment ordered by the dermatologist. The plan was to start [MEDICATION NAME] cream because, according to staff, this had been effective in the past. This treatment was not ordered and started. A 2/26/21 nursing progress note revealed the resident's rash areas were red with raised bumps to his bilateral lower extremities and right elbow. The 3/2/21 weekly nursing progress note revealed the resident had sores that were being treated by the dermatologist. It indicated his bilateral arms and back were healing. Review of the March 2021 MAR indicated [REDACTED]. He also did not receive the cream in the afternoon on 3/4/21. III. Staff interviews A staff member who wished to remain anonymous was interviewed on 3/4/21 at 8:48 p.m. The staff member said Resident #1 had a rash that he would rub and scratch at so much, it would cause open sores on his arms and legs. The staff member said the resident was obviously uncomfortable and they did not feel like the facility got the resident treatment in a timely manner. The director of nursing (DON) was interviewed on 3/5/21 at 11:51 a.m. She said skin assessments should be done by the nurses a minimum of weekly and they should document anything they saw. She said Resident #1 was being seen almost weekly by the nurse practitioner (record review revealed the resident was seen one to two times a month) and the facility had a really hard time getting him into a dermatologist. She said the resident missed one appointment because he was in the hospital and missed another appointment but she could not remember why. Licensed practical nurse (LPN) #2 was interviewed on 3/11/21 at 3:09 p.m. She said skin assessments were done weekly and any skin issue should be documented. She said if a rash turned into a sore, the sore should be monitored and documented on separately. She said Resident #1 would scratch so much that he would cause his sores and then would not leave them alone. She said his skin had gotten a lot better since he saw the dermatologist. She said the time the resident's Mupirocin cream was applied should have been changed if the resident was always sleeping at the time it was scheduled.

Based on interviews and record review, the facility failed to manage the pain of one (#3) resident reviewed out of 12 sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility failed to identify an increase in the intensity and frequency of the resident's pain as her pressure ulcer worsened (cross-reference F686), and failed to provide adequate pain relief for Resident #3. The facility failed to ensure pain relief measures were provided during wound care to ensure optimal comfort during the procedure. These facility failures contributed to the resident experiencing undue severe pain. The resident did not receive adequate pain management and suffered a restless, uncomfortable passing. Findings include: I. Facility policy and procedure The Pain Management policy and procedure, last revised [DATE], provided by the nursing home administrator (NHA) on [DATE] at 3:04 p.m., revealed in pertinent part, Pain is subjective and is what the resident says it is, existing when and where the resident says it does. Non-verbal indicators of pain include: increased agitation, crying, grimacing, holding the area where the pain is located, calling out, decreased appetite, and any other behaviors which are unusual for the resident. When a resident complains of pain, ask the resident to rate the level of pain using the numerical scale using a pain level of zero (none) to ten (severe). Cognitively impaired resident have pain evaluated using the PAINAD (Pain Assessment in Advanced Dementia) scale. Around the clock dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent [MEDICATION(S)] administration. Rescue doses may be prescribed for periodic breakthrough or incident pain related to activity, treatment and/or diagnostic procedures. Do not forget the non-pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage and humor therapy. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan. II. Resident #3 A. Resident status Resident #3, age 52, was admitted [DATE], discharged to the hospital on [DATE], readmitted to the facility [DATE] and expired at the facility [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and required extensive assistance of two people for her activities of daily living (ADLs). The resident received scheduled, as needed and non-medication interventions for pain. The pain assessment was not completed. B. Record review The [DATE] CPO revealed the resident had the following orders for pain management: -[MEDICATION(S)] Gel 1% apply one application transdermally one time a day for bilateral leg pain, this was discontinued on [DATE]; -[MEDICATION(S)] 15 (milligrams) mg one time a day for pain, this was discontinued on [DATE]; -Salonpas patch to each wrist daily at bedtime for pain, this was discontinued [DATE]; -[MEDICATION(S)] 10 mg three times a day for MS, initiated [DATE]; -Monitor pain every shift using ,d+[DATE] pain scale. Resident's acceptable level of pain was two, initiated [DATE]; -[MEDICATION(S)] 600 mg three times a day for nerve pain, initiated [DATE]; and -Acetaminophen (APAP) 1,000 mg every six hours as needed for pain, not to exceed 3,000 mg/day, initiated [DATE]. Review of progress notes revealed the resident developed a wound to her right upper thigh/buttock on [DATE]. The resident complained of occasional pain when the area was touched. Documentation showed the resident started to complain of pain more frequently, especially with dressing changes. A [DATE] daily wound monitoring progress note revealed the resident was in horrible pain and yelled out when being turned, when her wound was touched or when she was lying directly on the area. -However, no pain medication was documented as being administered. The [DATE] administration progress notes revealed the resident received APAP 1,000 mg at 8:12 a.m. for pain rated 5 out of 10 after being repositioned onto her left side. At 11:32 a.m. the APAP was documented as being ineffective and the resident continued to rate her pain at a 3 out of 10. There was no documentation any further pain relief measures were attempted until 4:16 p.m. when the resident received APAP 1,000 mg for pain rated 3 out of 10. It indicated the resident's pain was unrelieved by the air mattress or repositioning. The [DATE] administration progress notes revealed the resident received APAP 1,000 mg at 11:12 a.m. for a complaint of generalized buttock pain that was unrelieved by repositioning and was rated 3 out of 10. The effectiveness was not assessed until 6:01 p.m. and was documented as being ineffective and the resident rated her pain 4 out of 10. There was no documentation any further pain relief measures were attempted until the following morning, [DATE] at 9:07 a.m. The [DATE] administration progress notes revealed the resident received APAP 1,000 mg at 9:25 a.m. for complaints of generalized pain along right buttock unrelieved by repositioning that was rated 4 out of 10. The effectiveness was not assessed until 5:26 p.m. and was documented as being effective however the resident still rated the pain 4 out of 10 and received another 1,000 mg of APAP at that time. The [DATE] administration progress notes revealed the resident received APAP 1,000 mg at 10:14 a.m. for a complaint of generalized wound site pain that was rated 4 out of 10. It indicated the resident had been repositioned twice. The effectiveness was not assessed until 4:53 p.m. and was documented as ineffective and the resident received another 1,000 mg of APAP at that time for pain rated 4 out of 10. Review of the [DATE] medication administration record (MAR) revealed the resident had not taken any APAP the first part of the month but by the last week of the month the resident had taken the APAP one to two times a day five out of seven days. Review of the daily wound monitoring progress notes from [DATE] until [DATE] reveal the resident occasionally complained of pain when the wound was touched and during dressing changes but the pain was controlled with as needed (PRN) APAP and repositioning. However, there was no evidence the resident received pain medication prior to or after receiving wound care and dressing changes to decrease the residents discomfort during the procedure. The [DATE] MDS pain interview revealed the resident complained of frequent pain that occurred daily that made it hard for her to sleep. The resident was able to vocalize her pain and rated it severe, 8 out of 10. A [DATE] nursing progress note revealed the resident was gotten up for lunch and dinner but the resident was tearful during dinner and reported that her bottom was hurting. It indicated the resident's dressing change had been done prior to dinner and the resident had received APAP to help control her pain but it had not had time to take effect. The resident was taken back to her room and declined to eat. It indicated that the nurse was going to recommend not getting the resident up twice a day and that she was going to contact the physician for a stronger pain medication since the resident was only taking APAP. -This note indicated the resident was in so much pain it did not allow her to enjoy her meal during the dinner service or when the staff took her meal to her room later. According to the [DATE] MAR, the resident only received APAP once on [DATE] at 8:35 a.m. and did not receive any prior to dinner. Review of the record revealed no evidence the physician was contacted for a stronger pain medication as the APAP was not effective for pain management for Resident #3. The [DATE] daily wound monitoring progress note at 10:07 a.m. revealed the resident had pain when the wound was being cleansed. The resident was not administered pain medication until an hour and a half later, at 11:39 a.m., when, according to an administration progress note, the resident requested it for wound pain after the wound was cleansed and the dressing was changed. A [DATE] nursing progress note revealed the resident had a sudden change in cognition and was sent out to the hospital. A [DATE] nursing progress note revealed the resident was readmitted to the facility at 12:50 p.m. on hospice services with a stage 3 pressure ulcer to her right buttock. According to the [DATE] CPO, the resident returned to the facility on [DATE] with the following orders for pain management: -[MEDICATION(S)] 600 mg three times a day for [CONDITION(S)], this was discontinued [DATE]; -[MEDICATION(S)] 10 mg three times a day for MS, this was discontinued on [DATE]; -APAP 1,000 mg every six hours PRN pain, started [DATE]; and -[MEDICATION(S)] 20mg/milliliter (ml) give 10 mg (0.5ml) by mouth every one hour PRN (as needed) for pain, started [DATE]. According to the [DATE] discharge plan of care from the hospital, the resident was to start taking Lorazepam 2mg/ml 0.5 ml every four hours as needed for anxiety/agitation. This was not included on the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] -The order was put into the computer system on [DATE] but was struck out and never re-entered. This error was never identified. According to the [DATE] MAR, the resident did not receive any pain medication after her [DATE] readmission at 12:50 p.m. until [DATE] at 8:23 a.m., over 18 hours. The [DATE] hospice admission summary revealed the hospice nurse encouraged the facility nurse to give the [MEDICATION(S)] before changing the resident's dressing for pain control and as needed. The controlled substance administration record (narcotic count sheet) for the residents [MEDICATION(S)] received on [DATE] revealed two dose of [MEDICATION(S)] 5 mg (0.25ml) were signed out on [DATE] at 3:30 p.m. and 6:20 p.m. instead of 10 mg as ordered and these doses were not signed out on the MAR. -The resident was given half the amount of [MEDICATION(S)] for each dose of medication she received. Again receiving ineffective pain management from the facility. The narcotic count sheet for the Lorazepam received on [DATE], doses of the medication were signed out on [DATE] at 3:30 p.m., [DATE] at 8:30 a.m. and 2:00 p.m. These doses were not signed out on the MAR because an order had not been entered in the resident's record for the Lorazepam until after the hospice nurse visit. Comparison of the [DATE] MAR against the narcotic count sheet for the resident's [MEDICATION(S)] revealed a dose of [MEDICATION(S)] was signed out of the medication cart but was not documented as being administered to the resident on eight different occasions from ,d+[DATE]-[DATE]. A [DATE] hospice interdisciplinary progress note revealed the resident was restless during the hospice nurses visit at 2:00 p.m. It indicated the resident had received [MEDICATION(S)] an hour earlier but had not had the Lorazepam for almost six hours. The hospice nurse contacted the provider and received orders to schedule the [MEDICATION(S)] and Lorazepam every four hours. It indicated the provider requested the [MEDICATION(S)] be given then two hours later the Lorazepam alternating them every two hours to better keep something in her system around the clock. According to the [DATE] CPO, orders were received on [DATE] from hospice for the following: -Lorazepam 1 mg every four hours for anxiety; and, -[MEDICATION(S)] 10 mg every four hours for pain and continue 10mg every one hours PRN. The [DATE] MAR revealed the lorazepam and [MEDICATION(S)] were scheduled to be given at the same time every four hours instead of being altered as requested by the provider. The [DATE] administration progress notes revealed the resident received [MEDICATION(S)] 10 mg at 7:46 p.m. for non-verbal signs of pain and moaning, rated 5 out of 10. The effectiveness was assessed at 9:40 p.m. and was documented as ineffective and the resident's pain continued to be rated 5 out of 10. -There was no documentation the resident received any non-pharmacological interventions for pain relief and the resident did not receive another dose of [MEDICATION(S)] until 11:41 p.m. The [DATE] administration progress notes revealed the resident received [MEDICATION(S)] 10 mg at 11:18 a.m. for pain rated 4 out of 10. The effectiveness was not assessed until 6:18 p.m. and was documented as being ineffective and the resident was showing signs of non-verbal pain. -There was no documentation the resident received any non-pharmacological interventions for pain relief and the resident did not receive another dose of [MEDICATION(S)] until 7:30 p.m. for pain rated 5 out of 10. The [DATE] administration progress notes revealed the resident received [MEDICATION(S)] 10 mg at 8:00 p.m. for pain rated 5 out of 10. The resident's pain was reassessed at 9:20 p.m. and was documented as being ineffective with the resident moaning loudly in pain and pain was now rated 6 out of 10. However, the resident was not given any more pain medication until 10:30 p.m. The effectiveness was assessed at 11:45 p.m. and was documented as being ineffective and the resident's pain was rated 3 out of 10. The resident was given [MEDICATION(S)] 10 mg at that time. According to a [DATE] administration progress note the resident was yelling out in pain at 12:13 p.m., however her pain was only rated 3 out of 10. The resident was given [MEDICATION(S)] 10 mg at that time. A [DATE] hospice nurse progress note revealed a telehealth nurse visit was done that day and the LPN working at the facility reported the resident had a tearful morning related to the dressing change on her wound on her buttocks. It indicated the LPN reported she administered [MEDICATION(S)] just prior to wound change and then again one hour later, which did help calm the resident and provide some relief. According to a [DATE] nursing progress note, written at 12:02 a.m., the resident was being repositioned for better comfort and had been given PRN [MEDICATION(S)] every one hour. Review of the record revealed this was not accurate. According to the [DATE] MAR, a PRN dose of [MEDICATION(S)] was administered on [DATE] at 11:36 p.m. but had not been administered since [DATE] at 12:13 p.m., over 11 hours prior to that. A [DATE] hospice nurse progress note revealed the hospice nurse was in the facility from 12:45 p.m. until 1:45 p.m. The resident was lying in bed moaning and squirming, reaching out to grab the side bar. It indicated the facility nurse had just administered [MEDICATION(S)] to the resident so the hospice nurse contacted the provider and got orders to increase the resident's [MEDICATION(S)] to 15 mg (0.75 ml) every four hours routinely and every one hour PRN and added a PRN lorazepam order for 1 mg every two hours. After consulting with the hospice pharmacy, because the resident had required approximately 140 mg of [MEDICATION(S)] in the last 24 hours, it was recommended that the resident be placed on a [MEDICATION(S)] patch 50mcg and continue the PRN [MEDICATION(S)] for breakthrough pain. The physician was contacted with these recommendations and ordered the [MEDICATION(S)] 50 mcg patch to be placed then the scheduled [MEDICATION(S)] to be discontinued 12 hours after the first patch was placed. A [DATE] daily wound monitoring progress note revealed the resident was tearful with facial grimacing during the dressing change at 4:30 p.m. According to the [DATE] MAR the resident