Every finding on record at Horizons Care Center

Based on record review and interviews, the facility failed to report and investigate allegations of abuse involving three (#2, #3 and #7) of six residents reviewed for abuse out of 11 sample residents.Specifically, the facility failed to timely report potential abuse towards Resident #2, Resident #3 and Resident #7.Findings include:I. Facility policy and procedureThe Resident Protection Freedom from Abuse, Neglect, and Misappropriation policy, revised 11/3/22, was provided by the nursing home administrator (NHA) on 1/5/26 at approximately 6:00 p.m. It read in pertinent part, Each individual has the right to be free from verbal, sexual, physical, and mental abuse, including injuries of unknown source, misappropriation of resident property, corporal punishment, mistreatment, including, but not limited to, facility/service staff, other resident, consultants, volunteers, or other individuals. Employees must always report alleged abuse/neglect immediately to the supervisor or the building supervisor. The executive director /or designated representative must be contacted immediately by the supervisor or reporter regarding all allegations of abuse/neglect. Immediately reporting may be reported via voicemail/answering machine. Document the date and time of notification. The director of nursing will be contacted per protocol and will involve social services or designee. If there is suspicion that abuse occurred, it will be reported to the state reporting agency in accordance with the state law immediately, not later than 2 (two) hours if the alleged violation involves abuse or results in bodily injury and 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury.II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and passed away on 10/31/25. According to the October 2025 computerized physician orders (CPO), diagnoses included major depressive order, single episode, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting right dominant side, aphasia following cerebral infarction and Parkinson's disease without dyskinesia. The 9/11/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. Resident #2 had functional limitations of range of motion with his upper and lower extremities and used a wheelchair for mobility. He required staff assistance for his activities of daily living (ADL) and was dependent on staff to bathe, toilet, dress and transfer from surface to surface. The MDS assessment documented Resident #2 did not have physical or verbal behaviors directed at others and did not have rejections of care. B. Record reviewThe vulnerability care plan, resolved 6/18/25, identified Resident #2 was at risk for being vulnerable related to his cognition, hearing loss, slurred speech and use of a wheelchair. The care plan documented staff would provide a safe environment for the resident. -Review of the comprehensive care plan did not identify a care plan or care plan interventions between 6/18/25 and 10/31/25 that addressed the resident's vulnerability risk related to his physical and cognitive limitations. A 9/2/25 incident note documented a certified nurse aide (CNA) tried to get Resident #2's vital signs and he started fighting her and moaning in pain.-Review of Resident #2's progress notes did not identify any other negative interactions with a CNA (see interviews below).Record review of Resident #2's electronic medical records (EMR) did not identify the resident expressed concerns regarding fearfulness of staff. Review of records did not identify a report of an allegation of potential abuse, an abuse investigation or a grievance form related to potential abuse (see interviews below).C. Staff interviewsCNA #5 was interviewed on 1/5/26 at 12:14 p.m. CNA #5 said CNA #4 was too rough with Resident #2. She said Resident #2 told her that he was scared. She said CNA #4 would push and grab the resident's arm too hard. She said he had marks on his arm. She said she reported the incident to the former director of nursing (DON) who looked at his arm and would do something about it. She said it happened in September 2025 on a Friday during the day shift but she could not remember the exact date. CNA #5 said she also reported her concern to human resources and was told it would be looked into. She said she later asked the DON about the findings of the incident and she was told that there was no investigation because Resident #2's concerns were due to his dementia. Licensed practical nurse (LPN) #1 was interviewed on 1/5/26 at 4:02 p.m. LPN #1 said three or four months ago, Resident #2 reported to her that a CNA was talking rough towards him and he felt scared of the CNA. LPN #1 said she believed she documented the incident on a grievance form and gave it to the DON, the NHA and/or human resources. LPN #1 and the NHA were interviewed together on 1/5/26 at 6:06 p.m. LPN #1 said she may have only reported the incident with Resident #2 to the former DON. LPN #1 said she came into Resident #2's room one night and he was upset and said the CNA was verbally mean to him when he requested to use the restroom. LPN #1 she said she thought the former DON followed up on Resident #2's grievance because she had not heard anything more and she had not seen him as upset since the incident. She said since it was only verbal, she did not consider it abuse and that was why she only verbally reported it to the former DON. The NHA said she never received the grievance form and Resident #2's allegation was not reported to her. LPN #1 said she probably did not document the incident in a progress note. She said the 9/2/25 progress note that identified Resident #2 was fighting with a CNA because he was upset with his post-fall monitoring and neurological checks was not related to the resident's grievance incident.III. Resident #3A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included type 2 diabetes mellitus with hyperglycemia, encounter for palliative care, and unspecified dementia severe with agitation.The 10/21/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. Resident #3 was dependent on staff assistance for eating, toileting, bathing, dressing, footwear, repositioning, transfers and mobility. The MDS assessment documented Resident #3 did not have physical behaviors directed at others and did not have rejections of care. B. Record reviewThe vulnerability care plan, revised 10/17/25, documented Resident #3 was highly vulnerable due to severe cognitive impairment and behavioral challenges. According to the care plan, she was at risk for self-injury, social isolation, and distress from overstimulation. She required close supervision and individualized support to ensure safety, comfort, and emotional well-being. Interventions, dated 8/20/25, included allowing Resident #3 time to retry a task when she was resistant to care, notification of the physician and family as needed, observe for potential pain, discomfort and mental anguish and provide a safe environment. Interventions, dated 10/17/25, directed staff to monitor for her signs of overstimulation or agitation and provide redirection as needed and provide her with fidget toys and teddy bears to reduce risk of self-injury and promote calmness.The cognition care plan, revised 10/17/25, documented Resident #3 had severe cognitive impairment accompanied by behavioral challenges. According to the care plan, staff should use gentle redirection and reassurance as needed to maintain dignity and comfort.The dementia care plan, revised 10/17/25, directed staff to approach Resident #3 in a calm, slow manner and re-approach at a later time if needed.The 8/17/25 electronic medication administration record (eMAR) documented Resident #3 was screaming during care.The 8/23/25 eMAR documented the resident yelled and tried to push staff away during care.The 8/30/25 eMAR note documented Resident #3 was screaming when she was changed and repositioned.A second 8/30/25 eMAR note documented Resident #3 thought the staff was going to hurt her. The 9/8/25 eMAR note documented the resident was fearful when moving up in the bed.The review of the December 2025 and the January 2026 treatment administration record (TAR) documented Resident #3 exhibited fearfulness between 12/24/25 and 1/3/26. The review of reports with the State Agency, did not identify the facility reported allegations of potential abuse regarding Resident #3 (see interview below).C. Staff interviewsA staff member who requested to remain anonymous was interviewed on 1/5/26 at 5:33 p.m. The staff member said CNA #1 was needlessly rough with residents. The staff member said CNA #1 was rough with Resident #3. The staff member said CNA #1 would rip Resident #1's hands off of anything the resident would grab, such as the bed, equipment or anything else near her during ADL care. The staff member said Resident #3 would act like the ripping her hands off the equipment hurt her but she would act like a lot of things hurt her. The staff member said CNA #1 disliked using a gentle approach with the residents and preferred to be more physical with them than necessary. She said CNA #1 would skip being nice for speed. The staff member said she mentioned her concerns about CNA #1 to LPN #2 and another nurse, but she could not recall who the other nurse was. The staff member said she felt there was nothing major enough that happened between Resident #3 and CNA #1 to report the concern as abuse other than to tell her nurse. LPN #2 was interviewed on 1/5/26 at 6:27 p.m. LPN #2 said Resident #3 had some behaviors and she could not communicate. He said there were no staff members or residents who expressed concerns of CNA #1's treatment towards any of the residents to him. He said CNA #1 had difficulty positioning residents, especially residents who were larger in size. He said she needed to use a lot of momentum because it was physically hard for her to position residents. LPN #2 said CNA #1 could be a little rough but not to the level of abuse. He said abuse was anything that would make a person feel uncomfortable. He said Resident #3 would become scared when she was moved suddenly during ADLs with CNA #1. He said Resident #3 would grab and try to hold on to the bed. He said he did not report or document when he observed CNA #1 being a little rough with Resident #3. He said he did not offer suggestions to CNA #1 regarding approaches or techniques to provide care that was not as rough. He said CNA #1 would be retiring soon. IV. Resident #7A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included complete lesion at the C4 level of the cervical spinal cord, displaced fracture of the fourth cervical vertebra, quadriplegia (paralysis of all four extremities), post-traumatic stress disorder (PTSD), saddle embolus of the pulmonary artery with acute cor pulmonale (a large blood clot blocking the main pulmonary artery), neuromuscular dysfunction of the bladder and neurogenic bowel.The 12/16/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #7 was dependent on staff assistance for eating, toileting, bathing, dressing, footwear, repositioning and transfers. Resident #7 required a Hoyer lift (mechanical lift) for transfers and used a motorized wheelchair for mobility. The MDS assessment documented Resident #7 did not have physical or verbal behaviors directed at himself or others and did not have rejections of care.B. Resident interviewResident #7 was interviewed on 1/6/26 at 9:19 a.m. Resident #7 said approximately one week prior to the interview, CNA #1 and CNA #2 transferred Resident #7 to his wheelchair using a Hoyer lift. Resident #7 said during the transfer, his foot was resting on the Hoyer lift while he was approximately 18 inches from the ground. Resident #7 confirmed his leg was resting on the actuator (lifting motor) of the Hoyer lift when shown the Hoyer lift. Resident #7 said CNA #1 pushed his leg off of the Hoyer lift instead of holding and lowering his leg, causing his foot to hit the foot pedal of his wheelchair. Resident #7 said he asked CNA #1 to adjust his leg and that her pushing his foot off of the lift was unsafe. Resident #7 said CNA #1 replied by shrugging her shoulders and telling Resident #7 that she was retiring next week. Resident #7 said he asked CNA #2 if she observed the same thing during the transfer and asked CNA #2 to look for any injuries on his foot. Resident #7 said CNA #2 told him she did not see any injuries. Resident #7 said he was concerned because CNA #1 could have caused a skin tear to his foot, and due to his impaired mobility and circulation, previous injuries to his foot had taken six months to heal. Resident #7 said he also asked the night shift staff to assess his foot for injuries. Resident #7 said he was not sure if any staff reported the event. Resident #7 said the incident made him feel angry that CNA #1 did not seem to care about her actions. Resident #7 said CNA #1 frequently had a negative attitude toward him, telling him she was unable to complete his care and she would ask other staff members to complete his care instead. C. Record reviewThe vulnerability care plan, revised 10/8/25, documented Resident #7 was quadriplegic, resulting in total dependence on staff for mobility, positioning, hygiene, and safety needs. According to the care plan, the resident was at risk for injury, skin breakdown, infection, and psychosocial distress due to limited mobility and physical vulnerability. Interventions included removing the resident from potentially abusive situations, observing him for potential pain, discomfort, mental anguish and providing him with a safe environment.Record review of Resident #7's EMR revealed no documentation of the event with the hoyer lift and CNA #1 or an assessment of Resident #7's foot.An incident statement, dated 1/5/26 (during the survey), identified the incident Resident #7 described in the above interview. The incident statement documented Resident #7 felt CNA #1's actions were inappropriate, dangerous, neglectful and abusive. According to the incident statement, the resident felt disregarded by CNA #1 and unsafe. He did not want to work with CNA #1 and felt that residents who could not communicate and advocate for themselves, should not be working with CNA #1 either. Resident #7 said the incident was not isolated and CNA #1 often did not want to help him with his basic care needs. D. Staff interviewsA staff member who requested to remain anonymous was interviewed on 1/5/26 at 5:33 p.m. The staff member said she had seen CNA #1 be rough with Resident #7 when she would transfer him into his wheelchair. The staff member said CNA #1 was not careful with the resident's feet when she moved him. The staff member said Resident #7's feet would slip off the lift and become caught on the equipment. The staff member said he was at risk for injury if staff were not careful with his feet because his feet would easily become scraped. The staff member said CNA #1 was not always gentle with residents. The staff member said she felt CNA #1 was mean towards residents, had a negative demeanor and hated having to take care of them. The staff member said they felt CNA #1 was a little too mean and forceful. The staff member said when they reported their concerns to LPN #2, the concerns were just passed off and the staff member was told that was just how CNA #1 was or that management was looking into it. The staff member said they had abuse training online and in person but it was hard for them to tell if the concerns regarding CNA #1 were important enough to put in an official report. The staff member said they did not know if CNA #1's behaviors were just not polite, rude and non-coddling or if they were more concerning. The NHA was interviewed on 1/6/26 at 10:26 a.m. The NHA said registered nurse (RN) #1 informed her of suspected abuse or neglect on 1/5/26 at 4:50 p.m. regarding an allegation made by Resident #7. The NHA said when she heard about the suspected neglect or abuse, she had the social services assistant (SSA) interview all residents in the facility. The NHA said the SSA told her no other residents reported any abuse and they felt safe in the facility. The NHA said she placed CNA #1 on administrative leave and contacted the police, the ombudsman, and Resident #7's family. She said the other CNA who witnessed the event was identified as CNA #2. She said human resources was currently completing staff interviews. She said she submitted the initial report for abuse to the State Agency (during the survey). The NHA said it was possible Resident #7 did not report the allegation initially because he was new to the facility and was nervous to report. She said she spoke with Resident #7 to ensure he was aware of his rights and encouraged him to report concerns immediately going forward. She said the facility provided education on resident rights in written form on admission, signs were also posted in the facility and the resident council took time during each resident council meeting to review a part of the resident rights. She said she planned to complete additional abuse education with staff, but the education with staff would be based on the findings of the investigation. V. Additional staff interviewsThe NHA and the regional clinical consultant were interviewed together on 1/5/26 at 4:23 p.m. The NHA said when there was an allegation of abuse, she would follow up with the resident to make sure the resident felt safe. The NHA said she or the DON would report the allegation to the State Agency and start an investigation. She said the employee identified in the allegation would be placed on suspension during the investigation, and staff and residents would be interviewed. The NHA said she would conduct a chart review of the resident identified in the allegation, reviewing the care plan, diagnoses and medications. She said would discuss the allegation with the interdisciplinary team (IDT) and determine if the findings met the criteria for abuse. She said if the allegation of abuse was substantiated, the employee would be terminated. She said if the allegation was unsubstantiated, she would provide additional abuse education. The NHA said the human resources director would review the employee's file for past concerns. The regional clinical consultant said the facility had not reported abuse allegations to the State Agency. The NHA said she was not made aware of any allegations of abuse. The NHA said staff should always call her directly if they had any concerns or reports of potential abuse so she could report the allegation to the State Agency immediately. She said staff had been educated on abuse and how to report potential abuse to her. The assistant director of nursing (ADON) was interviewed on 1/5/26 at 5 :06 p.m. The ADON said if someone reported concerns of mistreatment or abuse, the facility would submit a grievance statement and the DON would investigate it. He said he was not aware of any concerns of abuse or mistreatment reported by staff. The human resources director was interviewed on 1/6/26 at 9:46 a.m. The human resources director said if she became aware of allegations of abuse or mistreatment of a resident, she would make sure the supervisors were aware of the concerns, the employee identified in the allegation would be put on suspension and an investigation would be started. She said she was not made aware of concerns related to CNA #1 or CNA #4. The human resources director said staff were trained how to recognize, help prevent and report abuse. She said staff should report any allegation of potential abuse to the DON, the NHA and contact authorities.The SSA was interviewed on 1/6/26 at 12:01 p.m. The SSA identified herself as the activity director who also assisted with social services. The SSA said all allegations of abuse should be reported to the NHA and the DON. She said if she became aware of any allegations of potential abuse, she would interview other residents using an abuse questionnaire. She said if the resident was not interviewable, she would interview the resident's family and CNAs who worked with the resident. She said was only aware of the abuse allegations made by Resident #7 on 1/5/26. She said she was not aware of any other concerns of abuse made by residents or staff.The NHA and the current DON were interviewed together on 1/6/26 at 1:07 p.m. The DON said if residents or staff used triggering words describing an incident or expressing feelings of abuse, neglect or pain, an allegation of potential abuse should be reported and investigated. The DON said if a resident did not want to talk about an incident or situation, that could also indicate possible abuse and could also prompt an investigation. He said staff had received education on statements of not feeling safe made by residents. The DON said if a resident reported that a staff member was too rough with care, that would also prompt an investigation. He said reports of disrespect, meanness, or demeaning speech would prompt an investigation. The NHA said she could not find a grievance form or other documentation regarding Resident #2 feeling scared of CNA #4 or that the resident felt CNA #4 was rough and mean to him. The NHA said she did not receive a report from the former DON regarding concerns brought up by LPN #1 regarding Resident #2 and CNA #4. She said the former DON did not report the allegations to the State Agency. The NHA said LPN #1 told her she was not sure if she reported the allegations to the former DON. The NHA said she spoke to LPN #1 on 1/6/26 (during the survey) and LPN #1 identified the CNA alleged in the potential abuse incident with Resident #2 was CNA #4. The NHA said LPN #1 should have contacted her by a phone call and told her about the incident when it occurred so it could be reported and investigated. The NHA said said yesterday (1/5/26) was the first time she was aware any grievance was filed regarding Resident #2. The NHA said she screened all the residents for abuse after she became aware of the incident with Resident #2 and CNA #4. The NHA said the reason for timely investigation and reporting was to ensure resident safety. She said if the allegation was reported earlier, then it would have prompted an investigation immediately. She said the words of the resident being scared would have met the definition to prompt an investigation. The NHA said if she was notified immediately, she would have been able to follow up with the resident immediately. She then could get exact statements of the concerns and events to make sure she had the correct words from the resident. She said if the same fearful speech was used after the resident was interviewed, the staff member identified in the allegation would have been placed on leave and an investigation of all residents would have started. The NHA said if it was substantiated, then CNA #4 would have been terminated. She said if she was still in the process of determining abuse, the staff member would not have been allowed near Resident #2. The NHA said she was concerned that LPN #1 said she did not feel the event was potential abuse because the allegation was verbal and not physical. She said staff had had multiple training sessions identifying that verbal abuse may not always include the word abuse. The NHA said education was provided to staff to call for additional guidance if they had any question as to whether or not a statement made by a resident should be filed as a grievance or investigated as possible abuse. She said she planned to continue this education at the all-staff meeting and she planned to send out written education today (1/6/26). She said her phone number was available at the nurses' station and the front desk as well as other locations throughout the building. She said the facility provided online education and followed up in person with education in the monthly meetings. The NHA said staff should be aware of what defined potential abuse and who to report it to. She said it was not appropriate to use a grievance form if the complaint involved an allegation of possible abuse. She said the nurse should notify the NHA by phone immediately and then complete a risk management documentation. The NHA said she planned to follow up with LPN #1 to complete the risk management form and planned to send out the email education to staff today. She said she planned to give the education to all staff. The DON said he planned to print the state guidance on the topic of abuse and reporting. The NHA said she planned to include specific education in the binder of trigger statements for possible verbal abuse. The DON said he provided written education on professional communication with residents, family and other staff. The NHA said she planned to have the SSA follow up with Resident #7 to ensure that he was safe. She said the resident told the SSA on 1/5/26 that he would feel safe if CNA #1 was not in the facility. The DON said he would want to ensure Resident #7 knew what to report and he would not face any retaliation. The NHA said she would ask staff their level of awareness regarding any allegations of abuse related to Resident #2, Resident #3 and Resident #7. She said she would ask staff to describe the events and whether or not they reported the incident to anyone. The DON said if the facility confirmed that abuse was substantiated, witnessed but not reported, he would ask what the barriers were that caused the situation not to be reported. The NHA said she would review Resident #3's care plan interventions and ensure the interventions were resident-centered. She said for residents like Resident #3, who were not interviewable, the facility would interview the resident's family and identify how Resident #3 responded to staff members. The NHA said she would conduct a record review to identify any possible patterns among staff members or possible injuries. The NHA said besides the education, she planned to provide posted written education in staff areas, the nurses' station and dining area that included information of who to contact, including education for residents and how to directly contact the ombudsman if they did not feel comfortable reporting an incident to staff. The NHA said she planned to send a letter to each resident on how and what to report, encouraging them to report directly to the NHA, the DON, or the SSA to ensure proper investigation. The NHA said the facility was planning to roll out angel rounding where staff would develop a rapport with the delegated residents and meet with residents on a routine basis and document rounding. The NHA said she would have leadership staff conduct the angel rounding during the week. She said education would be provided to specific weekend staff members to complete the rounds when leadership staff was not available. The NHA said she planned to complete education on abuse and reporting automatically every three months with new education to improve engagement and comprehension.

Based on observations, record review, and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Implement an effective water management plan; -Appropriately discard Resident #8's medication that was dropped; and, -Provide proper infection control practices while maintaining an indwelling catheter. Findings include: I. Failure to have an effective water plan A. Professional reference According to Center for Disease Control (CDC), Legionella (Legionnaires Disease and Pontiac fever), last reviewed 3/25/21, was retrieved on 11/12/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team -Describe the building water systems using text and flow diagrams -Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them -Establish ways to intervene when control limits are not met -Make sure the program is running as designed (verification) and is effective (validation) -Document and communicate all the activities. Principles: In general, the principles of effective water management include: -Maintaining water temperatures outside the ideal range for Legionella growth - Preventing water stagnation -Ensuring adequate disinfection -Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, reviewed 2/3/21, retrieved from on 4/1/24: Store hot water at temperatures above 140? and ensure hot water in circulation does not fall below 120?. Recirculate hot water continuously, if possible. Store and circulate cold water at temperatures below the favorable range for Legionella (77-113?); Legionella may grow at temperatures as low at 68?. B. Facility policy and procedure The Legionella Water Management Program policy was provided by the maintenance director (MTD) on 11/6/24 at 10:54 a.m. It documented in pertinent part, The purpose of the water management program is to identify areas in the water system where legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease. Identify where potentially hazardous conditions could occur in the building water systems. Examples include areas where water temperature could promote Legionella growth or where water flow might be low. Establish control measures and limits for each hazardous condition. Control measures are actions taken in the building water systems to limit growth and spread of Legionella. They can include adding disinfectant, cleaning, and heating. C. Record review The facility's water management plan was provided from the MTD on 11/6/24 at 10:54 a.m. -The facility water management plan failed to document how resident rooms that were empty for seven contiguous days or more were safely protected from the potential growth of Legionella. The facility log, dated 11/6/24 at 2:11 p.m. (during the survey), documented the MTD had appropriately flushed all empty rooms in the facility to ensure Legionella had not grown in the facility. -However, the facility did not have documentation indicating empty rooms were appropriately were appropriately flushed to prevent potential Legionella bacteria growth prior to 11/6/24 (see interview below) The resident occupancy history data was provided by the nursing home administrator (NHA) on 11/6/24 at 2:43 p.m. It documented that in the last 60 days, the facility documented 12 rooms that were empty for seven contiguous days or more in resident care areas that were available for resident use. D. Staff interviews The MTD and the NHA were interviewed together on 11/6/24 at 1:31 p.m. The MTD said the facility used a system of hot water flushing and visual inspection of the water systems to ensure waterborne bacteria such as Legionella did not grow in the facility. The MTD said the facility's water systems had been upgraded many times over the years and he did not know where all the water pipes in the facility were. The MTD said it was possible there were old pipes with stagnant water in the facility that he did not know about. The MTD said that he flushed empty resident rooms on a rotating basis but did not document when he completed this task. The MTD said the normal process was to pick a few rooms on each hall each week and flush them appropriately. The MTD said he could not verify that all rooms that had been empty for seven contiguous days or more were appropriately flushed to prevent the potential growth of waterborne pathogens. The NHA said there was a potential risk of Legionella bacteria growth if water were to sit for seven contiguous days or longer. The MTD said he would immediately flush all empty rooms in the facility and change his documentation process starting on 11/6/24 to verify all empty rooms in the building had been flushed every week to prevent the potential growth of waterborne pathogens such as Legionella. II. Failure to administer medications appropriately A. Facility policy and procedure The General Dose Preparation and Medication Administration policy, dated 2021, was provided by the nursing home administrator (NHA) on 11/7/24 at 1:47 p.m. It documented in pertinent part: If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy. B. Observations and interviews On 11/6/24 at 8:50 a.m., medication administration was observed for Resident #8 with licensed practical nurse (LPN) #2. While removing the resident's Zyrtec (allergy medication) from the container, one Zyrtec pill fell on to the green top surface of the medication cart. LPN #2 then used two empty medication cups to pick up the medication without touching it and attempted to add the medication to the medication cup filled with clean medications already prepared for Resident #8. LPN #2 dropped the medication a second time on the green top surface of the medication cart. LPN #2 used the two spare medication cups again to scoop up the Zyrtec medication a second time and added it to the clean cup of prepared medications for Resident #8. LPN #2 then administered the entire cup of medications including the twice dropped Zyrtec to Resident #8. C. Staff interviews LPN #2 was interviewed on 11/6/24 at 9:09 a.m. LPN #2 said she did not sanitize or clean the green top of the medication cart before preparing medications for Resident #8. LPN #2 said if a medication was dropped on the floor it must be discarded, but if a medication was dropped onto the green medication cart top surface then it was acceptable to recover the medication and administer the medication to residents. Registered nurse (RN) #1 was interviewed on 11/7/24 at 10:24 a.m. RN #1 said if a nurse dropped a medication on the green top surface of the medication cart it must be discarded. RN #1 said it was important to ensure medications were not contaminated prior to administration. The director of nursing (DON) was interviewed on 11/7/24 at 3:42 p.m. The DON said medications that were dropped on the green top surface of the medication cart must be discarded. The DON said it was not appropriate for LPN #2 to attempt to recover the Zyrtec medication by using two empty medication cups in a scooping motion. The DON said LPN #2 should have discarded the dropped Zyrtec and obtained another clean Zyrtec from the medication bottle. 40467 III. Failure to provide proper infection control practices while maintaining an indwelling catheter A. Facility policy and procedure The Indwelling Urinary Catheter (Foley) care and Management policy, revised 12/11/24, was provided by the NHA on 11/8/24 at 3:04 p.m. The policy read in pertinent part, Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI (catheter-associated urinary tract infection). However, do not place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI. B. Observations Resident #10 was sleeping in his bed on 11/04/24 at 1:58 p.m. An indwelling catheter bag was attached to the side of his bed without a bag cover. The bottom of the resident's indwelling catheter bag touched the floor. At 3:34 p.m. Resident #10 was still asleep in his bed and his catheter bag continued to touch the floor. On 11/5/24 at 12:58 p.m. Resident #10's catheter bag was on the floor during the duration of a wound dressing change with LPN #2 and the DON. The catheter bag, without a cover, was under the bed and folded in half by the trash can in front of the bed. At 1:33 p.m. LPN #2 picked the catheter bag off the floor and hung the bag off the side of the bed. On 11/6/24 at 4:11 p.m. Resident #10's catheter bag was uncovered and was attached to the side of his bed. The bag hung approximately two to three inches above the floor. Certified nurse aide (CNA) #1 entered the room, stood up against his bed as spoke to Resident #10. CNA #1's shoes were observed directly under the catheter bag. The bottom of the bag touched the top of her shoes. C. Record review The 7/16/24 physician's order documented Resident #10 had a suprapubic catheter related to his diagnosis of a flaccid neuropathic bladder. According to the computerized physician's orders CPO, staff should check the catheter tubing every shift for proper positioning and catheter care. The 2/15/24 catheter care plan read Resident #10 had a device that required continued monitoring and treatment. The care plan directed staff to monitor output every shift and provide adequate fluids to reduce infection potential. According to the care plan, the resident required assistance with care. -The care plan did not direct staff to ensure the resident's catheter bag was covered, off the floor and away from surfaces that could potentially contaminate the bag. D. Staff interview The DON was interviewed on 1/7/24 at 6:00 p.m. The DON said Resident #10's catheter bag should have been covered and off the floor to help ensure proper sanitation and keep germs and bacteria off the bag. She said contaminants could potentially get into the bag and use the tubing to travel up to the resident's bladder, causing an infection. She said the catheter bag on the floor was an infection control concern and she would re-educate the staff. She said the staff needed to be trained to keep his catheter bag covered and off the floor.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure hand hygiene was conducted appropriately; and, -Santitize potentially contaminated surfaces of a food preparation counter. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/22/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings (2/27/24), retrieved on 10/22/24 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, read in pertinent part, Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients. According to the CDC, hand washing should occur before preparing or eating food, before touching the eyes, nose or mouth, and after touching potential contaminated surfaces. II. Facility policy and procedure The Hand Hygiene policy, dated 8/19/24, was provided on 11/7/24 by the facility. The policy read in pertinent part, The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Because of this, hand hygiene is a single most important procedure to prevent infection to protect patients from Healthcare Associated infection, hand hygiene must be performed routinely and thoroughly. B. Observations During a continuous observation of the lunch meal service in the main kitchen and dining room on 11/6/24, beginning at 11:10 a.m and ending at p.m., the following was observed: At 11:27 a.m. cook (CK) #1 proceeded to take the temperature of the lunch meal items with a food thermometer and then placed them in the steam table for service. At 11:33 a.m. CK #1 dropped the thermometer onto the kitchen floor, the casing around the indicator head loosened from the drop. She quickly picked up the thermometer, snapped the loosened parts back together and placed the thermometer on the food preparation counter. CK #1 picked up the thermometer and wiped it down with an alcohol wipe and placed it back down on the food prep counter. CK #1 did not perform hand hygiene after she picked up the thermometer off of the floor. CK #1 did not sanitize the food preparation counter after setting the contaminated thermometer on it. -CK #1 continued to prepare for the upcoming meal service without ensuring her hands were clean after the contact with an item that fell on the floor between 11:35 a.m. and 11:45 a.m. At 11:35 a.m. CK #1 retrieved a pan from the pan rack. She left the main kitchen and filled the pan with ice at the drink station behind the service line window. She returned to the kitchen and placed the thermometer probe into the ice. CK #1 did not perform hand hygiene after she returned to the kitchen and after she touched high touch surfaces such as the ice scoop and the lid of the ice machine. She retrieved a large serving spoon and placed it on the unsanitized food prep counter. At 11:39 a.m. CK #1 left the kitchen and retrieved hot water from the drink station, touching high touch surfaces such as the handle of the hot water container. She returned to the kitchen and proceeded to puree Italian crusted fish. She placed the puree fish on the steam table. At 11:45 a.m. CK #1 washed her hands. This was the first time CK #1 washed her hands, after she picked up the food thermometer off the floor. At 11:50 a.m. certified nurse aide (CNA) #1 waited at the backside of the meal service window in the drink station area for the meal service to begin. CNA #1 touched her face under her eye and the side of her nose. She did not perform hand hygiene after touching her face. At 11:53 a.m. without performing hand hygiene after touching her face, CNA #1 filled a resident's drink container with milk and gave it to the resident. She removed the paper for a straw and placed it in the beverage. She returned to the drink station and performed hand hygiene. At 11:57 a.m. CNA #1 she touched both sides of her face as she waited for the meal service to begin. She did not perform hand hygiene after touching her face. At 11:59 p.m. meal service began. Without performing hand hygiene after touching her face, CNA #1 retrieved a plate from the service window, served a resident in the dining room and used the resident's utensils to help cut up the resident's food. CNA #1 returned to the drink station and performed hand hygiene. At 12:10 p.m. CNA #1 touched both sides of nose and placed her hands in her pockets as she waited to serve the next resident. She did not perform hand hygiene after touching her face. At 12:53 p.m. without performing hand hygiene after touching her face, CNA #1 sat between two residents who needed meal assistance. CNA #1 provided a bite size piece of food to a resident to her right using her right hand to pick up the utensil. The resident cleared his throat after swallowing the food. CNA #1 did not use hand hygiene after assisting the resident. At 12:54 CNA #1 provided a bite size piece of food to the resident to her left, using her right hand. CNA #1 did not perform hand hygiene before assisting the resident. CNA #1 did not use hand hygiene after assisting the resident. C. Record review A September 2024 All Staff Agenda was provided by the nursing home administrator (NHA) on 11/7/24 at 3:26 p.m. The agenda indicated staff were reminded to use hand hygiene during meals with residents. Employee sanitation practice training was provided by the NHA on 11/7/24 at 3:26 p.m. The training was conducted on 11/7/24 (during the survey). According to the training employees should wash their hands just before they start to work in the kitchen after smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes, touching of the face, hair, other people /or surfaces or items with potential for contamination. D. Staff interviews CNA #1 was interviewed on 11/06/24 at 1:51 p.m. CNA #1 said hand hygiene should have been conducted before serving residents their meals, when assisting a resident to eat, after touching body or clothes surfaces or any time the staff touch a potentially contaminated surface. The dietary manager (DM) was interviewed on 11/6/24 at 1:59 p.m. The DM said staff should perform hand hygiene anytime the hands were soiled, entered the kitchen, when changing gloves, and/or touch potentially contamination surfaces to prevent cross contamination of the food or food surfaces. The DM said hand washing should have been conducted if a staff member picked up an item from the floor. She said the staff serving the meals should perform hand hygiene throughout the meal service and after touching a potentially contaminated surface. The DM said body parts, hair nets and clothing were considered a potentially contaminated surface and staff should perform hand hygiene if they touch potentially contaminated surfaces when serving food and/or food related items. She said all food related surfaces should be kept clean. The DM said staff received routine hand hygiene training through the facility's online training program and as needed when corrections needed to be addressed.