received [MEDICATION(S)] 15 mg at her scheduled times of 2:00 p.m. and 6:00 p.m. but no PRN dose of [MEDICATION(S)] was documented as being administered prior to or after the dressing change. Review of the [DATE] MAR revealed the following: -The resident did not receive a PRN dose of [MEDICATION(S)] from [DATE] at 3:12 a.m. until [DATE] at 8:55 a.m. -The resident did not receive her scheduled dose of [MEDICATION(S)] 15 mg on [DATE] at 2:00 a.m. -The [MEDICATION(S)] patch was placed on the resident at 9:59 p.m. on [DATE] and the scheduled [MEDICATION(S)] was discontinued four hours early, after the 6:00 a.m. dose on [DATE], instead of after the 10:00 a.m. dose which would have been 12 hours later. -The PRN Lorazepam was never given. The [DATE] hospice nursing progress note revealed the director of nursing (DON), who was also working the floor, reported the [MEDICATION(S)] patch had been placed at 9:00 p.m. the previous night and the scheduled [MEDICATION(S)] was discontinued that morning, but the resident was still having signs and symptoms of discomfort and it seemed like anything that touched her hurt her so she was still getting the PRN [MEDICATION(S)]. According to the [DATE] MAR, the resident received PRN [MEDICATION(S)] at 8:55 a.m. and 10:30 a.m. A [DATE] nursing progress note revealed the resident was given [MEDICATION(S)] and Lorazepam at 1:30 p.m. (these were not signed out on the MAR) and when the nurse went back to check on her at 1:45 p.m. the resident had passed. The care plan, last revised [DATE], revealed the resident had chronic pain related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Administer analgesics as per orders; -Monitor pain level prior to, and during treatment and treat pain as per orders to ensure the residents comfort as needed; -Evaluate the effectiveness of pain interventions every shift and after PRN pain medication is administered; and notify the physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. C. Resident interviews Resident #6 was interviewed on [DATE] at 3:05 p.m. She said Resident #3 got a sore on her bottom in [DATE] and ended having to stay in bed all the time because of it. She said towards the end of the resident's life she would lie in bed yelling for assistance and cried out in pain almost constantly. She said it was heartbreaking to listen to. Resident #11 was interviewed on [DATE] at 10:30 a.m. She said Resident #3's room was just a couple of rooms down from hers and she could hear her moaning and crying out at all times during the day and night. She said it got really bad right before she died . Resident #10 was interviewed on [DATE] at 9:50 a.m. She said Resident #3 had been her best friend at the facility for years. She said she got a sore on her bottom in December and ended up being in bed all the time. She said she complained of pain to the area a lot to her. She said she was not allowed to go into the resident's room the last week of her life but she could hear her moan and cry out in pain frequently. She said she cried up until the time she died . III. Staff interviews A staff member who wished to remain anonymous was interviewed on [DATE] at 8:48 p.m. The staff member said Resident #3 was in a lot of pain the last couple weeks of her life even after being put on hospice. The staff member said the resident could be heard moaning and crying out in pain frequently. The dietary manager (DM) was interviewed on [DATE] at 12:57 p.m. She said Resident #3 ate well before she got the sore on her bottom then when she started having to stay in her bed, her appetite decreased. She said the staff had started trying to get the resident up for meals but she was in so much pain that she did not want to eat. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 1:05 p.m. She said it depended on what nurse was working, whether a resident got their pain medication or not. She said Resident #3 frequently was not given pain medication during the day but only on the night shift. She said she tried to give the resident her pain medication before she had to do wound care or before the staff was going to reposition her to make her more comfortable. She said she passed it on in report to continue doing this but often times noticed the resident went long periods of time without receiving any pain medication. She said she frequently would ask the medication nurse to give Resident #3 pain medication, they would say they did, but when she went back and checked, they frequently had not done it. She said this included the DON. The nurse practitioner (NP) was interviewed on [DATE] at 11:15 a.m. She said she retired at the end of 2020 so she did not care for the resident in the weeks before she passed. She said before the resident got the pressure ulcer, she had not complained of pain very often and usually refused narcotics. Two other staff members who wished to remain anonymous were interviewed on [DATE] at 12:35 p.m. They said Resident #3 could be heard yelling out and crying in pain down the hallways. They said it got worse the closer she got to dying. Certified nurse aide (CNA) #5 was interviewed on [DATE] at 2:25 p.m. She said if a resident was in pain, she would notify the nurse immediately but she said she would also try to make the resident as comfortable as possible by repositioning them, off-loading pressure, offering a massage or ice pack. She said Resident #3 was in horrible pain before she died . She said she was very restless and agitated. She said the morning the resident died , she was very restless and cried out whenever they tried to move her. She said she asked the DON, who was working the medication cart, if the resident could have pain medication and the DON would tell her the resident would have to wait because she had other residents to give medications to first. LPN #2 was interviewed on [DATE] at 3:09 p.m. She said whenever she gave pain medication she always tried to go back to the resident within an hour to assess the effectiveness of the medication. She said if it was ineffective, she would give the resident something stronger if they had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The NHA was interviewed on [DATE] at 4:02 p.m. She said residents should be asked to rate their level of pain and what their tolerable level of pain was to determine if pain medication should be administered. She said cognitive residents used the numeric scale and cognitively impaired residents used the PAINAID scale. She said if a resident was expressing pain, then pain medication should be administered after non-pharmacological interventions were attempted, such as repositioning, imagery, warm towels, distraction, a calming/soothing environment, or decreasing the light level. She said these interventions should be documented on the MAR whenever a PRN pain medication was given. She said if the medication was ineffective at relieving the resident's pain, the physician should be contacted.

Based on record review and interviews, the facility failed to ensure physician ordered laboratory services were provided in a timely manner for three (#8, #5 and #6) of three residents reviewed out of 12 sample residents. Specifically, the facility failed to ensure: -Scheduled laboratory tests for Resident #8 were obtained in a timely manner; and -Laboratory tests ordered by the physician for Resident #5 and #6 were obtained. Findings include: I. Facility policy and procedure The Anticoagulant Therapy policy and procedure, last revised 11/26/19, provided by the nursing home administrator consultant (NHAC) on 3/11/21 at 2:45 p.m., revealed in pertinent part, The facility is to provide consistent monitoring and reporting of the effects of anticoagulant therapy. The facility is to ensure INR (international normalized ratio) results are communicated to the primary care physician (PCP) promptly so dose adjustments are completed if applicable. II. Resident #8 A. Resident status Resident #8, age 85, was admitted [DATE], discharged to the hospital on [DATE] and readmitted [DATE]. According to the March 2021 CPO, [DIAGNOSES REDACTED]. The 12/29/2020 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. He required extensive assistance of two people for his activities of daily living (ADL). He received an anticoagulant medication five out of seven days during the assessment period. B. Record review The January 2021 computerized physician orders [REDACTED].>-[MEDICATION NAME] (a blood thinner) 5 milligrams (mg) daily, ordered 12/24/2020; and -PT ([MEDICATION NAME] time)/INR (a test done to monitor the therapeutic level of [MEDICATION NAME]) every three days, ordered 1/1/21. A 1/1/21 [MEDICATION NAME] ([MEDICATION NAME]) management progress note revealed the physician gave an order to start PT/INR ' s on 1/5/21 and then every three days moving forward. Review of the January 2021 Medication Administration Record [REDACTED]–hold/see progress note on 1/26/21. The progress note revealed they were waiting on supplies to come in to complete the PT/INR. Review of the progress notes revealed the following: -On 1/5/21 the venipuncture was unsuccessful and would be tried again in the morning. It indicated the physician was notified. -On 1/6/21 the venipuncture for the PT/INR was successful and the physician called to report the resident ' s INR was 7.0 (therapeutic levels are between 2.-3.5) and gave orders to hold the [MEDICATION NAME] for five days and recheck the INR in five days. The January 2021 CPO revealed an order on 1/6/21 to perform an INR on 1/11/21 and notify the provider with the results immediately. The 1/12/21 administration progress notes revealed the blood draw for the INR was obtained on the first attempt and was to be taken to the laboratory that morning. This was a day after it was ordered to be done by the physician and there was no documentation to indicate why the PT/INR was not collected on 1/11/21. According to the January 2021 treatment administration record (TAR), the INR on 1/12//21 was obtained at 9:41 a.m. Review of the record revealed no laboratory report for this blood draw. A 1/13/21 nursing progress note revealed a blood draw was attempted twice to collect a specimen for the PT/INR without success and would be attempted again the next day. It indicated the physician was aware. Review of the record revealed no further documentation regarding attempting to collect a blood specimen for the PT/INR ordered every three days until 1/26/21 where an administration note indicated the facility was waiting on supplies to come in to complete the test. A 1/27/21 nursing progress note revealed the physician was notified about the resident ' s INR and [MEDICATION NAME] being held due to lack of supplies and not being able to get blood drawn because the resident was a hard stick. It indicated orders to proceed with the resident ' s [MEDICATION NAME] regime was pending and the [MEDICATION NAME] was being held that day. According to the January 2021 CPO an order was received on 1/28/21 to check the PT/INR every Monday. Review of the record revealed the resident did not have a PT/INR drawn from 1/11/21 until 2/2/21. A 2/2/21 nursing note revealed the blood draw for the INR was unsuccessful three times by that nurse and the director of nursing (DON) was able to get a sample later that day but was unsure if it was enough blood. A 2/4/21 [MEDICATION NAME] management progress note revealed test results for the PT/INR were within normal limits. It indicated the physician was notified and orders were obtained to continue the same dose of [MEDICATION NAME] and recheck the PT/INR on 2/8/21. Review of the February 2021 treatment administration record (TAR) revealed the order for the PT/INR to be checked every Monday was coded 5 –hold/see progress note on 2/1/21 (no progress note was made), 2/8/21 (see below), and 2/22/21(no progress note was made) and it was blank on 2/15/21. The 2/8/21 administration progress note revealed the INR would be followed up on 2/9/21. Review of the record revealed no follow up. Review of the record revealed the resident did not have a PT/INR drawn from 2/2/21 until 3/3/21. III. Resident #5 A. Resident status Resident #5, age less than 55, was admitted [DATE] and readmitted [DATE]. According to the March 2021 CPO, [DIAGNOSES REDACTED]. The 2/18/21 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident was independent or required supervision with set up only for his ADLs. The resident had a diabetes [DIAGNOSES REDACTED]. B. Resident interview Resident #5 was interviewed on 3/2/21 at 3:30 p.m. He said the facility was supposed to draw blood for a test that helped monitor his blood sugar. He said they had drawn his blood three different times and it never got done. He said they either lost the blood or lost the results every time. He said he asked the director of nursing (DON) for his results and she told him she had to find them. He said he had not refused to have his blood drawn and was getting upset that the facility kept losing them and had to keep sticking him. C. Record review According to the February 2021 CPO, an order was received on 2/16/21 for a hemoglobin A1c (HgbA1c) to be done. This was a blood test that measured the average blood sugar level over 3 month. According to the February 2021 TAR, the HgbA1c was signed of as being completed on 2/16/21 at 4:47 p.m. by licensed practical nurse (LPN) #1. Review of the record revealed no laboratory report for this blood draw. According to a 3/1/21 nursing progress note, the resident refused to have the lab drawn. It indicated it would be attempted the next day. Review of the record revealed no further attempts for the resident ' s blood to be obtained for the ordered test and no documentation of the physician being notified of the test not being performed. IV. Resident #6 A. Resident status Resident #6, age 66, was admitted on [DATE]. According to the March 2021 CPO, [DIAGNOSES REDACTED]. The 2/18/21 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident required supervision with set up only for her ADLs. The resident had a [DIAGNOSES REDACTED]. B. Resident interview Resident #6 was interviewed on 3/2/21 at 3:05 p.m. She said she was supposed to have her blood drawn last month but the facility never did it. She said she needed the tests done to make sure she was taking the right dose of her [MEDICAL CONDITION] and diabetic medications. Resident #6 was interviewed again on 3/5/21 at 9:35 a.m. She said she asked the director of nursing (DON) about her laboratory tests and was told she was contacting the physician to get orders. C. Record review According to the February CPO, the resident had an order for [REDACTED]. Review of the record on 3/5/21 revealed the resident did not have any laboratory results for the TSH or HgbA1c that was due to be drawn in February 2021. A 3/8/21 nursing progress note revealed a CBC (complete blood count), CMP (comprehensive metabolic profile), lipid panel, TSH and HgbA1c were all drawn. A 3/9/21 laboratory report revealed the resident ' s TSH was less than 0.02 mIU/ml. Normal values are 0.5 to 5.0 mIU/L (milli-international units per liter). No results were found for an HgbA1c. A 3/9/21 nursing progress note revealed the physician was aware of the laboratory results and changed the resident ' s [MEDICAL CONDITION] medication dose based off the results. V. Staff interviews The director of nursing (DON) was interviewed on 3/4/21 at 1:56 p.m. She said Resident #8 was very hard to draw blood from and they were not able to get his labs done as ordered because of this. She said the laboratory would not accept a sample if it was not the exact amount required. She said it could not be more or less and she had a really hard time obtaining the correct amount. She said they ordered a machine to be able to do the test at the facility but once she got it she had to learn how to use it and had not been able to use it yet. She said the physician was aware of how hard it was for them to get a blood sample from the resident. She did not say the resident would be sent out to the laboratory if needed. Licensed practical nurse (LPN) #1 was interviewed on 3/7/21 at 1:05 p.m. She said she worked as the clinical coordinator (CC) on some days and the charge nurse (medication) nurse on others. She said if labs needed to be done, the DON had to do it because she was not certified to do it. She said she signed off Resident #5 ' s HgbA1c because she had seen the DON draw it but she said it did not get taken to the laboratory in time and was not able to be used. LPN #2 was interviewed on 3/11/21 at 3:09 p.m. She said the nurse assigned to be the CC was responsible for obtaining lab samples and following up on the laboratory results. She said if blood needed to be drawn and there was no one available in the facility to draw it, then she would send the resident to the hospital laboratory to have it drawn. The nursing home administrator (NHA) was interviewed on 3/11/21 at 4:02 p.m. She said if a medication was unavailable it should be taken out of the e-kit if available. If not, then the physician should be called and the medication put on hold until it could be received from the pharmacy or an alternative medication be obtained. She said it was the CC ' s responsibility to obtain laboratory samples and follow up on laboratory results.

Based on observations, record review and interviews, the facility failed to ensure two (#7 and #8) residents with catheters out of 12 sample residents, received the appropriate care and services to prevent urinary tract infections to the extent possible. Specifically, the facility failed to have complete physician orders [REDACTED].#7 and Resident #8's catheters. Findings include: I. Facility policy and procedure The Urinary Continence and Incontinence - Assessment and Management policy and procedure, last revised September 2010, provided by the nursing home administrator consultant (NHAC) on 3/10/21 at 7:05 p.m. revealed in pertinent part, Indwelling urinary catheters will be used sparingly, for appropriate indications only. The physician will identify situations in which an indwelling urethral or suprapubic catheter are indicated and will document why other alternatives are not feasible. If an indwelling catheter is needed, staff will monitor for and report complications such as evidence of a symptomatic infection. II. Resident #7 A. Resident status Resident #7, age less than 55, was admitted [DATE], discharged to the hospital on [DATE] and readmitted [DATE]. According to the March 2021 computerized physician orders [REDACTED]. The 12/3/2020 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He required the extensive assistance of two people for all his activities of daily living. The resident had an indwelling catheter with a [DIAGNOSES REDACTED]. B. Observations On 3/11/21 at 12:20 p.m. Resident #7 was sitting in the dining area in his electric wheelchair backed up against the wall. Catheter tubing and a urinary drain bag were observed hanging under the seat of the resident's wheelchair. C. Record review The care plan, last revised 11/23/2020, revealed the resident had a Foley catheter related to [MEDICAL CONDITION] bladder. Interventions included: -Change as needed for displacement, infection, or obstruction; -Position catheter bag and tubing below the level of the bladder and away from entrance to the room; -Check tubing for kinks frequently each shift; -Empty catheter bag at the end of every shift. Report any changes to the nurse; -Monitor/ document for pain/discomfort due to catheter; and -Monitor/record/report to the physician for signs and symptoms of a urinary tract infection [MEDICAL CONDITION]. The 3/10/21 readmission nursing data collection revealed the resident had a Foley catheter that was draining clear yellow urine. The March 2021 CPO revealed the resident had an order to change the Foley catheter every 2nd of the month for routine catheter care, initiated 11/4/2020. -The order did not indicate the size of the catheter or balloon, orders for the care of the catheter, to include flush orders, or a [DIAGNOSES REDACTED]. The catheter orders were incomplete and the facility failed to clarify the orders. III. Resident #8 A. Resident status Resident #8, age 85, was admitted [DATE] and readmitted [DATE]. According to the March 2021 CPO, [DIAGNOSES REDACTED]. The 12/29/2020 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident required extensive assistance of two people for his ADLs. The resident had an indwelling catheter but did not have a [DIAGNOSES REDACTED]. B. Observation On 3/3/21 at 11:25 a.m. Resident #8 was sitting in his wheelchair at the table in the dining room. Catheter tubing and a urine drainage bag were observed hanging underneath his wheelchair. The drainage bag was inside a privacy bag. C. Record review The care plan, last revised 12/3/2020, revealed the resident had a suprapubic catheter. Interventions included: -Change catheter every month and needed (PRN); -Empty catheter bag at the end of every shift and PRN. Report any changes to nurse; and -Catheter care every shift and PRN. No documentation was revealed to indicate why the resident had the suprapubic catheter. A 2/20/21 weekly nursing progress note revealed the resident used a Foley catheter. A 2/22/21 nursing progress note revealed the resident received new orders to flush the catheter every night at bedtime and urology appointment was scheduled for 3/9/21. The March 2021 CPO revealed the following orders: -Suprapubic catheter care daily. Cleanse and apply a protective dressing one time a day, ordered 11/2/2020; and -Mix 10 teaspoons white vinegar (5%) in 1,000 milliliters (ml) of sterile water then irrigate the suprapubic catheter with 60 ml at bedtime for Foley Catheter related to [MEDICAL CONDITIONS]. The only mention in the orders of any [DIAGNOSES REDACTED]. The MDS, the care plan, the nursing progress notes did not mention why the resident had a suprapubic catheter in place. The orders also did not include what size the catheter or balloon was or when to change the catheter. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/7/21 at 1:05 p.m. She said residents should have orders for urinary catheters that included the size of the catheter and balloon, how often to change the catheter and routine catheter care orders. She said some residents also had orders to flush the catheters. LPN #2 was interviewed on 3/11/21 at 3:09 p.m. She said a resident with a catheter should have orders for how often to change the catheter and to care for the catheter. She said they should also have an order for [REDACTED]. The nursing home administrator (NHA) was interviewed on 3/11/21 at 4:02 p.m. She said all indwelling catheters needed to have orders that contained the size of the catheter and balloon, the frequency of how often to change the catheter, the reason for the catheter and care of the catheter. The nursing home administrator consultant (NHAC) was interviewed on 3/11/21 at 4:30 p.m. She said the facility was reviewing all resident's with catheters to ensure they had the proper orders and had started a performance improvement plan (PIP) to educate the staff.

Based on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for two (#8 and #7) residents out of 12 sample residents. Specifically, the facility failed to: -Ensure Resident #8 was on the appropriate anticoagulant; -Ensure Resident #8's anticoagulant medication was administered according to physician orders and was being monitored appropriately; and, -Ensure Resident #7 only received antibiotics when required with the appropriate documentation for use. Findings include: I. Anticoagulant use A. Facility policy and procedure The Anticoagulant Therapy policy and procedure, last revised 11/26/19, provided by the nursing home administrator consultant (NHAC) on 3/11/21 at 2:45 p.m, revealed in pertinent part, The facility is to provide consistent monitoring and reporting of the effects of anticoagulant therapy. The facility is to ensure INR results are communicated to the primary care physician (PCP) promptly so dose adjustments are completed if applicable. All residents receiving long term [MEDICATION NAME] will have month INR values drawn unless otherwise ordered by the PCP. The target range will be identified by the physician. If no target range is identified, use 2.0-3.5. If the INR is outside the defined target range, the [MEDICATION NAME] will need to be adjusted. B. Resident #8 1. Resident status Resident #8, age 85, was admitted [DATE], discharged to the hospital on [DATE] and readmitted [DATE]. According to the March 2021 CPO, [DIAGNOSES REDACTED]. The 12/29/2020 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. He required extensive assistance of two people for his activities of daily living (ADL). He received an anticoagulant medication five out of seven days during the assessment period. 2. [MEDICATION NAME] use a. Record review According to the December 2020 CPO, the resident had the following orders: -Aspirin 81 milligrams (mg) one time a day, ordered 10/22/2020; and -[MEDICATION NAME] 30 mg/0.3 milliliter (ml) inject 30 mg subcutaneously one time a day to prevent blood clotting, ordered 10/22/2020. According to the December 2020 Medication Administration Record [REDACTED]. According to progress notes for those dates the medication was not in stock and the facility was waiting on delivery from the pharmacy. A 12/19/2020 progress note revealed the resident was at the emergency room and a physician order dated 12/19/2020 revealed the resident was sent to the emergency room for cold feet with no pulses. A 12/19/2020 nursing progress note revealed the report for the emergency room was the resident had an enormously large blood clot in his heart and he was being sent out to a hospital with a cardiac unit. The 12/19/2020 hospital history and physical exam revealed the resident had a large blood clot in his heart and was a poor candidate for surgical intervention so the recommendation was to give [MEDICATION NAME] (a blood thinner) intravenously (IV) and start [MEDICATION NAME] (oral [MEDICATION NAME]) therapy. According to a 3/9/21 physician record review by the facility corporate physician, [MEDICATION NAME] would never be indicated for routine care and was not approved for [MEDICATION NAME] as a diagnosis. Other than four very specific conditions (none of which this resident had in October 2020), the combination of [MEDICATION NAME] plus aspirin would not be indicated, as the risk of bleeding and death would be higher with this combination than the risk posed by [MEDICAL CONDITION] (blood clot formation) events. The [MEDICATION NAME] should have been discontinued at the time of readmission. b.Interviews The pharmacy consultant was interviewed on 3/5/21 at 2:30 p.m. He said there were no tests to perform to check the therapeutic level of [MEDICATION NAME]. He said it was a medication that should only be used short term for non-ambulatory patients. He said he questioned the length of time the resident was to be on the [MEDICATION NAME] but did not get a response from the facility. He said no doses of the [MEDICATION NAME] should have been missed because the medication was available in the facilities emergency medication kit. He said a pre-authorization was not required to remove the medication from the e-kit. 3. [MEDICATION NAME] use a.Record review According to the December 2020 CPO, the resident was readmitted to the facility on [DATE] with the following order: [MEDICATION NAME] 5 mg one time a day for chronic [MEDICAL CONDITION]. The [MEDICATION NAME] and aspirin had been discontinued. There were no orders to check the resident's [MEDICATION NAME] time and international normalized ratio (PT/INR), a test needed to monitor the dosing of [MEDICATION NAME]. A 12/28/2020 nursing progress note revealed a fax was sent to the provider requesting PT/INR lab work be done since the resident returned from the hospital with an order for [REDACTED].>A 1/1/21 [MEDICATION NAME] ([MEDICATION NAME]) management progress note revealed the physician gave an order to start PT/INR on 1/5/21 and then every three days moving forward. A 1/5/21 nursing progress note revealed the venipuncture was unsuccessful and would be tried again in the morning. It indicated the physician was notified. A 1/6/21 nursing progress note revealed the venipuncture for the PT/INR was successful and was to be taken to the laboratory that afternoon. Another 1/6/21 nursing progress note revealed the physician called to report the resident's INR was 7.0 (therapeutic levels are between 2.0-3.5) and gave orders to hold the [MEDICATION NAME] for five days and recheck the INR in five days. The 1/6/21 laboratory results for the PT was 68.6 and the INR was 7.49. The January 2021 CPO revealed an order on 1/6/21 placing the [MEDICATION NAME] on hold for five days and to perform an INR on 1/11/21 and notify the provider with the results immediately. The 1/12/21 administration progress notes revealed the blood draw for the INR was obtained on the first attempt and was to be taken to the laboratory that morning and a telephone call was made to the provider with instructions to hold the [MEDICATION NAME] until the next INR was obtained. (This was a day later that the physician ordered) According to the January 2021 treatment administration record (TAR), the INR on 1/12/21 was obtained at 9:41 a.m. Review of the record revealed no laboratory report for this blood draw. A 1/13/21 nursing progress note revealed a blood draw was attempted twice to collect a specimen for the PT/INR without success and would be attempted again the next day. It indicated the physician was aware. Review of the record revealed no further documentation regarding attempting to collect a blood specimen for the PT/INR ordered every three days until 1/26/21 where an administration note indicated the facility was waiting on supplies to come in to complete the test. The January 2021 TAR revealed no documentation of the PT/INR being completed on 2/5, 2/8, 2/11, 2/14, 2/17 and 2/20/21 and was coded 5- see progress note (see above) on 1/26/21. A 1/27/21 nursing progress note revealed the physician was notified about the resident's INR and [MEDICATION NAME] being held due to lack of supplies and not being able to get blood drawn because the resident was a hard stick. It indicated orders to proceed with the resident's [MEDICATION NAME] regime was pending and the [MEDICATION NAME] was being held that day. According to the January 2021 CPO an order was received on 1/28/21 to check the PT/INR every Monday. A 1/28/21 administration progress note revealed the [MEDICATION NAME] was held due to no recent INR completed. There were no orders to hold the [MEDICATION NAME]. Review of the record revealed the resident did not have a PT/INR drawn from 1/11/21 until 2/2/21. A 2/2/21 nursing note revealed the blood draw for the INR was unsuccessful three times by that nurse and the director of nursing (DON) was able to get a sample later that day but was unsure if it was enough blood. A 2/3/21 administration progress note revealed the [MEDICATION NAME] was on hold until a new INR was done. There were no orders to hold the [MEDICATION NAME]. A 2/4/21 [MEDICATION NAME] management progress note revealed test results for the PT/INR were within normal limits. It indicated the physician was notified and orders were obtained to continue the same dose of [MEDICATION NAME] and recheck the PT/INR on 2/8/21. Review of the record revealed the resident did not have a PT/INR drawn from 2/2/21 until 3/3/21. Review of the February 2021 MAR indicated [REDACTED]. Administration progress notes reveal the [MEDICATION NAME] was being held, waiting for the INR results. There were no orders to hold the [MEDICATION NAME]. Review of the February 2021 treatment administration record (TAR) revealed the order for the PT/INR to be checked every Monday was coded 5 -hold/see progress note on 2/1/21 (no progress note was made), 2/8/21 (see below), and 2/22/21(no progress note was made) and it was blank on 2/15/21. (cross reference F770 for failure to obtain laboratory services) The 2/8/21 administration progress note revealed the INR would be followed up on 2/9/21. Review of the record revealed no follow up. Review of the record revealed no follow up on the PT/INR or [MEDICATION NAME] until 3/3/21. A 3/3/21 [MEDICATION NAME] management progress note revealed test results for the INR obtained on 3/1/21 was 3.2. It indicated the physician was notified and the INR was to be rechecked on Wednesday 3/3/21. Another 3/3/21 [MEDICATION NAME] management progress note revealed test results for the INR obtained 3/3/21 was 1.6. It indicated the physician was notified and the [MEDICATION NAME] was discontinued and the resident was started on Xarelto (a different anticoagulant that did not require strict dosing with frequent blood draws). b. Interviews The director of nursing (DON) was interviewed on 3/4/21 at 1:56 p.m. She said Resident #8 was very hard to draw blood from and they were not able to get his labs done as ordered because of this. She said the laboratory would not accept a sample if it was not the exact amount required. She said it could not be more or less and she had a really hard time obtaining the correct amount. She said they ordered a machine to be able to do the test at the facility but once she got it she had to learn how to use it and had not been able to use it yet. She said the physician was aware of how hard it was for them to get a blood sample from the resident. The pharmacy consultant was interviewed on 3/5/21 at 2:30 p.m. He said [MEDICATION NAME] was a