Based on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#9) of two residents reviewed for skin breakdown out of 20 sample residents. Specifically, the facility failed to conduct an accurate and thorough assessment of a resident's skin. Findings include: I. Resident #9 A. Resident status Resident #9, age greater than age 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included gastroesophageal reflux disease with esophagitis without bleeding, acquired absence of other specified parts of digestive tract, personal history of transient ischemic attack (TIA), cerebral infarction with without residual deficits, Personal history of malignant neoplasm of other organs and systems, dysphagia, oropharyngeal phase, muscle weakness and reduced mobility. The 10/15/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not have limited range in motion with his upper or lower extremities. B. Resident observation and interview Resident #9 was interviewed on 11/4/24 at 2:19 p.m. Resident #9 had a large maroon colored bruise on his left forearm. The resident said bruises on his arms were common for him because he bumped into things. C. Record review The skin care plan, revised 9/4/24, identified Resident #9 had a high risk for skin breakdown due to having malnutrition and weakness. According to the care plan, the resident was able to reposition himself with the use of a positioning bar. The 10/30/24 nursing weekly skin check did not identify a bruise to the resident's arm. The 11/5/24 nursing weekly skin check did not identify a bruise to the resident's arm. The review of the October 2024 and the November 2024 progress notes did not identify a bruise on his arm. -However, Resident #9 had a large bruise visible on his left forearm on 11/4/24 (see observation above). II. Staff interview The director of nursing (DON) was interviewed on 11/7/24 at 4:27 p.m. The DON said any bruises or breaks in residents' skin or changes in the color of the skin should be documented on a skin assessment. The DON said she observed Resident #9's left forearm bruise on 11/7/24 and the resident said he bumped it on the bedside table on 11/6/24. -However, Resident #9 had a large bruise visible on his left forearm on 11/4/24 (see observation above). The DON was informed the bruise was visible on 11/4/24. The DON said she would conduct an education with the nurses who worked with Resident #9 between 11/4/24 and 11/7/24. She said the nurses did not document they were aware of or assessed the bruise even though the bruise was in a visible location and should have been documented. She said Resident #9's skin was very fragile and the facility would look at padding his bedside table and positioning bar.

Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#9) of one out of 20 sample residents. Specifically, the facility failed to appropriately assess Resident #9 for self-administration of medications. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 2016, was retrieved on 11/12/24, Do not leave medications at the bedside. If you leave the medication on the bedside table, how do you know they took the medication? Someone else could come in and take or discard the medication. II. Facility policy and procedure The General Dose Preparation and Medication Administration policy, undated, was provided by the nursing home administrator (NHA) on 11/7/24 at 1:47 p.m. It documented in pertinent part, Facility staff should not leave medications or chemicals unattended. III. Resident #9 A. Resident status Resident #9, age greater than age 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included gastroesophageal reflux disease with esophagitis without bleeding, acquired absence of other specified parts of digestive tract, personal history of transient ischemic attack (TIA), cerebral infarction with without residual deficits, personal history of malignant neoplasm of other organs and systems, dysphagia oropharyngeal phase (difficulty swallowing), muscle weakness and reduced mobility. The 10/15/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not have limited range in motion with his upper or lower extremities. According to the assessment, the resident had rejection of care behavioral symptoms. B. Observation and interview On 11/6/24 at 1:27 p.m. a single white tablet in a medication administration cup was observed next to the resident's meal tray. The resident said the medication was for his stomach. He said the nurse would usually leave his Zofran on his table so he could take it when he was ready. C. Record review The sleep care plan, revised 3/12/24, identified Resident #9 was at risk for altered sleep. According to the care plan, the resident slept less than normal requirements. The resident's goal was to have a restful sleep. -The care plan did not identify that the resident did not want to be woken up for medication administration. -The care plan did not direct staff what to do if the resident was asleep during his medication pass. The fall care plan related safety, revised on 11/7/24, documented Resident #9 desired to have medication left at his bedside for the resident to self administer. According to the careplan, the IDT felt it was unsafe for his medication to be left at bedside. The 11/7/24 care plan investigation directed staff not to leave medication at the resident's bedside. -Review of the comprehensive care plan did not indicate the resident was able to self-administer medications. A review of Resident #9's November 2024 CPO revealed a physician's order for Zofran, directed staff to administer four milligrams (mg) of Zofran in oral tablet form before meals and at bedtime for nausea and vomiting, ordered on 8/13/24. -The review of the CPO did not identify Resident #9 had a physician's order to self administer his medication. The November 2024 medication administration record (MAR) documented Resident #9 received Zofran four times a day. According to the MAR, the resident received the Zofran daily at 7:00 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. An on the spot training for medications was provided on 11/7/24 by the corporate consultant (CC). The training was conducted on 11/7/24 (see interviews below) during the survey period. The training read, Medication should not be left for the resident to take without supervision. If a resident voiced the desire to do self-administration, the IDT (interdisciplinary) team must meet to see if it is safe. If this is the route then the IDT team will get physicians to allow the resident to self-administer the medication. Do not leave medications on the bedside table. A 11/7/24 self-administeration of medications assessment was provided by the facility on 11/7/24 at approximately 5:45 p.m. The assessment was conducted during the survey period (see interviews below). The assessment identified Resident #9 wished to self administer medications or have them kept at bedside. According to the assessment, the resident sleeping patterns and timeliness of medication administration could be at a risk. The resident was deemed unsafe to self administer his medications. -The review of Resident #9's electronic medical record (EMR) did not reveal the resident had a self-administration assessment prior to 11/7/24. A 11/7/24 progress note documented the interdisciplinary team (IDT) met and discussed self-administration of medication for Resident #9. According to the note, the IDT felt the resident would not be safe for self medicating due to often falling asleep and not taking his medication timely. The note revealed it would be a risk for staff to leave the resident's medication at his bedside. D. Staff interview Registered nurse (RN) #2 was interviewed on 11/6/24 at 1:36 p.m. RN #2 said she tried to wake up residents if they were asleep when she was administering their medications. She said Resident #9 did not want to be woken up before meals to take his Zofran and would get upset. She said sometimes she would drop off the Zofran in his room if he was asleep. She said she left the Zofran tablet in his room at 12:30 p.m. so he could take it when he woke up. She said Resident #9 did not have a medication self administration order from the physician. RN #2 was interviewed again on 11/7/24 at 10:10 a.m. RN #2 said all physician's orders should be followed. She said she had not reached out to the physician to determine if Resident #9 would be appropriate for a medication self administered order. She said this morning (11/7/24) she made sure Resident #9 was awake before she gave him his Zofran and made sure he took it. She said residents should have a self administration order if they were not supervised for medication administration. RN #2 said Resident #9 would probably not be appropriate for a medication self administration order because he was sometimes confused and tired and may not administer the medication timely. She said Resident #9 liked to do things on his own time. The director of nursing (DON) was interviewed on 11/7/24 at 11:45 a.m. The DON said all medications should be stored in the medication cart until the nurse administers the medication. The DON said medication administration should be supervised by the nurse unless the resident had an order to self administer. She said Resident #9 did not have an order to self administer his medication and RN #2 should not have left Zofran alone in his room for him to take when he woke up. She said there were currently no residents that would wander in his room and take the medication but it was still a risk if left out. She said Resident #9 could be evaluated for self administration but it would be questionable if he would be appropriate. The DON said RN #2 would be re-education on medication administration on 11/7/24. She said would discuss a plan with Resident #9 and the physician so Resident #9 could receive his medication supervised and timely.

Based on record review and interviews, the facility failed to ensure resident choices for one (#18) of five residents reviewed for activities of daily living (ADL) out of 20 sample residents. Specifically, the facility failed to provide bathing assistance for Resident #18 per his preference. Findings include: I. Facility policy and procedure The Showers, Bed Bath and Tub Bath policy, revised March 2012, was received from the corporate consultant (CC) on 11/7/24 at 1:11 p.m. It documented in pertinent part, The facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes ensuring that the facility provides care and services for the following activities of daily living: hygiene - bathing. II. Resident #18 A. Resident status Resident #18, over the age of 65, was admitted on [DATE]. According to the November 2024 computerized physician order (CPO), diagnoses included neoplasm of the brain (cancer of the brain), chronic respiratory failure and unspecified dementia. According to the 9/20/24 minimum data set (MDS) assessment Resident #18 was intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment documented Resident #18 required moderate assistance with tub/shower transfers. The assessment documented the resident had no rejections of care. B. Resident interview Resident #18 was interviewed on 11/4/24 at 3:14 p.m. Resident #18 said he wanted to receive two showers per week, but that often did not happen. Resident #18 said he typically received one shower per week. He said he had gone a week of time without being offered a shower. Resident #18 said he felt ignored when the nursing staff did not offer him showers regularly. III. Record review The ADL plan of care, initiated on 6/24/24 and revised on 7/12/24, revealed Resident #18 required one person assistance with bathing. The Bathing/shower preference documentation, dated 6/24/24, documented Resident #18 requested two baths per week in the mid-morning. The facility point of care bathing documentation was reviewed for 30 days (10/6/24 and 11/6/24). In the 30 day review period, Resident #18 was documented to have received three baths out of eight opportunities for bathing. It revealed Resident #18 had refused two baths and was not available for one bath offered in the review period. -However, a review of the electronic medical record (EMR) did not document a reason for bathing refusals by Resident #18. Resident #18's EMR did not include documentation of bathing being re-offered to the resident after the resident refused bathing. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/6/24 at 4:11 p.m. CNA #1 said the residents typically received two baths per week unless they requested a different schedule. CNA #1 said if a resident refused a bath, the nurse should be notified and the bath should be re-offered that week. CNA #1 said the staffing at the facility had been much better recently since the facility census had been less than in recent months. CNA #1 said baths were documented electronically in the electronic medical record (EMR). Registered nurse (RN) #1 was interviewed on 11/7/24 at 10:24 a.m. RN #1 said the residents received two baths per week on specific days unless the resident had a more specific preference. RN #1 said baths should be re-offered to residents the same day if the resident refused. The director of nursing (DON) was interviewed on 11/7/24 at 3:42 p.m. The DON said she reviewed Resident #18's bathing documentation between 10/6/24 and 11/6/24. The DON said Resident #18 did not receive enough baths. The DON said the residents should receive two baths per week or by their stated preference. The DON said the nursing staff should investigate the reason why a resident would refuse their bath. The DON said the refused bath should be re-offered to the resident when they would prefer to have it. The DON said the facility documented all bathing offered electronically.

Based on observations and interviews, the facility failed to maintain a comfortable homelike environment for residents on one of four units. Specifically, the facility failed to ensure the 400 hallway maintained a temperature of 71 degrees fahrenheit (F) to 81 degrees F. Findings include: I. Facility policy and procedure The Safe Physical Environment policy, revised May 2023, was received from the director of nursing (DON) on 11/7/24 at 1:43 p.m. The policy documented that safe and comfortable temperatures were maintained in the facility. II. Resident interviews One of the residents who resided in room [ROOM NUMBER], who was cognitively intact, was interviewed on 11/4/24 at 3:11 p.m. The resident said his room felt very cold in the morning. He said he had to turn up the thermostat in his room to 78 degrees and close the door to make his room temperature comfortable. The second resident who resided in room [ROOM NUMBER], who was cognitively intact, was interviewed on 11/4/24 at 3:14 p.m. The resident said his room was very cold throughout the day, but mostly in the mornings. He said there was a cold draft outside of his room that he had to consider when choosing clothing or setting the room temperature. He said he felt frustrated that he had to change the temperature of his room several times throughout the day. III. Observations On 11/5/24 at 9:08 a.m., a cold draft was noted in the hallway outside of room [ROOM NUMBER]. The temperature outside room [ROOM NUMBER] read 56.8 degrees F. On 11/6/24 at 8:52 a.m., a cold draft was noted in the hallway outside of room [ROOM NUMBER] a second time. The temperature outside room [ROOM NUMBER] read 58.1 degrees F. On 11/7/24, there was not a cold draft noted in the hallway outside of room [ROOM NUMBER]. However, when a temperature reading of the area in the hallway outside of room [ROOM NUMBER] was obtained, the temperature read 70.2 degrees F. -The temperature reading in the hallway outside of room [ROOM NUMBER] on three consecutive days was below the comfortable and safe temperature level of 71 degrees F to 81 degrees F. IV. Staff interviews Housekeeper (HSKP) #1 was interviewed on 11/5/24 at 9:14 a.m. HSKP #1 said the cold draft on the 400 hall occurred because the facility had not placed covers over the vents in the ceiling outside of room [ROOM NUMBER]. HSKP #1 said the maintenance department was supposed to cover the ceiling vents in the wintertime. HSKP #1 said she did not know why the vents had not been covered yet since the outside temperatures had already dropped below freezing recently. The maintenance director (MTD) was interviewed on 11/7/24 at 10:02 a.m. The MTD said the ceiling vent on the 400 hall had not been covered from 11/4/24 to 11/6/24, when the temperature readings were obtained outside of room [ROOM NUMBER]. The MTD said the vent was covered by the maintenance assistant on the morning of 11/7/24 (during the survey). The MTD said he did not know what the appropriate temperature should be for the 400 hallway. The MTD said 56 degrees F was not an appropriate temperature for residents on a hallway because it was too cold. The DON was interviewed on 11/7/24 at 3:42 p.m. The DON said she was not aware a ceiling vent was open on the 400 hallway and was blowing cold air. The DON said she did not know what temperature was appropriate for the facility to maintain, but the temperature should be comfortable for residents. The DON said 56 degrees F was not acceptable for a hallway temperature and was too cold.

Based on record review and interviews, the facility failed to provide services by qualified persons for two (#14 and #30) of three residents reviewed for falls out of 20 sample residents. Specifically, the facility failed to ensure Resident #14 and Resident #30 were assessed by a registered nurse (RN) after sustaining unwitnessed falls. Findings include: I. Facility policy and procedure The Fall Management Program policy, undated, was provided by the nursing home administrator (NHA) on 11/7/24 at 3:41 p.m. It documented in pertinent part, All staff are trained on falls. If you are not a nurse and discover a resident has fallen - immediately have someone get a nurse to help assess/collect data while you stay with the resident. II. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included blindness, right and left leg amputations and generalized muscle weakness. The 9/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required moderate assistance with showering and dressing, was dependent on nursing care for shower transferring, and required set-up or cleanup assistance with eating and oral hygiene. B. Record review A Morse Fall Scale assessment, dated 1/12/24, documented Resident #14 was a low risk for falls. A neurological check assessment flow sheet for Resident #14 was provided by the nursing home administrator (NHA) on 11/6/24 at 11:14 a.m. It documented Resident #14 received neurological assessments starting at 7:15 a.m. on 1/13/24 through the evening shift of 1/15/24. -All documented assessments were completed by a licensed practical nurse (LPN) instead of a RN. Post-incident review documentation, dated 1/13/24, was provided by the NHA on 11/6/24 at 11:14 a.m. The documentation revealed that Resident #14 had an unwitnessed fall on 1/13/24 and was found laying on the floor between the bed and the wall with blood present on the back of his head. The documentation indicated Resident #14 fell because he was legally blind and did not have an assistive device attached to his bed as he did at home to assist in orienting the resident to where the bed was in relation to the room. The facility documented Resident #14 was offered to be evaluated in the emergency room which Resident #14 declined. -The documentation was signed by LPNs and did not contain a signature from a RN to indicate a RN had assessed Resident #14 following his fall. A nursing note dated 1/14/24 documented that Resident #14 denied pain on the back of his head after his fall. The note documented that Resident #14 had a bruise and skin tear on the back of his head. A nursing progress note dated 1/20/24 documented Resident #14 complained of additional pain to the back of his head and neck. The nursing note documented Resident #14 said this headache had existed for a few days and was getting progressively worse. The note documented the nurse informed the physician who recommended Resident #14 be evaluated in the emergency room . A final post-incident review, dated 1/22/24, documented Resident #14 developed additional neck pain on 1/20/24 which was not resolved by his ordered as-needed pain medication. The review documented that Resident #14 was sent to the emergency roiagnom on [DATE]. The review documented Resident #14 was diagnosed with a T-2 compression fracture and was returned to the facility on [DATE] with an additional prescription for pain medication. III. Resident #30 A. Resident status Resident #30, age greater than age 65, was admitted on [DATE] and passed away at the facility on 8/28/24. According to the August 2024 CPO, diagnoses included morbid obesity due to excess calories, chronic diastolic (congestive heart failure), pulmonary hypertension, hypertensive heart disease with heart failure and paroxysmal atrial fibrillation. The 8/15/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not have inattention or disoriented thinking. The resident required minimal assistance with her activities of daily living (ADL). According to the MDS assessment, the resident had not had a fall since admission. The assessment did not identify if the resident had a history of falls prior to admission. B. Record review The 8/9/24 fall risk summary note indicated Resident #30 had a Morse Fall Scale assessment completed. According to the note, the resident had a moderate risk for falling. The 8/28/24 post-incident note revealed Resident #30 had an unwitnessed fall at 6:00 a.m. According to the note, the resident was evaluated for injuries, the physician was notified and the appropriate staff was notified. The 8/28/24 neurological check assessment flow sheet was provided by the director of nursing (DON) on 11/7/24 at 2:04 p.m. The neurological check assessment flow sheet identified the resident was checked as scheduled. She was alert, with normal motor and sensory function. Her pupils were reactive to the light with brisk movement. The resident had pulse and blood pressure fluctuations. The assessment was completed at 6:20 a.m., 6:35 a.m., 7:35 a.m., 8:35 a.m. and 10:35 a.m. -The neurological check assessment flow sheet was signed by LPN #2 instead of a RN. The 8/28/24 at 6:20 a.m. post-incident review assessment was provided by the DON on 11/7/24 at 2:04 p.m. -The post-incident review assessment was completed and signed by LPN #2 instead of a RN. According to the assessment, the resident was found on the floor in her room. Resident #30 said was trying to walk to the bathroom. The resident did not have injuries as a result of the fall. The post-incident review documented the NHA and the DON were notified of the resident's fall at 7:00 a.m. -The DON, who was a RN, was not notified until an hour after Resident #30's fall. An 8/28/24 at 10:47 a.m. nursing note documented a RN assessed the resident after her fall on the morning of 8/28/24 and educated the resident on the need to be evaluated by her physician or the emergency room at the hospital. -However, according to the documentation provided by the facility (see above), LPN #2 initially performed the assessment on Resident #30 at the time of the fall on 8/28/24 at 6:00 a.m. The nursing note which indicated a RN assessed the resident was not documented until 10:47 a.m. on 8/28/24, over four hours after the resident's fall. IV. Staff interviews LPN #2 was interviewed on 11/5/24 at 9:09 a.m. LPN #2 said LPNs were not allowed to perform assessments on residents after a fall. LPN #2 said a RN must perform a post-fall assessment after a resident fell . Certified nursing aide (CNA) #1 was interviewed on 11/6/24 at 4:11 p.m. CNA #1 said if a resident fell , she would get a nurse right away to make sure the resident was okay. CNA #1 said she thought a RN had to perform a resident assessment after a fall because LPNs were not allowed to. RN #1 was interviewed on 11/7/24 at 10:24 a.m. RN #1 said a RN must perform all assessments on residents after a fall. RN #1 said LPNs were not able to perform assessments because it was outside of their scope of practice. The DON was interviewed on 11/7/24 at 12:34 p.m. The DON said she got a call by the night shift nurse that Resident #30 had an unwitnessed fall when she walked with her walker to the bathroom and her legs became weak. The DON said she was informed the resident was last seen approximately 15 to 30 minutes before she fell . The DON said the resident was able to ambulate with her walker independently but had not felt well and had emesis (vomiting) the night before. The DON said the resident informed the staff she did not hit her head, but because the fall was unwitnessed, a neurological assessment was conducted. The DON was interviewed a second time on 11/7/24 at 3:42 p.m. The DON said post-fall assessments must be completed by RNs because assessing residents was not in a LPNs scope of practice. The DON said she had reviewed post-fall documentation for Resident #14 on 1/12/24. The DON said the assessment documentation for Resident #14's fall was completed by LPNs. The DON said LPNs were allowed to gather information for RNs to interpret for an assessment, however, she said there was no documentation of a RN completing an assessment for Resident #14. The DON and the nursing home administrator (NHA) were interviewed together on 11/7/24 at 4:18 p.m. The DON said a LPN could gather data after a fall but a RN needed to be the one to assess the resident. The DON said LPNs did not have the scope of practice to assess a resident after a fall, but the facility did not have a RN on duty at the facility 24 hours a day. She said a resident should be immediately assessed after a fall. The DON said there was no documentation identifying a RN assessed Resident #14 after he fell in January 2024. She said if a resident fell at night, a resident would not be assessed by a RN. She said if staff had questions, they could call her and she could come in. The DON said she lived five minutes from the facility but she was not available to come in when Resident #14 fell . The NHA said a RN had to assess a resident after a fall. She said a LPN could call the RN and review all the information with the RN. The NHA said it was the facility's policy to contact the NHA, the DON or the assistant director of nursing (ADON) after a fall. The DON said she did not document she was notified right after Resident #30 fell . She said she did not think her documentation would matter. The DON said a RN assessment after a fall would include assessing the resident's grasp, pupils, vital signs, skin, range of motion, pain, mobility, change in speech and cognition. The DON said LPN #2 was the nurse who assessed Resident #30 after she was found on the floor at 6:00 a.m. The DON said LPN #2 put eyes on the resident after she fell and thought that was enough. The DON said she looked at all of the staff documentation related to the resident's fall and was able to piece together what happened. She said Resident #30 was not injured after the fall but she had a severe cardiac history. She said the physician was notified the resident was not feeling well and she was encouraged to go to the hospital after the fall. The DON said the resident declined going to the hospital and said she was just tired. 40467

Based on observations, record review and interviews, the facility failed to ensure two (#11 and#18) of five residents reviewed for activities of daily living (ADLs) received appropriate treatment and services to maintain or improve his or her abilities out of 20 sample residents. Specifically, the facility failed to provide the necessary assistance and equipment for Resident #11 and Resident #18, who required assistance and encouragement with eating. Findings include: I. Facility policy and procedure The Long-term care feeding policy, revised 12/11/23, was obtained from the corporate consultant (CC) on 11/7/24 at 3:41 p.m. It documented in pertinent part, Various disabilities and conditions may prevent a resident from self-feeding, including cognitive deficits, neuromuscular disease, cancer, obstructive lung disease, and traumatic injury. A resident who cannot self-feed is susceptible to malnutrition. The resident may also experience pain, nausea, depression, and anorexia as a result of the condition or its associated treatment. Meeting such a resident's nutritional needs requires determining food preferences; feeding the resident in a friendly, unhurried manner; encouraging self-feeding to promote independence and dignity; and documenting intake and output. Allow the resident control over mealtime, such as by letting the resident set the pace of the meal or decide the order in which to eat various foods because many adults consider being fed demeaning. Introduce adaptive feeding devices before mealtime, with the resident seated in a natural position. Explain and reinforce the purpose of the device, show the resident how to use it, and encourage practice. Encourage the resident to indicate readiness for another mouthful. Pause between courses and whenever the resident wants to rest. The Dining Experience: Staff Responsibilities policy, revised 2023, was provided by the CC on 11/7/24 at 4:31 p.m. It read in pertinent part, Staff will treat each individual with dignity and respect and strive to meet their personal needs. During meals staff will socialize with, listen, pay attention and converse with each individual. Staff should offer as many choices as possible when it comes to meal times: choices of what to eat, when to eat and who to eat with. Support staff work under the supervision of the registered dietitian. Staff will offer assistance as needed in order to maintain, improve and/or prevent a decline in eating ability. The Person-Centered Dining Approach policy, revised 2023, was provided by the CC on 11/7/24 at 4:31 p.m. It documented in pertinent part, Food and beverage preferences and special dietary needs should be met based on individual choice and/or physician's order. Individuals will be provided with the proper assistive devices and utensils identified by the care plan. Staff will provide support with assistive devices as needed. Staff will provide cueing, prompting or assistance as needed in order to maintain, improve and prevent decline in eating ability. II. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included unspecified severe dementia with psychological disturbance, dysphagia (difficulty swallowing) and Alzheimer's disease. The 10/8/24 minimum data set (MDS) assessment revealed the resident was rarely or never understood and could not complete the brief interview for mental status (BIMS) assessment. He was dependent on nursing staff for all cares and activities of daily living (ADL). The assessment documented Resident #11 was severely cognitively impaired and rarely or never made daily decisions. The assessment documented Resident #11 continuously presented with inattention, disorganized thinking, and an altered level of consciousness. The assessment documented Resident #11 had no rejections of care. B. Observations During a continuous observation in the dining room on 11/4/24, beginning at 11:27 a.m. and ending at 12:42 p.m., the following was observed: At 11:47 a.m. Resident #11 was assisted to the dining room at 11:47 a.m. Resident #11 was assisted with his meal from 11:53 a.m. to 12:09 p.m. by certified nurse aide (CNA) #3. At 12:09 p.m. CNA #3 stopped assisting Resident #11 and began assisting an unidentified resident who was sitting across the table from Resident #11. Resident #11 was without assistance in the dining hall between 12:09 p.m and 12:21 p.m. At 12:21 p.m. CNA #3 was observed to tell CNA #1 that Resident #11 was done eating and was ready to return to his room. At 12:22, CNA #1 was observed to remove Resident #11's clothing protector and assisted the resident out of the dining hall. Resident #11 was observed to eat less than 25% of this meal. -CNA #1 and CNA #3 did not offer Resident #11 extra time for meal assistance as identified in his nutritional plan of care (see below). -CNA #1 and CNA #3 did not offer Resident #11 an alternative meal option after he consumed less than 25% of the meal. During a continuous observation in the dining room on 11/6/24, beginning at 11:22 a.m. and ending at 12:57 p.m., the following was observed: At 11:48 a.m. the director of nursing (DON) was observed to sit by Resident #11 and assist him to drink fluids. At 11:49 a.m., the DON was observed to leave Resident #11 and go into the kitchen. At 12:01 p.m. CNA #3 was observed to place gloves on the dining table in front of Resident #11 but did not offer assistance consuming his beverage. At 12:18 p.m., CNA #3 was observed to sit next to Resident #11 and offer meal assistance to consume his beverage. At 12:19, CNA #3 was observed to leave Resident #11 alone and assist other residents in the dining hall. Resident #11 was without meal assistance between 12:19 p.m. and 12:24 p.m. At 12:24 p.m. CNA #1 was observed to sit next to Resident #11 and offer meal assistance drinking his beverage which Resident #11 accepted. CNA #1 was not observed to offer meal assistance to Resident #11 between 12:24 p.m. and 12:36 p.m. At 12:36 p.m. CNA #1 offered Resident #11 meal assistance drinking his beverage. At 12:37 p.m. CNA #1 was then observed to leave Resident #11 alone in the dining hall and assist other residents in the dining hall. Resident #11 was without meal assistance between 12:37 p.m. and 12:48 p.m. Resident #11's food was delivered to him at 12:48 p.m. At 12:49 p.m. CNA #1 returned to sit next to Resident #11 and offered food assistance. At 12:51 p.m. Resident #11's representative arrived in the dining hall for a visit. At 12:54 p.m., CNA #1 was observed to leave Resident #11 at the table with Resident #11's representative. At 12:57 p.m., CNA #1 offered for Resident #11 and Resident #11's representative to leave the dining hall to have a visit instead of eating which was accepted by the resident representative. At 12:58 p.m., Resident #11 was assisted out of the dining hall by CNA #1. Resident #11 was observed to eat less than 25% of the lunch meal and less than 25% of his beverage. -The facility served Resident #11's lunch meal was delivered more than one hour after he was assisted to the dining hall. -The facility did not provide extra time for Resident #11 to eat the lunch meal as identified in his nutritional plan of care (see documentation and interviews below) -The facility failed to offer a food alternative when Resident #11 was observed to eat less than 25% of the lunch meal. C. Resident representative interview Resident #11's representative was interviewed on 11/6/24 at 1:05 p.m. Resident #11's representative said Resident #11 had been actively declining while receiving hospice services recently. Resident #11's representative said there was a meeting today to discuss whether or not interventions should be changed further to reflect where Resident #11 was in his end of life care journey. Resident #11's representative said Resident #11 should be offered food alternatives if he ate very little at the meal. Resident #11's representative said Resident #11 required extra time to eat and drink because his intake pace had slowed in recent months. Resident #11's representative said Resident #11 should not have to wait more than an hour to receive his food after he was assisted to the dining hall. Resident #11's representative said he did not know how long Resident #11 had been eating in the dining room for lunch on 11/6/24 when he was offered to have a visit with Resident #11 instead of continuing to provide Resident #11 with meal service assistance. Resident #11's representative said the family did not provide assistance at meals. D. Record review The nutrition care plan, initiated on 2/9/23 and revised 10/28/24, revealed Resident #11 had the potential for unintentional weight loss and was initiated on hospice care. The interventions included providing assistance at meals as needed and as the resident allows, allowing ample time to consume food and fluids, monitoring the resident's intake, positioning the resident upright at meals as close to 90 degrees as possible while maintaining resident comfort and not to feed the resident if he appeared lethargic. A review of Resident #11's EMR revealed the following physician's orders: -Sit upright to eat and 30 minutes after, try to complete oral care after each meal, use a swab with mouthwash to clear residue on teeth, cheeks and tongue, ordered on 5/25/23. -Slow feeding, nectar thickened fluids. If the resident coughs hard or chokes during feeding, stop feeding for adequate time for the resident to recover, resume feeding and if coughs hard or chokes a second time stop feeding for that meal, ordered on 8/3/24. The Quick training documentation, dated 8/12/24, was provided by the director of nursing (DON) on 11/7/24 at 3:41 p.m. It documented that 12 bedside nursing staff members were educated Be sure to allow [Resident #11] to rest if he starts to cough. Then attempt to assist after adequate resting. If coughing continues, stop assisting with meal and notify the nurse. The 10/7/24 dietary data collection documented Resident #11 was normally eating 25-50% of all meals. The dietary data collection documented that Resident #11 had experienced weight loss in the last six months because of his declining condition. The dietary data collection documented that this was expected weight loss because Resident #11 was receiving hospice care services. The dietary data collection documented that Resident #11 required total assistance with meals. The dietary data collection documented that Resident #11 was accepting thickened liquids. -However, Resident #11 was not observed to receive consistent meal assistance on 11/4/24 and 11/6/24. The hospice visit note, dated 10/9/24, documented that Resident #11 required assistance with all ADL's. The hospice visit note documented Resident #11 required assistance with all meals including meal preparation, meals being fed to Resident #11, and that Resident #11 coughed with food and fluids. The hospice note documented Resident #11 had difficulty swallowing. The hospice visit note documented that Resident #11 was unable to communicate his needs. III. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), Alzheimer's disease, and severe dementia without behavioral disturbance. The 10/7/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The assessment documented Resident #18 required substantial or maximum assistance with eating and oral hygiene, and was dependent on nursing staff for all other cares and activities of daily living (ADL). The assessment documented Resident #18 continuously presented with inattention and disorganized thinking. The assessment documented Resident #18 had no rejections of care. B. Observations During a continuous observation in the dining room on on 11/4/24, beginning at 11:27 a.m. and ending at 12:42 p.m., Resident #18 was eating vegetable lasagna from a regular plate. Resident #18 ate less than 25% of this lunch meal. -Resident #18 was not offered a lipped plate as identified in his nutritional plan of care (see record review below). -Resident #18 was not offered an alternative food option after consuming less than 25% of the meal. C. Record Review The nutrition care plan, initiated on 2/9/23 and revised on 10/28/24, revealed Resident #18 had the potential for unintentional weight loss because of his COPD diagnosis, history of weight loss, diagnosis of essential tremors affecting intake and general decline. The care plan documented his goal was to slow and minimize weight decline. The interventions included providing a lipped plate, handled cups, and may use weighted utensils if requested, encouraging the resident to sit in the dining room for meals, having food available when the resident was hungry, offering the resident assistance at meals as needed, providing a lidded cup for soups and milkshakes due to tremors, allow ample time to consume food and fluids, and to monitor the resident's intake. The 10/7/24 dietary data collection documented Resident #18 normally ate 50-75% of all meals. The dietary data collection documented Resident #18 required adaptive equipment to eat including a lipped plate and a cup with both a lid and handles. Resident #18's weight decline was expected and was related to an overall decline in Resident #18's condition. -However, Resident #18 did not receive a lipped plate during meal observations on 11/4/24. On the Spot Training documentation was received from the nursing home administrator (NHA) on 11/7/24 at 3:26 p.m. (during the survey) The training documented While assisting residents with meals once we start we should not be getting up and down. Our focus should be focusing on maximum nutrition. If the resident is refusing to eat, offer a different option. If the resident is eating less than 50% of their meal, offer another option. III. Staff interviews CNA #1 was interviewed on 11/6/24 at 1:21 p.m. CNA #1 said if a resident ate less than 25% of their meal, an alternative meal option should be offered and the nurse should be notified. CNA #1 said that when staff members assist residents with eating one on one they should stay with the resident for the duration of the meal unless there is an emergency. CNA #1 said that residents should always receive the adaptive equipment needed to safely eat. -However, CNA #1 was observed to leave Resident #11 to assist other residents in the dining hall on 11/4/24 and 11/6/24 dining observations. The registered dietitian (RD) was interviewed on 11/6/24 at 1:41 p.m. The RD said that Resident #11 and Resident #18 required end of life care services. The RD said that residents requiring extra time to eat their meal should be given what time they need to eat what they want to eat. The RD said offering food to Resident #11 for less than 30 minutes was not appropriate because Resident #11 needed more time to eat. The RD said it was inappropriate for residents to be served their meal more than one hour after they are assisted to the dining hall. The RD said that if a resident eats less than 25% of their meal, a meal alternative should be offered. The RD said nursing staff should follow identified interventions in the nutritional plan of care. The RD said it was expected for Resident #11 and Resident #18 to have weight loss because they are both receiving end of life care services. CNA #3 was interviewed on 11/6/24 at 4:22 p.m. CNA #3 said residents should always be provided with the appropriate adaptive equipment. CNA #3 said that residents should be offered a meal alternative if they eat less than 25% of their meal. CNA #3 said CNA's at the facility try to stay with a resident, but that did not always happen. Registered nurse (RN) #1 was interviewed on 11/7/24 at 10:24 a.m. RN #1 said that if a resident ate less than 25% of a meal, then an alternative meal option should be offered. RN #1 said that it was important to make sure residents have the appropriate adaptive equipment so they have the ability to eat independently. The director of nursing (DON) was interviewed on 11/7/24 at 3:42 p.m. The DON said Resident #11 and Resident #18 required end of life care services and weight loss was expected in both residents. The DON said she did not know why Resident #11's meal service was significantly delayed at lunch on 11/6/24. The DON said she expected staff members to stay with residents requiring meal assistance throughout the meal unless an emergency occurred. The DON said facility staff should not be leaving residents alone without assistance during the meal service. The DON said that Resident #11 should have been offered fluids more frequently on lunch meal services that took place on 11/4/24 and 11/6/24. The DON said that residents should always be offered a meal alternative if they eat less than 25% of their meal. The DON said residents should be offered adaptive equipment identified in the nutritional plan of care. The DON said that if a resident required extra time to eat their meal then staff should offer assistance as long as the resident needs. The DON said that Resident #11 did not receive extra time to eat his meal on lunch observations that took place on 11/4/24 and 11/6/24. The DON said she was not aware Resident #18 did not receive a lipped plate for the vegetable lasagna served for lunch on 11/4/24.