tricky drug to get the dosing correct and should be monitored closely with blood draws. He said there were several other anticoagulant medications available that were safer for the elderly population and one of these should have been initiated a lot sooner. Resident #8's primary care physician (PCP) was interviewed on 3/5/21 in the afternoon. He said the facility had a hard time obtaining blood samples from the resident in order to monitor his PT/INR to be able to dose the [MEDICATION NAME] so he changed it to a different type of anticoagulant. He said the [MEDICATION NAME] should have been given even if the blood tests were not done and he did not give an order to hold the medication. Licensed practical nurse (LPN) #2 was interviewed on 3/11/21 at 3:09 p.m. She said if a medication was not available it should be removed from the e-kit if available, if not, the physician should be notified and the medication put on hold until it could be received from the pharmacy. She said she was sure if [MEDICATION NAME] was available in the e-kit or not. She said it was important for a resident to receive their anticoagulant as ordered to prevent the development of blood clots. She said the nurse assigned to be the clinical coordinator (CC) was responsible for obtaining lab samples and following up on the laboratory results. She said if blood needed to be drawn and there was no one available in the facility to draw it, then she would send the resident to the hospital laboratory to have it drawn. The nursing home administrator (NHA) was interviewed on 3/11/21 at 4:02 p.m. She said if a medication was unavailable it should be taken out of the e-kit if available. If not, then the physician should be called and the medication put on hold until it could be received from the pharmacy or an alternative medication be obtained. She said it was the CC's responsibility to obtain laboratory samples and follow up on laboratory results. II. Antibiotic use A.Facility policy and procedure The Urinary Continence and Incontinence - Assessment and Management policy and procedure, last revised September 2010, provided by the nursing home administrator consultant (NHAC) on 3/10/21 at 7:05 p.m. revealed in pertinent part, A urinalysis may detect hematuria (blood in the urine) and clinically significant pyuria (elevated white blood cells in the urine), but otherwise is like to have limited utility as a screening test because of the high prevalence of asymptomatic bacteriuria (bacteria in the urine) in the long-term care population. Urinalysis should not be confused with a urine culture. The presence of bacteriuria without symptoms, whether or not pyuria is present, does not usually merit antibiotic treatment, especially in individuals with indwelling urinary catheters. Published criteria for a symptomatic urinary tract infection should be followed. These differ between the catheterized and non-catheterized residents. The Antibiotic Stewardship policy and procedure, last revised December 2016, provided by the nursing home administrator consultant (NHAC) on 3/11/21 at 2:45 p.m., revealed in pertinent part, When a culture and sensitivity (C & S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. B. Resident #7 1. Resident status Resident #7, age less than 55, was admitted [DATE], discharged to the hospital on [DATE] and readmitted [DATE]. According to the March 2021 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 12/3/2020 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He required the extensive assistance of two people for all his activities of daily living. The resident had an indwelling catheter with a [DIAGNOSES REDACTED]. 2. Record review A 2/3/21 nursing progress note revealed a urine analysis (UA) was taken for possible urinary tract infection or otherwise result due to urine looking cloudy. It indicated the resident did not have an increased temperature and the vital signs were within normal limits. Review of the record revealed no physician order to obtain a UA. A 2/4/21 nursing progress note revealed the resident's catheter was changed and light colored urine returned. A 2/7/21 administration progress note revealed the resident had discharge around his penis for three days and his catheter was leaking that morning. It indicated a urine dip was done because results from the UA sent to the laboratory had not been received and the on-call physician was notified of the dip results and ordered an antibiotic for 10 days. Review of the record revealed no documentation of the dip results. The February 2021 CPO revealed orders [MEDICATION NAME](an antibiotic) 500 mg two times a day for 10 days for urinary tract infection [MEDICAL CONDITION] were obtained on 2/7/21. According to the February 2021 MAR, [MEDICATION NAME] given from 2/7/21 until 2/17/21 and it was started again on the evening shift 2/20/21 and given twice a day until the resident was discharged to the hospital on [DATE]. Review of the record revealed no UA results but laboratory results for a urine culture were received by the facility on 2/10/21 indicating the resident had a count of greater than 100,000 of the organism [DIAGNOSES REDACTED] pneumonia and it was sensitive to the Cipro. A 2/17/21 nursing progress note revealed the resident was to take his last dose of antibiotic that day and he had no discharge or catheter leakage, and his urine was light yellow and clear. It indicated the physician did an in-person visit and no new orders were received. Review of the 2/17/21 physician progress notes [REDACTED]. The note did not address the resident's urinary status at all. According to 2/20/21 nursing progress notes, the resident began having a fever earlier in the day and was given Tylenol however he continued to have a fever. It indicated a urine sample was drawn and dipped with abnormal values being documented and reported to the physician and he [MEDICATION NAME] mg twice a day for another 10 days. A 2/21/21 nursing progress note revealed the resident's urine was light yellow with sediment and a foul smell and he continued to spike temperatures throughout the day. It indicated the physician on call was notified and a CBC (complete blood count) lab was requested. Review of the record revealed this did not occur. A 2/22/21 activity progress note revealed the resident was admitted to the hospital that morning. A 2/22/21 hospital history and physical revealed the resident was admitted with healthcare associated bacterial pneumonia and complicated acute urinary tract infection [MEDICAL CONDITION] multidrug resistant Carbapenum resistant P. Aeruginosa UTI with limited treatment options. 3. Interviews LPN #2 was interviewed on 3/11/21 at 3:09 p.m. She said they were required to have a physician order to obtain urine to send to the laboratory for analysis but they were able to do urine dips at the facility without one. She said if the dip showed any abnormal values, the physician was notified and sometimes an order was obtained and the urine was sent to the lab for further analysis, other times, the physician will just order an antibiotic. She did not know what antibiotic stewardship was. The nursing home administrator (NHA) was interviewed on 3/11/21 at 4:02 p.m. She said an order was required to obtain a urine sample and send it to the laboratory but the staff had been trained on how to obtain a urine dip at the facility to get preliminary results if needed. She said the facility did not have a specific criteria they followed to determine if antibiotic use was appropriate. She said they just worked closely with the physicians, especially the medical director. The nursing home administrator consultant (NHAC) was interviewed on 3/11/21 at 4:20 p.m. She said the facility should be following the McGreer ' s criteria for determining if antibiotic use was appropriate.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed out of 12 sample residents was as free from unnecessary medications as possible. Specifically, the facility failed to: -Have documented behaviors to justify the use of [MEDICAL CONDITION] medications for Resident #1; -Ensure [MEDICAL CONDITION] medications were being administered to Resident #1 for the appropriate symptoms; -Resident #1 was assessed every 14 days by the physician to continue his as needed (PRN) anti anxiety medication; -Monitor the side effects of Resident #1's [MEDICAL CONDITION] medications to ensure they were not causing the resident to have increased falls; -Obtain consents for Resident #1's antidepressant and antianxiety medication; -Ensure all doses of Resident #1's anti anxiety medication given were documented in the record; and, -Document non-pharmacological interventions prior to administering Resident #1's PRN antianxiety medication. Findings include I. Facility policy and procedure The Psychopharmacological policy and procedure, last revised 1/10/19, provided by the nursing home administrator consultant (NHAC) on 3/11/21 at 2:45 p.m., revealed in pertinent part, If a resident is admitted with orders for psychopharmacological drug use the following will occur: 1. A licensed nurse will review admission medication orders and ensure appropriate [DIAGNOSES REDACTED]. 2. The licensed nurse or social service director (SSD) will determine if there are any potential behavior symptoms that require special monitoring and/or care planning. 3. The licensed nurse will document any admission order for the use of [REDACTED]. 4. Within 48 hours of admission, a licensed nurse will indicate the use of psychopharmacological drugs on the baseline care plan to initiate the first step in the care plan process. 5. The licensed nurse or designee will document any known targeted behaviors and potential interventions on the kardex. 6. The licensed nurse or SSD will initiate behavior monitoring within the first 24 hours of admission. Behavior monitoring is mandatory for residents who take [MEDICAL CONDITION] medications. II. Resident #1 A. Resident status Resident #1, age 71, was admitted on [DATE], discharged to the hospital on [DATE] and was readmitted [DATE]. According to the March 2021 CPO, [DIAGNOSES REDACTED]. The 2/4/21 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident required supervision with set up or physical assistance of one person for his ADLs. The resident took an antianxiety medication two out of seven days and an antidepressant seven out seven days during the assessment period. B. Record review The December 2020 CPO revealed the resident was readmitted with the following orders: -Duloxetine 60 mg give one capsule by mouth one time a day for depression, ordered 12/15/2020; and, -[MEDICATION NAME] 0.5 mg give one tablet by mouth every 12 hours as needed (PRN) for anxiety, ordered 12/15/2020. Review of the record revealed the resident was not on these or any similar medications prior to being discharged to the hospital on [DATE] for a gastrointestinal (GI) bleed and [MEDICAL CONDITION]. Review of the December 2020 Medication Administration Record [REDACTED]. Notes indicated the [MEDICATION NAME] was being administered for itching. Review of the record revealed the resident did not have a consent for the duloxetine or the [MEDICATION NAME] prior to the medication being administered. It also revealed the resident's provider did not reassess the resident every 14 days and re-order the [MEDICATION NAME] based on that assessment. A 12/20/2020 nursing progress note revealed the resident was offered [MEDICATION NAME] ([MEDICATION NAME]) for the first time on 12/19/2020 and the resident stated I finally didn ' t itch like crazy and got some sleep. It indicated the resident was given a prn dose of the [MEDICATION NAME] and he was sleeping without scratching himself. A 12/21 2020 skilled nursing note revealed the resident had been getting prn doses of the [MEDICATION NAME] and had done very well with increased sleep, decreased itching and decreased nerve pain. Comparison of the controlled drug receipt record/disposition form for the residents [MEDICATION NAME] received on 12/16/2020 with the December 2020 MAR indicated [REDACTED]. A 1/18/21 nursing progress note revealed the resident stated he fell the day before on his way to the restroom and now had complaints of rib pain. A 1/26/21 nursing note revealed recommendations were made during a psychopharmacological review meeting to do a gradual dose reduction on the duloxetine to 40 mg a day. It indicated the provider was sent a fax. A 1/30/21 nursing progress note revealed the resident had fallen in his room by the door on his way to the bathroom. It indicated the resident stated he got dizzy and fell . Comparison of the controlled drug receipt record/disposition form for the residents [MEDICATION NAME] received on 12/16/2020 and 1/7/21 with the January 2021 MAR indicated [REDACTED]. Comparison of the controlled drug receipt record/disposition form for the residents [MEDICATION NAME] received on 1/7/21 with the February 2021 MAR indicated [REDACTED]. The medication was changed to routinely on 2/4/21. According to the February 2021 CPO, the resident's order for [MEDICATION NAME] 0.5 mg was changed on 2/4//21 to be given routinely every night at bedtime for anxiety and his duloxetine was decreased to 40 mg a day. According to the 2/4/21 informed consent for psychoactive medications only listed the [MEDICATION NAME], not the duloxetine and revealed a message was left for the resident's son to call the facility. Review of the record revealed no behavior tracking to indicate and justify why the resident's [MEDICATION NAME] was changed from PRN to routine. A 2/5/21 nursing progress note revealed several messages had been left for the resident's son to call the facility about the medication changes. A 2/10/21 psychosocial progress note revealed the resident had a PHQ-9 (quick depression assessment) score of 0 (a score of 0-4 indicated no depression) and was inaccurate in saying the resident was not on any psychoactive medications. A 2/16/21 risk management review note revealed the resident had an unwitnessed fall on 2/14/21. Review of the record revealed no documentation the resident was offered any non-pharmacological interventions prior to his PRN [MEDICATION NAME] being administered and before his [MEDICATION NAME] being upgraded to a scheduled dose for a [DIAGNOSES REDACTED]. III. Staff interviews The pharmacy consultant (PC) was interviewed on 3/5/21. He said he reviewed all resident's records monthly and gave his recommendation to the director of nursing (DON) to follow up on. He said he the physician should have reassessed Resident #1 every 14 days to determine the necessity of continuing the PRN [MEDICATION NAME]. He said the physician will usually just make the medication routine so he does not have to do that. He said he thought that was probably why Resident #1's [MEDICATION NAME] was scheduled. Licensed practical nurse (LPN) #1 was interviewed on 3/7/21 at 1:05 p.m. She said she was not aware consents had to be obtained for [MEDICAL CONDITION] medications before they could be administered. She said they did all their behavior charting by exception in the behavior book. She said Resident #1 was taking the PRN [MEDICATION NAME] almost daily before so they just made it routine. She said he was taking it for his itching and it seemed to help. She said anytime a PRN medication was administered, it needed to be documented in the MAR. She said the medication may have contributed to his increase in falls the last couple of months. LPN #2 was interviewed on 3/11/21 at 3:09 p.m. She said was not familiar with the different types of [MEDICAL CONDITION] medications and did not know they needed consent prior to administration. She said they did all their behavior charting in the behavior book and only if there was an issue. She said Resident #1 was taking the [MEDICATION NAME] for his itching. The nursing home administrator (NHA) was interviewed on 3/11/21 at 4:02 p.m. She said consents were needed for any [MEDICAL CONDITION] medications and it was the responsibility of the director of nursing (DON) to obtain those from the resident or the resident's representative. She said the facility had a monthly meeting to review all the [MEDICAL CONDITION] medications. She said the medical director, the resident's physician, the SSD, DON, NHA and pharmacist were present for this meeting.

Based on observations, record review and interviews, the facility failed to ensure notification of change for one (#1) of three sample residents. Specifically, the facility failed to notify the responsible party of behaviors for Resident #1. Findings include: I. Resident status Resident #1, age 63, was admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 10/1/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. No physical behaviors were noted, and verbal behaviors were noted to have occurred one to three days in the past seven. The MDS did not identify the use of any antipsychotic medications. II. Record review The progress note dated 11/23/2020 at 3:58 p.m. included, The daughter requested to please notify her of any behaviors her dad is having anytime of the day or night. III. History of behaviors The kiosk for certified nurse aide (CNA) behavior documentation provided by the director of nursing (DON) on 12/8/2020 at 8:55 a.m. from 10/23/2020 to 12/8/2020 identified: -On 11/25/2020 Resident #1 displayed yelling/screaming/calling out behaviors. Attempted interventions are unknown. -On 11/26/2020 Resident #1 displayed pacing behavior. Attempted interventions are unknown. -On 11/28/2020 Resident #1 displayed throwing objects behavior. Attempted interventions are unknown. -On 12/2/2020 Resident #1 displayed grabbing behavior. Attempted interventions are unknown. The facility failed to notify the Power of Attorney (POA) of behaviors. Cross-reference F605 and F744. IV. Interviews The POA was interviewed by phone on 12/7/2020 at 1:30 p.m. She said every time she had called the facility for an update on her fathers status, she was told he had been a little restless and a bit irritable. She said no one called her when her dad had a behavior. She said she asked to be notified of any and all future behaviors day or night. Certified nurse aide (CNA) #1 was interviewed on 12/7/2020 at 3:05 p.m. She said Resident #1 did have behaviors. She said the facility stopped letting him watch scary movies and R rated movies and he had become calmer. She said when he had a behavior she would tell the nurse and document the behavior in the kiosk. Housekeeper (Hskg) #1 was interviewed on 12/7/2020 at 3:10 p.m. She said she did not know of any behaviors from Resident #1. She said she would tell the nurse if she saw anything unusual. Registered nurse (RN) #1 was interviewed on 12/7/2020 at 3:20 p.m. She said Resident #1 did not display behaviors until recently. She said the R rated movies and scary movies seemed to set him off, and since he no longer watched the movies his behaviors decreased. She said the behaviors were tracked in the behavior monitoring tracking form. The director of nursing (DON) was interviewed on 12/7/2020 at 4:25 p.m. She said the daughter should have been notified of all the behaviors after 11/23/2020. She said it's important to keep the POA updated on Resident #1's status.

Based on interviews and record review, the facility failed to ensure one (#1) out of three sample residents attained and maintained their highest practicable well-being in an environment that prohibits the use of chemical restraints out of 28 residents reviewed. Specifically, the facility failed to obtain consent prior to the administration of an antipsychotic injectable medication and failed to ensure the antipsychotic medication administered was given to treat the resident's medical symptoms and not used for discipline or convenience. This failure resulted in the resident being administered [MEDICATION NAME] 5mg intramuscularly (IM) after displaying aggressive behaviors without the consent from the legal representative. Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 12/7/2020-12/8/2020, resulting in the deficiency being cited at past non-compliance with a correction date of 11/25/2020. Findings include: I. Restraint Policy Acknowledgement The restraint policy acknowledgement, revised 2014, from Resident #1's electronic record, included: (Facility), in accordance with federal and state laws, has a very strict policy regarding the use of physical and chemical restraints for residents. For these reasons and in accordance with federal and state laws, restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident (or other residents) and under all of the following conditions: 1) As a last resort measure after a trial period where least restrictive measures have been undertaken and proven unsuccessful; 2) With a physician order [REDACTED]. 3) With the consent of the resident or legal surrogate or representative (the legal surrogate or representative cannot give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms); and 4) When the benefits of the restraint outweigh the identified risks. II. Resident status Resident #1, age 63, was admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 10/1/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. No physical behaviors were noted, and verbal behaviors were noted to have occurred one to three days in the past seven. The MDS did not identify the use of any antipsychotic medications. III. Record review Physician orders [REDACTED]. The care plan, initiated on 10/19/2020 and revised on 10/23/2020, identified the resident was at risk for the behaviors of aggressiveness and agitation, and to document observed behavior and attempted interventions. Interventions included: Behavior monitoring; Administer medications as ordered. Monitor/document for side effects and effectiveness; and, anticipate and meet the resident's needs. -The facility failed to implement a person centered care plan for specific target behaviors for Resident #1 and monitor for effectiveness. No specific interventions were documented to ensure the facility staff new how to ensure Resident #1 was given the best outcome possible for behaviors exhibited, but also now what would provoke unwanted behaviors from Resident #1 as well. October 2020 The behavior monitoring tracking form documented on 10/17/2020 at 11:50 a.m. Resident #1 punched a staff member. The staff documented they had redirected the resident to the dining room where he calmed down and ate his lunch. A progress note documented on 10/17/2020 at 12:04 p.m. Resident #1 had displayed an increase in his verbal and physical aggression over the past couple of weeks. The behavior monitoring tracking form documented on 10/18/2020 at 10:52 a.m. Resident #1 slapped a CNA on the right side of their face while their back was turned to the resident. The staff member documented they had redirected him to have a seat on his bed. His documented response was he laughed. A progress note documented on 10/18/2020 at 12:09 p.m. Resident #1 was physically and verbally aggressive with staff during cares. The behavior monitoring tracking form documented on 10/23/2020 at 10:50 a.m. Resident #1 was observed punching his television three times. He was cussing and refusing care. The staff documented they had redirected him. His response was to cuss and refuse care, eventually quieting down. -No specific information was documented to indicate what interventions were done for Resident #1 to ensure other staff utilized the same redirected measures for future occurrences that were the least restrictive. November 2020 The behavior monitoring tracking form documented on 11/17/2020 at 5:15 p.m. Resident #1 made a lewd gesture by putting his hands to his genitals and grunting loudly. He was redirected to his room to watch television. His response was to sit in his chair and did not want his television on. The behavior monitoring tracking form documented on 11/18/2020 at 7:00 p.m. Resident #1 was pulling a CNA's hair trying to hit her face. The staff put a movie on his television to calm him down. His response was to continue to yell in his room. -No specific information was documented to indicate what interventions were done for Resident #1 to ensure other staff utilized the same redirected measures for future occurrences that were the least restrictive. -The facility failed to update the care plan interventions, monitor, and were not reviewed for efficacy after several behavioral episodes with physical aggression were documented. The resident was given a chemical restraint. See below 11/19/2020 day of administration of chemical restraint being used The progress note dated 11/19/2020 at 5:44 p.m. included: BEHAVIOR: this morning Resident #1 was yelling and cursing in the middle of the hall about 'where is my girlfriend'. Unable to state who his girlfriend is. He was being COVID tested and he grabbed the breast of staff. He then hit a staff member in the head. He was inconsolable, non redirectable, and threatening to hit staff. Call was placed to medical doctor (MD) and order given for one time [MEDICATION NAME] 5mg IM which was given. Family was notified. -This progress note written by the DON, did not include or indicate what other interventions besides redirection was tried before giving the [MEDICATION NAME] injection. No specifics were provided to state why the resident was inconsolable and what was tried to conclude the resident was non redirectable. IV. Interviews The POA was interviewed by phone on 12/7/2020 at 1:30 p.m. She said the facility's administration had not notified her about the [MEDICATION NAME] IM before it was administered. She said she was called by another individual that worked there. She said the injection was given without her knowledge or consent. She said she was never asked permission to give the medication. She said she would call the facility several times a week and every time she had called the facility for an update on her father's status, she was told he had been a little restless and a bit irritable, and then received a call and was notified of the [MEDICATION NAME] injection. The reason the facility said he received the injection was for hitting a staff, pulling a CNA's hair, and cussing. She said no one called her when her dad had a behavior, nor did the facility ask for advice for interventions, and she wanted to be involved. She said after the [MEDICATION NAME] injection she told the facility not to let him watch scary movies because they can cause the behaviors. She said instead of rated R movies or scary movies, let him watch Disney movies and Big Bang Theory. She said she was very upset about the [MEDICATION NAME] injection. She said when she researched [MEDICATION NAME], she found out it should not be used on individuals with dementia. She said she had asked the facility if they had tried anything before the [MEDICATION NAME] injection and the facility did not give her an answer. She said she was told the [MEDICATION NAME] injection was given because Resident #1 had struck a CNA. She said she told the facility she did not want him to get [MEDICATION NAME] anymore, and asked to be notified of any and all future behaviors day or night. The MD was interviewed on 12/7/2020 at 2:00 p.m. He said he gave the order for [MEDICATION NAME] IM because the resident was aggressive with the staff. He said it was illegal to give an injection of [MEDICATION NAME] without a physician's orders [REDACTED].>Certified nurse aide (CNA) #1 was interviewed on 12/7/2020 at 3:05 p.m. She said Resident #1 did have behaviors. She said the facility stopped letting him watch scary movies and R rated movies and he had become calmer. She said when he had a behavior she would tell the nurse and document the behavior in the kiosk. Housekeeper (Hskg) #1 was interviewed on 12/7/2020 at 3:10 p.m. She said she did not know of any behaviors from Resident #1. She said she would tell the nurse if she saw anything unusual. Registered nurse (RN) #1 was interviewed on 12/7/2020 at 3:20 p.m. She said Resident #1 did not display behaviors until recently. She said the R rated movies and scary movies seemed to set him off, and since he no longer watched the movies his behaviors decreased. She said the behaviors were tracked in the behavior monitoring tracking form. She said she had received training on PRN medications, specifically [MEDICAL CONDITION] medications, and if an order was received, to let the DON, the family know, and call the consultant for further guidance. The director of nursing (DON) was interviewed on 12/7/2020 at 4:25 p.m. She said during COVID-19 testing, Resident #1 had grabbed her breast, hit a CNA in the head, and was yelling at staff. She said redirection was ineffective. She said she called the MD and he gave the order for the [MEDICATION NAME] 5 mg IM to be given. She said she did not obtain consent from the POA, nor did she tell her before the injection was given. She said she called her after the injection was given to notify her. She said after the [MEDICATION NAME] was administered, the daughter offered suggestions to include restricting R rated movies and scary movies. She said she had not asked the daughter for suggestions prior to the administration of [MEDICATION NAME]. She said the resident had a history of [REDACTED]. She said he had been physical with staff before 11/19/2020. V. Facility correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: During the November psych/pharm review on 11/24/2020 the social services consultant discovered the as needed (PRN) [MEDICATION NAME] injection. The management and the social services consultant immediately completed an audit on Resident #1's medications, who at the time was not ordered/taking any [MEDICAL CONDITION] medications. After talking to the responsible party, the facility agreed that the resident would not receive another PRN IM [MEDICATION NAME] intramuscular (IM) injection for behaviors. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The facility completed an audit on all the residents to verify no other resident had received or had an order for [REDACTED].>3. Address what measures will be put into place or systemic changes made to ensure the deficient practice does not recur: Upon discovery of the [MEDICATION NAME] injection, the DON was immediately educated on the regulations. The social services consultant developed a spreadsheet to monitor behaviors. Education was provided to all the nursing staff that included: Anytime a [MEDICAL CONDITION] medication is going to be administered either PRN or is newly scheduled you must call the POA/guardian/MDPOA/elder prior to administration to be given permission. you must also go into pcc and fill out a nursing- informed consent for psychoactive medications. All the nursing staff completed the training. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The plan of correction must be integrated into the quality assurance system: This issue was added to those monitored by the QA (quality assurance) committee for planning, implementation, monitoring and evaluation. The results of the audits will be evaluated for effectiveness in the QA committee to ascertain and ensure resident safety on an ongoing basis. The facility reviewed all the resident behaviors by reviewing the behavior monitoring tracking form, progress notes, and the kiosk where the CNAs document behaviors. The social services consultant will perform monthly behavior and medication reviews for all the residents. 5. Include dates when corrective action will be completed. The corrective action completion dates must be within acceptable time frames: The corrective actions were completed by 11/25/2020, prior to the investigation, resulting in this deficiency being cited as past non-compliance.