Based on observations, record review and interviews, the facility failed to ensure one (#10) of two residents reviewed for pressure injuries out of 20 sample residents received care and services necessary to prevent the development of pressure injuries. Specifically, the facility failed to ensure staff consistently followed the care planned wound prevention interventions for Resident #10, who had a facility-acquired pressure ulcer. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 10/8/24, Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individual with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. The Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss. Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss. Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcer can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown. Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar tan, brown or black) on the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth,and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Prevention and Treatment of Pressure Ulcers/Pressure Injuries policy, dated 11/22/22, was provided by the director of nursing (DON) on 11/7/24 at 5:49 p.m. It read in pertinent part, It is the policy of the facility to properly identify and assess residents whose clinical conditions increase the risk of impaired skin integrity, and pressure room, preventive measures and to provide appropriate treatment modalities for wounds according to professional standards of care. III. Resident #10 A. Resident status Resident #10, age greater than age 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included chronic systolic (congestive) heart failure, atherotherosclerolic heart disease of the native coronary artery without angina pectoris (hardening of the arteries from plaque build impacting blood flow), type two diabetes mellitus without complications, weakness, and audio and visual hallucinations. The 8/9/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #10 exhibited inattention or disoriented thinking. According to the MDS assessment, the resident was at risk for developing pressure ulcers and received hospice care. B. Resident interview Resident #10 was interviewed on 11/5/24 at 4:18 p.m. Resident #10 was not able to say if he had wounds on his feet or if he was comfortable with his heel protective boots and heel offloading device in place. The resident said he was not in pain. C. Observations On 11/4/24 at 11:58 p.m. Resident #10 was sleeping in his bed. His heel offloading device was sitting on the floor next to the wall, between his bed and his closet. Resident #10 did not have a heel offloading device under his legs to offload the pressure on his heels. At 3:34 p.m. Resident #10 was sleeping in his bed. His heel offloading device remained off the bed and in the same location. The heel offloading device was not in place to offload the pressure on the resident's heels as he laid in bed. On 11/5/24 at 12:58 p.m. wound care for Resident #10 was provided by licensed practical nurse (LPN) #2, registered nurse (RN) # and the DON. After completing the wound care, the DON placed a bolster wedge upright between the resident's footboard and Resident #10's heel protective boots. There was no visible space between the wedge and the Podus boot. The bottom of the resident's heel protective boots were slightly compressed against the surface of the bolster wedge, which did not allow the resident's heels to be appropriately offloaded. At 4:10 p.m. Resident #10 was sitting in the lobby in a wheelchair. The resident was wearing slippers on his feet. The foot pedals of his wheelchair were folded up against each side of the wheelchair and not in use. Resident #10 requested the activity assistant (AA) take him to the living room to watch television as he waited for dinner. The AA proceeded to assist Resident #10 in his wheelchair down the hall towards the living room. Resident #10's slippered feet skimmed the surface of the floor as he was pushed in his wheelchair. -The AA did not unfold the resident's wheelchair foot pedals and place his feet on the foot pedals before he was transported down the hall. On 11/6/24 at 4:10 p.m. Resident #10 was awake in bed. He did not have his heel protective boots on his feet. The heel offloading device device was not in place and his heels were not offloaded off of the bed. The bolster wedge was at the head of the resident's bed. On 11/7/24 at 9:27 a.m. Resident #10 was assisted to bed by certified nurse aide (CNA) #4 and another staff member. At 9:35 a.m. Resident #10 was in bed after CNA #4 and the other staff member assisted him to bed. The resident's heel offloading device was up against the wall and not placed under the resident's legs to float his heels and offload the pressure from his heels. At 9:57 a.m. Resident #10 was sleeping in bed. His heel offloading device remained up against the wall on the floor. D. Record review The skin care plan, revised 11/4/24, documented Resident #10 was at risk for skin breakdown on his heels from poor nutrition, impaired mobility and his preference to stay in bed. According to the care plan, heel protectors were in use. According to the care plan, the resident occasionally declined to float his heels. Interventions included offering the resident repositioning assistance if needed when he laid bed (initiated 2/15/24), providing heel protective boots to the resident while he was in bed to prevent skin breakdown to his heels and ankles related to his preference to frequently stay in bed (revised 10/22/24), providing verbal cues to the resident during transfers to assure safety and decrease risk of injury (initiated 10/21/24) and providing the resident a heel offloading device, if the resident allowed, to reduce pressure to his heels. The resident was re-educated on the need to use the heel protective boots and the heel offloading device (revised 9/25/24). The 8/6/24 Braden Scale for Predicting Pressure Sore Risk assessment documented Resident #10 was at moderate risk for developing a pressure sore. According to the assessment, the resident had very limited sensory perception, had very limited mobility, requiring moderate to maximum assistance in moving and had the potential for inadequate nutrition. The 10/22/24 Braden Scale assessment for Resident #10 documented he remained at a moderate risk for pressure injury. Review of the November 2024 CPO revealed the following physician's orders: Resident #10 was admitted to hospice related to congestive heart failure, ordered 8/12/24. Offload heels at all times, especially his left heel, twice a day for his wound, ordered 9/25/24. Wound care left heel: Cleanse with a wound cleanser, apply Santyl (wound treatment used to remove damaged tissue from wounds) to the slough (yellow/white dead tissue) in wound bed, apply Calcium Alginate (wound treatment) to wound bed and cover the wound with a foam dressing that extends out from the wound. Changed every five days and PRN (as needed), ordered 10/29/24. The 9/25/24 eInteract situation background assessment recommendation (SBAR) post incident review documented Resident #10 had a stage two pressure wound to his left heel. The 9/29/24 IDT post incident note documented Resident #10 raised the head of his bed independently and lowered his feet independently, which removed the heel offloading device, pushed his feet against the footboard and frequently slid down in bed. The resident's legs would extend over the footboard. The resident had potential risk of injury to his feet and toes related to self propelling his wheelchair or kicking his legs over the side of the bed. According to the IDT note, Resident #10 was provided a heel offloading device, heel protective boots and wound care as ordered by the physician. The 10/30/24 IDT review note documented Resident #10 received continued education for floating his heels and using heel offloading devices for his bilateral lower extremities. According to the note, Resident #10 verbalized and demonstrated positive results for reinforcement of the education. The 11/3/24 skin/wound evaluation indicated Resident #10 was educated to keep his heels floated. According to the care plan, the resident would kick the heel protectors off the bed. Review of Resident #10's progress noted between September 2024 and November 2024 did not identify the resident refused heel offloading interventions (see interviews below). A 11/7/24 On the Spot staff training with the AA was provided by the corporate consultant (CC) on 11/7/24 at 2:53 p.m. The training documented the AA was provided training (during the survey) not to push residents in their wheelchairs without their feet on the foot pedals to prevent friction on the residents' feet. A 11/7/24 On the Spot staff training for foot pedals was provided by the CC on 11/7/24 at 2:53 p.m. Eight staff members received the training on 11/7/24 (during the survey). The training informed staff to make sure a resident's feet were not dragging when a resident was transported with a wheelchair. According to the training, staff should use foot pedals to ensure the resident's feet did not touch the floor because it increased the risk for skin breakdown. A 11/7/24 On the Spot staff training was provided by the CC on 11/7/24 at 2:53 p.m. The training documented twelve staff members received training on 11/7/24 (during the survey) regarding bolster wedges. According to the training, bolsters should be placed at the top of the bed to prevent added pressure to the foot of the bed. IV. Staff interviews LPN #2 was interviewed on 11/6/24 at 4:41 p.m. LPN #2 said Resident #10 had a pressure wound on his foot. She said hospice had determined it to be unavoidable as of the morning of 11/6/24 but she had not added the order to his electronic medical record (EMR) yet. LPN #2 said she believed the pressure ulcer on his foot was from his footboard on his bed. She said Resident #10 would use his bed controller to raise the head of his bed up and then he would slide to the foot of his bed. She said he would prop up his feet on his footboard. She said protective interventions had been put in place to reduce the pressure of his heels and decrease the risk of his pressure reducing mattress moving and sliding down, touching the foot board with heels. LPN #2 said Resident #10 had soft heel protective boots, a heel offloading device under his lower legs as he laid in bed and a bolster wedge to help keep the mattress in place so it would not slide down when he lifted the head of the bed and to reduce the risk for pressure to the resident's feet. LPN #2 said the bolster wedge should be positioned at the head of the bed and not the foot of the bed to keep the mattress in place. LPN #2 said Resident #10 should wear his heel protective boots when he was in bed to offload his heels and reduce pressure. LPN #2 said Resident #10 was at risk for pressure ulcers because he had poor circulation, refused nutritional interventions and self propelled his wheelchair. She said staff needed to ensure interventions were in place to help decrease Resident #10's pressure ulcers from worsening and help prevent new pressure ulcers from developing. LPN #2 said staff needed to help reposition him every two hours during the day and every four hours at night, put on his heel protective boots and place his heel offloading device under his lower legs so his heels could float. She said he should have his heel offloading device in place every time he was in bed. LPN #2 said the CNAs and the nurses should do visual checks on the resident. LPN #2 said the foot pedals on Resident #10's wheelchair should be used when staff propelled his wheelchair to prevent injury and reduce friction between his feet and the floor. She said Resident #10 could only hold his feet up for short distances. LPN #2 said staff should reapproach and encourage the use of his pressure reducing and prevention interventions and document the resident's refusals to offload his heels. CNA #4 was interviewed on 11/7/24 at 10:07 a.m. CNA #4 said Resident #10 should be repositioned every two hours, his heel protective boots should be on and his heel offloading device should be in place when he was in bed CNA #4 said the resident would take his heel protective boots off when he wanted to get up and out of bed but she said otherwise, Resident #10 was compliant with wearing the heel protective boots if he was given a reminder on why he needed to wear them. The DON and the CC were interviewed on 11/7/24 at 12:10 p.m. The DON said Resident #10 had been on hospice services since 8/6/24 but because of his declining circulation, the physician determined the development of pressure ulcers were unavoidable. She said the 11/6/24 order had not yet been uploaded to his EMR. The CC said failure to follow wound interventions could increase the risk for worsening of the pressure ulcer and would be considered an avoidable development. She said all wound prevention interventions should be consistently followed. The CC and the DON said the heel offloading device should be in place when Resident #10 was in bed. The DON said staff should not push his wheelchair when his feet were not on his foot pedals due to the risk of injury. The DON said there was some confusion on where the bolster wedge should be placed on Resident #10's bed. She said the staff was placing the wedge at the foot of the bed as a buffer between his feet and the footboard. She said it was determined the wedge should be at the head of the bed to help reduce the risk of the air mattress sliding down and decreasing the risk of his feet touching surfaces that could contribute to pressure. The DON said she would be providing staff education related to the placement of the bolster wedge.

Based on observations, record review and interviews, the facility failed to provide respiratory care services for one (#8) of two residents reviewed for respiratory care services out of 20 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #33. Findings include: I. Facility policy and procedure The Oxygen Administration, Long Term Care, [NAME] policy and procedures, revised 12/11/23, was provided by the director of nursing (DON). According to the procedures, oxygen administration supplies the body with enough oxygen to meet its cellular needs. The implementation of oxygen administration required verifying the practitioner's (physician) orders, assisting in the placement of the prescribed oxygen delivery device on the resident, making sure that the oxygen device fit properly and adjusting the oxygen flow rate as ordered. Staff should not administer oxygen nasal cannula at more than 2 (two) liters per minute (lpm) to a resident with chronic lung disease, unless there was a specific order to do so. The Lippincott procedures for oxygen identified a nasal cannula as an oxygen administration system. The plastic cannula (tubing) delivered oxygen into the resident's nostrils. According to the procedures, the cannula could become easily dislodged. II. Resident #8 A. Resident status Resident #8, age greater than age 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2024 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (lungs unable to adequately exchange oxygen, leading to low oxygen levels), dependence on supplemental oxygen, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, hallucinations and reduced mobility. The 8/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She did not exhibit inattention or disoriented thinking. She was dependent on staff for most of her activities of daily living (ADLs). According to the MDS assessment, the resident had shortness of breath or trouble breathing with exertion and when laying flat. The assessment identified the resident required continuous oxygen therapy. The resident did not have behaviors or rejections of care. B. Observations and resident interview On 11/4/24 at 1:20 p.m. Resident #8 was lying in bed. Resident #8's eyes were closed and her mouth was open as she took shallow breaths. Her oxygen concentrator was turned on and set at 3 liters per minute of oxygen (LPM). Her nasal cannula, attached to the oxygen concentrator, was not in her nostrils and was laying on her chest. Resident #8 kept her eyes closed as she lifted up the nasal cannula, brought it up near her and then placed it back down on her chest. The resident roused when her name was called. The resident said she was not feeling well and had some shortness of breath (SOB). Resident #8 placed her nasal cannula in her nostrils and turned on her call light. The nurse entered the room. Resident #8 was interviewed on 11/5/24 at 10:50 a.m. Her oxygen concentrator was set at 2 LPM. She said her nasal cannula would often come off when she was sleeping. She said she would place it back in her nostrils when she woke up. Resident #8 said she would become short of breath when she was not not wearing her nasal cannula. She said she also had difficulty breathing if the water container attached to the oxygen contractor was low. She said the water container would sometimes run out of water or the water level would run low which made it harder for her to breathe. She said she tried to watch the water level from her bed and make sure there was enough water in the container. Resident #8 said she had to remind the staff to fill the water container. On 11/6/24 at 1:32 p.m. Resident #8 was in her room. Her oxygen concentrator was set at 3 LPM and the water container was less than half full. The resident said the oxygen should be set at 2 LPM and she did not know why it was set at 3 LPM. The resident said the water in her oxygen concentrator was less than half full and said she wanted it filled because she was nervous it might run out of water. Resident #8 requested for a nurse to look at her oxygen LPM setting and the water level in the water container. At 1:40 p.m. registered nurse (RN) #2 entered Resident #8's room and observed the resident's oxygen concentrator set at 3 LPM. RN #2 told the resident her oxygen was set too high and turned it down to 2 LPM. RN #2 checked Resident #8's oxygen saturation levels. RN #2 asked the resident to take in some deep breaths. The resident, confused by the directions, held her breath. RN #2 reminded Resident #8 to breathe normally and her saturation levels rose to 92%. RN #2 observed the water level in the container attached to the resident's oxygen concentrator. RN #2 told the resident the water level was less than half full and it should be over half full. RN #2 filled the water container. C. Record review A 6/6/24 nursing agenda was provided by the DON on 11/7/24 at 4:57 p.m The agenda identified oxygen was reviewed with the nurses. -The agenda did not identify what was reviewed with the nurses regarding oxygen. Review of Resident #8's November 2024 CPO revealed the following physician's orders: Continuous oxygen set at 2 LPM via nasal cannula every shift for cough, congestion related to chronic respiratory failure with hypoxia and heart failure, ordered 8/13/24. Document if the resident had shortness of breath every shift related to heart failure with the following codes: -(1) no SOB; -(2) SOB at rest; -(3) SOB with exertion; and, -(4) SOB while lying flat, ordered 8/13/24. Interview resident, family members, and/or staff for any noted shortness of breath when the resident attempts to lie flat, or avoids lying flat because of shortness of breath. Observe the resident during various activities, sitting at rest, and when in bed and document in progress notes, ordered 8/13/24. Check and clean or change oxygen supplies every Saturday during the night shift, ordered 8/13/24. The oxygen care plan, revised 10/21/24, documented Resident #8 required oxygen at 2 LPM via nasal cannula related to a diagnosis of heart failure. The care plan directed staff to change her oxygen tubing weekly and PRN (as needed), monitor and document level of consciousness, mental status, and lethargy PRN and notify the nurse if oxygen saturation levels dropped under 90% (percent). A 10/21/24 oxygen audit was provided by the DON at 4:35 p.m. The audit documented 12 residents with supplemental oxygen who were reviewed for oxygen care plans and physician orders in place. According to the audit, Resident #8 had physician orders for oxygen at 2 LPM and her care plan was in place. The November 2024 oxygen saturation log, between 11/2/24 and 11/5/24, documented the resident's oxygen saturation levels were checked two to three times a day and ranged between 91% and 96%. The November 2024 medication administration and treatment record (MAR/TAR), reviewed from 11/1/24 through 11/5/24, documented Resident #8 had experienced SOB daily with exertion and when laying flat. The oxygen care plan, revised 11/7/24 (during the survey), revealed Resident #8 expressed concerns over the concentrator water level being below the minimum fill line. The resident felt she was able to breathe better with the water at a higher level. The care plan directed staff to check the resident's water bottle on the concentrator to ensure that it was filled at the maximum water level and ensure the resident had her oxygen tubing placed on her face. An On The Spot training sheet was provided by the corporate consultant (CC) on 11/7/24 at 3:37 p.m. The training was conducted on 11/7/24 (during the survey). The training sheet identified that 13 staff members were told the nurses were the only ones that could touch residents' oxygen settings. According to the training, if a resident was requesting more oxygen, staff should notify their nurse so that the correct procedures could be followed with obtaining a physician's order. Staff should ensure the oxygen tubing was in the nasal canal and not laying on the resident's face. Staff were also reminded to make sure the water was filled to the proper level on the oxygen concentrator D. Staff interviews RN #2 was interviewed on 11/6/24 at 1:36 p.m. RN #2 said she thought Resident #8's oxygen setting should be 3 LPM but would need to confirm it. RN #2 reviewed Resident #8's oxygen order and said the resident's oxygen concentrator should be set at 2 LPM per the physician's order. She said only nurses were allowed to adjust the oxygen settings on the concentrator. She said she had been Resident #8's nurse all day and she had not adjusted the resident's oxygen setting. RN #2 said the only reason for the increase in LPM would be if the resident was desaturating, but she said the last documented oxygen saturation level (amount of oxygen in the blood) was 98% on 11/5/24. She said a certified nurse aide (CNA) should not adjust the oxygen setting and the resident was not physically able to adjust the oxygen setting herself. RN #2 was interviewed a second time on 11/6/24 at 1:49 p.m. RN #2 said she would fax the physician and ask if there should be any changes to her oxygen orders and confirm what LPM her oxygen concentrator should be set at. CNA #1 was interviewed on 11/6/24 at 1:51 p.m. CNA #1 said the water level in the water container on the oxygen concentrator should be maintained above the minimal line. She said the oxygen concentrator should be set according to the nurse's directive. She said CNAs were never allowed to adjust the oxygen settings on residents' oxygen concentrators. CNA #3 was interviewed on 11/7/24 at 9:30 a.m. CNA #3 said Resident #8's nasal cannula frequently fell off her face at night and sometimes during the day when the resident slept. She said the resident did not take it off on purpose and it was very important to Resident #8 that she had it in her nose. CNA #3 said the resident was receptive to having staff assist her with wearing her nasal cannula and would not resist or decline the oxygen use. CNA #3 said Resident #8 would get short of breath if she was not wearing her nasal cannula, if the tubing had a kink in it which would limit the oxygen flow and if the water level in the water container on the oxygen concentrator was low. She said she tried to keep the water level in the container more than half full. She said Resident #8 told her that the water levels impacted her breathing and she would watch the water level. CNA #3 said Resident #8's oxygen concentrator was usually set between 2 LPM and 3 LPM. She said she could adjust the oxygen setting if she confirmed the setting with the nurse. RN #2 was interviewed a third time on 11/7/24 at 9:16 a.m. RN #2 said there was not a change in Resident #8's oxygen flow rate since the 11/6/24 observation. She said the resident's oxygen order remained at 2 LPM and she did not have a physician's order to titrate (adjust oxygen flow rate) the resident's oxygen to a different flow rate. RN #2 said she had spoken to the night shift nurse who said the resident would sometimes insist on having her oxygen setting increased. RN #2 said the physician's orders should be followed. She said an oxygen saturation level of 98% was pretty high for the resident. She said the resident's usual oxygen saturation levels were around 95% and did not usually drop under 90%. The DON was interviewed on 11/7/24 at 11:53 a.m. The DON said it was not appropriate for physician's orders not to be followed. She said only nurses were allowed to set the LPM on the residents' oxygen concentrators. She said the nurse should only adjust the setting based on the physician's order for oxygen. The DON said if Resident #8's oxygen setting was increased then there should have been a documented rationale and the physician should have been contacted. The DON said the water level in the water container on the oxygen concentrator should be monitored every shift and be between the minimum and the maximum level lines. She said Resident #8 worried about the water level and had a fear of running low on the water level. The DON said the resident wanted the water level to be maintained at the maximum water line to ease her worry. She said the resident's preference on the water container level on the oxygen concentrator was not care planned but it should have been. She said staff should check her water levels each time they went into her room. The DON said Resident #8 did not take off her own nasal cannula. She said staff checked on Resident #8 every two hours during rounds. The DON said she would update the CNA task sheet and the resident's MAR to include more frequent observations with Resident #8 because the nasal cannula would fall off when the resident was sleeping. The quality assurance and improvement coordinator (QAIC) was interviewed on 11/7/24 at 5:18 p.m. The QAIC said oxygen was reviewed in the facility's quality assurance and improvement committee but oxygen had not been identified as a recent concern. She said audits were conducted and there were no concerns found. She said the staff were doing what they were supposed to be doing. She said it had been a while since staff had received education related to oxygen.

Based record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#1) of three residents reviewed for falls out of three sample residents. Specifically, the facility failed to ensure Resident #1, who was at high risk for falls, had adequate supervision at night. Resident #1 was left alone on 7/7/23 late at night in the living room without a call light available so she could call for help. As a result, Resident #1 sustained a fall on 7/7/23 and had to be airlifted to the hospital for treatment, where she was diagnosed with a subdural hematoma (a collection of blood that forms on the surface of the brain). Findings include: I. Facility policy The Fall Management Program policy, revised 10/24/22, was provided by the health information manager (HIM) on 9/5/23 at 5:38 p.m. and read in pertinent: All residents are assessed to identify risk for falls and individualized fall precautions will be developed in their care plan. Falls Program: 1. All staff will be responsible for fall prevention and monitoring; 4. All staff are trained on falls. II. Resident status Resident #1, age 82, was admitted on [DATE] and was readmitted to the facility on [DATE]. According to the September 2023 computerized physician orders (CPO) diagnoses included insomnia, hydrocephalus (abnormal build-up of fluid deep in the brain), epilepsy, difficulty walking (used a wheelchair), dysarthria (difficulty speaking because the muscles used for speech are weak) and anarthria (complete loss of speech), moderate dementia, traumatic subdural hemorrhage without loss of consciousness (bleeding between the skull and the brain) and unspecified altered mental status. The 6/5/23 minimum data set (MDS) assessment showed a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Resident #1 used a wheelchair and required extensive assistance from staff for all activities of daily living (ADLs) and she usually required two staff members to assist her. She had one fall without a major injury. III. Record review A. Care plan and fall risk assessments Resident #1 had four fall risk assessments completed for 2023 as follows: On 2/27/23 she scored a 55 which indicated she was a high risk for falls. On 6/29/23 she scored a 55 which indicated she was a high risk for falls. On 7/13/23 she scored a 75 which indicated she was a high risk for falls. On 7/19/23 she scored a 75 which indicated she was a high risk for falls. Resident #1's care plan, revised 7/21/23, had falls documented as a focus area. Initial fall interventions upon admission, 8/24/22, were listed as follows: Anticipate and meet needs, Be sure the call light is within reach and encourage the resident to use it for assistance as needed. Prompt response to all requests for assistance, Keep needed items in reach, Make sure personal needs are met. On 1/26/23 Resident #1's care plan had the following fall interventions added: Doctor notification (for falls), Neuro check per policy. On 3/21/23 Resident #1's care plan had the following fall interventions added: Monitor for the 5 P's (personal items, positioning, pain, personal needs, and proper sleep), Bed at the appropriate height, Toileting program- offer toileting before and after each meal and every two hours if she is awake. On 7/7/23 (the day of Resident #1's fall) Resident #1's care plan had the following fall interventions added: Be sure the call light is within reach and encourage the resident to use it for assistance as needed. Prompt response to all requests for assistance, Keep needed items in each, Doctor notification (for falls), Neuro check per policy, Review information on past falls and attempt to determine the cause of falls. Record possible root causes. Remove any potential causes if possible. Educate as to causes. On 7/18/23 Resident #1's care plan had the following fall interventions added: Administer medications per the doctor's orders, observe for side effects and effectiveness, Analyze previous falls to determine whether a pattern or trend can be addressed, Be sure the call light is within reach and encourage the resident to use it for assistance as needed. Prompt response to all requests for assistance, Family notification if falls occur, Follow facility fall protocol, Investigate causal factors, Keep needed items in reach, Make sure personal needs are met, Monitor for the 5 P's (personal items, positioning, pain, personal needs, and proper sleep), Neuro checks per policy, Review information on past falls and attempt to determine the cause of falls. Record possible root causes. Remove any potential causes if possible. Educate as to causes, Staff to anticipate and meet needs as necessary, Advise family to ask for assistance with transfers. On 7/21/23 Resident #1's care plan had the following fall intervention added: Staff should observe me (Resident #1) when I am sitting in the living room at night. -However, many of the interventions entered into Resident #1's care plan had previously developed as interventions. The facility failed to ensure Resident #1 had a way to call for help while in the living room since a call light was not within reach as her care plan had said it needed to be. B. Facility investigative report An incident report provided by the social service director (SSD) on 9/5/23 at 1:45 p.m. documented in pertinent part: On 7/7/23 at 2:02 a.m. Resident #1 had an unwitnessed fall that led to a subdural hematoma (brain injury). Resident #1 was refusing to stay in her room and wanted to watch television (TV) in the TV room. Staff reported they heard a loud noise and when the staff checked on her she was on the floor and bleeding from her head. Staff provided first aid and sent her to the hospital by ambulance. While Resident #1 was at the emergency room she was airlifted to another hospital after being diagnosed with a subdural hematoma to the frontal lobe. The facility documented if and when the resident returns to the facility the resident's care plan would be updated with new safety interventions put in place. The facility said they ensured that residents always have a way to call for help from staff in order to prevent this from happening again. Staff statements from incident: A certified nurse aide (CNA), who worked the night of the fall, provided the facility with her statement as follows: At 12:35 a.m. resident was in TV room. I asked resident if she was ready for bed. Resident stated no. I then stated let's go to your room and use the restroom. Resident was wet and I changed her. I asked again if she was ready for bed. Resident stated again she was not tired. I then said do you want to watch TV in your room. Resident stated she wanted to go back to the TV room. I then took her back to the TV room. At 1:40 a.m. I went back to the TV room and asked resident if she was ready for bed. Resident again said no. I then went to lunch at 1:45 a.m. I then came back from my lunch and saw the lights on in the TV room and resident was on the floor. I then observed resident sitting up against the piano on the floor, she had a cut on her forehead and one above her right eye. I saw her wheelchair by her side with brakes on and she had slippers on her feet. A licensed practical nurse (LPN), who worked the night of the fall, provided the facility with her statement as follows: At 1:58 a.m. this nurse was in rehab dock room when a loud noise was heard. This nurse rounded on all her patients and the other residents, all persons were observed safely in bed. This nurse entered TV room and observed Resident #1 to be sitting on the floor with her back leaned against the leg of the piano, legs extended out in front of her with bleeding from the top of her head, blood noted on the ground to her right and her glasses were noted to be broken on the floor next to her as well. This nurse alerted another LPN, he and a CNA responded. CNA was directed to bring vitals tower (machine to take vital signs) while this nurse and fell ow nurse assessed resident. Vitals were unremarkable and found to be within normal limits. Upon assessment, an open contusion was noted to the front, upper portion of resident's forehead. Pressure was applied to active bleeding with gauze and was well controlled under mild pressure. Swelling to right eye with bloody runoff entering the waterline was noted. Palpation (feeling with fingers) of facial structure and upper c-spine was negative for step-offs and crepitus (fractured bones). Resident did report pain during palpation. Upper, mid, and lower spine negative for step-offs and resident denied pain. Palpation of bilateral upper extremities (both arms) with offset pressure of bilateral lower extremities (both legs) were negative but swollen, tender hematomas (bad bruises) were noted to bilateral hands on various digits (fingers). Palpation and offset pressure of bilateral lower extremities was negative and resident denied pain. Resident does not take anticoagulants, but tools for further evaluation to rule out more serious injuries are limited within facility; emergency medical services (EMS) was notified for transport at 2:07 a.m. While waiting for EMS to arrive, resident's wounds were dressed and blood was cleaned from resident's face. It is also noted that resident was wearing appropriate footwear at the time of the incident and her wheelchair was in a locked position. EMS arrived by 2:20 a.m., a thorough report was given as well as resident's face sheet, current orders, and medical orders for scope of treatment (MOST) form. Another LPN, who worked the night of the fall, provided his statement to the facility as follows: Called to dining room by the second nurse to find the resident sitting on her buttocks with legs stretched out, contusion noted to resident's forehead and suspected injury to right eye, hematomas to bilateral hands. Resident's vitals were taken and within normal limits, grip weak to left hand normal in right, wound cleansed and eye covered and dry dressing to contusion and right eye, EMS called for transport. Doctor notified and received order to transport to emergency department called and message left to call back, social services called and message left to call back, director of nursing (DON) called and message left to call back, power of attorney (POA) called and informed of transport. The fourth staff, who worked the night of the fall, did not provide a statement for the incident and no longer worked for the facility. C. Hospital summary Resident #1 was admitted to the hospital on 7/7/23 and discharged back to the facility on [DATE]. The hospital records said she was treated for subdural bleeding. Radiology completed multiple images while Resident #1 was at the hospital. A CAT scan (imaging) of her brain was completed on 7/7/23. The radiologist documented a right-sided subdural hematoma that involves the anterior (inside), middle, and posterior (outside) fossas (depression in the base of the skull) that measured up to four millimeters in thickness. III. Family interview Resident #1's family/power of attorney (POA) was interviewed on 9/5/23 at 1:18 p.m. The POA said, Resident #1 was left in the TV room until 2:00 a.m. At that point in time she could get out of her chair and walk across the room. I have seen her get up and try to walk and almost fall. I reported it to the facility but they never told me anything. The POA said Resident #1 was not herself anymore mentally. She had a decrease in communication since the fall and it was barely coming back. I do not think she should have been left in the TV room because there was no call light. She does not really refuse anything if you just tell her what is best for her and she will respond. The POA said Resident #1 was able to use her call light before the fall but now not so much. She would only attempt to walk if she had to use the bathroom and falls are not regular at all for her. IV. Staff interviews The director of nursing (DON) was interviewed on 9/5/23 and 2:04 p.m. He said he received a phone call when a fall happened and he would ask for details on what happened, where and when. He said he tried to see if the nurse working knew why it happened. The DON said, I will do a scene investigation and see if they are incontinent, what kind of footwear they have on, the position of the bed or the wheelchair. I asked the pharmacist to do a medication review to see if the medications could have contributed to the fall. He said the staff notified the resident's doctor, social services director (SSD), nursing home administrator (NHA), the resident's POA/family, and himself. If a major injury occurred the risk management team at the corporate office would get involved as well. Interventions were discussed to see what the facility could do to keep residents safe and current interventions were reviewed with the interdisciplinary team (IDT) to see if it was appropriate for the resident. If a second fall occurred then the interventions were not working. The DON said after Resident #1's fall, training was provided to the staff, regular and agency, regarding fall prevention and seizures since the resident had a history of epilepsy. The training was due to be completed by all staff on 7/17/23. The DON was not aware the training was not completed by all staff but should have been. Review of facility training records revealed out of 36 regular staff, 11 staff had not completed the fall training as of the day of the survey on 9/5/23. Out of 36 regular staff, 30 staff had not completed the seizure triggers training as of 9/5/23. -However, the facility did not update the care plan (noted above) with many new interventions to prevent falls. Several of the interventions were already added to the care plan on a previous date. CNA #1 was interviewed on 9/5/23 at 5:07 p.m. She said she was extra cautious with Resident #1 since her fall. Resident #1 had her call light in place, she was frequently toileted, repositioned, and monitored by all staff working. CNA #1 said she had training regarding falls and if a resident had a fall the staff completed a fall huddle to try and determine what had happened. She was not able to recall if the team figured out the cause of Resident #1's fall in July 2023. The DON was interviewed again on 9/5/23 at 5:51 p.m. He said a lot of the interventions in place for residents were attached to the kardex (CNA care plan) so the staff had quick access to it. Resident #1's hours of sleep were monitored since her fall on 7/7/23. It was discussed at a care conference when her POA said she was concerned that Resident #1 was up late. Resident #1 had a diagnosis of insomnia. The DON said there were no interventions in place for the resident and he did not feel she needed interventions because she was always in bed. The DON had not received any recent reports of Resident #1 staying up late since her fall. The DON said a nurse and he observed staff for spot checks starting 8/7/23. He said these spot checks were observations and training on the spot if needed. These trainings were provided every two to three days. The DON and nurse provided observations and training for peri-care, feeding, transfers, hygiene and wound care. -However, falls and fall prevention observations were not completed on the spot check tracking form.