Based on record review and interviews, the facility failed to ensure a resident was diagnosed with [REDACTED].#1) of three sample residents. Specifically, the facility failed to comprehensively assess and effectively identify person-centered individualized approaches for Resident #1 with a [DIAGNOSES REDACTED]. The facility failed to implement appropriate interventions timely, subsequently Resident #1 was given a [MEDICATION NAME] intramuscular injection (cross-reference F605) . Findings include: I. Resident status Resident #1, age 63, was admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 10/1/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. No physical behaviors were noted, and verbal behaviors were noted to have occurred one to three days in the past seven. The MDS did not identify the use of any antipsychotic medications. II. Record review The care plan, initiated on 10/19/2020 and revised on 10/23/2020, identified the resident was at risk for the behaviors of aggressiveness and agitation, and to document observed behavior and attempted interventions. Interventions included: -Behavior monitoring. -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Anticipate and meet the resident's needs The care plan, initiated 8/18/2020 and revised 10/7/2020 identified the resident had the potential to be verbally aggressive related to dementia. Interventions included: -Assess and anticipate the resident's needs; food, thirst, toileting needs, comfort level, body positioning, pain, etc. -If Resident #1 becomes agitated; intervene before agitation escalates, get away from source of distress, engage calmly in conversation, and if response is aggressive, staff are to walk away calmly and approach later. -Monitor behaviors of aggressiveness and or agitation. Document observed behavior and attempt interventions. The care plan, initiated 8/18/2020 and revised on 10/7/2020 identified the resident had a history of [REDACTED]. Interventions included: -Monitor/record/report to medical doctor (MD) as needed (PRN) mood patterns, signs and symptoms of depression, and sad mood as per facility behavior monitoring protocols. -Social services director (SSD) will provide Resident #1 with one to one psych social support for opportunities to express himself to the best of his abilities. -Staff will monitor/record mood changes to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Review of social services notes failed to reveal any one to ones with the resident from October 2020 to 12/9/2020. The progress note dated 11/23/2020 at 3:58 p.m. included, We discussed how much better her dad was doing with his behavior since we stopped letting him watch scary or R rated movies. The daughter shared that Resident #1 liked Disney movies, The Little Mermaid, Beauty and the Beast, or Big Bang Theory or Dances With Wolves. The care plans had not been updated as of 12/7/2020 to reflect the effect scary and R rated movies had an impact on Resident #1's behavior and the intervention of other types of movies/television shows he preferred. The care plans failed to identify person centered individualized interventions beyond redirection for behaviors associated with dementia. III. History of behaviors The behavior monitoring tracking form for Resident #1 identified the [DIAGNOSES REDACTED]. October 2020 The behavior monitoring tracking form documented on 10/17/2020 at 11:50 a.m. Resident #1 punched a staff member. The staff documented they had redirected the resident to the dining room where he calmed down and ate his lunch. A progress note documented on 10/17/2020 at 12:04 p.m. Resident #1 had displayed an increase in his verbal and physical aggression over the past couple of weeks. The behavior monitoring tracking form documented on 10/18/2020 at 10:52 a.m. Resident #1 slapped a certified nurse aide (CNA) on the right side of their face while their back was turned to the resident. The staff member documented they had redirected him to have a seat on his bed. His documented response was he laughed. A progress note documented on 10/18/2020 at 12:09 p.m. Resident #1 was physically and verbally aggressive with staff during cares. The CNA documentation on 10/23/2020 noted Resident #1 displayed abusive language, restlessness, rejection of care, and striking out behaviors. Attempted the intervention redirection which made the behaviors worse or unchanged. The behavior monitoring tracking form documented on 10/23/2020 at 10:50 a.m. Resident #1 was observed punching his television three times. He was cussing and refusing care. The staff documented they had redirected him. His response was to cuss and refuse care, eventually quieting down. The CNA documentation on 10/28/2020 noted Resident #1 displayed striking out and restlessness behaviors. Attempted intervention of redirection provided partial improvement. No specific information was documented to indicate what interventions were done for Resident #1 to ensure other staff utilized the same redirected measures for future occurrences that were the least restrictive. November 2020 The CNA documentation on 11/16/2020 noted Resident #1 displayed pacing behavior. Attempted interventions are unknown. The behavior monitoring tracking form documented on 11/17/2020 at 5:15 p.m. Resident #1 made a lewd gesture by putting his hands to his genitals and grunting loudly. He was redirected to his room to watch television. His response was to sit in his chair and did not want his television on. The CNA documentation on 11/17/2020 noted Resident #1 displayed abusive language behavior. Attempted interventions are unknown. The behavior monitoring tracking form documented on 11/18/2020 at 7:00 p.m. Resident #1 was pulling a CNA's hair trying to hit her face. The staff put a movie on his television to calm him down. His response was to continue to yell in his room. The CNA documentation on 11/25/2020 noted Resident #1 displayed yelling/screaming/calling out behaviors. Attempted interventions are unknown. The CNA documentation on 11/26/2020 noted Resident #1 displayed pacing behavior. Attempted interventions are unknown. The CNA documentation on 11/28/2020 noted Resident #1 displayed throwing objects behavior. Attempted interventions are unknown. The CNA documentation on 12/2/2020 noted Resident #1 displayed grabbing behavior. Attempted interventions are unknown. No specific information was documented to indicate what interventions were done for Resident #1 to ensure other staff utilized the same redirected measures for future occurrences that were the least restrictive. Cross-reference F605 The facility failed to update the care plan interventions, monitor, and were not reviewed for efficacy after several behavioral episodes with physical aggression were documented. After the increase in documented behaviors, the facility failed to review interventions for efficacy and ask family for suggestions to help person-center and individualize the care plan for Resident #1's dementia and increasing aggressiveness in a timely manner. IV. Interviews The Power of Attorney (POA) was interviewed by phone on 12/7/2020 at 1:30 p.m. She said when she called the facility to see how her dad was doing, she was told he had been a little restless and a bit irritable. She said no one called her when her dad had a behavior, nor did the facility ask for advice for interventions, and she wanted to be involved. She said she knew her dad very well and the facility never asked her to offer suggestions for him when he was being aggressive and or angry. When she was called after an outburst that resulted in a [MEDICATION NAME] injection, she told the facility not to let him watch scary movies or R rated movies because they can cause outbursts and behaviors. She suggested to let him watch Disney movies and big bang theory. She said she asked to be notified of any and all future behaviors day or night to possibly offer suggestions to help calm him. Certified nurse aide (CNA) #1 was interviewed on 12/7/2020 at 3:05 p.m. She said Resident #1 did have behaviors. She said the facility stopped letting him watch scary movies and R rated movies and he had become calmer. She said when he had a behavior she would tell the nurse and document the behavior in the kiosk. She said she had received training on dementia. She did not identify specific interventions for Resident #1 when he would display behaviors. Housekeeper (Hskg) #1 was interviewed on 12/7/2020 at 3:10 p.m. She said she did not know of any behaviors from Resident #1. She said she would tell the nurse if she saw anything unusual. She said she received training on dementia. She said if she saw any behaviors from Resident #1 she would tell the nurse on duty. Registered nurse (RN) #1 was interviewed on 12/7/2020 at 3:20 p.m. She said Resident #1 did not display behaviors until recently. She said the R rated movies and scary movies seemed to set him off, and since he no longer watched the movies his behaviors decreased. She said the behaviors were tracked in the behavior monitoring tracking form. She said she had received training on dementia. She did not identify specific person centered interventions when Resident #1 displayed behaviors. The director of nursing (DON) was interviewed on 12/7/2020 at 4:25 p.m. She contacted the daughter on 11/19/2020 and the daughter offered suggestions to include restricting R rated movies and scary movies. She said the resident had a history of [REDACTED]. She said the intervention utilized was redirection. She said redirection was a very broad intervention and could be used in a variety of ways. She said she had not asked the daughter for suggestions while Resident #1's behaviors increased to lead up to the [MEDICATION NAME] injection. She said the suggestion to stop rated R and scary movies was received and implemented after talking to the daughter about the [MEDICATION NAME] injection. She said she had trained the staff to avoid rated R and scary movies for Resident #1. She said since the change in movies and television shows the behaviors decreased. She said the one to one interventions from the SSD care plan was not attainable at this point and would revise the care plan as well as the care plans to address the movies and preferences. She said the goal of the facility was to have person centered individualized interventions for Resident #1.

Based on observations, record review and interviews, the facility failed to maintain acceptable parameters of nutritional status for two (#3 and #17) of four residents reviewed for nutrition out of 13 sample residents. The facility failed to appropriately assess and timely address the Resident #3's significant weight loss and initiate nutritional interventions. According to the record review and interview the registered dietitian (RD) was not involved in the Resident #3's weight loss evaluation and nutritional assessment. Furthermore, Resident #3 was at nutritional risk due to his [DIAGNOSES REDACTED]. Speech therapy (ST) recommended mechanical soft/ground textures diet. The facility's failures contributed to Resident #3 sustaining significant weight loss of 31 pounds (lbs) which was 20% in six months. Furthermore, Resident #17 at nutritional risk due to needing staff assistance at meals. The resident was not consistently weighed weekly with the risk of weight loss outlined in her comprehensive care plan. The RD was not notified timely of weight loss to complete evaluation and nutritional assessment. Due to the facility failures, Resident #17 sustained a significant weight loss of 14 lbs, which was a 11.4% weight loss in about seven weeks. Findings include: I. Facility policy and procedure The Nutrition policy and procedure, dated 1/12/16, was provided by the director of nurses (DON) on 10/1/2020 at 9:30 a.m. read in pertinent part; Based on a residents comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the residents clinical conditions demonstrate that this is not possible. II. Resident #3 A. Resident status Resident #3, age 72, was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The 7/20/2020 MDS assessment revealed the resident's cognitive skills for daily decision making were severely impaired. He required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use and personal hygiene, and extensive assistance of one person with eating. His weight was 125 lbs and weight loss was documented and not being on physician prescribed weight loss regimen. Daily medications routine included an antipsychotic and antidepressant. B. Record review The comprehensive care plan revealed: Nutrition: (Resident's name) could have potential for weight fluctuate r/t (related to) him walking up and down the halls and burning more calories than he takes in, (Resident's name) has an allergy to raw tomatoes. (Resident's name) is currently in a wheelchair d/t (due to) a fall he had and upon his return from the hospital. (Resident's name) needs more assistance and monitoring and needs to eat in the dining room during the COVID-19 non communal dining. (dated 7/31/2020) Interventions included: Monitor weights as ordered. Obtain food preferences and offer as able. Offer food alternates of equal nutritional value. Provide, serve diet as ordered. Regular/Regular/Thin. Monitor intake and record q (every) meal. -The care plan failed to address Resident #3's significant weight loss, specify his food preferences and nutritional interventions (see below). Resident #3's weights documented in his medical record: 3/2/2020 - 151 lbs 5/28/2020 - 145.7 lbs, 5.3 weight loss which was 3.5% 8/31/2020 - 120 lbs, 31 lbs total weight loss since 3/2/2020 which was 20.5% weight loss in 6 months. The 4/9/2020 Dietary Nutritional Assessment completed by the dietary manager (DM), revealed: (Resident's name) was on a regular diet and tolerated his current texture without difficulties. His meal intake has been 76-100% for breakfast and 50-75% for lunch and supper, fluids were less than 1000 milliliters (ml) with meals. He liked to drink Pepsi at most of his meals and in between meals. Current weight was 146.8 w/BMI of 27.7 overweight. He has maintained his weight in the range of 151 to155 since his admission, however over the last 30 days his weight was 146.8 which was down 4.2 lbs. in 30 days. No labs to report at this time. Will continue to monitor. -There were no additional interventions added when the resident had 4.2 lbs weight loss in 30 days. The 6/29/2020 weight warning note documented by the DM, revealed Resident #3's weight was 133 lbs, 12.1 lbs weight loss (8.3%) over a 30 days period. (Residents name) has a history of wandering around the hall most all of the day, this could contribute to some of his weight loss. Will continue to monitor. -There were no additional nutrition interventions added when the resident had a 12.1 lbs weight loss to meet his nutritional needs with him wandering with increased activity. The 7/16/2020 weight warning note documented by the DM, revealed Resident #3's weight was 125.2 lbs, 8.4 lbs weight loss (6.3%) from last weight (6/29/2020). (Resident's name) weight reflects a weight loss on 8#'s (lbs) from his last weight, this was his weight upon return from the hospital, we will use the (weight) as our new baseline weight for (Resident's name). Will notify (NP, nurse practitioner) of his weight loss and see what her recommendations are. -No recommendation from the physician or NP were documented in Resident #3's medical record. Additionally, the resident had 8.4 lbs weight loss without adding additional nutritional interventions and documenting that was considered his new baseline weight when previous records indicated his baseline weight was 151 to 155 lbs. The 7/19/2020 Dietary Nutritional Assessment, completed by the DM, revealed: (Resident's name) is on a regular/regular/thin diet staff makes food choices for him based on past food preferences. He is currently eating all of his meals in his room d/t (due to) COVID-19 non communal dining. He does have an allergy to raw tomatoes. His meal intake has been 25-50% need to encourage fluids. He likes Pepsi for lunch and supper. Has no teeth or dentures and tolerates the texture without any difficulties. -The resident had a 8.4 lbs weight loss per weight warning note on 7/16/2020 which was not addressed in the Dietary Nutritional Assessment and his meal intake was only 25-50% which was not meeting his nutritional needs based on the resident's continued weight loss. The 7/19/2020 Speech Therapy Evaluation and Plan of Treatment revealed Resident #3 was referred to ST due to new onset of decreased oral/pharyngeal function and decreased safety during oral intake placing patient at risk for aspiration. The evaluating therapist recommended a mechanical soft/ground texture diet with thin liquids. -The ST recommended diet texture to prevent risk for aspiration was not documented in Resident #3's care plan and the resident was not served the appropriate diet (see resident observations below) The 8/27/2020 Nurse Practitioner note revealed Weight is stable last month although he has lost 20# (pounds) since May (2020). -There were no additional interventions implemented with the resident's continued weight loss since May 2020. The physician's orders [REDACTED]. The 9/4/2020 weight warning note documented by the DM, revealed Resident #3's weight was 120 lbs, 7 lbs weight loss (5.5%) over 30 days period. (Resident's name) weight reflects a weight loss in 30 days. His meal intake has declined a little some days he will eat really good and then other days he will only eat 25-50% of his meals. His weight has been in the range of 120-127 over the last 4 weights. His current BMI is 22.7 a healthy weight. Will continue to monitor. Record review revealed the resident was not assessed by a registered dietitian (RD) for his weight loss since he started losing weight identified in April 2020. There were no interdisciplinary team notes related to Resident #3's significant weight loss assessment of nutritional interventions added with his ongoing weight loss since April 2020. C. Resident observations On 9/29/2020 at 12:30 p.m. Resident #3 was observed in his room, sitting in his wheelchair. He was assisted by a certified nurse aide (CNA) with his lunch meal. The meal included pork chop, baked potato, glazed carrots and biscuit. The pork chop was not grinded. The resident consumed a small piece of the pork chop, and a couple bites of the potato and carrots. The resident ate approximately 25% of his lunch meal. On 9/30/2020 at 12:39 p.m. Resident #3 was observed in his room, assisted by CNA#1 with lunch meal. The meal included beef Stroganoff, egg noodles, seasoned broccoli and roll. The resident ate just the broccoli. At 12:45 p.m., CNA #1 was taking the food tray out of the resident's room and said Resident #3 consumed less than 25% of his meal. Resident #3's meal intake record was reviewed with the DM on 10/1/2020 at 9:00 a.m. The 9/29/2020 and 9/30/2020 lunch meal intake was documented 51%-75%, which was documented incorrectly since he ate approximately 25% at each meal observed. D. Staff interviews CNA #1 was interviewed on 9/30/2020 at 1:14 p.m. He confirmed he routinely worked with Resident #3 for the past couple months. He said he was not able to provide any care for himself and required total assistance to eat his meals. He said the resident was receiving regular diet, regular texture meals as most residents. He said he did not know the resident's food preferences. He said when Resident #3 refused to eat his meal, the staff did not offer him any other food choices. CNA #1 said meal intakes were recorded by each CNA for each resident they took care of that shift and entered into the medical record. The dietary manager (DM) was interviewed on 10/1/2020 at 9:00 a.m. She said Resident #3 was on regular diet and regular texture. She said she was aware of Resident #3's significant weight loss. She said the facility had a contract with a registered dietitian (RD), however the RD was not coming to the facility since March 2020 due to the pandemic. She said she was not a certified dietary manager however she was working to obtain the certificate by the end of this year. She said she was working in the facility's dietary department and was promoted to the dietary manager position. She said she was completing all of the nutritional assessments for all residents in the facility including newly admitted residents and residents who sustained a weight loss. She said Resident #3 was not assessed by the RD or the NP for his weight loss and consequently he was not on any nutritional/ protein supplementation. She said she did not know Resident #3 food preferences and did not contact his family to ask about his favorite foods. She said she would call the resident's daughter and ask after the weight loss was identified on survey. She said she will talk to the nurse practitioner about nutritional supplement forResident #3. She said she did not observe residents during their meals to see their meal intake or what they were eating as she was helping in the kitchen and passing the food trays to residents. She said she would provide education to staff on how to appropriately document meal intakes. The DM said according to the meal intakes record Resident #3 should not be losing weight. -However, there were no RD assessments that determined he was meeting his nutritional needs. III. Resident #17 A. Resident #17 Resident #17 age 94, was readmitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 8/20/2020 minimum data set (MDS) assessment revealed the resident had cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. She had extensive assistance of two persons for toileting, transfers, dressing and hygiene. She was limited to one person assist with meals. No weight loss, no swallowing or nutrition issues. B. Record review The resident's weight on readmission 8/13/2020 was 122.6 pounds (lbs), 8/20/2020 weight was 121.6 lbs, 9/4/2020 weight was 111.2 lbs (9.2% in about three weeks) and on 10/1/2020 weight was 108.2 lbs. -The resident had a total of 14 lbs weight loss, which was a 11.4% weight loss in about seven weeks. Weekly weights were not obtained for three weeks after she lost weight on 9/4/2020, as outlined in her nutrition care plan (see below). The nutritional assessments dated 6/22/2020 and 8/6/2020 under sections for Resident #17 N(estimated nutritional needs) how many calories, protein and fluids were needed, and P(nutrition care process) nutritional interventions, recommendations and care plan, showed no documentation to be filled out. -There were no nutritional assessments completed on 9/4/2020 or 10/1/2020 when the resident had significant weight loss to determine her estimated calorie, protein and fluid needs. The nutrition care plan dated 7/17/2020 for Resident #17 read in pertinent part; Resident was on a CCHO (constant carbohydrate diet), she was able to make her own food choices and right now ate all of her meals in her room due to non communal dining. Resident #17's weight was to remain stable without significant change through the next review. The interventions were to encourage the resident to comply with meal intake and explain consequences of refusal which were malnutrition risk factors. Offer food alternates of equal nutritional value. Monitor/record/report to the physician as needed and signs or symptoms of malnutrition: emaciation (Cachexia), muscle wasting, significant weight loss: three pounds in one week, greater than five percent weight loss in one month, greater than seven and a half percent weight loss in three months and greater than 10 percent weight loss in six months. RD (registered dietitian) to evaluate and make diet change recommendations -However, the RD was not notified timely when the resident had weight loss on 9/4/2020 and 10/1/2020 and she did not have consistent weekly weights identified in her care plan. The activities of daily living (ADL) care plan for eating dated 7/17/2020 read in pertinent part; Resident #17 required meal set up assistance by one staff person to eat. Meal intake log for September 2020 read in pertinent part; Resident #17 had six out of 90 meals at 25 percent (%) intake, 14 meals out of 90 at 25-50% intake, 30 meals out of 90 at 50-75% intake and 27 meals out of 90 over 75% intake. C. Facility follow-up The registered dietitian (RD) note dated 9/30/2020 (during survey) at 4:48 p.m. for Resident #17, read in pertinent part; Noted weight change to 111 pounds with a body mass index (BMI) of 17.9. Reviewed diagnoses, available labs and history and physical. Resident #17 noted to be eating less, and was more active in movement. Estimated calorie needs of 1258 to 1510, and the resident appeared to be offered that. Recommend to offer house milkshakes, verify weight with possible wheelchair attachments and liberalize diet to regular. No other assessments or notes from the RD since admit. IV. Staff interviews The dietary manager (DM) was interviewed on 9/30/2020 at 11:04 a.m. She said when a resident lost weight she filled out the section on the minimal data sheet (MDS) which triggered the care plan to be updated. She said when a resident had swallowing or chewing difficulty the RD would complete the assessment. Licensed practical nurse (LPN) #1 was interviewed on 10/1/2020 at 9:30 a.m. She said when a resident had weight loss the computer triggered the facility to look at that resident. She said the dietary manager called the physician to get a supplement ordered for the resident and then told the nurse. Registered nurse (RN) #2 was interviewed on 10/1/2020 at 9:45 a.m. She said when a resident lost weight the dietary manager was aware and supplements were ordered. Certified nurse aide (CNA) #4 was interviewed on 10/1/2020 at 12:10 p.m. She said snacks for residents were delivered in the afternoon. She said she had not seen the snack cart in a few days. The director of nurses (DON) was interviewed on 10/1/2020 at 1:15 p.m. She said residents who lost weight were started on a supplement drink to help promote weight gain. The RD assessment was completed for any new interventions.

Based on observations, record review and interviews, the facility failed to ensure one (#43) of two residents reviewed for accident hazards out of 21 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to implement individualized safety interventions resulting in the resident sustaining a fracture of her upper extremity and head trauma. The findings included: Resident #43 Resident Status: Resident #43, age 82, was admitted on [DATE]. According to the October 2017 computerized physician orders [REDACTED]. No minimum data set (MDS) assessment available as the resident was a new admission. Record Review: 1. The resident's care plan, initiated 10/16/17, identified the resident was at high risk for falls related to (r/t) deconditioning, gait/balance problems and unaware of safety issues. Interventions included the resident required a safe environment with non-skid socks, anticipate and address resident's needs, ensure call light was in reach and encourage resident to use the call light. The resident needed prompt response to all requests for assistance. Educate elder (resident) and family about safety and reminders of what to do in the event of a fall. 2. Resident Falls 10/17/17 associated with injury and pain Record review revealed the resident fell twice within three hours. There was insufficient evidence care planned interventions to keep the resident, who was known to be at high risk, safe. Moreover, there was no evidence the resident was assessed by qualified staff after either fall. Cross reference F282. a. First fall at 7:35 p.m. A log note dated 10/17/017 at 7:35 p.m. documented in part: Staff in to notify this nurse that elder had fallen trying to get assistance. Elder was sitting on her coccyx in front of team window. Elder had scooted on her bottom from her room. Elder v/s (vital signs) taken and range of motion (ROM) were all within in normal limits (WNL). Elder did not complain of (c/o) pain at this time. Elder was assisted back to her room via w/c (wheelchair). Signed by LPN #1. There was no documentation in the resident's record of neurological assessments following the fall on 10/17/17 at 7:35 p.m. and none provided during survey. In addition, there was no evidence the resident was assessed by a registered nurse. There was no documentation the cause of the fall was investigated, no evidence whether the call light was accessible and used by the resident, and no evidence whether the resident was wearing non-skid socks, both expectations per the resident's care plan. b. Second fall at 10:15 p.m. A log note documented in part: Elder (resident) found sitting on floor beside bed. Elder had a large goose egg on right forehead. Elder c/o right wrist pain. Elder v/s taken and ROM, T (temperature) 97.8, P (pulse) 93, R (respirations) 24, B/P (blood pressure)192/124, O2 (oxygen saturation) 94 RA (room air). Elder was assisted to w/c and ice pack applied to wrist. Physician notified of the fall (second fall tonight). Family notified of the fall. Physician wanted frequent checks done on elder to watch for any symptoms of bleeding. Elder was already on falls/neuro from previous falls this evening. Elder had a handrail on bed yesterday and tonight they are not there. A handrail and bed chair alarms would help with falls in the future. An incident report dated 10/17/17 (no time provided), also completed by LPN #1, documented in part: Elder noted to be sitting on floor beside her bed. Elder has a bump on right forehead. Elder ROM and v/s taken T 97/8 P 93. R 24 B/P 192/124, O2 94%. Elder was assisted to wheelchair. Elder c/o right wrist pain. Elder was assisted back to her room and helped to bed. Elder was using both arms to help herself into bed. At this time elder did not complain of very much pain while using her arms. Elder was talking and was smiling at staff ice was applied to elders arm for comfort. Physician called on call for dr. (doctor) stated to monitor elder B/P and if B/P does not go down to go ahead and send her to ER (emergency room ). In addition, family notified of fall daughter stated she would be in in the morning to see elder. Elder already on fall/neuros and continued monitoring elder. Dr. ordered transportation to ER for thorough evaluation if nurse felt elder needed to be seen. Head injury top of scalp and right wrist. Predisposed confused gait imbalance identified as high risk for falls, poor impulse control weakness fainted fall in past 30 days impaired memory. Recent room change ambulating without assist. Another incident report dated 10/17/17 at 10:30 p.m. by LPN #1 documented in part: 10/17/17 Elder has fallen twice this evening. Elder would benefit from chair and bed alarm to prevent future falls. On 10/17/17 10:30 p.m., staff to get nurse, elder had fallen for second time. Elder was sitting on the floor beside the bed. Elder has a bump on her right forehead. Elder also states her arm is hurting. Elder was assessed for injuries v/s and ROM of all extremities checked. Elder was assisted to w/c. Staff then assisted elder to bed, elder was using both arms to help assist herself to bed. Elder was not complaining of very much pain at this time. Elder was checked on several times and only stated her arm hurt a little she was still using her arms, she was smiling and talking normally, there was no grimacing, groaning or guarding of her arm. Ice pack applied to elders arm at this time. Elder stated the ice felt really good. At 12:30 a.m., elder was asleep in bed with eyes closed. No c/o pain at this time. At around 2:00 a.m., elder awakened wanting to know why I would not let her take a shower. Elder was still not complain of much pain. At 3:00 a.m., elder c/o of more pain and pain medication was given to elder. Elder repositioned herself in the bed and went back to sleep. At 4:45 a.m., elder was complaining or more pain and elders arm was a little swollen. Elder's daughter notified and decision made to take elder to ER. Daughter stated she wanted to transport elder to ER in personal vehicle. While there was evidence the resident was monitored through the early morning on 10/18/17, there was no evidence staff monitored the resident after her first fall until she fell a second time, no evidence staff ensured the resident's call light was accessible and that the resident understood its use, and no evidence the resident was in non-skid socks. As with the resident's earlier fall, there was no evidence the resident was assessed by a registered nurse (RN) after the fall. A log note dated 10/18/17 at 5:28 a.m. documented in part: Elder having pain from wrist wants to go to hospital. (Vital signs) taken T 96.9, R 20, P 72, B/P 211/109 and O2 91 RA. Elder's daughter was called to notify her B/P and elder was going to ER per Dr. Order. Daughter wanted to take elder in personal vehicle. Elder left with daughter at 6:00 a.m., to ER. Signed by LPN #1. c. Harm A log note dated 10/18/17 at 10:45 a.m. documented in part: Resident returned from visit at ER. Daughter transported the resident in her private vehicle. ER noted reviewed with Dr. Will order tylenol #3 as ordered with Dr. approval. Awaiting Orthopedic consult from Dr. Will continue with fall charting. VS upon arrival 160/80 72-20-98. 98. 0-94%. The emergency report dated 10/18/17 and received 10/31/17 read in part, Soft cast in place until arm can be put in hard cast. Continue on therapies until consultation. On 10/19/17 at 8:23 a.m., the resident was observed sitting in the dining room. She stated she had broken her arm but could not recall what happened. She was observed to have a cast on her wrist. C. Staff Interviews Staff interviews indicated an insufficient number of staff to meet the resident's safety needs, as care planned. Interview further revealed staff failed to ensure the resident was properly assessed after her falls. LPN #1, interviewed on 10/18/17 at 6:46 a.m., said the facility has two certified nurse aides (CNAs) during evening shifts and for the acuity of the facility residents, we do not have enough staff available. The LPN said, We have one resident who requires three CNAs to assist her which takes away from other residents on the hall. We have three new residents which has added a lot of work. One resident was currently under isolation precautions, which also takes away from staff. We have a resident who wanders and another resident who falls out of bed and a resident who gets angry when we do not answer (the) call light in a reasonable time. Then resident #43 had two falls in one evening. CNA #2 interviewed on 10/18/17 at 7:18 a.m., said We consider all residents to be a fall risk but we can not watch them all. The director of nursing (DON) was interviewed on 10/19/17 at 11:40 a.m. The DON said she had an in-service with nursing staff. The DON said she instructed all nursing staff that when a resident has a fall she is the first person who needs to be contacted. DON said night staff had not been calling her after a fall. The DON stated staff should not be moving the resident prior to calling her. She said she was aware a LPN could not do an initial assessment with a potential head injury. The DON said a LPN could not adequately assess a resident and could miss an intracranial bleed where an RN could properly assess the elder.