Based on observations, record review and interviews, the facility failed to ensure that the residents environment was free from accident hazards and received supervision and assistance to prevent accidents and hazards for two (#9 and #13) of six sample residents out of 26 sample residents. The facility failed to ensure a hot beverage was a safe temperature before it was served to Resident #9. Due to the facility failures, the resident experienced a burn that caused her pain after a hot beverage spilled onto her right lower leg. In addition, Resident #13 was kept free from an accident in a malfunctioning wheelchair. Findings include: I. Professional reference According to the U.S. Consumer Product Safety Commission (CPSC) regarding Tap Water Scalds. Document #5098, retrieved from https://www.cpsc.gov on 4/19/23. Most adults will suffer third degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees; a five minute exposure could result in third degree burns. II. Facility policy and procedure The Safe Water Temperatures policy and procedure, reviewed March 2021, was provided by the registered dietitian (RD) on 4/13/23 at 12:35 p.m. It revealed in pertinent part, Water temperatures will be monitored and logged in all food and dining areas accessible to employees, patients/residents, and guests as part of routine facility maintenance. Hot beverages and food temperatures will be monitored on a regular basis to assure appropriate temperatures at the point of service. The Safe Physical Environment/Right to have Personal Property policy and procedure, reviewed September 2019, was provided by the director of nursing (DON) on 4/13/23 at 3:37 p.m. It revealed in pertinent part, Resident preferences and choice, along with diagnosis and care needs are to be integrated into the physical environment to minimize risk and to assist the resident in attaining or maintaining the highest practicable level of function and independence. III. Resident #9 A. Resident status Resident #9, age 82, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included fibromyalgia (disorder causes pain), complex regional pain syndrome of bilateral lower extremities, monoplegia (weakness) of lower limb and heart failure. The 2/11/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required extensive assistance of two persons with transfers, extensive assistance of one person for dressing, toileting, limited assistance of one person for bed mobility, personal hygiene, and was independent with set up assistance only for eating. B. Resident interview and observation Resident #9 was interviewed on 4/10/23 at 3:16 p.m. Resident #9 said she was eating lunch in bed with the bedside tray pulled across the bed. A cup of tea spilled with the hot fluid landing on her right lower leg. Resident #9 said she did not know how the cup tipped over or if the cup had a lid. She said the area on her right shin hurt a lot but the pain was improving. The resident had a dark red area, approximately 2.5 inches in length and 2.0 inches in width, was observed on Resident #9's right shin. Blisters were not observed in the reddened area. C. Record review The activities of daily living care plan (ADL) care plan, initiated on 2/10/22 and revised on 1/31/23, documented the resident had a generalized weakness related to a diagnosis of muscle weakness. It indicated that the resident preferred to eat in her room in bed. Interventions included staff to assist with helping resident sit up in bed and setting up the food tray. The nutrition care plan, initiated on 8/17/20 revised on 2/13/23, indicated that the resident preferred to eat meals in bed and staff to set up meals at bedside. On 4/10/23 the care plan indicated that the resident requested hot beverages be served piping hot and the resident would like hot beverages to be served in a mug designated for her or in a styrofoam cup only. The 4/10/23 nursing progress notes revealed a post-incident note of a change in skin condition that occurred on 4/9/23 at 1:50 p.m. The resident was assessed for injuries. The physician, family and appropriate nursing staff were notified. The 4/11/23 nursing progress notes revealed the resident was complaining of pain and tenderness to the red area on her right lower leg. She was given Tylenol, triple antibiotic cream and a dressing was applied to the wound. She verbalized relief from the pain. The 4/10/23 physician orders revealed monitor right lower extremity for blistering until resolved. If blistering was noted, notify the physician. IV. Hot temperatures in the building A. Resident group interview A resident group interview was conducted on 4/11/23 at 3:08 p.m. with six residents present. Resident #5 said sometimes the coffee was too hot to drink so she had to let it cool. Resident #18 said he sometimes helped himself to the coffee machine to pour himself a cup of coffee located in a carafe in front of the coffee brewing station outside of the kitchen. Resident #18 agreed that the coffee was often hot and he would have to let it cool before he drank it. Resident #18 and Resident #5 said they were never burned with the hot water or the coffee. B. Observations and staff interview On 4/10/23 at 6:17 p.m. the temperature of the hot water was obtained directly from the hot water spout. It was 174 degrees Fahrenheit. Dietary aide (DA) #2 was interviewed on 4/10/23 at 6:17 p.m. She said she served hot water to residents directly out of the hot water spout. She said she had not been instructed to take the temperature of hot beverages prior to service. The DON with a DA was observed on 4/11/23 at 7:17 a.m. taking the temperature of the coffee from the drink station across from the kitchen and attached to the resident dining room. The DON said she was making sure the coffee was at a temperature of 150 degrees F or less. The DON was interviewed on 4/11/23 at 7:27 a.m. She said the facility was instructing all staff that all hot beverages needed to be temped at 150 degrees F before they were served to the residents. The DON said the residents did not serve themselves from the beverage station but she would double check on that. She said she did not know what the hot water temperature out of the coffee machine spout was, but all hot beverages were to be served out of a carafe or pot and the temperature checked before it was served. Between 7:44 a.m. and 8:08 a.m. the DON was observed monitoring the dining room and the drink station. At approximately 9:00 a.m. the hot water from the spout of the coffee brewing machine had a temperature of 158.4 degrees Fahrenheit. The dietary manager (DM) was interviewed on 4/11/23 at 3:05 p.m. She said the facility did not take the temperature of hot water beverages prior to serving them to residents. She said the registered dietitian (RD) was creating a new template to document the temperatures of hot beverages prior to service. The DM was interviewed again on 4/11/23 at 4:09 p.m. She said the hot water spout was not turned off at night. At 4:21 p.m. DA #2 was observed filling coffee carafes and a pot of hot water from the coffee brewing machine. The DA said she was preparing the hot beverages for dinner. She said she would not serve the beverages until just before the meal service and after the hot water and coffee reached 150 degrees Fahrenheit or less. The interim nursing home administrator (INHA) was interviewed on 4/11/23 at approximately 6:00 p.m. She said she learned two ambulatory residents (Resident #18 and Resident #5) who were independent with eating, occasionally poured themselves a cup of coffee from the coffee carafe at the drink station outside the kitchen. The INHA said the facility would no longer have the coffee brewing station in use at the drink station and hot beverages would be brewed and prepared from the kitchen. She said the facility would meet with the two residents to determine how to better meet their hot beverage needs while ensuring residents' safety, now that the coffee carafe would not be accessible outside the kitchen. The drink station was observed with the DON on 4/12/23 at 7:05 a.m. The coffee brewing machine was turned off with a yellow lockout tag on its cord. The DON said all hot beverages would be brewed and the temperature obtained from the kitchen and not from the drink station. At 12:14 p.m. the dietary manager (DM) took two bowls of tomato soup out of the microwave. The first bowl of soup was 161 degrees Fahrenheit. The DM poured the bowl of soup into a handled mug and gave it to an unidentified dietary aide (DA) for service. -The tomato soup was served 11 degrees above the correct temperature guidelines after the staff education had been completed (see below). The INHA was interviewed on 4/13/23 at 6:16 p.m. She said the coffee brewing machine at the drink station was tagged out and no longer operational or available for direct resident use. The INHA said the facility would be purchasing a new system for hot water and coffee brewing that would be placed in the kitchen. The new system would allow staff to better control the hot beverage temperature. The INHA was informed food temperatures were observed to be served over 150 degrees Fahrenheit. She said they would continue to inservice staff and monitor temperatures. C. Record review The DON provided a hot beverage and food inservice on 4/11/23 at 9:55 a.m. The inservices were conducted on 4/10/23 and 4/11/23 with the facility staff. The inservice read: Hot beverages could cause a burn for our residents if they were to spill/splash on them. Due to this-hot water and brewed coffee will set in carafe to cool until it reaches 150 degrees. Hot beverages will not be served if it is over this temperature to a resident. Residents will be encouraged to use mug and not styrofoam for these beverages, The inservice for hot food items such as hot cereal, soup, sauces and gravy read: These items will be temped before serving to a resident and the temperature would not exceed 150 degrees Fahrenheit. Nursing will not reheat these items in the microwave. If the resident is dissatisfied with this ,please notify the nurse manager or dietary manager to follow up. The 4/13/23 staff inservice agenda was provided by the facility on 4/13/23. The inservice identified a microwave and hot drinks presentation was conducted during the all staff inservice on 4/13/23 at 2:00 p.m.; the certified nurse aide (CNA) meeting on 4/13/23 at 1:00 p.m and 5:00 p.m.; and, the nurse meeting on 4/13/23 at 2:00 p.m. and 6:00 p.m. V. Staff interviews The DON and INHA were interviewed on 4/10/23 at 6:25 p.m. The DON confirmed Resident #9 was burned when hot tea in a styrofoam cup tipped over and spilled on her leg. The DON said the resident was assessed and there was a small pink area to the resident's leg with no blistering. She said an incident report was created. The INHA said she was not sure what range of temperature the coffee machine with hot water access was kept at. The registered dietitian (RD) joined the interview. The RD said she was informed that Resident #9 was burned when her tea spilled on her. The RD said Resident #9 preferred to drink her hot tea out of a styrofoam cup. The RD said she met with the resident and requested the resident use a plastic mug with a handle and wider bottom base to help prevent future spills. The RD said the resident agreed as long as the cup could have her name on it. The RD said she took the temperature of the hot water after the incident and it was at 180 degrees Fahrenheit. She said the resident usually was served her meals and drinks in her room. The RD said she determined from staff interviews it took about 10 minutes from the time the tea would have been poured and then served. She said she took the temperature of the hot water in a cup after 10 minutes and the hot water dropped down to 159 degrees Fahrenheit. The RD said the residents in the past have complained the hot beverages were not hot enough. She said to meet residents' preferences, the brewing machine temperature was set between 160 and 180 degrees Fahrenheit and served out of the carafes. The nurse manager (NM) was interviewed on 4/13/23 at 12:15 p.m She said temperatures for hot beverages served to residents should be checked before serving. She said safe temperatures should be reached prior to serving. She said hot beverages should be served in cups with lids. The DON was interviewed on 4/13/23 at 4:15 p.m. She said hot water for beverages should have the temperature taken prior to being served and should be served at 150 degrees Fahrenheit or below. Residents evaluated at a high risk of spilling would be served hot beverages in a cup with a lid. VII. Resident #13 A. Resident status Resident #13, age 67, was admitted on [DATE]. According to the April 2023 CPOs, the diagnoses included early onset Alzheimer's disease and generalized anxiety disorder. The 2/13/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in long and short term memory. She required extensive assistance of two people with bed mobility, transfers, dressing, toileting, personal hygiene and extensive assistance of one person for eating. B. Observations On 4/10/23 at 3:35 p.m. Resident #13 was observed sitting in a tilt in space wheelchair next to the birdcage. Resident #13 was actively moving self down in the chair. Unidentified CNAs were observed readjusting the resident's position in the wheelchair and applying heel boots. At 5:05 p.m. Resident #13 was observed in the dining area and actively moving self down in the wheelchair. Two unidentified CNAs were observed adjusting the resident up in the wheelchair and returned the resident to the table. At 5:30 p.m. Resident #13 was observed to be actively moving him/herself down in the wheelchair. The resident was assisted by an unidentified CNA to the resident's room and observed to be assisting the resident with eating in the room. On 4/11/23 at 9:00 a.m. the resident was observed to be lying in bed. On 4/12/23 at 9:00 a.m. and at 10:30 a.m. the resident was observed lying in bed. On 4/13/23 at 9:00 a.m. the resident was observed lying in bed. -No observation on 4/11/23, 4/12/23 and 4/13/23 was made of Resident #13 being up in a wheelchair due to her moving herself in the chair on 4/10/23. C. Record review The activities of daily living (ADL) care plan, initiated on 11/20/19 revised on 3/9/23, indicated required extensive two assist with hoyer lift for transfers. The falls and safety care plan, initiated on 3/23/23 revealed that resident was at high risk for falls related to a diagnosis of dementia and psychosis with a history of falls. Interventions included making sure personal needs were met (personal items,pain, hunger, positioning, toileting and sleep). Person centered interventions were not identified for Resident #13's tilt in space wheelchair in the safety/falls or ADLs care plan. The 4/9/23 nursing progress notes documented Resident #13 had an other incident at 8:10 a.m. Resident was evaluated for injuries and physician, family and appropriate staff were notified. The 4/12/23 interdisciplinary/fall team progress note reviewed the investigation into the root cause of Resident #13 incident was sitting in a tilt in space wheelchair when it collapsed underneath her. The root cause analysis documented the chair was taken out of service, tagged and locked out. The hospice provider was notified and had delivered a new tilt in space wheelchair. D. Staff interview The DON was interviewed on 4/13/23 at 2:30 p.m. She said she was present when Resident #13's tilt in space wheelchair collapsed under her. She said the wheelchair did not go down very far and the resident was not injured. She said the chair was immediately removed from service and the hospice provider had picked it up for repair. A new wheelchair was delivered by hospice and Resident #13 was using on it 4/10/23. She said Resident #13 was uncomfortable in the new wheelchair and was constantly moving around in it. The staff had put the resident back to bed because of concerns of Resident #13 falling out of the wheelchair. She said they were anticipating the return of the resident's wheelchair on 4/13/23. She acknowledged that staff training on the safe operation of the wheelchairs had not been discussed. The hospice registered nurse (RN) was interviewed on 4/13/23 at 3:15 p.m. He said the tilt in space wheelchair was a donated wheelchair that Resident #13 had for approximately three months. He said the chair was removed from service after staff reported the chair collapsing and picked up for repair by the hospice provider. He said while the chair was being repaired they were unable to replicate how it collapsed. He said the cables on the chair were replaced proactively. He said there was a bolt missing on the brake mechanism on the wheels which was replaced. The plan was to return the wheelchair to the resident on 4/13/23. The interim nursing home administrator (INHA) was interviewed on 4/13/23 at 5:00 p.m. She said a root cause analysis was done to identify and address the problem and notify all pertinent parties. She said training staff on the safe use and operation of the wheelchairs had not been discussed but was an important part of addressing the issue. She acknowledged the ultimate goal was to keep it from happening again. 40467 46022

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on three of four units and one of two dining rooms. Specifically, the facility failed to: -Ensure appropriate hand hygiene practices during meals and doffing personal protective equipment (PPE); -Ensure appropriate use of PPE such as masks; -Ensure medical equipment was disinfected after use; and, -Ensure high touch surfaces were disinfected after potentially contaminated items were placed on top of the surfaces. Findings include: I. Facility policy and procedure The Hand Hygiene policy, reviewed 8/19/22, was provided by the director of nursing (DON) on 4/11/23 at 10:12 a.m. The policy read in pertinent part: The hands are conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from the staff member to a patient. Therefore, hand hygiene is the single most important procedure in preventing infection. To protect a patient from healthcare-associated infection, hand hygiene must be performed routinely and thoroughly. The Personal Protective Equipment (PPE) policy, reviewed 8/19/22, was provided by the DON on 4/11/23 at 10:12 a.m. The policy read in pertinent part: Standard and transmission-based precautions help prevent the spread of infection from patient to patient, from patient to healthcare worker, and from healthcare worker to patient. They also reduce the risk of infection in immunocompromised patients. The PPE policy identified how to properly wear face masks. According to the policy, staff should: Place the mask snugly over your nose and mouth and below your chin. secure the ear loops around your ears and or tie the strings at the middle of the back of your head and neck so the mask won't slip off. If the mask has a metal nose strip, squeeze it to fit your nose firmly but comfortably. The policy read staff should: Put on a face mask to avoid exposure to infectious agents and potentially infectious blood or body fluids. II. Observations On 4/10/23 at 3:00 p.m. dietary aide (DA) #2 was observed on the 400 hall pushing a hydration cart. Her face mask was below her nose and over her mouth. The DA touched the outside of the face mask to pull it up over her nose but the mask fell below her nose a second time. The DA secured the face mask in place and exited the hall with the hydration cart. DA #2 did not perform hand hygiene after touching and adjusting the outer surface of her face mask. -At 3:25 p.m. DA #2 was observed crossing the lobby with her hydration cart. She passed by two residents sitting in the lobby. The DA's face mask was again below her nose. On 4/10/23 at 5:20 p.m. certified nurse aide (CNA) #3 was observed outside the kitchen service window, preparing to service a meal tray. The CNA dropped a clipboard with attached sheets of paper onto the floor. She picked up the clipboard and papers from the floor with her hands and set the clipboard on the wastebin cover positioned below and to the side of the kitchen service window. The CNA attached the papers on the clipboard and then set the clipboard on the top surface of the kitchen service window counter where trays were placed for meal delivery. The clipboard was not disinfected before it was placed on the counter for meal service and after it was on the floor and on top of a waste bin. The kitchen window counter, used for meal service, was not disinfected after the potentially containment clipboard was set on the top of its surface. CNA #3 then stood the clipboard up on the counter resting up against the wall and performed hand hygiene before serving a meal tray from the kitchen service counter. Room tray meal delivery was observed on the 200 hall on 4/10/23 between 5:46 p.m. and 5:48 p.m. -CNA #3 delivered a meal tray to room [ROOM NUMBER]. She did not perform hand hygiene before serving the meal tray and entering the resident's room. She did not perform hand hygiene after delivering the meal tray and on exit or after exit of the resident's room. DA #2 delivered a meal tray to room [ROOM NUMBER]. She did not perform hand hygiene before serving the meal tray and entering the resident's room. She did not perform hand hygiene after delivering the meal tray and on exit or after exit of the resident's room. On 4/13/23 at 10:27 a.m. CNA #4 was observed entering room [ROOM NUMBER] with her face mask below her nose and over her mouth. Housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER] on 4/13/23 between 10:55 a.m. and 11:15 a.m. -At 11:02 a.m. she dropped a packet of the resident's wipes and a magazine off a small dresser and onto the floor. The HK picked the items off the floor with her gloved hands and placed the items onto the cushion of the resident's chair. She did not change her gloved hands and perform hand hygiene after she picked up the packet and the magazine. The HK wiped down the top surface of the small dresser with her potentially contaminated right gloved hand, while resting her potentially contaminated left gloved hand on the top surface of the dresser. She then returned the potentially contaminated packet of wipes and magazine to the top surface of the dresser. She did not disinfect the items after they fell on the floor and before she returned them to the dresser for resident use. On 4/13/23 at 11:08 a.m. CNA #4 was observed entering room [ROOM NUMBER] to provide resident care. Her face mask was below her nose and over her mouth. -At 6:15 p.m. CNA #4 was observed entering the dining room with her face mask below her nose. The CNA said the face mask should have been over her nose and mouth. The CNA pulled up the face mask over her nose and performed hand hygiene. III. Staff interview The infection control preventionist (ICP) and the regional nurse consultant (RNC) was interviewed on 4/12/23 at 1:05 p.m. According to the IPC, staff were trained on infection control during their new hire orientation/onboarding, annual training, and all staff in-services. The training included the chain of infection, PPE use and hand hygiene. The RNC said infection control and prevention practices would be reviewed at the next staff in-service on 4/13/23. The ICP said the facility was constantly reviewing hand hygiene and conducted on the spot training when concerns were identified. The IPC and RNC said the facility recently increased hand hygiene supplies. They said alcohol-based hand rub (ABHR) dispensers were added to the resident rooms in addition to the ABHR dispensers out of each room in the hallway. The ICP said hand hygiene should be conducted with residents before they eat and after toileting. Staff should perform hand hygiene before and after room trays and resident activity of living (ADL) care. He said staff should also perform hand hygiene before entering and exiting resident rooms. The IPC said staff should also perform hand hygiene before donning gloves and after doffing the gloves. The ICP said face masks were currently in place in the facility because there was at a moderately higher level of COVID in the community. He said face mask use was a form of source control and was designed to decrease the spread of transmission based infection and limit potential exposure. He said the face mask needed to be secured over the nose and mouth for proper use. The RNC said earlier this week the facility had to conduct a corrective action with a staff member for improper mask use but had seen an improvement with that staff member's mask use after the corrective action. The staff must use proper face mask practices in residents' areas in the facility. The ICP staff PPE training was part of staff training reviewed when staff were hired, annually, periodically when infections were present in the facility. He said the PPE training sometimes also included demonstrations of proper PPE use. He said there was currently a sign near the front entrance of the facility informing staff and visitors of the need for facemasks in the facility. The RNC said staff should conduct hand hygiene after touching their face mask. She said the facility had plenty of PPE available and staff should regularly change the mask if it was moist and or dirty. The IPC said staff participated in a skills fair last Fall 2022, review skill competency including infection control. He said individual departments such as dietary and housekeeping received additional infection control training specific to their department. He said the dietary director and environment service director (ESD) provided additional training to their staff. The ESD was interviewed on 4/13/23 at 11:22 a.m. The ESD said housekeeping staff were trained to clean the cleanest areas of the room and work towards the dirtiest parts of the room. He said the floor was one of the last areas to be cleaned. The ESD said staff use a peroxide based disinfectant with a three to five minute surface disinfectant time. He said staff should ensure high touch surfaces were properly cleaned as part of the room cleaning process. The ESD said gloves should be changed and hand hygiene should be conducted between tasks and after touching potentially contaminated surfaces. The above housekeeping observations were shared with the ESD. The ESD said the HK should have not returned items to a clean surface after falling on the floor. He said the HK should have also changed her gloves and performed hand hygiene after picking the residents items off the floor and the fallen items should have been disinfected or replaced. He said he reviews infection control procedures with his staff and will review infection control observed concerns with HK #1. The ESD said the housekeepers were responsible for ensuring resident room and common area sanitation and played an important role in facility infection control and prevention. The ICP was interviewed again on 4/13/23 at 1:54 p.m. He said staff needed to be aware of what they were touching to prevent potential cross-contamination. He said the last infection control training prior to todays (4/13/23) in-services was on 3/22/23 and during the fall skills training. The interim nursing home administrator (INHA) was interviewed on 4/13/23 6:16 p.m. She said infection control was discussed during interdisciplinary team (IDT) meetings and with staff during training and when there was an increase in antibiotics and infections in the facility. She said the IDT has also reviewed proper cleaning of medical equipment but has not identified a recent concern. 47350 VI. Standard precautions for resident equipment A. Professional reference Centers for Disease Control and Prevention. (2019). Part III: Precautions to Prevent Transmission of Infectious Agents. https://www.cdc.gov/handhygiene/providers/guideline.html retrieved on 4/19/23. Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions, except sweat, non intact skin and mucous membranes may contain transmissible infectious agents. These include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluid must be handled in a manner to prevent transmission of infectious agents (wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). B. Manufacturer recommendations [NAME] Smart Meter Glucometer Cleaning and Disinfecting Manufacturer Guidelines (2018). https://nurserosie.com/wp-content/uploads/2019/05/RosieSmart-Meter-User-Manual.pdf, retrieved on 4/18/23, included the following recommendations, Cleaning Procedure: 1. Place the device and wipes on a smooth surface. Be sure there is enough light. 2. Wash hands with soap and warm water and pat dry. 3. Put on a protective glove. 4. Take a piece of germicidal wipe out of the canister. 5. Wipe the entire device until visibly clean. 6. Throw away the used wipe. Please do not reuse the wipe. Disinfecting procedure: 1. Prepare wipes and meter. 2. Take a germicidal wipe out of the canister. 3. Put the moistened wipe on a smooth surface. 4. LCD (liquid crystal display) side up. Wipe the device from left to right 3 times slowly. All other sides and surfaces should be wiped in this way. 5. Make sure the meter stays wet for 1 minute. Please do not get disinfectant liquid into the tet strip slot. 6. Throw away the used wipes. 7. After disinfection, the user's gloves should be discarded properly and hands should be thoroughly washed with soap and water before proceeding to the next patient. Super Sani-Cloth Germicidal Disposable Wipe Manufacturer Guidelines (2023). https://pdihc.com/products/environment-of-care/super-sani-cloth-germicidal-disposable-wipe/ retrieved on 4/18/23, included the following recommendations, May be used on hard nonporous surfaces of: bed railing, blood glucose meters (glucometers), cabines, carts, chairs, counters, dental unit instrument trays, exam tables, gurneys, isolettes, IV (intravenous) poles, stethoscopes, stretchers, tables, telephones, toilet seats, diagnostic equipment, patient monitoring equipment, patient support and delivery equipment. Overall contact time is 2 minutes. C. Observations On 4/12/23 at 7:00 a.m. licensed practical nurse (LPN) #1 was observed obtaining a blood glucose on Resident #25. LPN #1 performed hand hygiene with alcohol based sanitizer and put on clean procedure gloves and obtained Resident #25's dedicated glucometer. LPN #1 placed a test strip into the glucometer, swabbed the resident's finger with an alcohol prep pad and using a sterile disposable lancet poked finger and placed a drop of blood onto the test strip. LPN #1 removed gloves and disposed of the test strip into trash, performed hand hygiene and placed lancet into sharps container and performed hand hygiene. LPN #1 placed glucometer into case without cleaning or disinfecting. LPN #1 cleaned off the case with an alcohol prep pad and placed the case back into the medication cart. D. Staff interviews LPN #1 was interviewed on 4/12/23 at 7:15 a.m. She said the night staff did glucometer checks at night and were cleaned during the glucometer checks. The infection preventionist (IP) was interviewed on 4/12/23 at 2:15 p.m. He said that residents that required glucose monitoring had their own dedicated glucometer. He said that glucometers should be cleaned according to the manufacturer recommendations or with the PDI Sani cloth germicidal wipes for the recommended surface disinfectant times. The nurse manager (NM) was interviewed on 4/13/23 at 12:15 p.m. She said that residents have their own designated glucometers and should be cleaned with the designated germicidal wipes after every use and at least once a shift. The director of nursing (DON) was interviewed on 4/13/23 at 4:10 p.m. She said that glucometers were wiped down with germicidal wipes and kept wrapped and kept wet per recommended manufacturer surface disinfectant times. She said that this was done after every use. V. Record review The ESD provided housekeeping training materials for infection control and specific staff training on 4/13/23 at 1:48 p.m. The ESD provided the staff attendance during an infection control training on 3/22/23 and 3/23/23. The training reviewed handwashing and glove use for all staff and peri care for clinical staff. The March 2023 infection control inservice identified staff who attended, including HK #1, DA #2. The ESD provided HK #1 competency training logs conducted in 2022 and 2023. HK #1 last housekeeping training related to housekeeping procedures in residential care settings was completed on 2/2/23. Specific infection control staff training materials were provided by the ICP on 4/13/23 at 1:54 p.m. The training material included a brochure outlining the Break the Chain of Infection. The brocher read in pertinent part: There are many different germs infections inside and outside of the healthcare setting. Despite the variety of viruses and bacteria, germs spread from person to person through a common series of events. Therefore, to prevent germs from infecting more people, we must break the chain of infection. No matter the germ, there are six points of which the chain can be broken and a germ can be stopped from infecting another person. The six links include: the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. The way to stop the germs from spreading is by interrupting this chain at any length. break the chain by cleaning your hands frequently, staying up to date on your vaccines, Covering coughs and sneezes and staying home when sick, following the rules for standard and contact isolation, using PPE the right way, cleaning and disinfecting the environment, sterilizing medical instruments and equipment, following safe injection practices and using antibiotics wisely to prevent antibiotic resistance. The ICP also provided a 9/14/22 PPE education for HK #1 identified she was training for hand hygiene and PPE use. The education was conducted by the ICP. The 4/13/23 staff inservice agenda was provided by the facility on 4/13/23. The inservice identified infection control was reviewed during the all staff inservice on 4/13/23 at 2:00 p.m.; the certified nurse aide (CNA) meeting on 4/13/23 at 1:00 p.m. and 5:00 p.m.; and, the nurse meeting on 4/13/23 at 2:00 p.m. and 6:00 p.m. The infection control review included hand hygiene, donning and doffing of PPE, enhanced barrier precautions and clean surfaces in relation to the dining room and in room meal trays. The review included hand wipes available for meal trays. During the nurse meetings on 4/13/23, the facility reviewed the glucometer cleaning process and reminded staff that each resident needed to have their own individual glucometers. 46022

Based on observations, record review and staff interviews the facility failed to provide services three (#23, #27 and #21) out of seven residents reviewed out of 26 sample residents according to professional standards of practice. Specifically, the facility failed to ensure: -Resident #23 and #27's blood pressure was monitored prior to the administration of a blood pressure medication; and, -Resident #21 skin assessment was performed underneath bilateral lower extremity fracture walking boots. Findings include: I. Blood pressure parameters A. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK532906 on 4/17/23. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockage of these receptors with beta-blocker medications can lead to many adverse effects. Bradycarida (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. According to Kizior, R. J., Hodgson, K. J. (2023). Metoprolol. Saunders Nursing Drug Handbook. Elsevier, p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. B. Resident #23 1. Resident status Resident #23, age 75, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included myocardial infarction , atrial flutter and hypertension. The 3/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting, personal hygiene and was independent with setup for eating. 2. Observations On 4/12/23 at 7:00 a.m. licensed practical nurse (LPN) #1 was observed dispensing and administering Metoprolol 12.5 milligrams (mg), a blood pressure medication, to Resident #23. LPN #1 did not assess the resident vital signs including the resident's blood pressure; check the order for blood pressure parameters; or review the resident's most recent vital signs prior to administering the Metoprolol medication to Resident #23. 3. Record review The April 2023 CPO documented a physician order of Metoprolol 25 mg tablet, give 12.5 mg twice a day. -The CPO did not document any vital signs parameters for when to hold the Metoprolol medication or when to notify the physician of irregular vital sign results. The April 2023 medication and treatment administration record (MAR/TAR) did not document how often the resident's vital signs should be checked. The April 2023 vital signs summary revealed Resident #23's blood pressure was only assessed once a day on 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23 and 4/13/23 and the resident was not administered the blood pressure medication when the blood pressures were obtained. 4. Staff interviews LPN #1 was interviewed on 4/12/23 at 7:15 a.m. She reviewed the Metoprolol physician's order and said there were no parameters orders. She acknowledged Resident #23's blood pressures were not available prior to the administration of Metoprolol. LPN #3 was interviewed on 4/13/23 at 10:10 a.m. She said residents that were on a blood pressure medication should have a blood pressure taken prior to administration. She said the resident's medical record was reviewed for physician ordered parameters. If there were no parameters ordered, the blood pressure medication was held if the systolic blood pressure was less than 100 and the pulse was less than 60. She said holding the blood pressure medication was documented in the resident's medical record and the physician was notified. The director of nursing (DON) was interviewed on 4/13/23 at 4:15 p.m. She said blood pressure medication administration parameters were dependent on physician ordered parameters and each individual resident. She said nursing clinical judgment was used to monitor for signs and symptoms of low blood pressure and a blood pressure was obtained as part of that assessment. 46022 C. Resident #27 1. Resident status Resident #27, age 81, was admitted on [DATE]. According to the April 2023 CPO, the diagnoses included history of falling, weakness, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and anemia (low red blood cell count). The 1/25/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 12 out of 15. He required extensive assistance of two people for bed mobility. He required extensive assistance of one person for transfers, locomotion on and off the unit, dressing and toileting. He required limited assistance of one person for personal hygiene. 2. Resident interview Resident #27 was interviewed on 4/10/23 at 3:09 p.m. He said the nursing staff did not take his blood pressure regularly. He said he took a blood pressure medication as he has a history of high blood pressure. Resident #27 said he thought his blood pressure should be taken prior to receiving his blood pressure medication. 3. Record review The April 2023 CPO documented a physician order of Metoprolol Tartrate Oral tablet 75 MG (Metoprolol Tartrate), give 75 MG by mouth two times a day for hypertension, ordered on 1/26/23. -The CPO did not document any vital signs parameters for when to hold the Metoprolol medication or when to notify the physician of irregular vital sign results. The April 2023 MAR/TAR did not document how often the resident's vital signs should be checked. The February 2023, March 2023 and April 2023 vital signs summary revealed Resident #27's blood pressure and pulse were only assessed on 2/2/23 and 4/8/23 and not daily at the time the resident was administered blood pressure medication. 4. Staff interviews LPN #2 was interviewed on 4/12/23 at 5:25 p.m. She said medications such as Metoprolol should have parameters. She said if blood pressure medication was given to someone without checking their blood pressure, it could cause their blood pressure to drop and the resident could pass out. The DON was interviewed on 4/13/23 at 10:29 a.m. She said vitals were taken for residents who were actively on therapy caseload. She said all other residents should have orders for monthly vital signs. The DON was interviewed again on 4/13/23 at 6:16 p.m. She said Resident #27 did not have an order to obtain vital signs. 5. Facility follow-up On 4/17/23 at 1:49 p.m. the facility provided a copy of the fax note that was sent to the physician on 4/14/23 (after the survey process). It revealed the facility asked the physician if he would like the nursing staff to obtain blood pressures prior to administration and if they licensed nursing staff should follow parameters for administering the Metoprolol. II. Failure to obtain physician orders for parameters for bilateral lower extremity braces. A. Professional reference According to the Journal of Wound care website, Device-Related Pressure Ulcers: Secure Prevention, https://www.magonlinelibrary.com/doi/full/10.12968/jowc.2020.29.Sup2a.S1 (Retrieved 4/18/23). DRPU (device-related pressure ulcers) develop faster than non-DRPU because of the vulnerability of the patient and body sites affected. They are most likely to be facility-acquired. Specific factors include: devices often do not fit patients properly due to their generic designs and limited range of size, device materials are often very stiffend do not conform to tissue shape, causing localized skin distortions when they interact with skin and underlying soft tissue, inadequate guidance is provided on devise application by both commercial suppliers and clinical educators, many individuals have comorbidities that limit their tolerance to mechanical loads on vulnerable skin and soft tissue sits and/or lead to uncontrolled oedema and hostile local tissue microclimate, lack of clinician awareness of the important of repositioning, offloading, rotating devices or correctly fitting or securing them. Examples of devices associated with DRPU include: continuous positive airway pressure (CPAP) masks, endotracheal tubes, orthopedic devices, bed frames and spectacles. B. Resident #21 1. Resident status Resident #21, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the April CPO the diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia (low blood oxygen), nondisplaced fracture of medial malleolus of right tibia (right ankle fracture, nondisplaced fracture of lateral malleolus of left fibula (left ankle fracture), anxiety disorder, heart disease, depression, dementia and peripheral vascular disease (reduced blood flow to the limbs). The 4/1/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 12 out of 15. He required extensive assistance of one person for personal hygiene. He required extensive assistance of two people for bed mobility, transfers, dressing and toileting. He required total assistance of one person for walking in the corridor and locomotion on and off the unit. He required supervision with set-up assistance for eating. 2. Resident interview and observation Resident #21 was interviewed on 4/10/23 at 4:22 p.m. He said he fractured both of his ankles. He said he wore boots to his lower extremities at all times. He said staff did not offer to remove the boots at any time. He said when he was provided showers, the staff would cover the boots with plastic bags to prevent them from getting wet. At this time, Resident #21 was sitting in a reclining chair with orthopedic boots to bilateral lower extremities. On 4/12/23 at 1:09 p.m. Resident #21 was sitting in a reclining chair with orthopedic boots to bilateral lower extremities. At 4:19 p.m. a skin check was performed by LPN #2. She removed the orthopedic boots that Resident #21 was wearing on his bilateral lower extremities. LPN #2 confirmed Resident #21 had a half dollar sized circumscribed dark red/brown area to his right lateral heel that was not opened and a quarter sized circumscribed dark red/brown area to his left medical heel that was not opened. LPN #2 touched the area on Resident #21's right heel and Resident #21 reported pain to the area. -LPN #2 did not report her findings to the physician (see interview below). On 4/13/23 at 12:25 p.m. another skin check was completed for Resident #21. LPN #1 said the resident did not have any pressure injuries to his lower extremities. She said she cleaned his feet, because he had a build-up of betadine on his feet that needed to be washed off. -Resident #21 did not have a physician's order to apply betadine to his feet. On 4/13/23 at 3:17 p.m. Resident #21 was sitting in a reclining chair with orthopedic boots to bilateral lower extremities. 3. Record review The activities of daily living (ADL) care plan, initiated on 2/22/23 and revised on 2/24/23, revealed Resident #21 got short of breath with exertion and had a fall that resulted in bilateral fractured ankles with orthopedic boots and non weight bearing to one side. The interventions included: non-weight bearing to the right side, partial-weight bearing to the left side, providing one staff member for bed mobility, providing extensive assistance for transfers, providing staff assistance for ambulation and locomotion, providing assistance with the bedpan or urinal, providing assistance of two staff members for toileting, providing one person assistance for locomotion, providing extensive assistance for personal hygiene and grooming, providing hands-on assistance for dressing, providing one person assistance for bathing, providing physical help for bathing, providing set-up assistance and supervision for dressing/grooming/hygiene, providing extensive assistance to help the resident in getting dressed. The skin care plan, initiated on 2/22/23 and revised on 2/24/23, revealed Resident #21 was at risk for skin breakdown related to cardiac and respiratory conditions which impacted his endurance. Resident #21 had long term use of steroids for breathing. Resident #21 required assistance to get in and out of bed. The interventions included: inspecting the resident skin daily with care and to report any concerns to the nurse, offering assistance to reposition when sitting or lying as needed, involving and educating the resident on his skin conditions, keeping the residents bed linen dry and wrinkle free, moisturizing the residents dry skin as needed, bathing the resident with mild soap, notifying nursing if the resident had pain in either or both heels, notifying nursing/physician of any dark spots or discoloration on heels of the resident, providing a pressure reducing device for bed, providing a pressure reducing device for chair and completing weekly skin assessments by licensed nurses. The 2/23/23 nursing weekly skin assessment documented the resident had bruising to his right ankle and left toes. The 3/8/23 orthopedic physician's note documented the resident was to continue with non-weight bearing status with either a use of a walker or wheelchair. The physician documented to continue with ice and elevation and it was ok to take the fracture boot off for bathing and to let skin air out. The 4/3/23 nursing weekly skin assessment documented the resident had a right and left lower leg fracture. The 4/11/23 nursing weekly skin assessment documented the resident had a right lower leg fracture. The 4/4/23 Braden scale assessment documented the resident was at risk for developing pressure injuries. The 4/13/23 nurses progress note documented there was a noted brownish/rustic color to the resident bilateral heels and plantar aspects of the feet. The note documented upon washing the with soap and water the discoloration was resolved. The skin was intact and pink. No discoloration or redness to bilateral plantar aspect of feet or heels. The resident's feet were lotioned. A review of the April 2023 CPO did not reveal an order for the resident to wear the orthopedic boots to his lower extremities. 4. Staff interviews LPN #2 was interviewed on 4/12/23 at 5:25 p.m. She said she started working at the facility on 4/7/23. She said she removed Resident #21's boots to his bilateral lower extremities on Friday (4/7/23) and noticed a reddened area on both heels. She said she did not notify the doctor, as she thought the facility was already aware of the skin issue. LPN #2 said she did not document her findings in the resident's electronic medical record. LPN #2 said she removed Resident #21's boots a couple days ago and washed his feet and left his lower extremities open to air to help prevent any further skin issues from forming. Certified nurse aide (CNA) #4 was interviewed on 4/13/23 at 3:16 p.m. She said she assisted Resident #21 with his showers. She said when she helped the resident shower she did not remove the bilateral orthotic boots. She said she placed plastic over the boots to prevent them from getting wet. The DON was interviewed on 4/13/23 at 10:29 a.m. She acknowledged the resident did not have any current physician orders to wear or take off the bilateral orthopedic boots. The DON said the resident was recently hospitalized and the physician orders must have been discontinued when he was transferred to the hospital. The DON said Resident #21 was to wear the orthopedic boots around the clock. She said CNAs should take the boots off for showers. The DON was interviewed again on 4/13/23 at 4:22 p.m. She said the boots should be removed to ensure the resident's skin was intact regularly. 5. Facility follow-up On 4/17/23 at 1:49 p.m. the facility provided a copy of the rehab splint or brace assist program guidelines for the recommendations for restorative nursing program that was completed on 4/14/23 (after the survey process) for Resident #21. It revealed the resident was to receive cleaning and lotioning to his lower extremities twice a day. On 4/17/23 at 1:49 p.m. the facility provided a copy of the telephone order completed by the physician on 4/14/23 (after the survey process) on 4/17/23 at 1:49 p.m. It read, continue cam boots - may remove twice a day, each shift, to check pulses and skin integrity. On 4/17/23 at 1:49 p.m. the facility provided a copy of Resident #21's update care plan. The restorative plan of care, revised on 4/14/23, revealed the resident had right and left fracture boots. The resident had actual impaired functional range of motion of the right and left lower extremities. The interventions included: monitoring and reporting and issues of pain related to splint application, monitoring skin conditions under splint upon splint remove and report an areas of concern to nursing, notifying the nurse if resident declines to participate and providing a restorative splinting program by removing fracture boots in the morning and evening, cleaning right and left legs and feet, applying lotion in the morning and the evening.

Based on observations, interviews and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#3, #27 and #21) of four residents reviewed out of 26 sample residents. Specifically, the failed failed to: -Ensure Resident #3 received care to prevent a mat from forming in her hair; and, -Ensure Resident #3, Resident #27 and Resident #21 received bathing according to their preference and plan of care. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised October 2021, was provided by the nursing home administrator (NHA) on 4/13/23 at 12:52 p.m. It revealed in pertinent part, Purpose: to assist resident in achieving maximum functional ability with dignity and self-esteem, to provide assistance to residents as necessary, to supervise and assess resident function in order to plan care to maintain optimum ADL function as long as possible, and to teach resident use of assistive devices to maintain optimum ADL function as long as possible. Facility ensures a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Procedures: when the facility has recognized and assessed an inability to perform ADLs, or a risk for decline in ability they have to perform ADLSs; facility will: develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences, and recognized standards of practice that address the identified limitations in ability to perform ALDs; monitor and evaluate the resident's response to care plan interventions and treatment; and, revise the approaches as appropriate. II. Resident #3 A. Resident status Resident #3, age 71, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included pathological fracture in other disease right femur subsequent encounter for fracture with routine healing (right leg fracture), pathological fracture in other disease left femur subsequent encounter for fracture with routine healing (left leg fracture), lateral subluxation of left patella subsequent encounter (knee cap that moved out of place), morbid obesity, chronic respiratory failure, acquired abscess of uterus, anxiety, hemoperitoneum (bleeding in the abdominal cavity), edema and depression. The 3/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing and personal hygiene. She required set-up assistance for eating and total dependence of two people for toileting. The MDS assessment documented bathing did not occur in the review period. The MDS assessment documented the resident had an indwelling catheter and was always incontinent of bowel. B. Observation and resident interview Resident #3 was interviewed on 4/10/23 at 3:51 p.m. She said she often got sweaty and preferred to shower frequently. She said her hair has been matted and she wanted it brushed out. She said the staff had tried to brush her hair a little bit, but had not made any progress. Resident #3 was lying in bed. She had mid-length hair. Her hair was matted on the back of her head and the mat extended to the bottom tips of her hair. Resident #3 said she wanted the matting removed from her hair as it bothered her. Resident #3 was interviewed again on 4/12/23 at 1:13 p.m. Her hair continued to be matted. Resident #3 said unfortunately she thought her hair was going to have to be cut. C. Record review The activities of daily living (ADL) care plan, initiated on 3/9/23 revealed Resident #3 had preferences related to her ADLs. The interventions included: providing a mechanical lift with assist of two for transfers, providing assistance with ambulation and locomotion, providing assistance with toileting. The interventions documented the resident was independent with bed mobility, bathing, dressing and grooming. -However, according to the MDS assessment and interviews Resident #3 needed assistance with all ADLs. The point of care task documentation revealed the resident preferred to have showers on Mondays and Thursdays. The March 2023 shower documentation from 3/9/23 through 3/30/23 revealed Resident #3 received bathing on 3/27/23 and 3/30/23. -It indicated Resident #3 received bathing on two out of six opportunities. -It indicated Resident #3 did not receive a bath for 17 days from her admitted on 3/9/23 through 3/26/23. -Review of the resident's medical record revealed there were no progress notes to indicate if Resident #3 admitted to the facility with matted hair or steps the facility had taken to help remove the matted hair. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/11/23 at 4:50 p.m. She said Resident #3 received bed baths on Mondays and Thursdays. She said she had brushed Resident #3's hair, but was unsuccessful in removing the matted hair. Licensed practical nurse (LPN) #3 was interviewed on 4/12/23 at 5:20 p.m. She said Resident #3 had bilateral broken legs and was unable to get out of bed. She said nursing staff provided Resident #3 with bed baths. LPN #3 said Resident #3 refused showers. LPN #3 said Resident #3 had matted hair. She said staff had attempted to put detangler in her hair to help improve the matting and were unsuccessful. LPN #3 said they attempted to make an appointment with the beauty salon on 4/12/23 to help with the matting (during the survey process). The director of nursing (DON) was interviewed on 4/12/23 at 4:03 p.m. She said she was aware of Resident #3's matted hair. She said Resident #3 was in pain upon admission and that was why she was not showered for a few days. The DON said there was no documentation in Resident #3's medical record that indicated the resident admitted to the facility with matted hair. III. Resident #27 A. Resident status Resident #27, age 81, was admitted on [DATE]. According to the April 2023 CPO, the diagnoses included history of falling, weakness, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and anemia (low red blood cell count). The 1/25/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 12 out of 15. He required extensive assistance of two people for bed mobility. He required extensive assistance of one person for transfers, locomotion on and off the unit, dressing and toileting. He required limited assistance of one person for personal hygiene. The MDS assessment indicated bathing did not occur during the review period. B. Observation and resident interview Resident #27 was interviewed on 4/10/23 at 2:51 p.m. He was wearing a long sleeved gray shirt with three buttons. Resident #27 was observed walking down the hallway the morning of 4/11/23. He was wearing the same long sleeved gray shirt with three buttons. Resident #27 was interviewed on 4/12/23 at 1:29 p.m. Resident #27 said he preferred to have a couple showers a week. He was wearing the same long sleeved gray shirt with three buttons. On 4/13/23 at 9:50 a.m. Resident #27 was observed in the same long sleeved gray shirt with buttons. -Resident #27 was observed wearing the same shirt on 4/10/23, 4/11/23, 4/12/23 and 4/13/23. C. Record review The ADL care plan, initiated on 10/19/22 and revised on 12/28/22, revealed Resident #27 had preferences regarding his ADLs. Resident #27 was working with therapy and was encouraged to be out of bed as much as possible and Resident #27 was to use his call light for assistance. The interventions included: encouraging the resident to sit up in his wheelchair or recliner for meals, encouraging Resident #27 to shower on Wednesdays evenings, but he often decline, setting up shower a shower schedule for three times a week, providing two person assist for bed mobility, providing assistance for transfers and ambulation, encouraging Resident #27 to use a front wheel walker for ambulation, providing extensive assistance with personal hygiene and grooming, providing one person assistance for dressing and hygiene, providing two person assistance for bathing, providing extensive assistance of staff to dress and checking to ensure clothing and footwear was clean and appropriate. The incontinence care plan, initiated on 10/19/23 and revised on 11/9/22, revealed Resident #27 had incontinence or altered elimination. Resident #27 required treatment, monitoring and cares due to his condition. The interventions included: assisting the resident to and from the toilet, changing incontinent briefs as needed, keeping a urinal next to the resident on his bedside table, asking if the resident was able to use the toilet, responding timely when the residents call light was on, providing frequent checks and checking and changing the resident as he was always incontinent of bowel. The point of care task documentation revealed the resident preferred to have showers on Wednesday evenings. The February 2023 shower documentation revealed Resident #3 did not receive a bath during the month. -It indicated Resident #27 did not receive a shower out of four opportunities. The March 2023 shower documentation revealed Resident #3 did not receive a bath during the month. -It indicated Resident #27 did not receive a shower out of five opportunities. The April 2023 shower documentation from 4/1/23 through 4/11/23 revealed Resident #27 did not receive a bath during the month. -It indicated Resident #27 did not receive a shower out of one opportunity. -Review of the shower documentation for February, March and April 2023 revealed Resident #27 had not had a documented shower in 69 days. -Review of the resident's medical record revealed there were no progress notes to indicate why the resident refused showers on multiple dates and the staff had attempted to try at another time to complete the shower when he refused. D. Staff interviews CNA #1 was interviewed on 4/11/23 at 4:50 p.m. She said Resident #27 received showers on Wednesday evenings. The DON was interviewed on 4/12/23 at 4:03 p.m. She said she was unable to verify the last time Resident #27 received a shower due to the lack of documentation. The DON said Resident #27 often refused his showers and preferred to give himself a spit bath in the sink. The DON said she had noticed issues with ADL documentation recently and needed to educate the staff on documenting appropriately. CNA #6 was interviewed on 4/12/23 at 6:26 p.m. She said Resident #27 received showers on Wednesday evenings. She said Resident #27 often refused his showers. She said she did not document in the point of care system when Resident #27 refused his showers. CNA #6 said she should document when the resident refused showers. CNA #6 said when Resident #27 refused his showers, she did not notify the charge nurse. CNA #6 said she should notify the charge nurse to help intervene. IV. Resident #21 A. Resident status Resident #21, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 CPO the diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, nondisplaced fracture of medial malleolus of right tibia (right ankle fracture, nondisplaced fracture of lateral malleolus of left fibula (left ankle fracture), anxiety disorder, heart disease, depression, dementia and peripheral vascular disease (reduced blood flow to the limbs). The 4/1/23 MDS revealed the resident had moderate cognitive impairment with a BIMS with a score of 12 out of 15. He required extensive assistance of one person for personal hygiene. He required extensive assistance of two people for bed mobility, transfers, dressing and toileting. He required total assistance of one person for walking in the corridor and locomotion on and off the unit. He required supervision with set-up assistance for eating. The MDS assessment documented bathing did not occur during the review period. B. Record review The activities of daily living (ADL) care plan, initiated on 2/22/23 and revised on 2/24/23, revealed Resident #21 got short of breath with exertion and had a fall that resulted in bilateral fractured ankles with orthopedic boots and non weight bearing to one side. The interventions included: non-weight bearing to the right side, partial-weight bearing to the left side, providing one staff member for bed mobility, providing extensive assistance for transfers, providing staff assistance for ambulation and locomotion, providing assistance with the bedpan or urinal, providing assistance of two staff members for toileting, providing one person assistance for locomotion, providing extensive assistance for personal hygiene and grooming, providing hands-on assistance for dressing, providing one person assistance for bathing, providing physical help for bathing, providing set-up assistance and supervision for dressing/grooming/hygiene, providing extensive assistance to help the resident in getting dressed. The point of care task documentation revealed the resident preferred to have showers on Wednesdays and Thursdays. The January 2023 shower documentation from 1/13/23 through 1/31/23 revealed Resident #21 did not receive a bath during this period. -It indicated Resident #21 did not receive a shower out of five opportunities. Resident #21 did receive a shower on 1/26/23 the day after his shower was not offered on 1/25/23. The February 2023 shower documentation from 2/1/23 through 2/16/23 and from 2/23/23 through 2/28/23 revealed Resident #21 refused a shower on 2/11/23. Resident #21 was in the hospital from 2/17/23 through 2/22/23. -It indicated Resident #21 did not receive a bath out of six opportunities. -It indicated Resident #21 had not received a bath in 21 days from 1/26/23 through 2/16/23. He was sent to the hospital on 2/17/23. The March 2023 shower documentation revealed Resident #21 received a shower on 3/4/23 and 3/25/23. -It indicated Resident #21 received a bath on two out of nine opportunities. -It indicated Resident #21 had not received a bath in 20 days from 3/5/23 through 3/24/23. The April 2023 shower documentation from 4/4/23 through 4/12/23 revealed Resident #21 did not receive a shower in this period. Resident #21 was in the hospital from 4/1/23 through 4/3/23. -It indicated Resident #21 did not receive a bath out of three opportunities. -It indicated Resident #21 had not received a bath in nine days since returning from the hospital on 4/3/23. D. Staff interviews CNA #4 was interviewed on 4/13/23 at 3:16 p.m. She said she gave Resident #21 his showers. She said she placed plastic over the residents bilateral lower extremity orthopedic boots and did not wash underneath the boots.

Based on observations, record review, and interviews, the facility failed to ensure one (#1) of one sample residents received care, consistent with professional standards of practice, to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable; and to promote healing, prevent infection and prevent new ulcers from developing. Specifically the facility failed to ensure appropriate interventions were in place and followed related to Resident 16's pressure ulcer. Findings include: I. Facility policy and procedures The Prevention and Treatment of Pressure Ulcers/Pressure Injury policy, last revised 11/22/22, was provided by the interim nursing home administrator (INHA) on 4/13/23 at 12:52 p.m. The policy documented the following pertinent information: It is the policy of (the facility) to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventive measures and provide appropriate treatment modalities for wounds according to professional standards of care. II. Resident status Resident #16, age 79, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, Parkinson's, localized edema, anxiety disorder, obesity, type 2 diabetes mellitus, dementia and other diseases classified elsewhere, moderate, with agitation, and insomnia. The 4/2/23 minimum data set (MDS) assessment indicated Resident #16 cognition was severely impaired with a staff assessment for mental status. The staff assessment identified the resident had short and long term memory with inattention and an altered level of consciousness. Resident #16 required total dependence from two or more persons with almost all of her activities of daily living (ADLs), including bed mobility and transferring. The resident had a stage 1 or greater unhealed pressure ulcer and was at risk for developing pressure ulcers. According to the MDS assessment, the resident had an unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar. The MDS assessment indicated the resident had a pressure reducing device on her wheelchair, a pressure reducing device for her bed, was on a turning/repositioning program and received pressure ulcer care. III. Observation On 4/10/23 at 11:42 a.m. Resident #16 was observed in the lobby in front of the bird aviary with her eyes closed. She was leaning slightly on her left hip. She sat on a thick wheelchair cushion and a cloth with handles. Her reclining high back wheelchair was tilted slightly back. -At 11:44 a.m. she opened her eyes as certified nurse aide (CNA) #3 took her vitals. The CNA did not attempt to reposition the resident off her left hip. -At 3:37 p.m. Resident #16 was observed again in the lobby with her eyes closed. She was leaning slightly on her left hip sitting on the thick wheelchair cushion and a cloth with handles. Her reclining high back wheelchair was tilted slightly back. On 4/12/23 at 7:15 a.m. Resident #16 was observed laying flat on her back in bed and sleeping. Her feet were raised off the bed with a heel flotation device. She did not have pillows or positioning wedges to help prop her off her back and on to her side. The resident was on an air mattress. On 4/12/23 between 8:25 a.m. and 8:28 a.m. Resident #16 was awake, laying flat on her back with a pillow under her head as she called out for help. -At 8:28 a.m. CNA #3 entered the resident's room and asked the resident what she needed. The resident did not respond, the CNA washed the resident's face, collected the room trash, and exited the room. The CNA did not turn the resident on her side or attempt to reposition the resident. CNA #3 said the resident's calling out was part of her behavior (care planned). -At 8:34 a.m. Resident #16 proceeded to call out for help, CNA #3 entered the room and asked the resident if she was ok. The resident said yes. The CNA asked the resident if she was in pain, the resident said no. The CNA asked the resident if she slept well, the resident said yes. CNA #3 exited the room. The CNA did not attempt to reposition the resident of her back or turn her to her side. -At 9:54 a.m. Resident #16 yelled out for help as she laid flat on her back in bed. The resident was asked what she needed help with. She said she did not know. -At 9:57 a.m. CNA #3 entered the resident's room. She asked the resident if she wanted to get up and out of bed. A second CNA entered the room and closed the door. -At 10:47 a.m. Resident #16 was observed sitting in her room in her reclined wheelchair calling out. -At 11:17 a.m. Resident #16 was in the lobby in front of the bird aviary. She was grimacing. Her feet were lower than her wheelchair footrest. Her head was significantly below the top of the back of her wheelchair. Her shirt was rolled up at her stomach. The resident was attempting to lean forward and up in the chair unsuccessfully. An identified staff member observed the resident and pulled her shirt down. The resident leaned her back to the back of the chair. The staff member did not reposition the resident. -At 11:22 a.m. the nurse manager (NM) provided Resident #16 a supplement to drink. As the resident drank the supplement she repeatedly said please help. The resident was able to tell the NM she liked the supplement. -At 11:31 a.m. CNA #3 and CNA #2 reposition Resident #16 in her wheelchair. The CNAs stood on the left and right side of the resident and scooted up in the chair by sliding her back up against the back of the wheelchair by use of the sheet straps. The CNAs did not recline the wheelchair or lift the resident's back side off the surface of the wheelchair as they repositioned the resident higher in her wheelchair. The resident said ouch loudly when she was slid up the chair. CNA #2 asked the resident if she said ouch because she was hurting or because moving her scared her. The resident did not answer. -At 1:30 p.m. licensed practical nurse (LPN) #1, identified as the facility wound nurse, was observed providing wound care to Resident #16. The LPN cleaned off the bedside table with germicidal wipes. She placed a clean pad over the table and placed clean supplies onto the clean pad. The LPN performed hand hygiene and placed on gloves. The adhesive edges on the dressing were rolled up at the bottom. The LPN removed old dressing over the coccyx and disposed of it in trash. A small amount of serosanguineous (blood, serum) drainage was observed from the wound. She removed her gloves, performed hand hygiene and donned clean gloves. The LPN opened sterile gauze and applied dermal wound cleanser. The LPN measured the wound at 0.8 centimeters (cm) x 0.3 cm with superficial depth. She applied skin prep around the wound edges. She applied Tegaderm foam dressing and marked the date and time. The LPN removed gloves and performed hand hygiene. The LPN stated the wound/pressure ulcer was unstageable due to slough on the wound bed. The wound bed was difficult to see and the wound edges appeared pink. On 4/13/23 at 10:12 a.m. Resident #16 laid in bed on her right side as she slept. Her head was propped up by pillows and the head of the bed was raised at a 45 degree angle. -At 10:30 a.m. CNA #5 entered the doorway of Resident #16, observed the resident sleeping and exited the room. -At 10:47 a.m. CNA #5 entered Resident #16 room and identified the resident needed her brief changed. The CNA radioed for staff assistance. -At 3:40 p.m. Resident #16 was observed in bed asleep. She layed on her back with a thin pillow placed partially under the resident's left shoulder, slightly lifting the shoulder. The head of the bed was at a 45 degree angle. -At 5:25 p.m. Resident 16's air mattress (Invacare MicroAir MA 600) was observed to be set at a comfort setting of seven (P7) and a therapy mode of Static. IV. Record review The CPO identified Resident #16 was admitted to hospice on 12/28/22. The order read the resident was admitted to hospice with a diagnosis of Alzheimer's disease. According to the order, the resident had a limited life expectancy of six months or less if the terminal illness ran its normal course. The skin care plan, initiated on 2/14/22 and last revised on 4/10/23, identified Resident #16 was at risk for skin breakdown related diabetes, antidepressant use, frequent incontinence and decreased mobility. The care plan dated 3/30/23 identified the resident had an unstageable pressure ulcer to her coccyx. Interventions in pertinent part included: -Turn and reposition every two hours during the day and every 4 hours at night and PRN (as needed). Initiated 3/3/22, revision on 1/30/23. -Lift do not slide resident/use assistive devices to decrease skin friction. Initiated 1/30/23. -Pressure reducing device for bed Invacare air mattress provided by hospice. Initiated on 1/26/23, revision on 2/3/23. -Pressure reducing device for chair. Span America Equalizer placed on bed which is for maximum redistribution of pressure under the thighs, greater trochanters, ischial (sit bone) and coccyx for those at moderate to high risk. Revision on 2/24/23. The care plan identified the resident should have been turned every two hours during the day and staff should not slide the resident when repositioning the resident (as observed on 4/12/23.) The care plan did not identify what the pressure level the reducing air mattress should be set at. The 3/9/23 interdisciplinary team (IDT) note read Resident #16 received hospice care. The Braden scale identified the resident was at high risk for skin breakdown with a score of nine. The resident was on a turning and repositioning and check and change program. Additional interventions included a Invacare air mattress provided by hospice and a Span America Equalizer cushion on her wheelchair. The 3/16/23 hospice progress note read the hospice CNA identified skin break down and reported it to the nurse. The 3/16/23 weekly skin measurement note read Resident #16 had an unstageable pressure ulcer on her coccyx measuring 1.3 cm in length, 0.03 cm in width. The depth was undetermined. According to the weekly skin note, the pressure ulcer had 100% slough in the wound bed with periwound blanchable erythema. There was no drainage observed. The note identified the resident would be treated with a foam dressing. The dressing would be changed every three days and PRN (as needed.) The note read the resident had an air mattress in place and was on a turning schedule. The 3/17/23 Braden skin and risk summary read a Braden scale was completed on 3/17/23. The resident scored an eight indicating the resident was at very high risk for skin breakdown. The CPO, start date 3/19/23, read: Wound care to coccyx/sacral (for) unstageable wound: Cleanse with wound cleanser then apply foam dressing (and) change every three days and PRN (as need.) The physician's orders did not include an air mattress or setting the mattress should be at as part of the treatment plan. The 3/20/23 IDT note read the interdisciplinary (team) reviewed the resident's new skin condition. According to the note, the skin condition (pressure ulcer) root cause was the resident had a general decline and was on hospice services. The note read the resident was not eating well and preventative measures were in place. The 3/22/23 provider note read Resident #16's sacral pressure site was being addressed by staff and not improving but not worsening by report. The 3/23/23 weekly skin measure note identified Resident #16's unstageable pressure ulcer on her coccyx measuring 0.8 cm in length, and 0.4 cm in width. The pressure ulcer remained at 100% slough in the wound bed with periwound blanchable erythema. The 3/29/23 medicare note read IDT review of unstageable (pressure ulcer) to coccyx area was stable. According to the note, the resident continued on interventions of alternating pressure mattress, wheelchair cushion, with repositioning and supplements. The 3/29/23 Braden skin and risk summary read the Braden scale was completed on 3/29/23 with a score of 8.0 putting the resident at very high risk for skin breakdown. The 3/30/23 weekly skin measure note read Resident #16's unstageable pressure ulcer on her coccyx measuring 0.5 cm in length, and 0.3 cm in width. The pressure ulcer remained at 100% slough in the wound bed with periwound blanchable erythema. According to the note the resident has some denuded tissue on her bilateral buttocks. The note directed staff to encourage the resident to stay off her bottom (coccyx/sacrum) as much as possible while in bed. The April 2023 treatment administration record (TAR) for Resident #16 did not include the resident's air mattress or what pressure the air mattress should be set at specifically for the resident's skin needs. The 4/3/23 weekly skin measure note read weekly skin measure note read Resident #16's unstageable pressure ulcer on her coccyx measuring 0.4 cm in length, and 0.3 cm in width. The 4/5/23 IDT note read the resident's coccyx area was stable over last week. The 4/10/23 weekly skin measure note read Resident #16's unstageable pressure ulcer on her coccyx measuring 0.4 cm in length, and 0.3 cm in width. The pressure ulcer remained at 100% slough in the wound bed with periwound blanchable erythema. According to the note the resident has some denuded tissue on her bilateral buttocks The 4/12/23 IDT note read the resident had wound was unstageable to her coccyx. The resident's pain level ranged between zero and seven by use of the PAINAD (pain assessment in advanced dementia) scale. According to the note, the resident no longer verbalized pain much. According to the note, was on hospice end of life with an expected decline. The 4/13/23 nurses weekly wound documentation assessment read the resident's skin condition was first identified on 3/16/23. The wound documentation identified the wound was not healed and was in house (facility) acquired. The unstageable pressure ulcer to the resident's coccyx measured 0.8 cm x 0.3 cm with superficial depth. The wound bed had 5% slough with 95% granulated tissue. According to the documentation, the wound was moist. The wound was intact with erythema. The wound documentation read the plan for the resident was to change the foam dressing every three days and PRN. The resident had an air mattress in place and a turning schedule. The plan directed staff to turn the resident side to side and encourage the resident to stay off her bottom (coccyx/sacrum) as much as possible when in bed. V. Family interview Resident #16's family member was interviewed on 4/13/23 at 1:40 p.m. She said she was informed that the resident had a small laceration but that it was normal related to the resident's condition. Resident #16's family member was interviewed again on 4/13/23 at 4:00 p.m. She said the resident was not able to use her arms and was not able to reposition herself. She said she visits almost daily and had to ask the staff to reposition Resident #16. VI. Staff interview LPN #1 was interviewed on 4/13/23 at 2:09 p.m. She said she was the wound nurse but was still working on becoming certified. The LPN said she made weekly wound rounds based on residents with identified concerns through risk management incident reports or staff or the director of nursing notified her of skin/wound concerns. She said the floor nurses were conducting weekly skin checks looking for any new skin issues and making sure the dressings were intacted. LPN #1 said the CNAs were looking at the residents' skin daily during ADLs and would notify nursing if they identified a concern. LPN #1 said staff were directed to reposition the resident in bed by turning from side to side every two hours in the day and every four hours at night to prevent wound/pressure ulcer from worsening and progressing. The LPN said the unstageable pressure last measured 0.8 cm x 0.3 cm. with a decrease in slough. On her gluteal cleft (the area/groove between the buttocks that extends from just below the sacrum to the perineum). LPN #1 said the resident had a pressure relief cushion needed to have limited time up in her wheelchair. The LPN said when the resident was in her wheelchair and needed to be repositioned, staff should recline the chair all the way back and lift the resident off of the surface of the wheelchair. She said it was possible to manually lift the resident up with two staff members when the resident was reclined fully back in her chair. LPN #1 said sliding the resident up the wheelchair could cause shearing. The LPN said the resident preferred to sleep on her back and staff should be watching for that and reposition her. Pillows could be used to help maintain the resident's side to side position. She has not done formal training with the staff but has shown them and verbalized to them, how the position/reposition the resident. She said the repositioning of the resident was in her care plan. She said staff should inform the nurse when the dressing was observed not in place. The LPN said during the resident's dressing change on 4/12/23, the LPN identified the dressing was dislodged on the edge and soiled. The hospice nurse was interviewed on 4/13 at 3:16 p.m. He said that he and the hospice CNA were at the facility once a week and as needed to see Resident #16. He said Resident #16 had a change in condition a few months ago with a decrease in food and fluid intake. She had a dental issue and was taken to the dentist. The dentist did not recommend further dental procedures related to the resident's health, and comfort care was recommended. The resident's dental issues affected her eating ability so the resident has been downgraded to a puree which has helped some and she received assistance with feeding. The hospice RN said he routinely reviewed the resident's pressure ulcer with nursing. He said the resident treatment was a foam dressing covering the coccyx. He said he and hospice CNAs were aware that the resident was to be turned from side to side when in bed to alleviate pressure off of the wound/pressure ulcer. The hospice RN said the wound was progressing and not healing related to lower nutritional intake and not moving much. He said when hospice was at the facility they continued to reposition her and offer her bathing. CNA #5 was interviewed on 4/13/23 at 3:47 p.m. She said staff used a body pillow to help position Resident #16 on her side. The resident was observed with the CNA and the body pillow was located at the top of the bed above the resident's other pillows. She said the body pillow was mainly used at night. The resident had a flat pillow under her shoulder up as the resident layed on her back (see above observation.) She said the resident sometimes did not stay on her side. CNA #5 said the resident could not bend much at her trunk. She said when she repositioned her, they reclined the wheelchair almost flat so she was not working against gravity and tried not to hurt her wound/pressure ulcer. CNA #5 said she would have and another CNA lift the resident by use of the sling straps. Two CNAs would lift the resident, one on each side of her. CNA #5 said she felt strong and able to fully lift the resident on her side but some of the CNAs were not as strong as her, so when she lifted up the resident from her side, they would have to slide the resident up on their side. The director of nursing (DON) was interviewed on 4/13/23 at 5:27 p.m. The DON said Resident #16 had an alternating pressure reducing air mattress on her bed related to skin breakdown risk and current pressure ulcer. Observations of the pressure relieving air mattress at a setting of seven (P7) and static were shared with the DON. The DON said she did not know what the air mattress should be set at based on the resident's weight and the setting level was not care planned or documented in the resident's medical record. The DON said she would get together with the hospice provider and IDT to determine the appropriate setting the air mattress should be set out based on the resident's comfort level and tolerance. She said there were not physicians orders for the air mattress for her high risk of skin break down and current pressure ulcer. She said it depended on the facility's corporation if the physician orders were needed for the air mattress. The DON confirmed the resident had an pressure ulcer that was unstageable related to the presence on sloth and the pressure ulcer was facility acquired. She said the resident had hospice care. The DON said staff should alternate the resident from side to side when she was in bed. She said staff should position the resident on her side at at least a 30 degree angle. The staff could use pillows or positioning wedges to help maintain her position. The DON said the resident had a good pressure reducing wheelchair cushion from Span America, that was implemented in February 2023, but staff should lay the resident down between meals. The DON said when the resident was in her wheelchair and needed to be repositioned, the resident should be reclined back in her wheelchair depending on how much the resident had slid down, how stiff she was and how much the staff had to move the resident back in position.The resident should be picked up by two staff members, lifting on each side by use of a draw sheet. The DON said staff should pick up the resident and not pull her up to help prevent shearing of her skin. She said repositioning was planned. The DON said staff received training on positioning from their online training program. The DON said management conducted spot checks and rounding and would train on the spot if they saw a concern. The DON was informed of the above observations. She said she would work with the hospice provider to help on looking at the resident's wheelchair, ensuring it was the right fit for her and how to help prevent the resident from sliding down when in the wheelchair because the resident was so rigid. The DON said she would do an inservice with the staff on positioning, update the resident's care plan and provide increased monitoring. VII. Facility follow up The 4/13/23 nurse meeting agenda was provided by the facility on 4/13/23. The nurse meeting was held on 4/13/23 at 2:00 p.m. and 6:00 p.m. During the meeting the facility reviewed changes of condition for skin prevention and treatment. The agenda items for skin included residents for low risk (of skin breakdown) received a basic cushion on their wheelchair and residents with moderate to high risk were fitted with a Span America cushion. According to the agenda, for new skin issues, nurses should update the care plans, look at turning and repositioning and toileting plans and determine if changes were needed. The agenda also instructed the nurses to notify the physician and get wound orders. Verbal physician orders for the Invacare air mattress, dated 4/14/23, was provided by the regional nurse consultant (RNC) on 4/14/23 via email. According to the orders the settings on the air mattress should be checked three times a day with a current setting at P2. The order is read if the resident was uncomfortable the nurse could adjust the setting to assist in comfort. The order directed staff to the care plan any changes made to the adjustments. Updates to Resident #16's care plan was provided by the RNC on 4/14/23 via email. The updated care plan included the P2 setting on the air mattress and directed staff to inform the nurse if the resident was uncomfortable. Invacare Microair MA600 Alternating Pressure Low Air Mattress System was provided by RNC on 4/14/23 via email. According to the user manual, the Invacare air mattress was Recommended for use in the prevention and treatment of pressure ulcers stage one, to three (medium risk). The manuel read for higher risk patients, please contact Invacare for additional product offerings to address the higher risk patient. The suggested weight guidelines according to the user manual identified a P2 setting for a weight of 121 lbs to 184 lbs. The manual identified P7 (as observed above) was for a weight of 397 lbs to 441 lbs. The user manual included a handwritten notation signed by the RNC. The notation read Resident #16 weighed 141 lbs on 4/11/23. On 4/14/23 the facility set the air mattress at P2. If the resident was uncomfortable per Invacare, it could be adjusted for comfort.