Based on record review and interviews, the facility failed to ensure sufficient nursing staff to provide nursing-related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual care plans for 21 sample residents, including residents #1, #2, #4, #5, #7, #29, #30, #33, #39, #43 and #44. Specifically, the facility failed to provide sufficient staffing to ensure cares were provided to the residents. This contributed to a failure to implement resident #43's care plan to address her risk for falls. The resident fell twice in one evening and sustained a fracture and head injury. The facility's failure to ensure sufficient staff also contributed to reported waits for staff assistance of over an hour, contributing to attempts to transfer independently and incontinence, as well call lights were answered timely, residents not checked, changed or repositioned timely and bathing was not always completed. The findings included: A. Cross-referenced deficiencies F-222 failure to prevent chemical restraints related to antipsychotic administration to resident #30. F-282 failure to ensure a registered nurse completed assessments after falls for resident #43 and #39. F-309 failure to have an effective system in place to evaluate and treat resident #2, #30 and #33's pain. F-311 failure to provide a restorative program for resident #2 to maintain or improve activities of daily living (ADLs). F-312 failure to provide necessary assistance to the bathroom and/or with incontinence care for resident #29. F-314 failure to provide timely repositioning for resident #2 to prevent pressure injuries. F-323 failure to provide supervision for resident #43 to prevent accidents with injury. Resident #43 fell twice in one evening, sustaining a fracture and head injury. F-327 failure to provide adequate hydration for resident #2. F-329 failure to ensure nonpharmacological interventions were attempted for resident #13 prior to administering an as needed (PRN) medication. The cross-referenced deficiencies above revealed an insufficient number of staff to ensure, among other quality of life and care expectations, that resident choices were honored, assessments were completed and that repositioning, restorative services, accident prevention, pain and incontinence were timely and adequately provided and/or managed. B. Record Review According to the Resident Census and Conditions report signed by the director of nursing (DON) on 10/16/17, the resident census was 28. The report indicated all residents required some staff assistance with activities of daily living. A number of residents were dependent on staff. The following care and service needs were enumerated in the report: -13 residents required assist of one to two staff for bathing and 15 residents were dependent for bathing. -23 residents required assist of one to two staff for dressing and five residents were dependent for dressing. -22 residents required assist of one to two staff for transfers and five residents were dependent for transfers. -23 residents required assist of one to two staff for toilet use and five residents were dependent for toilet use. -28 residents required assist of one to two staff for eating -19 residents were occasionally or frequently incontinent of bladder. -12 residents were occasionally or frequently incontinent of bowel. -2 residents were bedfast all or most of the time, 19 residents were in a chair all or most of the time. -7 residents ambulated with assistance or an assistance device. -3 residents had contractures. -2 residents had pressure ulcers. Both residents with pressure ulcers had pressure ulcers present on admission to the facility. -28 residents were receiving preventative skin care. -7 residents had documented signs and symptoms of depression. -14 residents had dementia-related diagnoses. -2 residents had behavioral healthcare needs. -9 residents were on psychoactive medications including two residents on antipsychotic medications. -14 residents were on a pain management program. -5 residents were receiving rehabilitation services. -1 resident had significant, unplanned weight loss. Resident council minutes were reviewed from June 2017 to September 2017. -The July council meeting read in pertinent part, Counsel reported increased time of call lights being answered again with one elder reporting she and her husband are timing aides 45 minutes or longer to get assistance. -The August council meeting read in pertinent part, Shower schedules are not being followed as elders' report not getting their scheduled showers. C. Interviews 1. Resident Interviews Resident #7 was interviewed on 10/17/17 at 10:57 a.m. He said he did not get the help he needed timely when he turned the call light on. The resident said he waited anywhere from 30 minutes to an hour depending on how many staff were working. He said he asked why they were short of staff and was told there were enough staff. Resident #44, who had a recent fracture of his hip and elbow and who was unable to ambulate without staff assistance, was interviewed on 10/19/17 at 9:12 a.m. He said the facility was short staffed most days. The resident said it affected him when he had to wait 20-30 minutes to get help to the bathroom after he turned the call light on. He said he'd had diarrhea since admission and attempted to get to the bathroom independently and didn't make it a few times. The resident said the staff finally went in to help him and ended up having more work to do because he could not wait. Resident #1 was interviewed on 10/18/17 at 3:36 p.m. She said the evening shift was always short of staff. The resident said she had to wait until the other residents were in bed before she could get a shower, usually after 10:00 p.m. She said she had to wait a half hour or longer for the call to be answered a minimum of five to six days a week and it was all shifts because other residents needed help, too. She said the residents who were unable to use the call lights did not get help until the staff could get to them. Resident #5 was interviewed again on 10/19/17 at 9:12 a.m. She said the staff were swamped and could not get to her. The resident said it took a half hour to an hour and a half at times for her light to be answered. She said they walked in and told her they would return and got busy and forgot. The resident said when the staff finally entered the room to help her, they worked as fast as they could because there were other lights on. She said there were times she needed medication and the CNAs forgot to tell the nurse and also times forgot to go back to her room and finish helping her. The resident said the staff worked double shifts often and were tired of working short and the residents did not get their needs met. 2. Family Interviews The family member of resident #2 was interviewed on 10/16/17 at 12:50 p.m. She said there was not always enough staff to help when needed. The family member said there were times her family member did not have help with repositioning and changing when soiled or wet in a timely manner. She said they had to wait 45 minutes a few times for a small tank of oxygen. The family member of resident #4 was interviewed on 10/16/17 at 12:23 p.m. She said they never had enough staff and they had cut back on CNA hours. The family member said she asked administration about the lack of staff and they told her one CNA to 10 residents was sufficient. She said they had more staff today than normal on the floor and dining room for lunch. She said the administrative staff had told her staffing was appropriate for the number of residents. She said her family member needed two people to assist with changing when soiled or wet and with ADLs. She said her family member was incontinent and had several urinary tract infections, and thought it could be due to sitting for a half an hour or longer when soiled or wet. The family member said she has asked staff to check on the resident's needs instead of asking, because the resident was not able to give an accurate answer of what her needs were. 3. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 10/18/17 at 6:46 a.m. She said the facility did not schedule a registered nurse (RN) for the third shift when she worked. She said there was an on-call RN, but she did not call them. -The LPN said she and two CNAs were scheduled from 10:00 p.m. to 6:00 a.m. She said they had one resident who required all three staff when care was provided. The LPN said they did not have extra staff to care for the other residents for approximately 30 minutes while they provided care for this resident. -The LPN said they needed at least a fourth person. The LPN said they had four new residents admitted within the last couple of weeks that had added a lot of extra work at night. She said one resident wandered throughout the night, a couple of the residents were high risk for falls and another resident would get angry when his call light was not answered timely, within five minutes. The LPN said it was difficult to make sure she completed medication administration, treatments and wound or skin care. CNA #2 was interviewed on 10/18/17 at 7:18 a.m. She said there were several residents who required one and two person assistance; she was unable to give exact number. The CNA said they worked short 1-2 times a week when someone called off and was not replaced. She said it was difficult with four CNAs but it was more difficult with three. The CNA said lights were not answered timely and care - such as bathing and getting the resident to the bathroom or changed - was not always completed the way it should be. CNA #1 was interviewed on 10/18/17 at 2:33 p.m. She worked from 2:00 p.m. to 10:00 p.m. and occasionally worked 10:00 p.m. to 6:00 a.m. The CNA said there were three CNAs from 5:00 p.m. to 10:00 p.m. and only two from 10:00 p.m. to 6:00 a.m. -She said there were nine to ten residents who required two person assist for transfers, toileting and other cares. She said it was difficult when residents wanted to go to bed and they had to wait 30-45 minutes until two people were available. The CNA said there were two residents who required three staff members to provide care, one all of the time and another one sometimes because the resident was afraid of the lift and required two to guide for the resident's comfort. -She said when a CNA called off the work load was difficult and the residents had to wait longer for care. She said the floor nurses helped when they could but the management team did not leave their offices to help. -The CNA said residents were not getting bathed as scheduled because there was not enough staff, the restorative CNA, who helped with bathing and restorative was let go because the census was down. She said there were days when her shift started and she was not able to bathe residents as scheduled. -The CNA said the resident who fell twice on 10/17/17 (cross reference F323) was found by the activity director on the floor outside of the staff room. CNA #1 was bathing a resident, the other CNA was assisting LPN #1 with a dressing change. She said there was no staff on the floor and she had to choose between leaving the resident she was bathing alone or helping the resident who fell . She asked the activity director to look for the nurse and other CNA and the resident was on the floor until they were located and she was assessed. The CNA was not working when the resident fell a second time, but was informed at shift change she had broken her arm and she could see the goose egg on her forehead. Registered nurse (RN) #3 was interviewed on 10/18/17 at 3:20 p.m. She said staff had to work short a few times a week due to call offs. -The RN said low staffing caused additional work and it rolled into the next shift being behind and the residents' care not as it should be. She said call lights were not answered timely, residents were not checked or changed timely and bathing was not always completed. The RN said the nurse had to help from 5:00 p.m. to 6:00 a.m. because there were three CNAs from 5:00 p.m. to 10:00 p.m. and two CNAs from 10:00 p.m. to 6:00 a.m. -The RN said there were residents who required three staff for assistance, and when staff were in these residents' rooms there was no staff to care for or watch over the other residents. She said there was only one RN scheduled from 6:00 a.m. to 6:00 p.m. on weekends to complete wound care, treatments and administer medication and help the CNAs when needed. The nursing home administrator (NHA) was interviewed on 10/19/17 at 12:40 p.m. She said she had placed ads the last few months, completed a pay study and determined they offered a competitive and above minimum wage, but it has been a challenge to hire. The NHA said they recently hired an RN and a CNA for the night shift, although they had not yet started their employment. She said they also added a full time CNA from 9:00 a.m. to 5:00 p.m. to help during the busiest time to help the other four CNAs answer lights and with resident care. The NHA said staff requirements were determined by patient per day and acuity in determining the number of CNAs per shift. The NHA and director of nursing said they both covered shifts when needed. The NHA said she had not identified any negative outcomes related to staffing. C. Staffing schedule Review of the September and October 2017 staffing schedule confirmed the level of staffing reported in the interviews above. However, as noted in the Resident Census and Condition, as well as the cross-referenced deficiencies, this staffing level led to falls and delays in staff assistance, in particular, during the overnight shift with residents requiring two or three staff person assist. 1. CNA Schedule for 10/1-10/19/17 Day shift 6:00 a.m. - 2:00 p.m.: 3 CNAs from 10/1-10/15 and 10/17-10/19 2 CNAs 10/16 and 1 CNA worked 10a.m. -2:00 p.m. on 10/16/17 1 CNA Monday through Friday from 9:00 a.m. to 5:00 p.m. Afternoon Shift 2:00 p.m. to 10:00 p.m. 3 CNAs from 10/1-10/19/17 Night Shift 10:00 p.m. to 6:00 a.m. 1 CNA worked the day shift and night shift on 10/1/17 2 CNAs scheduled from 10/1-10/19/17 2. CNA Schedule for September 2017 Day shift 6:00 a.m. - 2:00 p.m.: 3 CNAs from 9/1-9/30/17 1 Bath aide 9/1/17, 9/14/17, 9/5/17, 9/6/17, 9/7/17 Afternoon Shift 2:00 p.m. to 10:00 p.m. 3 CNAs from 9/1-9/30/17 Night Shift 10:00 p.m. to 6:00 a.m. 2 CNAs scheduled from 9/1-9/30/17.