Based on record review and interviews, the facility failed to identify the use of the indwelling catheter in the medical record for one resident (#3) of one resident reviewed for catheter use out of 26 sample residents. Specifically, the facility failed to ensure an assessment of the indwelling catheter that included a comprehensive, interdisciplinary review identifying the underlying factors which support the clinical indication for the initiation and continued need for catheter use, the development of a plan for removal, consideration of complications resulting from the use of an indwelling catheter, insertion, ongoing care that adhered to professional standards of practice and infection prevention and control procedures; and ongoing monitoring for changes related to potential catheter associated urinary tract infections (CAUTIs). Findings include: I. Facility policy and procedure The Indwelling Urinary Catheter (foley) Care and Management policy, dated 11/28/22, was provided by the nursing home administrator (NHA) on 4/13/23 at 12:52 p.m. It revealed in pertinent part, Catheter insertion for inappropriate indications is common. Appropriate indications for catheter use include: perioperative use for selected surgical procedure, such as urologic surgery or surgery on contiguous structures of the genitourinary tract, prolonged surgery (with removal of catheters inserted for this purpose in the postanesthesia care unit), surgery requiring large-volume infusions or diuretic use, continuous bladder irrigation for clot retention or intravesical drug infusion, administration of drugs directly into the bladder, such as chemotherapy, intraoperative urine output monitoring, prolonged immobilization, such as for an unstable thoracic or lumbar spine or multiple [NAME] injuries, including pelvic fractures, need for accurate hourly urine output measurement in critically ill patients, acute urinary retention or urinary obstruction, assistance in the healing of open pressure injuries or skin grafts in selected patients with urinary incontinence and improved comfort during end-of-life care. Inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter-associated urinary tract infection (CAUTI). II. Resident #3 A. Resident status Resident #3, age 71, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included pathological fracture in other disease right femur subsequent encounter for fracture with routine healing (right leg fracture), pathological fracture in other disease left femur subsequent encounter for fracture with routine healing (left leg fracture), lateral subluxation of left patella subsequent encounter (knee cap that moved out of place), morbid obesity, chronic respiratory failure, acquired abscess of uterus, anxiety, hemoperitoneum (bleeding in the abdominal cavity), edema and depression. The 3/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing and personal hygiene. She required set-up assistance for eating and total dependence of two people for toileting. The MDS assessment documented the resident had an indwelling catheter. It documented a trial of a toileting program had not been attempted on admission or since urinary incontinence was noted in the facility. It documented the resident was always incontinent of bowel. B. Resident interview Resident #3 was interviewed on 4/10/23 at 4:01 p.m. She said she was not aware of why she had a catheter. C. Record review The activities of daily living (ADL) care plan, initiated on 3/9/23 revealed Resident #3 had preferences related to her ADLs. The interventions included: providing a mechanical lift with assist of two for transfers, providing assistance with ambulation and locomotion, providing assistance with toileting. The interventions documented the resident was independent with bed mobility, bathing, dressing and grooming. -However, according to the MDS assessment and interviews Resident #3 needed assistance with all ADLs. The catheter care plan, initiated on 3/10/23, revealed Resident #3 had a foley catheter placed due to her immobility, obesity, skin condition and assist with pain management. Resident #3 was unable to get out of bed and had a diagnosis of an acquired absence of uterus, hydronephrosis (a condition where the kidneys become stretched) and hemoperitoneum (internal bleeding of the abdomen). The interventions included: keeping the catheter tubing free of kinks, keeping the drainage bag below bladder level, maintaining a closed catheter drainage system, monitoring and recording output every shit, monitoring for change in amount, color, consistency or odor and providing adequate fluids to reduce infection potential. The obesity care plan, revised on 3/10/23, revealed Resident #3 was immobile and unable to get out of bed. It documented all cares were provided in bed. The interventions included: educating the resident on disease process and making comfortable decisions, encouraging small frequent feedings instead of large meals, encouraging good fluid intake, providing medications as ordered, monitoring the residents food and fluid intake, offering emotional support, encouraging the resident to vent feelings, praising the resident ' s efforts in simple daily tasks and obtaining arm measurements. Review of the April 2023 CPO on 4/12/23 revealed the attending practitioner ' s orders failed to contain a valid clinical indication to support the use of an indwelling catheter. The April 2023 CPO revealed the following physician orders for the resident ' s catheter and mobility: foley catheter: -Every shift every monday related to pathological fracture in other disease right femur subsequent encounter for fracture with routine healing and pathological fracture in other disease left femur subsequent encounter for fracture with routine healing, changedown drain bag weekly. Date and initial on change and at bedtime every 30 days use size 16 (french) inflation 10 mL (milliliters) and every shift check tubing for proper positioning and catheter care and as needed flush catheter with 30 mL of NS (normal saline) every shift PRN (as needed) and repeat as necessary and every shift for intake and output monitoring intake and output amounts, ordered on 4/10/23 -Weight bearing as tolerated, ordered 3/10/23. The 3/12/23 bowel and bladder data collection assessment documented the resident was always continent of bladder. It documented the resident ' s incontinence was being managed by a foley catheter. The assessment documented the resident was always incontinent of bowel. The assmented documented the residents bowel incontinence was not a direct result from this illness or injury. The resident ' s bowel incontinence was being managed by incontinence products. The resident had an indwelling catheter. The assessment documented the diagnosis for use of the catheter was broken legs and unable to get up or move easily. The assessment documented the size of the catheter was 16/10 and the balloon inflation was 16/10. The discontinuation plan for the catheter was after the resident healed and was able to move easier without so much pain. The assessment documented there had not been attempts to discontinue the catheter. The 4/6/23 nursing weekly skin check documented the resident had no new skin issues. The resident had dry skin to bilateral lower extremities and lotion was applied as the resident would allow. The resident had mild redness noted under bilateral breasts and pannus. The 4/8/23 change in condition evaluation documented the resident complained of pain in the vaginal area where her foley was inserted. The assessment documented anxiety and pain medications made the condition or symptoms unchanged. The physician ordered to flush the foley and if the foley was still not draining urine to change the foley and call the physician back. The 4/8/23 nursing progress note documented Resident #3 complain of abdominal pain. It was received in report that the residents output was 350 cc (cubic centimeter) for the day. The exiting nurse obtained an order to change the resident ' s catheter and to notify the doctor if there was no or minimal output. The note documented two nurses removed and replaced the resident ' s foley catheter using universal precautions and sterile technique. A 16 french and a 5 cc bulb was inserted and 600 cc of yellow fluid was in the closed drainage system. The note documented the resident tolerated the procedure well and verbalized immediate relief upon liquid flow. The physician communication note on 4/12/23 (during the survey process) documented it was requested for physical and occupational therapy to work with the resident on increased bed mobility and work on bedpan use. The goal was to be able to discontinue the foley catheter if resident can tolerate using a bed pan. -Upon review of the resident ' s medical record on 4/13/23 there was no assessment of the indwelling catheter that was a comprehensive, interdisciplinary review that included identifying the underlying factors which support the clinical indication for the initiation and continuing need for catheter use, determination of which factors could be modified or revered and the development of a plan of removal. -A request was made for documentation revealing the interdisciplinary team discussed Resident #3 ' s continued use of the indwelling catheter on 4/13/23 at 4:22 p.m. The facility did not provide documentation revealing a comprehensive, interdisciplinary review. III. Staff interviews The physician (MD) was interviewed on 4/11/23 at 3:32 p.m. He said Resident #3 had a catheter because she was bed bound. He said a voiding trial had not been completed. The infection control preventionist (ICP) and the regional nurse consultant (RNC) were interviewed on 4/12/23 at 12:08 p.m. The RNC said Resident #3 had broken legs and ankles and was bed bound. The RNC said Resident #3 had incredible amounts of pain and it took three to four people to help move Resident #3. The RNC said the facility looked at Resident #3 ' s catheter and did not think it could be removed as they did not think the resident would be able to utilize a bedpan. The RNC said the facility was concerned about Resident #3 ' s lack of movement. She said a bladder and bowel assessment was completed upon admission. The ICP said keeping a catheter in place significantly raised the risks of urinary tract infections (UTI). Licensed practical nurse (LPN) #2 was interviewed on 4/12/23 at 5:15 p.m. She said Resident #3 was non-weight bearing to her lower extremities due to bilateral leg fractures. LPN #3 said Resident #3 had brittle bones. LPN #3 said the MD told her today that they could remove the left leg immobilizer as the leg was healing well. LPN #3 said they were unable to use a mechanical lift for Resident #3 due to her leg fractures. -However, according to the April 2023 CPO Resident #3 was weight bearing as tolerated. LPN #3 said on Saturday (4/8/23) Resident #3 ' s catheter became clogged and she tried to irrigate it, but was unsuccessful. LPN #3 said Resident #3 complained of abdomen and vaginal pain. She said she obtained physician orders to replaced Resident #3 ' s catheter. The regional operations director (ROD) and the director of rehabilitation (DOR) were interviewed on 4/13/23 at 9:04 a.m. The ROD said all residents should be evaluated by physical, occupational and speech therapy upon admission. The ROD said Resident #3 had not been seen by physical or occupational therapy since she was admitted to the facility. The director of nursing (DON) was interviewed on 4/13/23 at 10:29 a.m. She said Resident #3 had a catheter due to pain and immobility. She said Resident #3 required three to four people to turn her related to pain and anxiety. The DON said Resident #3 had become more trusting and had started to become more mobile. The DON said the MD ordered for staff to remove the left leg immobilizer as the resident ' s left leg was healing. The DON was interviewed again on 4/13/23 at 4:22 p.m. She said the interdisciplinary team had talked about Resident #3 ' s catheter She said the resident was having increased pain and at risk for skin breakdown so the facility decided to leave the catheter in place. IV. Facility follow-up On 4/17/23 at 1:49 p.m. the facility provided a physician order for Resident #3. It read: discontinue foley catheter one time only for one day, ordered on 4/17/23. On 4/17/23 at 1:49 p.m. the facility provided an updated incontinence plan of care, it revealed the resident had triggered for incontinence or altered elimination. Resident #3 needed treatment, monitoring and cares due to this condition. Resident #3 had pain related to bilateral leg fractures, was immobile and had incontinence. She was unable to get herself to the toilet. The interventions included: assisting the resident with perineal hygiene after toileting, checking and changing the resident due to functional incontinence every two hours during the day and every four hours at night, evaluating bladder control and pattern, assisting the resident with toileting as she was functionally disable, providing a bedpan for the residents use, monitoring for urinary retention and notifying nursing and physician if necessary and monitor for urinary retention as the resident had a foley catheter removed on 4/17/23.

Based on observations, record review and interviews, the facility failed to ensure each resident received necessary respiratory care and services that is in accordance with professional standards of practice and the resident's care plan for one (#21) of three residents reviewed for oxygen therapy out of 26 sample residents. Specifically, the facility failed to ensure Resident #21 received oxygen therapy in accordance with the physician's order. Findings include: I. Professional reference [NAME]/[NAME]/[NAME]/[NAME]/[NAME], Lewis's Medical-Surgical Nursing Assessment and Management of Clinical Problems, eleventh edition, 2019, page 566. Oxygen Therapy is often used in the treatment of COPD (chronic obstructive pulmonary disease) and other problems associated with hypoxemia (low levels of oxygen in the blood). Used clinically, it is considered a prescribed medication. II. Facility policy The Oxygen Administration, Long-Term Care policy, revised 11/28/22, was provided by the nursing home administrator (NHA) on 4/13/23 at 12:52 p.m. It revealed in pertinent part, Implementation: verify the practitioner's order for oxygen therapy. Prolonged high concentrations of oxygen can cause lung injury. III. Resident #21 A. Resident status Resident #21, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, nondisplaced fracture of medial malleolus of right tibia (right ankle fracture, nondisplaced fracture of lateral malleolus of left fibula (left ankle fracture), anxiety disorder, heart disease, depression, dementia and peripheral vascular disease (reduced blood flow to the limbs). The 4/1/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score with a score of 12 out of 15. He required extensive assistance of one person for personal hygiene. He required extensive assistance of two people for bed mobility, transfers, dressing and toileting. He required total assistance of one person for walking in the corridor and locomotion on and off the unit. He required supervision with set-up assistance for eating. The 2/28/23 MDS assessment revealed the resident received oxygen therapy. B. Observation and resident interview Resident #21 was interviewed on 4/10/23 at 4:35 p.m. He said he had worn oxygen for a long time. Resident #21's oxygen concentrator was set to 5 liters per minute (LPM). Resident #21 said he was non-weight bearing and unable to walk without staff assistance. Resident #21 was sitting in a recliner and his oxygen concentrator was approximately four feet from him. Resident #21 was interviewed on 4/12/23 at 1:09 p.m. His oxygen concentrator was set at 4 LPM. The director of nursing (DON) entered the resident's room and acknowledged the resident's oxygen concentrator was set at 4 LPM (see interview below). C. Record review The oxygen care plan, initiated on 2/24/23, revealed Resident #21 used oxygen with an oxymizer for COPD and acute and chronic respiratory failure. The interventions included: keeping the resident's call bell within reach, monitoring and documenting for signs of restlessness, agitation, confusion, increased heart rate or bradycardia, monitoring and documenting level of consciousness, mental status and lethargy as needed, notifying the nurse if the residents oxygen saturation was below 90% (percent), changing the oxymizer monthly and the oxygen tubing weekly, providing oxygen and providing good oral care daily and as needed. The respiratory care plan, initiated on 2/22/23 and revised on 2/24/23, revealed Resident #21 had a respiratory diagnosis, abnormal lung sounds and shortness of breath. Resident #21 had a history of carbon dioxide (CO2) retention and required an oxymizer medallion along with his oxygen therapy at all times. Resident #21 had a history of pneumonia, sepsis and use of steroids. Resident #21 got short of breath when lying flat. The interventions included: administering medications as ordered, assisting the resident with activities that cause shortness of breath, demonstrating effecting coughing and deep breathing techniques, encouraging fluid intake unless contraindicated, encouraging rest periods throughout the day, giving nebulizer treatments and oxygen therapy as ordered, notifying the physician if increased coughing occurs, observing for signs and symptoms of infection and elevating the residents head of the bed as he got short of breath when lying flat. The April 2023 CPO revealed the following oxygen order: -Oxygen at 2 L/M (liters per minute) nc (nasal cannula) every shift related to chronic obstructive pulmonary disorder (COPD), ordered 4/3/23. The 1/4/23 grievance form filed by Resident #21 revealed the resident desired to have increased oxygen flow and longer oxygen tubing, so he could reach the bathroom with the oxygen tubing. Resident #21 had a history of desaturation of oxygen levels with short tubing and was frustrated. The form documented the concern was discussed with the practitioner. The practitioner did not agree with increased oxygen flow. A bedside commode was put into place. The summary statement of the grievance form documented the concern was discussed with the resident and the impact the short oxygen tubing could have on his oxygen levels. The form documented the resident continued to voice concerns. The summary of the findings section of the form documented due to Resident #21's medical status, history of desaturation with short oxygen tubing and risk of CO2 retention with increased oxygen flow the residents request was unable to be met. IV. Staff interviews The DON was interviewed on 4/12/23 at 1:18 p.m. She acknowledged Resident #21's oxygen was set at 4 LPM. The DON said she turned Resident #21's oxygen concentrator down to 2 LPM and was going to verify the physician's order. Licensed practical nurse (LPN) #3 was interviewed on 4/12/23 at 5:20 p.m. She said the DON notified her that Resident #21's oxygen was set at 4 LPM. LPN #3 said Resident #21 had a physician's order for oxygen at 2 LPM. LPN #3 said it could be dangerous for a resident to receive too much oxygen. The DON was interviewed again on 4/13/23 at 10:29 a.m. She said Resident #21 used to have a physician order for oxygen to be on at 4 or 5 LPM. The DON said the resident was at high risk no matter what oxygen saturation level he was at. The DON said the resident had a history of asking for staff members to turn his oxygen up. The DON said they had provided education to the resident to keep his oxygen at the physician ordered level. V. Facility follow-up The DON provided a copy of the in-service regarding oxygen settings that was given on 4/12/23 (during the survey process). It revealed staff were to check oxygen settings to ensure they were set at the same rate as ordered, if a resident or family requests for oxygen to be changed from what was ordered, notify the charge nurse so they can educate and request change from physician and the charge nurse should check oxygen settings and adjust as needed.

Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for two (#21 and #3) out of 26 sample residents. Specifically, the facility failed to: -Offer non-pharmacological pain interventions for Resident #21; -Determine an acceptable pain level for Resident #21 and #3; and, -Administer pain medications per physician's order for Resident #3. Findings include: I. Resident #21 A. Resident status Resident #21, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, nondisplaced fracture of medial malleolus of right tibia (right ankle fracture, nondisplaced fracture of lateral malleolus of left fibula (left ankle fracture), anxiety disorder, heart disease, depression, dementia and peripheral vascular disease (reduced blood flow to the limbs). The 4/1/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of 12 out of 15. He required extensive assistance of one person for personal hygiene. He required extensive assistance of two people for bed mobility, transfers, dressing and toileting. He required total assistance of one person for walking in the corridor and locomotion on and off the unit. He required supervision with set-up assistance for eating. The 2/28/23 MDS assessment documented Resident #21 had pain almost constantly. Pain made it difficult for him to sleep at night and limited his day-to-day activities. The MDS assessment documented Resident #21 had moderate pain. B. Resident interview Resident #21 was interviewed on 4/10/23 at 4:15 p.m. He said he was in constant pain due to his bilateral ankle fractures. He said he had requested ice packs to help with the pain, but nursing staff did not provide them. Resident #21 said staff did not offer him other pain interventions besides medications. C. Record review The 4/6/23 pain data collection documented the resident was not on a scheduled pain medication regimen, received as needed pain medications or pain medications were offered and declined and received non-medication intervention for pain. The assessment documented the resident reported he had almost constant pain, which made it difficult for him to sleep at night and limited his day-to-day activities. Resident #21 reported his pain was moderate. The summary of the assessment documented Resident #21's pain had significantly less complaints of pain then he did a month ago. Resident #21's pain was managed by as needed Tramadol (pain medication). The pain plan of care, initiated on 4/3/23, revealed Resident #21 had a history of falls with right and left ankle fractures. Resident #21 had chronic obstructive pulmonary disease (COPD), a recent acute episode of respiratory failure and a history of chronic respiratory failure. Resident #21 was able to verbalize his pain, but if his oxygen saturation dropped he became confused. The interventions included: administering medication per physician orders for pain management, administering medication per physician order for breakthrough pain, assisting the resident to meet his needs and maintain safety, by keeping his call light within reach, keeping personal items within reach and reminding the resident to avoid sudden position changes that may increase pain, explaining procedures and interventions to motivate the resident's cooperation, monitor of facial gestures of pain., keeping the resident as active as possible, monitoring for constipation, monitoring for pain characteristics, monitoring tolerance of activity and report changes to physician and family, providing resident with frequent rest periods, reporting increased pain to physician, -An additional intervention was in place that said other pain interventions, but was left blank and not personalized to the resident. -The care plan did not include personalized non-pharmacological pain interventions. The April 2023 CPO revealed the following physician's orders for pain: -Tramadol HCL Tablet 50 MG, give 50 MG by mouth every six hours as needed for pain 0-10 not to exceed 300 MG in 24 h ours., ordered 4/3/23. A request for the residents' documented acceptable pain level was made on 4/13/23 at 10:29 a.m. The facility did not provide documentation revealing the residents' acceptable pain level was documented in Resident #21's medical record. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 4/12/23 at 5:20 p.m. She said she removed Resident #21's orthopedic boots for bilateral ankle fractures on Friday 4/7/23 to help alleviate some pain. Certified nurse aide (CNA) #6 was interviewed on 4/13/23 at 10:03 p.m. She said Resident #21 occasionally reported pain to her. CNA #6 said she would report the resident's pain to the charge nurse. CNA #6 said she was not aware of any non medication pain interventions to provide to the resident. The director of nursing (DON) was interviewed on 4/13/23 at 1:51 p.m. She said Resident #21 had an order for as needed ice packs. She said Resident #21 recently was sent to the hospital and the order was not restarted upon readmission. She said she was not aware of Resident #21 asking for ice. The DON said she would call the physician and request a new order. She said other non-pharmacological pain intervention the staff provided was entering the residents room with a smile and positive attitude. The DON said non-pharmacological pain interventions were documented on the resident's care plan. -However, Resident #21's care plan did not have personalized non-pharmacological pain interventions. II. Resident #3 A. Resident status Resident #3, age 71, was admitted on [DATE]. According to the April 2023 CPO, the diagnoses included pathological fracture in other disease right femur subsequent encounter for fracture with routine healing (right leg fracture), pathological fracture in other disease left femur subsequent encounter for fracture with routine healing (left leg fracture), lateral subluxation of left patella subsequent encounter (knee cap that moved out of place), morbid obesity, chronic respiratory failure, acquired abscess of uterus, anxiety, hemoperitoneum (bleeding in the abdominal cavity), edema and depression The 3/15/23 MDS assessment revealed the resident was cognitively intact with a BIMS with a score of 14 out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing and personal hygiene. She required set-up assistance for eating and total dependence of two people for toileting. The MDS assessment documented the resident was on a scheduled pain medication regimen, received as needed pain medications and received non-medication interventions for pain. The MDS assessment documented the resident had frequent moderate pain. B. Resident interview Resident #3 was interviewed on 4/11/23 at 10:05 a.m. She said she had recently broken both of her legs and was unable to get out of bed. She said she was frequently in pain. C. Record review The 3/12/23 pain data collection documented Resident #3 received scheduled pain medications. Resident #3 did not receive as needed pain medications and received non-medications interventions for pain. Resident #3 reported frequent moderate pain in the last five days. Resident #3's pain did not make it hard for her to sleep at night or affect her day-to-day activities. The summary of the assessment documented Resident #3 received routine pain medications with positive effects for bilateral broken legs and repositioning frequently. The April 2023 CPO revealed the following physician's orders for pain: -Fentanyl transdermal patch 72 hours 25 MCG/HR (microgram per hour) apply 25 MCG/HR transdermally one time a day every three days related to pathological fracture in other disease right femur subsequent encounter for fracture with routine healing and pathological fracture in other disease left femur subsequent encounter for fracture with routine healing and remove per schedule, ordered 3/9/23. -Ibuprofen oral tablet 600 MG, give 600 MG by mouth with meals related to pathological fracture in other disease right femur subsequent encounter for fracture with routine healing and pathological fracture in other disease left femur subsequent encounter for fracture with routine healing, ordered 3/9/23. -Acetaminophen oral tablet 325 MG, give 650 MG by mouth every four hours as needed for pain 1-6 (on a scale with 10 being the worst pain), do not exceed 3 grams in 24 hours, ordered 3/14/23. -Hydromorphone HCL oral tablet 2 MG (Hydromorphone HCL), give 2 MG by mouth every four hours as needed for moderate-severe pain 7-10, ordered 3/14/23. A review of Resident #3's medication administration record (MAR) from 3/14/23 through 3/31/23 revealed the following: -Resident #3 received 650 MG Acetaminophen on 3/18/23 and 3/19/23 when she reported her pain level at an 8 out of 10. -Resident #3 received Hydromorphone 2 MG the following days with the reported pain levels: -On 3/22/23 Resident #3 reported her pain level was 0. -On 3/23/23 Resident #3 reported her pain level was 5. -On 3/25/23 Resident #3 reported her pain level was 5. -On 3/36/23 Resident #3 reported her pain level was 3. -On 3/29/23 Resident #3 reported her pain level was 4. -On 3/31/23 Resident #3 reported her pain level was 3. A review of Resident #3's April 2023 MAR from 4/1/23 through 4/13/23 revealed the following: -Resident #3 received one tablet of Tramadol 50 MG on 2/11/23 when she reported her pain level was a 6, received one tablet of Tramadol 50 MG on 2/15/23 in the morning when she reported her pain level as a 6, received two tablets of Tramadol 50 MG on 2/15/23 in the evening when she reported her pain level as a 3, one tablet of Tramadol 50 MG on 2/24/23 when she reported her pain level was a 6 and one tablet of Tramadol 50 MG on 2/26/23 when she reported her pain level as a 6. -Resident #3 received 650 MG Acetaminophen on 4/3/23 when she reported her pain was 7. -Resident #3 received Hydromorphone 2 MG the following days with reported pain levels: -On 4/1/23 she received Hydromorphone 2 MG twice when she reported her pain was a 4. -On 4/3/23 Resident #3 reported her pain was 4. -On 4/6/23 Resident #3 reported her pain was 0. -However, the CPO indicated to give Acetaminophen 650MG for a pain level of 1 to 6 and Hydromorphone 2 MG for a pain level of 7-10. A request for the residents' documented acceptable pain level was made on 4/13/23 at 10:29 a.m. The facility did not provide documentation revealing the residents' acceptable pain level was documented in Resident #3's medical record. D. Staff interviews LPN #3 was interviewed on 4/12/23 at 5:20 p.m. She said Resident #3 had bilateral broken legs. LPN #3 said Resident #3 had Acetaminophen as needed for a pain level of 1 to 6 and Hydromorphone as needed for pain seven to ten. LPN #3 said the physician's order should be followed when administering pain medication. LPN #3 said she had not administered the Hydromorphone to Resident #3. LPN #3 said staff attempted to reposition Resident #3 frequently. Certified nurse aide (CNA) #6 was interviewed on 4/13/23 at 10:03 a.m. She said Resident #3 reported pain to her occasionally. CNA #6 said when Resident #3 reported pain, she would report it to the nurse. The DON was interviewed on 4/13/23 at 10:29 a.m. The DON said Resident #3 admitted with a lot of pain related to her bilateral leg fractures. The DON said Resident #3 often changed her mind. The DON said she thought the resident might have reported a pain level and then changed her mind, which was why the physician's order was not always followed correctly. The DON said a progress note or documentation should have been completed if this was the case.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for medication errors out of seven sample residents received treatment and care in accordance with professional standards of practice. The facility failed to administer long term use medication for Resident #1 as ordered, resulting in severe withdrawal symptoms contributing to her hospitalization . Resident #1 experienced confusion, anxiety, pain and hallucinations. The facility failed to have a system in place to ensure the resident's order for the controlled substance medication [MEDICATION(S)] could be filled, when the medication did not arrive with her other medications. The facility failed to identify [MEDICATION(S)] was not available immediately on admission during a medication review, resulting in the facility having to rely on on-call providers who would not provide a prescription for the controlled substance. The facility did not contact the medical director to obtain the prescription, resulting in the resident having to wait for the primary nurse practitioner (NP) to write the prescription on the following Monday, 8/2/21. Due to Resident #1 having an increase in confusion and behaviors, the NP determined she had signs of oversedation. The nurse practitioner did not write the [MEDICATION(S)] prescription until 8/4/21, after he was informed on 8/3/21 that the resident had been on [MEDICATION(S)] for many years and had possible withdrawal symptoms from lack of administration. Findings include: I. Facility policy The Nursing Drug Regimen Review policy, dated October 2018, provided by the facility on 10/12/21, read in pertinent part: It is the policy of (the facility corporation) to ensure residents are safe from medication related adverse events and to ensure the highest practicable quality of life for those we serve. This includes medication/drug reconciliation upon admission, re-admission, and upon receipt of new orders. The process involves timely communication with the provider (physician or physician extender) when a potentially clinically significant medication issue arises so the risk can be mitigated and prevent future harm. For admission and readmission for Medicare A residents, a medication reconciliation/DRR (drug regimen review) will be completed upon admission. When clinically significant medications issues are identified, the provider is notified and actions taken by midnight of the next calendar day. Upon receipt of new orders, the nurse will review the orders for potential clinically significant medication issues and report them to the physician/physician extender. Potentially clinically significant medication issues are identified and monitored on an on-going basis throughout the resident's stay through discharge. II. Professional reference The pharmacy manufacturer drug label for [MEDICATION(S)] ([MEDICATION(S)]), revised June 2020, accessed on 10/14/2021, retrieved from http://labeling.pfizer.com/showlabeling.aspx?id=561, under Warnings and precautions read in part, Increased [CONDITION(S)] frequency or other adverse reactions may occur if [MEDICATION(S)] is rapidly discontinued. Withdraw gradually over a minimum of one week. The manufacturer's label under Controlled Substance identified [MEDICATION(S)] as a Schedule V controlled substance. The manufacturer's label under Dependence read in part, In clinical studies, following abrupt or rapid discontinuation of [MEDICATION(S)], some patients reported symptoms including [CONDITION(S)], nausea, headache, or diarrhea, consistent with physical dependence. In the postmarking experience, in addition to these reported symptoms, there have also been reported cases of anxiety and hyperhidrosis (abnormally excessive sweating). The US National Library of Medicine, National Institutes of Health, featured an article and case study on [MEDICATION(S)]-associated Discontinuation Symptoms: A Case Report, published on 10/8/2018, accessed on 10/12/2021, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 77/, which read in in part: [MEDICATION(S)] taper has been associated with an increased risk of [CONDITION(S)] and confusion. The discontinuation of [MEDICATION(S)] is considered to be clinically safe if it was tapered gradually over a period of one week. An article published by the American Addiction Centers, last updated 10/23/19, accessed on 10/15/21, retrieved from https://americanaddictioncenters.org/prescription-drugs/[MEDICATION(S)]-withdrawal-symptoms, read in part: In many cases you can become dependent on [MEDICATION(S)] and experience withdrawal effects after using a drug for an extended period Signs and symptoms of [MEDICATION(S)] withdrawal include headache, mood changes, agitation, depression, anxiety, confusion, suicidal thoughts, nausea, sweating, diarrhea, increased heart rate, craving for the medication, [CONDITION(S)] and seizures. III. Resident status Resident #1, age 76, was admitted on [DATE] and discharged on [DATE]. According to the October 2021 discontinued computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/4/21 minimum data set (MDS) assessment indicated a brief interview for mental status (BIMS) was not conducted. The MDS identified Resident #1 required extensive assistance of two or more persons for bed mobility, transfers, dressing, and toileting. She needed extensive physical assistance of one person for personal hygiene and locomotion on and off the unit. Resident #1 required supervision with set up for eating. IV. Family interview A family member of Resident #1 was interviewed on 10/12/21 at 11:18 a.m. She said Resident #1 had withdrawal symptoms from the removal of some of her medication she was on for years. She said the emergency department (ER) at the hospital had to sedate her to examine her on 8/4/21 because of her pain and behavior. She said she was not aware the medication changes occurred at the facility. The family member said the resident had a change in cognition by Sunday (8/1/21) while she was in the facility. The resident reported to the family on 8/1/21 that she did not know where she was and proceeded to call the family 15 times. A second family member of Resident #1 was interviewed on 10/12/21 at 7:40 p.m. She said the NP contacted her and informed her the resident's [MEDICATION(S)] would be restarted and it had been held. She said she later was informed that Resident #1's [CONDITION(S)] was so bad that she had to go to the ER. She said she agreed with the request because she saw the changes in her mom during a recent window visit. The family member said she was very confused during the visit. She said the nursing home experience had been a scary process. V. Staff interviews The nursing home administrator (NHA) was interviewed on 10/12/21 at 11:41 a.m. The NHA said on 7/30/21, the day of the resident's admission, the night nurse identified [MEDICATION(S)] had not arrived at the facility even though an admission drug regimen review of all her medication was completed without an identified concern. She said Resident #1 was admitted on a Friday. She said the facility did not have the [MEDICATION(S)] to administer so the weekend on-call physician was contacted. The on call physician was not comfortable writing the prescription for [MEDICATION(S)] because he was not familiar with the resident. The NHA said the on call nurse practitioner was contacted and also was not comfortable writing the prescription. She said attempts were ongoing over the weekend to obtain even an emergency prescription. She said the pharmacy required an actual script for the prescription for [MEDICATION(S)] as a controlled substance. She said the facility had to wait until the following Monday (8/2/21) to have the [MEDICATION(S)] order filled. On Sunday night (8/1/21) Resident #1 started exhibiting behaviors of hollering out. The NHA said nurses should have contacted the medical director for assistance in obtaining the medication for Resident #1. The NHA said the resident became very confused. She said on 8/2/21, the primary nurse practitioner (NP) visited the resident and felt she was over-sedated and did not provide the order for [MEDICATION(S)]. Resident #1 was starting to hallucinate, which increasingly became worse on Tuesday (8/3/21). She said registered nurse (RN) #2 was concerned about the resident's increasing behaviors and researched the resident's history. She said RN #2 was concerned her [MEDICATION(S)] was stopped without a taper. RN #2 requested the NP to start the [MEDICATION(S)] based on her findings. LPN #1 was interviewed on 10/12/21 at 12:42 p.m. She said she identified [MEDICATION(S)] was on hold as of 8/2/21. She said further review determined Resident #1 had a treatment order for the [MEDICATION(S)] to be discontinued due to oversedation. She said the facility was in continued contact with the family of Resident #1. She said the family also had a window visit with the resident. She said they were informed of the discontinuation of [MEDICATION(S)] because of the impression of oversedation. The LPN said the family did not express a concern about the discontinuation. The LPN said the resident was exhibiting pain with care including any light touch, such as taking her vitals. According to the LPN, the family was also informed of the resident's high level of confusion and that she was hallucinating. The NP was interviewed on 10/12/21 at 1:20 p.m. The NP said he first saw Resident #1 on 8/2/21. He said she had symptoms of pneumonia. He said he did not restart the [MEDICATION(S)]/[MEDICATION(S)] because the resident also exhibited signs of over-sedation. He said when a person was sick, sometimes medications were backed off when conditions were acute. The NP said he kept Resident #1 on the Oxycodone but not the [MEDICATION(S)]. He said her condition worsened from 8/2/21 to when he saw her again on 8/4/21. He said he was not initially aware the resident had long term use of [MEDICATION(S)]. He said he started the resident back on [MEDICATION(S)] when he found out she had been on the medication for awhile. The NP said he diagnosed Resident #1 with [CONDITION(S)]. He said the [CONDITION(S)] could have been from multiple issues, such as withdrawal, pneumonia, or other factors. The NP said labs were drawn and she had elevated white blood cells and [CONDITION(S)] so decided to send her to the ER. The medical director (MD) was interviewed on 10/12/21 at 3:59 p.m. He said he had reviewed the concerns surrounding Resident #1 not receiving the [MEDICATION(S)]. He said the resident should have been weaned off the medication. He said she had withdrawal symptoms. The MD said the resident was on a high dose of [MEDICATION(S)] at 300 mg and it should have not been stopped immediately. Withdrawal symptoms for the medication could have contributed to her agitation, discomfort, and hallucinations. The MD said the on-call providers should have been thoughtful of controlled substances. He said they could have provided a three day emergency order for the [MEDICATION(S)]. He said the resident was part of their private practice, and he thought they should have assisted in the request from the facility. He said he was planning on reviewing the concerns with the other providers. The MD said his role as the facility medical director was to provide oversight of the other providers, as well as helping with clinical issues as they arose. He said his role was to ensure residents at the facility received the appropriate care. He said the facility should have contacted him when they could not obtain the prescription for [MEDICATION(S)] over the weekend. He said it would have been normal practice for them to contact him with the concern. The MD said the medication concerns surrounding Resident #1 were later reviewed in the quality assurance and dose reduction meetings at the facility. He said the director of nursing (DON) also provided education to the nurses. RN #1 was interviewed on 10/12/21 at 5:51 p.m. According to RN #1, the weekend on-call providers would not write prescriptions for narcotics and controlled substances when the facility made the requests. RN #2 was interviewed on 10/13/21 at 8:50 a.m. RN #2 said the family of Resident #2 contacted her on 8/2/21 and was concerned about Resident #1's increased confusion and that she did not sound like herself. The RN said her first interaction with the resident on 8/2/21 identified the Resident #1 was able to answer questions. The RN said by her next shift (8/3/21), the resident was very confused and very sensitive to touch, saying, Oh, you're hurting me, and screaming. She said anytime anyone touched the resident it hurt her. RN#2 said she reviewed the resident's chart and history. She said she was concerned the resident's [MEDICATION(S)] had a cold stop, and she faxed her concern to the NP. The director of nursing (DON) was interviewed with the nurse consultant (NC) on 10/12/21 at 6:35 p.m. The DON said she was new to the facility at the time Resident #1 was admitted on [DATE]. The DON said she was acclimating to her role at the time and was primarily covering floor nurse shifts. She said she was not contacted when the nurses were having difficulty obtaining the [MEDICATION(S)] prescription for Resident #1. She said she was not made aware of the resident's increasing behaviors or pain. She said the nurses did not contact the medical director to assist them. She said she conducted nurse education, reviewing the medication policy, after the incident. VI. Record review A. Hospital records The 7/30/21 discharge hospital records were provided by the facility medical records director on 10/12/21 at 4:25 p.m. The hospital discharge summary read Resident #1's overall status at discharge was progressing to baseline and her condition was stable. The 7/30/21 hospital general nursing note read Resident #1 was alert and oriented and was able to make her needs known. According to the 7/30/21 note, the resident did not show signs of respiratory distress and denied pain. The home medication report from the hospital identified Resident #1 should have continued her order of [MEDICATION(S)] ([MEDICATION(S)]) 300 mg after discharge from the hospital on 7/30/21. The home medication report indicated Resident #1 last received the [MEDICATION(S)] on 7/30/21 at 10:20 a.m. The 8/4/21 readmission hospital records were provided by the hospital medical records on 10/11/21 at 10:25 p.m. The 8/4/21 emergency room report indicated Resident #1 had an altered mental status of [CONDITION(S)] and was likely going through withdrawal after not receiving her [MEDICATION(S)] at the facility. The 8/4/21 hospital health information management history and physical identified the resident would be admitted to the hospital and administered Oxycodone and [MEDICATION(S)] to help with her symptoms of allodynia (neuropathic nerve pain) that she was experiencing from chronic [CONDITION(S)]. The 8/8/21 hospital health information management progress note under assessment and plan read the resident had acute [CONDITION(S)] from a recent narcotic/[MEDICATION(S)] withdrawal which was slowly improving as of 8/8/21. B. Facility records The August 2021 admission care plan, initiated on 7/30/21, read the resident would remain safe and comfortable in her new environment. Interventions included completing her treatments as ordered. According to the care plan, the facility was to monitor and document the treatment effectiveness and notify the physician of any changes as needed. The October 2021 discontinued CPO identified Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The CPO also identified the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxycodone was the only narcotic medication ordered. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR, [MEDICATION(S)] was not provided as ordered with multiple missed doses. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (See progress notes below.) The 7/30/21 at 2:00 p.m. drug regimen review note documented by LPN #2, read a nursing drug regimen review and evaluation was completed for Resident #1 on 7/30/21. According to the nursing note, the complete drug regimen review resulted in no issues found. There were no other corresponding notes related to the nursing drug regimen review. The 7/30/21 at 10:00 p.m. eMAR note for [MEDICATION(S)] ([MEDICATION(S)]) Capsule 300 MG read [MEDICATION(S)] was on order. The 7/31/21 eMAR note for [MEDICATION(S)] Capsule 300 MG read [MEDICATION(S)] was not received from the pharmacy. The 7/31/21 pharmacy consultant note revealed an admission medication regimen review was completed using all documentation available at that time. The note read there were no clinically urgent time sensitive recommendations made for this review. An 8/1/21 eMAR note read the resident had pain in her head and back. An 8/2/21 at 10:00 a.m eMAR note for [MEDICATION(S)] Capsule 300 MG read the pharmacy needed a hard script. According to the note, the facility left a message with on-call providers on 8/1/21 and were waiting for an order from the in-house physician on 8/2/21. An 8/2/21 at 6:53 p.m. eMAR note for [MEDICATION(S)] Capsule 300 MG read the NP wrote progress note today that he does not want her taking this for fear it may sedate her. The 8/2/21 provider progress note documented by the nurse practitioner (NP) read the order for Oxycodone would continue. According to the note he was concerned the [MEDICATION(S)] (anticonvulsant and nerve pain medication) would cause oversedation and would be monitored. During the interview on 10/12/21 with NP (see above), he clarified that [MEDICATION(S)] was written in error and was referring to [MEDICATION(S)]. An 8/2/21 at 6:53 pm eMAR note for [MEDICATION(S)] Capsule 300 MG read the NP wrote progress note today that he does not want her taking this for fear it may sedate her. An 8/3/21 verbal order summary for [MEDICATION(S)] Capsule 300 MG identified [MEDICATION(S)] was discontinued on 8/3/21. An 8/3/21 faxed communication note from registered nurse (RN) #2 to the NP was provided by the facility on 10/11/21. According to the communication note, RN informed the NP that Resident #1 had increased behaviors with anxiety, hallucinations, yelling and at times complete panic. The note identified the resident as having nausea, diarrhea and extreme pain when you lightly touch her skin. The RN wrote that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN informed the NP the resident had been on [MEDICATION(S)] 300 mg since 4/9/15 and asked the NP if the stopping of the [MEDICATION(S)] could have caused the behavior and requested the NP to assess. The 8/4/21 at 11:05 a.m. provider progress note documented by the NP read Resident #1's [MEDICATION(S)] ([MEDICATION(S)]) would restart to the previous dose at 300 mg PO BID (by mouth twice a day). According to the note, the resident was on the medication for quite some time now. An 8/4/21 at 10:46 a.m. provider progress notes documented by the NP included Resident #1 was very complex and appeared to have [CONDITION(S)] with hallucinations and anxiety, noting the resident was seeing spiders and felt the bed was swallowing her. An 8/4/21 at 3:54 p.m. provider progress note identified lab results revealed Resident #1 had a urine analysis but had elevated ketones. According to the progress note, the NP determined a need to send the resident to the hospital related to her elevated white blood count, continued confusion, and abdominal pain. The 8/4/21 Medicare note identified Resident #1 received skilled nursing for management and education of [CONDITION(S)] with recent (resolved) pneumonia and associated weakness, and [CONDITION(S)] management and education. The note identified the resident's discharge plan as uncertain related to behaviors. Behaviors identified included hallucinations and yelling out. The Medicare note indicated the increased behaviors were not common for the resident per a report received. According to the note, occupational therapy had difficulty evaluating the resident because she was non-participatory and uncooperative. The note identified that her rehab potential would improve if behaviors were better controlled. The note also indicated the resident's meal intake had declined and she was having difficulty swallowing, prompting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The 8/4/21 post incident review read Resident #1 had admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the incident review, the staff made multiple attempts to obtain the prescription but were not successful. According to the incident note the medication was discontinued on 8/2/21. The review read the resident went several days without medication and had increased confusion, anxiety, hallucinations, nausea, diarrhea, dry heaving, and pain. The incident review identified the root cause of the incident was not receiving the [MEDICATION(S)] as ordered. The incident review revealed why Resident #1 did not receive her medication as ordered: -The prescribing physician needed to send all narcotic or controlled scripts to the pharmacy; -The admitting nurse should make sure all hard scripts were sent. -The admitting nurse should follow up with the discharging physician or primary care physician for them to send the hard script. If nursing was having trouble getting a script filled, nursing needed to notify the medical director. The SBAR (situation, background, assessment and recommendation) communication form and progress note for RN/LPNs revealed the resident had worsening of chronic pain and exhibited non-verbal signs of pain to include occasional labored breathing, short period of hyperventilation, repeated trouble calling out, loud moaning or groaning, crying, facial grimacing and fidgeting. The 8/4/21 eINTERACT SBAR summary for providers assessment identified abdominal pain, altered mental status, functional decline (worsening function and/or mobility) and nausea/vomiting as a change in condition for Resident #1. The summary noted the medication change of the discontinuation of [MEDICATION(S)] 300 mg twice a day. According to the summary, the resident had increased confusion with new or worsened delusions or hallucinations. The resident had new blood, urinalysis or culture testing orders and new intervention orders for IV (intravenous) or subcutaneous fluids. The summary revealed the primary care provider recommended to send Resident #1 the ER (emergency room ) for an evaluation and treatment. A 8/5/21 facility investigation report for Resident #1 was provided by the facility on 10/11/21. The report identified medication held since 7/30/21, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was alert and oriented and able to make her needs known at the time of admission. The resident was confused at the time of her discharge to hospital. The report documented the resident did not receive her [MEDICATION(S)] since admission and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated the investigation was conducted related to an allegation of neglect and reported to the State survey agency. The finding of the facility investigation determined a medication prescription for [MEDICATION(S)] was not sent over from the hospital to the pharmacy. The facility contacted the pharmacy, the on call provider for the primary care physician and the on call nurse practitioner, but was unable to obtain a prescription for the medication. The investigation report revealed the facility scheduled a nurse meeting to ensure all nursing staff were aware of the policy and procedure when a medication was ordered but not available. The 8/6/21 post incident note for Resident #1 identified the incident as a medication error.

Based on observations, record review and interviews, the facility failed to provide an environment as free from accident hazards as possible for one (#7) of five residents reviewed for falls out of 19 sample residents. The facility failed to ensure Resident #7's care plan was followed, and failed to continuously monitor the effectiveness of interventions and update the care plan accurately. The facility failed to implement new, effective, person-centered interventions timely after each of three falls on 8/6/21, 8/30/21 and 9/15/21. The falls resulted in Resident #7 hitting his head and sustaining injuries each time. Resident #7 experienced pain and required 15 stitches to the area near his right eye resulting from the fall on 8/30/21. The facility failed to include a clear directive of what type of preventative assistance Resident #7 required to decrease the risk of further falls. The facility further failed to provide adequate supervision and monitoring for Resident #7, who had moderate cognitive impairment and impaired safety awareness. Moreover, the facility failed to demonstrate that all measures were taken, such as a thorough medication evaluation, sleep analysis, time of day or situation, to determine the specific root cause of his falls other than that he fell asleep which in turn led to his falls. Cross-reference F725, insufficient nursing staffing Findings include: I. Facility policy and procedure The Falls Prevention and Reduction policy, dated March 2018, was provided by medical records (MR) on 9/28/21 at 10:50 a.m. The policy documented in part, In the initial assessment of the client, or later re-assessments, the RN (registered nurse) identifies any concerns suggesting that the client may be at risk of falls, the RN will do a focused falls assessment and screening. Based on this falls assessment, the RN will identify any needed interventions, will educate the client and will make recommendations about actions the client should take to reduce the risk of falls. The RN will incorporate any interventions to prevent or reduce the risk of falls into the client's care plan and will communicate these interventions to staff providing services to the client. The RN will contact the client's physician if therapy or other treatment should be considered. II. Resident status Resident #7, age 74, was admitted on [DATE]. According to the September 2021 computerized physician's orders (CPO), diagnoses included chronic systolic heart failure, [CONDITION(S)] [CONDITION(S)], anxiety and history of traumatic fracture. According to the 7/2/21 minimum data set (MDS) assessment the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of ten out of 15. He had moods that included feeling tired or having little energy. He did not have any behaviors assessed during the assessment period. He required limited assistance from one person for bed mobility, transfers and walking in his room. His balance was unsteady with transfers and walking. He had no issues with range of motion (ROM). He was identified as a fall risk and had a fall with injury since the prior assessment. III. Record review The resident's fall prevention care plan, initiated 3/2/21 and revised on 6/29/21, identified the resident as a high fall risk due to decreased stamina secondary to [CONDITION(S)] (chronic obstructive pulmonary disease). The goal was that he would be free from falls (target date 7/6/21). Interventions included: -Educate the resident to lay down in bed while napping. -Keep the floor clear of blankets and sheets. -Anticipate and meet needs such as food and fluid, activities, pain and symptoms associated with [CONDITION(S)]. The 6/30/21 fall risk assessment revealed the resident had a score of one, which indicated he was at low risk for falls. The 7/23/21 fall risk assessment revealed the resident had a score of 26 which indicated he was at moderate risk for falls. A. Fall #1 - 8/6/21 A nurse note dated 8/6/21 documented in pertinent part the resident stated he fell forward and hit his nose on the table causing a small laceration to his nose. A post-incident review dated 8/6/21 documented in part that the resident said he dozed off and fell forward and hit his nose on the table but did not fall on the floor. Fall interventions documented that the resident was educated to lie down in bed while napping and the floor was to be clear of blankets and sheets. The nurse was on a different unit passing medications at the time of the fall. The resident reported a pain level of 3 out of 10 (with 10 being the most sever pain on the scale) and ice was placed to the area. The IDT (interdisciplinary team) post investigation review dated 8/8/21 documented in part the resident had an unwitnessed fall. The review further documented that the root-cause analysis showed that he overreached while lying in his bed, causing him to roll out of the bed. A reacher (a type of grabbing tool) was recommended. -There was no update to the care plan following the above incident and no evidence to demonstrate that increased monitoring, resident education or supervision was implemented or occurring. B. Fall #2 - 8/30/21 A nurse note dated 8/30/21 documented in pertinent part the resident fell and hit his right eye on the base of the bedside table, causing two large lacerations and periorbital bruising. The NP (nurse practitioner) stitched the laceration at a clinic next door to the facility. A post incident review dated 8/30/21 documented in part that Resident #7's roommate was yelling for help. When the nurse entered the room she found Resident #7 sitting on his bed with blood on his face. According to the resident's roommate, he fell asleep and fell forward, hitting his face on the bedside table at the base. The resident stated a pain level of 3/10 and ice was applied to his face. A provider progress note dated 8/30/21 by the NP documented in part the resident had right sided facial lacerations with bleeding controlled. There was a 3-4 centimeter laceration to his right eyebrow and a 3 centimeter laceration below the right eye requiring 15 stitches. The IDT post investigation review dated 9/1/21 documented in pertinent part the resident had a fall with suspected head injury. The review further documented the root-cause analysis of the fall was that the resident fell asleep sitting up on the edge of his bed and fell forward, hitting the frame of the overbed table. The recommendation was to remove the over bed table per resident request and obtain a reclining chair. -There was no update to the care plan following the above incident and no evidence to demonstrate that consistent monitoring, resident ongoing education or supervision was implemented or occurring. The facility was asked to provide evidence of frequent checks related to Resident #7's falls (as indicated in the DON interview, see below). The facility provided an every 30-minute look-back monitoring tool for the month of September 2021. From 9/1/21 to 9/5/21, the tool failed to demonstrate that consistent 30-minute checks were occurring and showed that there were significant gaps of time in the documentation as evidenced by gaps of one to up to four hours as follows: -Beginning on 9/1/21 checks were done at 7:17 p.m., 7:18 p.m., 8:30 p.m., 9:00 p.m. and 9:30 p.m. There were no checks from 9:30 p.m. until 9/2/21 at 12:06 a.m. -9/2/21: 12:06 a.m., 1:25 a.m., 2:25 a.m., 3:02 a.m., 5:57 a.m., 6:00 a.m., 6:30 a.m., 7:00 a.m., 7:30 a.m., 8:00 a.m. and every 30 minutes until 12:30 p.m. Then starting again at 1:30 p.m. From 1:30 p.m. the next entry was not until 7:12 p.m. and 7:13 p.m. There were no further entries documented after 7:13 p.m. until the following morning. -9/3/21: 12:10 a.m., 5:11 a.m., 10:44 a.m. and 12:00 p.m. There were five hours between 12:10 a.m. and 5:11 a.m., and an hour and fifteen minutes between 10:44 a.m. and 12:00 p.m. Beginning from 12:30 p.m. to 9:30 p.m. entries ranged from every 30 minutes to every hour and ending at 9:30 p.m. There were no further entries after 9:30 p.m. until the following morning. -9/4/21: 12:50 a.m., 2:23 a.m., 5:26 a.m.11:22 a.m., 12:30 p.m., 1:30 p.m., 6:30 p.m., 8:30 p.m., 9:00 p.m., 11:49 p.m. and 11:59 p.m. -9/5/21: 2:55 a.m., 5:22 a.m., 6:00 a.m., 6:30 a.m., 7:00 a.m.,7:30 a.m., 8:00 a.m., 8:30 a.m., 9:30 a.m., 10:30 a.m., 11:30 a.m., 12:00 p.m. 12:30 p.m., 1:30 p.m., 6:33 p.m., 10:22 p.m., 10:47 p.m. and 11:16 p.m. -There were no 30-minute checks provided following the 8/6/21 fall. The 30-minute checks (above) were not part of an IDT follow up. In addition, review of an email communication on 9/2/21 by the life enrichment coordinator to the nursing home administrator (NHA) documented that the recliner request was made. An email communication dated 9/24/21 between the NHA and an occupational therapist for the corporation documented that the recliner had arrived and was to be placed in the resident's room this day. C. Fall #3 - 9/15/21 A nurse note dated 9/15/21 documented in pertinent part the resident fell and hit his head, causing a laceration above the right eye, a skin tear to the right arm and bruising to the right elbow. An incident report dated 9/15/21 documented in pertinent part the resident was found sitting on the floor leaning against his dresser. He said he fell asleep sitting on the side of his bed and fell off. An IDT post investigation review dated 9/17/21 documented in pertinent part the resident had a fall with suspected head injury. The review further documented that he would not lay down to rest and fell asleep while sitting on the edge of the bed. He was educated to lay down in bed while napping and the floor was to be clear of blankets and sheets. The effectiveness section of the review said a recliner chair was pending. -There was no update to the care plan following the above incident and no evidence to demonstrate that increased monitoring, resident education or supervision was implemented or was consistently occurring. There was no documentation that the resident was involved in discussions about the intervention or that he agreed to it. Furthermore, the recliner chair recommended and requested did not arrive in a timely manner (see above) after the resident experienced another fall with injury. Review of the 30 minute checks record between 9/15/21 and 9/20/21 identified Resident #7 was observed on 9/15/21 at 12:30 p.m., 15 minutes before the resident fell on [DATE] at 12:45 p.m. On 9/16/21, a day after the resident had his third recent fall, he was not monitored every 30 minutes. The record indicated from 1:08 a.m. to 5:30 p.m. was monitored every one and half to two hours on average between 6:00 a.m. and 5:30 p.m. Larger gaps in time were noted between 3:07 a.m. and 5:59 a.m. with almost a three hour gap in monitoring and a 10 hour gap in time between 9/16/21 and 9/17/21. According to the record the resident was not monitored between 5:30 p.m. on 9/16/21 and 3:34 a.m. on 9/17/21. On 9/17/21 the resident was inconstantly monitored. The record identified the resident was observed on average every hour and a half to two hour monitoring with sporadic 30 minutes checks between 3:34 a.m. and 1:30 p.m. The record identified the resident was not monitored for five hours between 1:30 p.m. and 6:33 p.m. The record identified the resident was not monitored for eight and a half hours between 6:33 p.m. and 2:05 a.m. The pattern of inconsistent monitoring continued on 9/18/21, 9/19/21 and 9/20/21 with an average every hour and a half to two hour monitoring with sporadic 30 minutes checking on Resident #7. Large gaps of time were recorded on 9/18/21 between 1:30 p.m. and 3:21 p.m. Between 9/18/21 at 9:30 p.m. and 9/19/21 a.m. and 12:19 a.m. the record did not identify the resident was monitored. On 9/19/21 there was no monitoring between 6:13 p.m. and 12:28 a.m. on 9/20/21. On 9/20/21 there was over a four hour gap in time to monitor the resident between 1:30 p.m. and 4:48 p.m. The record also identified the resident was not monitored between 5:49 p.m. on 9/20/21 to 6:00 a.m. on 9/21/21. The 9/27/21 fall risk assessment, documented 10 days after the resident's 9/17/21 fall, revealed the resident had a score of 50 which indicated he was at high risk for falls. IV. Observations and interview Resident #7 was interviewed on 9/27/21 at 11:30 a.m. He was in bed, sitting up on the side of the bed. He nodded off and woke himself back when he started to lean. He said that he had fallen a lot onto the floor and did not know how it happened. On 9/28/21 at 9:50 a.m. he was in his wheelchair in the doorway of his room which was located at the end of the hall. On 9/28/21 from 9:58 a.m. to 10:06 a.m. he was in his wheelchair leaning and bobbing forward over his knees. His eyes were closed and he appeared to be sleeping. There was no staff in the area. Resident #7 was interviewed a second time on 9/28/21 at 4:43 p.m. He said he received a new recliner but did not like it and would not use it. Resident #7 said he had never liked recliners and did not agree to have one placed in his room. He said that his over bed table was also taken away and that he wanted it back. V. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 9/27/21 at 3:54 p.m. She said that the facility was short staffed and that she believed this contributed to resident falls. The CNA said they were not able to provide ongoing supervision of the high risk residents or respond to the call lights fast enough to prevent falls because of limited staffing. She said she was responsible for covering one hall and a half of another hall by herself, so many times there would be no one on one of the halls if she was helping residents in another hall. (cross-reference F725, sufficient nursing staff). The director of nursing (DON) was interviewed on 9/28/21 at 5:11 p.m. with the new on coming director of nursing ([NAME]). The DON said that some of the methods they used to prevent falls would be to assess for pain, make sure residents' personal needs were met, and provide proper positioning. She said falls were reviewed using the Morse fall scale when there was a change of condition and quarterly. She said the interdisciplinary team (IDT) reviewed falls at the morning meetings. She said when reviewing falls the IDT looked at trends, and reviewed if a resident had therapy or restorative needs. She said the IDT also did a medication review and had the physician input as well. She said if a resident was a high fall risk or was impulsive, staff would look in on them when doing rounds. She said once in a while the nurse would do 15-minute checks after a fall. She said that Resident #7 sat at the edge of his bed and would fall over when he fell asleep sitting up. The post-incident review dated 8/6/21 and IDT (interdisciplinary team) post investigation review dated 8/8/21 were reviewed with the DON. She acknowledged that each review identified a different cause of the fall. She said it was important to know how an incident happened so they could choose the proper interventions. She said that the nurse did not put in any new interventions appropriate for the situation immediately after the fall and no new interventions were added to the care plan to prevent future falls of this nature. She said after the 8/30/21 fall she had the physician do a review and a recliner chair was recommended. The DON reviewed the resident's medical record and could not confirm the physician completed a review of his fall. She said there were no other interventions put in place other than the recliner. She said she later found out there would be a delay in the arrival of the recliner. She said no additional interventions were put in place to prevent future falls while he waited for the recliner to arrive. She said she was not aware if the recliner had arrived at the facility at the time of the interview on 9/28/21, nor had she spoken to the resident and staff on how the resident responded to the intervention. The DON was informed the recliner was in the room of Resident #7, and according to the resident, it arrived a couple of days prior to 9/28/21. The DON was informed that the resident was not happy that the recliner was in his room and was not planning on using it. The DON said after the 9/15/21 fall she talked to the physician about doing a possible sleep study. She said she did not have that documented anywhere and had not followed up on that and did not consider a neurological review. She said that the physician discontinued the resident's morning dose of [MEDICATION(S)] (anti-anxiety medication). She said she had told the physician that she thought the resident may have [CONDITION(S)] (uncontrolled daytime sleepiness), however she did not follow up on this. The DON and the [NAME] were asked how they were going to attempt to prevent future falls of similar nature for Resident #7. The [NAME] said he was already scheduled for 30 minute checks but still fell on [DATE]. She said she did not know when the 30 minute checks had started because she was only able to pull a 30 days in the look back report in the point of care system. She said the resident attended activities, was encouraged to lay down when tired and had a medication change but still presented the same high risk for falling in the same nature as prior falls. -However, the 30 minute frequent checks, ordering a sleep study and his medication changes were not indicated on his fall care plan or in the IDT review of the resident's falls. The DON said she would review Resident #7's multiple falls with the facility's medical director, place him on 15 minute checks and would attempt to move him to a room closer to the lobby instead of the last room at the end of the hall. She said moving him to one of the first rooms in the hall would provide more visual supervision because all staff entering the hall would have to walk past his room to go down the hallway. The nursing home administrator (NHA) was interviewed on 9/28/21 at 6:18 p.m. She said that they reviewed falls in their QA (quality assurance) meetings and that they had been reviewing them since the beginning of the year. She said they were seeing an increase in falls toward the end of their COVID-19 outbreak because residents had been staying in their rooms more at that time. She said that they had noticed a higher number of falls over the last two months. She said they had looked at the root-cause and had been able to determine some reasons for the falls around mealtimes or when a resident was having a medical issue. She said she did not feel that an increase in falls had to do with lack of staffing.

Based on observation, staff interviews and record review, the facility failed to ensure two (#3 and #5) out of five sample residents were free from resident-to-resident abuse. The facility's failures to implement timely interventions for residents with Alzhiemer's, dementia and aggressive behaviors put all residents in the memory care unit at risk and in an unsafe environment. These failures contributed to multiple resident-to-resident altercations involving Resident #3, Resident #9, Resident #5 and Resident #7. The facility failed to protect these residents from abuse. Furthermore as a result of an altercation with Resident #9 and Resident #3, Resident #3 sustained loss of consciousness of an unknown duration with multiple episodes of vomiting, hematoma, contusion and a concussion. See Emergency department note dated 7/20/2020 below. The facility substantiated the allegation of abuse, see section II-D, and III-C altercation. Findings include: I. Facility policy The Resident/Client/Participant Protection/Freedom From Abuse, Neglect and Misappropriation policy and procedure, revised May 2020, was provided by the nursing home administrator (NHA) via email on 7/30/2020 at 9:58 a.m., included: Each individual has the right to be free from verbal, sexual, physical and mental abuse . The policy defined physical abuse as: The use of force that may result in bodily injury, physical pain or impairment. II. Resident #9 to Resident #3 physical abuse A. Resident #3 status Resident #3, age 81, was admitted on [DATE] and readmitted on [DATE]. According to the July 2020 computerized physician orders [REDACTED]. The 6/10/2020 minimum data set (MDS) revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. No behavioral or wandering symptoms were noted. She required supervision to walk in the corridor and locomotion on and off the unit. B. Resident #9 status Resident #9, age 77, was admitted on [DATE]. According to the July 2020 computerized physician orders [REDACTED]. The 7/28/2020 minimum data set (MDS) revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Verbal and physical behaviors were noted to have occurred one to three days of the look back period. The resident required supervision for walking in the corridor and was independent, with no help or staff oversight for locomotion on and off the unit. C. Observations On 7/28/2020 at 12:35 p.m. Resident #9 was observed in the memory support unit (MSU) seated at a table in the common area. Certified nurse aide (CNA) #1 was seated directly behind the resident and said she was doing one-to-one observations. On 7/29/20 at approximately 9:50 a.m. Resident #9 was observed in the MSU. She walked from the common area to the end of the hallway and entered her room. She was observed and followed by CNA #4. Resident #9 shut the door to her room and CNA #4 positioned herself in a vacant room across the hall in view of Resident #9's room. D. Altercation 7/20/2020 A provider progress note dated 7/20/2020 at 4:54 p.m., revealed the provider was asked to check on Resident #9 after she had pushed Resident #3 who fell back and hit her head. Resident #9 was noted to be a danger to others with aggression and was started on an atypical antipsychotic medication. A post incident note dated 7/20/2020 at 6:26 p.m. revealed Resident #9 had an individual-to-individual altercation on 7/20/2020 at 3:30 p.m. A nurses note dated 7/20/2020 at 6:35 p.m. revealed Resident #9 had pushed another resident down after her door was opened by the other resident. An emergency department note dated 7/20/2020 and electronically signed by the emergency room physician at 11:32 p.m., was provided by the nursing home administrator via email on 7/30/2020 at 9:54 a.m. The note revealed a chief complaint of a fall with a head injury. There was a reported loss of consciousness of an unknown duration with multiple episodes of vomiting while in the emergency room . Her discharge problems included hematoma, contusion and a concussion. The facility abuse investigation file was provided by the NHA for review on 7/28/2020 at approximately 1:34 p.m. Review on the facility's investigation revealed a timely and thorough investigation in which the allegation of physical abuse was confirmed. -One-to-one staff supervision was initiated for Resident #9 on 7/22/2020 (two days after the incident occurred). E. Resident #9's progress notes A review of progress notes preceding the incident documented on 7/20/2020 included the following: A nurses note dated 6/16/2020 at 6:48 p.m. revealed Resident #9 was lying on the sofa in the sun room. Another resident entered the sunroom and threw a sandwich at Resident #9 and she retaliated by hitting the other resident with her shoe. The AA intervened and separated the two residents and no injuries were reported. A behaviors and mood note dated 6/19/2020 at 1:34 p.m. revealed Resident #9 grabbed a chair from another resident and sat down in the same chair. It was noted the resident continues to refuse to wear her oxygen and when she did not wear her oxygen her behaviors would increase. A nurses note dated 6/24/2020 at 6:52 p.m. documented a nurse entered the MSU unit at 2:30 p.m. Resident #9 was noted to be walking in front of Resident #1 and repeatedly looking over her shoulder. The nurse wrote she was made aware earlier in the day of the need to keep these two residents separated. She asked regular staff if intervention was needed and staff did not appear alarmed and did not intervene. Shortly after, the activities assistant (AA) reported Resident #9 approached Resident #1 from behind and pushed her. Resident #1 did not fall and was not injured. An interdisciplinary team (IDT) post investigative note dated 6/29/2020 at 9:55 a.m. revealed the resident had an individual-to-individual altercation with with Resident #1. The root cause was determined to be Resident #9 did not like her personal space invaded and has a strong dislike for Resident #1. The plan was to continue to provide a safe environment and redirect other residents when possible. -However, no specific interventions were implemented by the IDT to keep Resident #1 safe from Resident #9. A social services note dated 7/7/2020 at 1:24 p.m. revealed Resident #9 was standing in Resident #1's doorway laughing at her and calling her an old hag. A social services note dated 7/17/2020 at 4:30 p.m. revealed Resident #9 was assessed due to her making suicidal threats. Staff was advised to observe the resident frequently without actually engaging with her as this would escalate her attention seeking behavior. F. Resident #9's care plan A behavioral care plan was initiated on 5/5/19 and revised on 1/13/2020. Noted behaviors included wandering, a history of hitting other residents and being very territorial over her personal space and room. Interventions initiated on 5/5/19 were to administer medications as ordered and anticipate and meet her needs. Further interventions initiated on 5/23/19 included approaching the resident in a calm manner, explaining all procedures before starting, providing emotional support and a program of activities of interest. -There were no behavioral interventions specific to the history of hitting other residents and being territorial until after the resident-to-resident incident on 7/20/2020. One-to-one supervision of Resident #9 was initiated on 7/22/2020. Interventions related to previous instances of aggressive behavior specific to Resident #3 were initiated on 7/22/2020 and Resident #1 on 7/23/2020. Interventions included keep Resident #9 separated from these residents and provide close observation if they are even in the general area of each other. A vulnerability care plan was initiated on 4/25/19 and revised on 5/11/2020. The resident was noted to yell and push other residents if they were in her personal space. An intervention to redirect residents if they go near Resident #9's room or if they invade her personal space was initiated on 7/19/19. An escalation care plan was initiated on 7/23/2020. The resident was noted to have a history of hitting, shoving and throwing objects at other residents. She was noted to be very territorial over her space and room and did not like other residents near her room. -Interventions included one-to-one staff supervision while the resident was awake that was started on 7/22/2020. G. Staff interviews CNA #1 was interviewed on 7/28/2020 at approximately 12:40 p.m. She said she was assigned one-to-one observation for Resident #9 due to aggressive behaviors. She said she was unaware of any supervision requirements for Resident #9 prior to the incident on 7/20/2020. LPN #1 was interviewed on 7/29/2020 at approximately 10:30 a.m. She said she was not working the day of the altercation between Resident #9 and Resident #3. She said Resident #9 was the only resident currently assigned one-to-one supervision. She said it takes all of the staff to monitor the hallway, common area and sunroom. She said the general rule was to keep an eye on everyone and try to keep Resident #9 and Resident #1 separated. The director of the memory support unit (DMS) was interviewed on 7/29/2020 at approximately 10:40 a.m. She said Resident #9 was increasingly more behavioral. She said she had a history of [REDACTED].#1 in particular. She said Resident #9 had no specific history with Resident #3. She said staff tried to keep Resident #9's door closed and all of the other residents away from her door. She said one-to-one supervision was initiated after the incident with and resulting injuries to Resident #3. The NHA was interviewed on 7/28/ 8 at approximately 3:30 p.m. She said the residents involved in resident-to-resident altercations were separated immediately. She said Resident #3 was recovering in a room outside of the MSU. She said Resident #9 would continue on one-to-one supervision for the safety of all the residents while the facility continued to pursue placement for a geriatric psychiatric evaluation. III. Resident #7 to Resident #5 physical abuse A. Resident #5 status Resident #5, age 83, was admitted on [DATE]. According to the July 2020 CPO [DIAGNOSES REDACTED]. The 7/15/2020 MDS revealed a severe cognitive impairment from the staff assessment for mental status. He required extensive assistance of one person for eating and two person assistance for bed mobility, transfers and activities of daily living (ADL). B. Resident #7 status Resident #7, age 72, was admitted on [DATE]. According to the July 2020 CPO [DIAGNOSES REDACTED]. The 7/15/2020 MDS revealed the resident had a moderate cognitive impairment with a BIMS score of 10 out of 15. He displayed verbal behavioral symptoms directed towards others one to three days in the look back period. He was independent with no staff help or oversight at any time to walk in the corridor or for locomotion on and off the unit. He had received antipsychotic, antianxiety, antidepressant medications seven out of seven days prior to the assessment. C. Altercation 5/28/2020 Review of the facility's recent abuse investigations revealed a resident-to-resident altercation between Resident #5 and Resident #7 on 5/28/2020. At approximately 5:33 p.m., the DMS unit contacted the NHA to report the incident. The NHA entered the MSU and witnessed Resident #5 on the floor being assessed by the nurse on duty and assisted by two CNAs. Staff members reported Resident #5 was self-propelling his wheelchair by Resident #7's room as he was exiting. Resident #7 grabbed the back of Resident #5's wheelchair and pulled it backwards causing the resident to fall to the floor. Resident #5 expressed some feeling of pain at the time of the altercation and felt somewhat better once assisted back into his wheelchair. There were no documented injuries. The residents were separated and Resident was put on one to one supervision to ensure the safety of all residents. Resident #7 was interviewed by the NHA and he admitted to being angry about something that had happened earlier in the day and for that reason he pulled the chair away from Resident #5. The facility investigation substantiated the physical abuse. D. Resident #7's progress notes A social services note dated 5/4/2020 at 2:29 p.m., revealed he raised his fist at a female resident to get out of his physical space and he did not make contact. A behaviors and mood note dated 5/8/2020 at 5:40 p.m., revealed he was seated in the television room approximately six to eight feet from a female resident and he told her: I wish you would (expletive) die already. Just (expletive) die, just (expletive) die. A behaviors and mood note dated 5/10/2020 at 5:20 p.m., revealed he raised his fist as to hit a female resident as she moved towards him. Staff intervened and redirected the female resident. A nursing note dated 5/10/2020 at 10:31 p.m., revealed the resident became angry with another resident and stuck his hand in his glass of water and started flicking water at her and yelling: Get back! A provider note dated 5/11/2020 at 12:02 p.m., read the provider was asked to see the resident due to recent increased anxiety and some aggressive statements. A nursing note dated 5/15/2020 at 2:26 p.m., revealed he threw three cups at another resident which struck her in the chest. He said the resident had touched his back but two staff members witnessed the event and indicated he had not been touched. An IDT note dated 5/18/2020 revealed the root cause to be resident became agitated when his personal space was invaded. A behaviors and mood note dated 5/22/2020 at 5:16 p.m., revealed the resident displayed threatening behaviors and directed comments towards a female resident that: She's going to die tonight. A post incident note dated 5/28/2020 at 5:35 p.m., revealed the resident had been in an individual-to-individual altercation with Resident #5. E. Resident #7's care plan The resident's care plan was reviewed in detail. Despite six separate documented instances of verbal and/or physical aggression in May 2020 there were no revisions made to his behavioral, mood or vulnerability care plans until after the resident-to-resident altercation on 5/28/2020. Increased risk for agitation was initiated in Resident #7's care plan on 6/3/2020. F. NHA interview The NHA was interviewed on 7/29/2020 at approximately 12:30 p.m. She said Resident #7 remained on one-to-one supervision until he ultimately was transferred out of the MSU to the general area of the facility on 6/9/2020. She said Resident #7 was adjusting well and had no further aggressive behaviors.

Based on record review and interviews, the facility failed to provide necessary pain management at end of life and per hospice orders for one (#8) of 10 sample residents. Licensed practical nurse (LPN) #1 failed to timely respond to signs and symptoms of pain during end of life with an actively dying resident who had [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS]. The resident was ordered pain and anti-anxiety medication as needed (PRN) every hour, and hospice advised the facility to administer it every hour. However, the nurse allowed a lapse of three to four hours between medication administrations, even though the resident was exhibiting pain and shortness of breath, and the resident's family was requesting symptom relief for the resident. These failures caused Resident #8 to experience undue pain and distress in the last hours of her life. Findings include: I. Facility policies and procedures The following policies were provided by the medical records director on the morning of [DATE]. The Pain Evaluation and Management policy, revised (MONTH) (YEAR), included: -If the resident is experiencing unrelieved pain, refer to the interdisciplinary team, and the MD/NP/P[NAME] Residents will be interviewed and monitored for verbal and non-verbal indicators of pain. The interviewing process occurs PRN (as needed) with pain control issues. -After a single episode of pain is resolved with the pain management plan, any new occurrence of pain will initiate the process again. The End-of-Life Care policy, dated (MONTH) (YEAR), included: -Follow the plan of care for addressing pain and pain management. -Listen. Allow the resident/family/visitors to talk. -Tell the resident when you leave the room and when you plan to return to alleviate fears. II. Resident status Closed record review revealed Resident #8, age 83, was admitted on [DATE]. According to the medical record face sheet, [DIAGNOSES REDACTED]. The resident died in the facility on [DATE]. The resident needed extensive assistance for bed mobility, dressing, grooming, toilet use and transfers, according to the care plan initiated [DATE]. She had severe cognitive impairment and was alert and oriented to self, family and situation only. She was able to make her needs known. She was receiving hospice services for a [DIAGNOSES REDACTED]. III. Family interviews The resident's daughter/power of attorney (POA) was interviewed by phone on [DATE] at 10:10 a.m. She said that on [DATE] she and her family were with the resident all day. The resident's pain was not well managed and hospice had given an order for [REDACTED].#1 came on duty. The POA said LPN #1 wasn't checking on Mom at all - I'd have to go find her. Each hour I'd let the nurse know she needed her [MEDICATION NAME] and [MEDICATION NAME]. The nurse (LPN #1) wasn't coming and giving it to her. I'd have to go out and tell her Mom was restless, moving her arms. She'd be on break or at lunch and the CNA would tell me, 'I'll let her know.' When (LPN #1) came in to give her meds we thought she was giving it, but nothing was helping, she was just still real restless. I'd go try to find (LPN #1), and (after about 8 p.m.), Mom just never settled at all. She was throwing her arms and legs around and everything. I went out and told (LPN #1) that did not help at all. I told my family I didn't think she gave her the medicine because before she'd settle right down. (LPN #1) came in 15 minutes later, said she called hospice and they said to give [MEDICATION NAME] which she did and it still didn't help. An hour later when I told her she was still restless, she came in at around 9:00 p.m. and gave her the medication. She gave her [MEDICATION NAME] and [MEDICATION NAME] together in the syringe and Mom started choking like it was water, like when we'd given her water before (and she was unable to swallow it). Her eyes came right open, my son, daughter-in-law and I held her and she just gasped for breath until she passed away. The nurse came in and I said, 'Isn't there something you can do?' She was very sharp, said she'd done everything she could. The POA said she spoke with the hospice nurse who investigated and told her the resident had not been given medication from 3 or 4 p.m. until 7 or 8 p.m. and that's why she had been so restless. I've been with several family members who passed away. They'd been given [MEDICATION NAME] and none of them had passed in the way she did. I hated to have my son and his wife see that and see the horror in my Mom's face when she was trying to talk with her eyes wide open. She should've passed peacefully and I don't think she passed peacefully. The resident's son was interviewed by phone on [DATE] at 4:25 p.m. He lived out of state and said he visited the resident on [DATE], arrived at about 3:00 p.m., and she was pretty relaxed having just received [MEDICATION NAME] at that time. He thought the resident was given [MEDICATION NAME] at around 4 p.m. and again at 5 p.m. Family came and went, then the resident started getting a little restless so they asked the nurse for medications. She came in and said she did (give the medications), then Mom started getting really restless. She was restless for more than an hour, raising her hands, grabbing her head, moaning in pain. We asked if she could do something and the nurse said 'No, I've done all I can do.' She came in at about 8 p.m. and said she gave her something, but she was totally in pain the whole time. So then about 8:15 we asked again if there was anything else they could do. Mom was sitting up, starting to cramp up, so I grabbed her hand and held onto her hand. She was moaning and trying to say something but couldn't. She started gasping for air, for a few minutes, and then she passed away. The resident's son said his father and brother were on [MEDICATION NAME] at the end of their lives and passed easily. He said, It was hard to see her pass in so much pain. The nurse never came in unless we asked her to come in. It was really hard. Both family members said during interviews that they never requested pain medications to be held (see late entry nurse notes below). IV. Record review [NAME] Care plan The resident's care plan, initiated [DATE], identified the resident was at end stage of life and utilizing hospice services for heart failure. Her daughter was very involved in her care and visited with her regularly. The terminal [DIAGNOSES REDACTED]. She has support of family. Resident has cognitive impairment which may have impact upon her ability to process declines/changes as she approaches death. Goals were: Pain medications bring relief to the resident. Resident will express feeling supported. Resident will be comfortable. Interventions included: Observe for non-verbal signs of pain which are evidenced by facial grimacing and restlessness; pain meds per physician, monitor for effectiveness; provide support to family and significant others. Non-pharmacological interventions included deep breathing, lotion, massage; frequent turning and repositioning; providing a peaceful, comfortable environment; journaling with family, rechargeable candles, and prayer. The fall prevention care plan, initiated [DATE], called for hourly rounding for the 4Ps: personal items, pain, personal needs, positioning. The pain care plan, initiated [DATE] and not revised, included: Resident will demonstrate minimal discomfort or absence of acute pain and identify positive coping behaviors for chronic pain. Administer medication per MD order for pain management. Report any increase in pain to MD/NP. Report to nursing any signs of pain. Reposition resident for comfort. B. Pain assessment The only pain assessment, dated [DATE], documented no history of pain, no pain within the last five days, no current pain, no nonverbal indications of pain, no scheduled or PRN pain medications, and no non-medication interventions for pain. The resident's pain scale goal was zero. C. Medication orders [DATE] computerized physician orders [REDACTED]. [MEDICATION NAME] sulfate (concentrate) solution 20 mg/ml, give 0.25 ml by mouth every 1 hour PRN for pain and dyspnea. [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 mg, give 0.5 mg by mouth every 1 hour as needed for anxiety/agitation. D. Medication Administration Record [REDACTED] The (MONTH) 2019 MAR indicated [REDACTED]. However, the resident only received: -[MEDICATION NAME] sulfate at 11:22 a.m., 12:51 p.m., 3:00 p.m., 4:00 p.m., 7:04 p.m. (three hours later) and 8:24 p.m. The doses were documented as effective except for the last dose which was documented as unknown effectiveness. -[MEDICATION NAME]/[MEDICATION NAME] at 11:22 a.m., 12:50 p.m., 3:00 p.m., 7:23 p.m. (four hours later) and 8:24 p.m. The doses were documented as effective. The Individual Narcotic Record for [DATE] showed [MEDICATION NAME] 0.5 mg was signed out at 1 p.m., 3 p.m., 7:20 p.m. and 8:20 p.m. [MEDICATION NAME] sulfate 0.25 was signed out at an undocumented time, 1 p.m., 3 p.m., 4 p.m., 7 p.m. and 8:19 p.m. There was a three-hour gap between the resident's documented [MEDICATION NAME] doses and a four-hour gap between her [MEDICATION NAME]/[MEDICATION NAME] doses. Although the resident could have received both medications every hour, and her family was requesting it on her behalf, she did not receive her pain and antianxiety medications every hour. E. Nursing notes On [DATE] at 12:58 a.m., LPN #1 documented, hospice nurse was notified, per family request, they wanted prn order for [MEDICATION NAME] and [MEDICATION NAME] to be changed to every hour as needed. Received the order from (physician) to have prn every hour as needed. -At 2:35 p.m., LPN #1 documented, went in to patient's room to introduce myself to the family as the nurse for the ,[DATE] shift, resident was resting quietly in bed, resp(irations) even and unlabored, no s/s (signs/symptoms) of distress or pain at this time. -At 3 p.m., LPN #1 documented, went in to resident's room, she appeared to be resting well, resp even and unlabored, no s/s of distress, gave prn [MEDICATION NAME] to maintain comfort measures. -At 9:20 p.m., resident passed away with family and hospice nurse at bedside, time of death was 2045. Hospice nurse notified doctor and funeral home. There were no other nursing notes other than the following late entries dated [DATE] documented by LPN #1: -patients family requested some medication for resident stating she appeared to be in pain and anxious. I gave resident prn [MEDICATION NAME] and [MEDICATION NAME] for discomfort, resident appeared to be resting well, resp even and unlabored, no s/s of distress. LPN #1 documented in late entries on [DATE] that she gave [MEDICATION NAME] at 3 p.m., 4 p.m., 7:20 p.m., 8:17 p.m. LPN #1 noted that at 5:15 p.m. family requested for prn pain meds to be held until they asked for them due to family coming in later to visit. Resident appears to be comfortable at this time. (Family stated in interview this was not true - they never asked for medications to be held and all the family members had arrived by this time.) -At 8:17 p.m., resident is struggling at this time having severe SOB, hospice nurse is present, family took 02 off resident and is holding her, I gave prn [MEDICATION NAME] and [MEDICATION NAME] to help with SOB and pain. -At 8:35 p.m., family is very upset and asking for more prn medication. I explained that resident just had medication at (8:19 p.m.) and that I could not administer it again due to its order every hour, patient is struggling severely with SOB. 02 still not in place, hospice nurse made aware and went in to speak with family about medication not being able to be administered. Residents HOB is up at 90 degrees. An IDT/post investigative review note dated [DATE], documented by the regional nurse consultant, revealed, The IDT team reviewed the incident and determined . additional training will be given by hospice to all nurses at (facility) for hospice care and pain management at end of life. Additional training on proper documentation will also be given. (LPN #1) received individual training on documentation and pain management. No neglect was found in thorough investigation on the part of the staff member. V. Staff interviews The nursing home administrator, directors of nursing, social services director and regional nurse consultant were interviewed on [DATE] at approximately 2:00 p.m. and the findings above were discussed. They acknowledged the concerns and said they had initiated process improvement plans to address the failures. The family interviews and their concerns with LPN #1 and her lack of timely response to the resident at the end of life were discussed. They said they had attempted to contact the family but the family would not speak with them, so they did not have the benefit of that interview. They said they would develop a monitoring and supervision plan for LPN #1, who was a PRN agency nurse. VI. Facility follow-up An email note from the facility on [DATE], signed by the co-DON, documented, We are changing (LPN #1) from the night shift to the day shift for monitoring, and closer supervision of nursing duties related to hospice patients and pain management. Training completed on hospice, pain management, and documentation.

Based on observations, record review and staff interviews, the facility failed to prevent pressure ulcers from developing for two of three residents reviewed for pressure ulcers (#101 and #13) out of 36 sample residents. Specifically: -The facility failed to prevent two pressure ulcers from developing for resident #101; -The facility failed to prevent two pressure ulcers from developing for resident #13; and -The facility failed to assess and document weekly wound measurements when resident #13's pressure ulcers were first identified, and failed to conduct daily wound measurements as ordered by the physician. These failures contributed to resident #101 acquiring an unstageable pressure ulcer which initially increased in size, and in resident #13 developing stage II and stage III pressure ulcers per the physician's initial assessment. The findings include: A. Professional Reference The National Pressure Ulcer Advisory Panel, NPUAP Pressure Ulcer Stages/Categories 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (accessed on 10/21/2015), reads in pertinent part: NPUAP Pressure Ulcer Stages/Categories The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. -The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal [MEDICAL CONDITION] and those due to deep tissue injury. -The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. International NPUAP-EPUAP Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones and may indicate at risk persons. Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. B. Facility Policy On 10/20/15 at 12:50 p.m., the director of nurses (DON) provided the facility's policy and procedure titled Policy and Procedure for the Prevention and treatment of [REDACTED]. A) Turning and Repositioning Observation (tissue tolerance) Pressure is the primary cause of pressure ulcers. An effective turning and repositioning schedule can help reduce the risk of developing a pressure ulcer . B) Nursing: Monitoring of Skin Integrity -Skin will be observed daily with cares by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse. -Weekly skin audits on the bath/shower day will be performed by the Licensed Nurse . -If a dressing is ordered, it will be monitored for appropriate placement on resident . -The Nurse Manager or Wound Nurse will be notified upon identification of a wound. -The care plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident . D) Therapy -A therapy evaluation will be requested for wheelchair seating evaluation as appropriate. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 1. Initiate the GSMS Wound Care Protocols. 2. Notify physician/nurse practitioner and family/designee. 3. Notify supervisor/designee as assigned. 4. Notify Dietary for nutritional interventions. 5. Notify Therapy Department for seating surface evaluation and possible treatment interventions and other interdisciplinary team members as appropriate . 8. Re-evaluate interventions per risk factors identified . 9. Update the care plan for Skin Integrity and nursing assistant care cards with any skin concern. Include appropriate risk factors, turning intervals and interventions as appropriate. 10. Initiate Weekly Wound Documentation Progress Form in electronic health record which will include: type of wound, location, date, stage (pressure ulcers only) .length, width and depth; wound base description, wound edge description and if present: drainage, odor, undermining, tunneling, and/or pain. The Weekly Wound Documentation Progress Form should only have one wound per form . 11. When a wound is present, daily wound monitoring should include: -An evaluation of the wound, if no dressing is present. -An evaluation of the status of the dressing, if present. -The status of the area surrounding the ulcer/wound (that can be observed without removing the dressing). -The presence of possible complications, such as signs of infections. -Whether pain, if present, is being adequately controlled. Document on any changes or concerns in the nurses' notes and re-evaluate prior steps 1-9 as appropriate. 12. Notify the physician/nurse practitioner, family and supervisor/designee if the ulcer(s) have not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate . C. Resident Failures 1. Resident #101 Resident #101, age 85, was admitted to the facility on [DATE]. According to the face sheet [DIAGNOSES REDACTED]. The 30-day scheduled Minimum Data Set (MDS) assessment, dated 8/20/15, included a Brief Interview for Mental Status (BIMS) score of 7, which indicated she was severely impaired. She had adequate hearing, vision and clear speech, and no [MEDICAL CONDITION] or rejection of care. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She was at risk for pressure ulcers and had no current or unhealed pressure ulcers. She had pressure reducing devices for her chair and bed. Record Review: The resident's care plan, initiated 9/14/15 and last revised 10/5/15, identified the following problems, goals and interventions: The resident has actual alteration of skin integrity due to the following risk factors: At risk for immobility, cognitively impaired. -The goal was that The skin will remain intact to both heels through next review. -The interventions included: AFOs (ankle foot orthotics) while up in wheelchair (initiated 10/14/15). Elevate heels off the bed to maintain pressure relief. Heel protectors to be worn at all times .Keep resident's bed linen dry and wrinkle free. Lift, do not slide resident/use assistive devices to decrease skin friction. Notify family if a wound is becoming worse or not showing progress in 2-4 weeks. Notify nursing if resident has pain in either or both heels .Pressure reducing device for bed. Pressure reducing device for chair. Pressure reduction to heels. Pressure relieving air mattress in place. Resident is prone to softness, spongy heel(s). Notify nursing if this occurs. Weekly skin assessment by licensed nurses. Weekly wound progress assessment/documentation by nurse. The resident's care plan initiated 7/27/15 and last revised on 10/14/15, identified the following problems, goals and interventions: ADLs (activites of daily living): Resident has an ADL self care deficit related to the following etiologies: Dementia. The resident's level of weakness/ability fluctuates from day to day on assistance required for bed mobility, and amount of staff assist related to [DIAGNOSES REDACTED]. -The goal was that the resident would Be able to perform ADLs with set up help only over the next 90 days. -The interventions included Hard-shell boots on during day, off at night. Soft booties while in bed. Resident may kick them off during the night. Replace on turning/repositioning rounds .Resident is able to reposition self in bed but at times sleeps so sound that she doesn ' t reposition herself. On turn and reposition schedule . The nurses' progress notes dated 7/27/15 documented (Resident #101) was admitted on [DATE] status [REDACTED]. Resident is alert and oriented to person only, skin is warm, pink and dry with no areas of concern .one-plus [MEDICAL CONDITION] noted in BLE (bilateral lower extremities) .resident is eating fair at meals, completes ADLs and transfers with one assist and the use of the FWW (front-wheeled walker) or WC (wheelchair). Resident continues to work well with physical therapy/occupational therapy/speech therapy and skilled nursing and plans to discharge back to (name of another facility) when her goals are met. The nurses' progress notes dated 8/6/15 documented Resident is noted to have had a weight loss of nine pounds from 153.2 to 144.8 pounds. Primary care provider notified and daughter (name of daughter) notified of weight loss. PO (oral) intake appears to be 50-100% with at least two meals at 76-100% daily. Dietician wishes no changes be made to dietary plan at this time. The physician's progress note dated 8/11/15 documented in pertinent part: .prior to her hospitalization had developed leg [MEDICAL CONDITION] and leg pain limiting her walking. Now the [MEDICAL CONDITION] is virtually gone .Weight down nine pounds from admit, mostly from resolution of her [MEDICAL CONDITION] . The nurses' progress notes dated 8/12/15 documented .resident's urine was obtained for in-house urine dip related to increased confusion and was positive. Primary care provider notified and orders obtained to send urine for culture and sensitivity and start resident on oral antibiotics . The nurses' progress note dated 8/14/15 documented .Resident is currently being treated for [REDACTED]. The nurses' progress notes dated 8/18/15 documented Resident is somewhat lethargic this AM but did become more alert during the day. Resident is requiring assistance with ADLs and transfers .Skin is intact, warm and dry. The nurses' progress notes dated 8/19/15 documented Resident is on an antibiotic for pneumonia . The nurses' progress notes dated 8/22/15 documented Resident continues on antibiotic [MEDICATION NAME] . The nurses' progress notes dated 8/27/15 documented Resident has complaints of indigestion this AM. Had emesis during night. Gave [MEDICATION NAME] which appears to have helped with her comfort. Aide reported the resident had watery/loose stool. This nurse verified. Reported to manager and resident was placed on isolation .Skin is intact, warm and dry . The nurses' progress notes dated 8/29/15 documented Resident is off isolation per nurse manager .Resident has had no nausea or vomiting for two days. The nurses' progress notes dated 8/31/15 documented Resident appears to have increased confusion today. Is oriented to self only. Is having difficulty verbalizing needs. Will attempt urine dip. Resident has occasionally been experiencing episodes of nausea and loose stool .Skin is intact, warm and moist . The nurses' progress notes dated 9/1/15 documented Resident moved to room (from rehabilitation unit to long term care) as planned for transition into long term care . The nurses' progress notes dated 9/2/15 documented Urine specimen obtain(ed) due to behavior changes reported by rehabilitation staff .She did not eat well at breakfast . The nurses' progress notes dated 9/3/15 documented Physical therapy does report resident has had some pain in her right knee. MD was faxed request for x-ray to the right knew from 'twisting' when assisted with transfer .resident is planned to transfer to long term care status 9/4/15. The nurses' progress notes dated 9/4/15 documented Resident refused care this morning. She kicked the CNA (certified nurse aide) that was trying to get her dressed and was screaming and yelling while the CNAs were doing all care on her. The nurses' progress notes dated 9/5/15 documented Resident complained of pain in her bilateral legs and left knee when the CNAs stood her with the stand up lift but when I gave her meds and explained it had pain medication in it and it would help with her pain she just spit them out. There were no additional progress notes documented again until 9/20/15, and did not include documentation that addressed the suspected deep tissue injuries to her right and left heels that were first identified on 9/14/15. The facility used the Braden Scale to assess the resident's level of risk for development of pressure ulcers, and documented the following: -7/30/15 = Score 17 (mild risk) -8/06/15 = Score 17 (mild risk) -8/13/15 = Score 17 (mild risk) -8/20/15 = Score 17 (mild risk) -9/14/15 = Score 18 (mild risk) No additional Braden Scales were documented after 9/14/15, which is the day the pressure ulcers were identified. The Nur(se) Bath Skin Check forms were reviewed from 7/30/15 through 9/14/15 and documented the following: -8/28/15 = Skin is clear and intact. -9/2/15 = Skin is clear and intact with no concerns. -9/14/15 = Right heel 2 x 3 bruise. Left heel 0.5 x 1 bruise. Rest of skin is clear and intact with no concerns. There were no Bath Skin Checks documented between 9/2/15 and 9/14/15, for a total of 11 days in between skin checks. The Nur(se) Weekly Wound Documentation form dated 9/14/15 was reviewed and documented that a left heel pressure ulcer was first identified 9/14/15 and was In-house acquired and was a Suspected Deep Tissue Injury (SDTI). The initial wound measurements were 0.5 centimeters (cm) length (L) by 1.4 cm width (W) and included Resident presents with SDTI to left heel, area reddish brown, tender to touch, no open areas, non-blanchable. Additional comments included Resident requires one person extensive assist with bed mobility and one to two person assist with transfers. Resident incontinent of bowel and bladder, alert and oriented to self. Placing resident on a P300 air mattress, floating heels while in bed, heel protectors while resident up in wheelchair and turn and reposition every two hours . The Nur(se) Weekly Wound Documentation form dated 9/14/15 was reviewed and documented that a right heel pressure ulcer was first identified 9/14/15 and was In-house acquired and was a SDTI. The initial wound measurements were 2.7 cm L by 3.0 cm W and included Resident presents with SDTI to right heel, area with no drainage, dark purple soft area, no redness noted to surrounding tissue. Additional comments included Purple blood blister. The Nur(se) Weekly Wound Documentation forms for the left heel pressure ulcer were reviewed from 9/21/15 through 10/14/15 and included the following: -9/21/15 = 1.2 cm L x 0.5 cm W, Correction-measurements for 9/14/15 incorrect; length is 1.4 and width 0.5 -9/23/15 = 1.0 cm L x 0.4 cm W -9/30/15 = 0.8 cm L x 0.4 cm W -10/7/15 = 0.3 cm L x 1.0 cm W -10/14/15 = 0.3 cm L x 0.8 cm W The Nur(se) Weekly Wound Documentation forms for the right heel pressure ulcer were reviewed from 9/21/15 through 10/14/15 and included the following: -9/21/15 = 3.1 cm L x 3.1 cm W, Wound increased in length and width, no open areas noted and no redness surrounding SDTI -9/23/15 = 3.1 cm L x 3.1 cm W -9/30/15 = 2.9 cm L x 3.0 cm W -10/7/15 = 2.8 cm L x 3.2 cm W -10/14/15 = 1.7 cm L x 2.6 cm W The current Order Summary Report dated 10/19/15 included the following orders: -AFOs on while up in wheelchair. Turn and reposition every two hours while in bed and place heel protectors on while in bed, started 10/15/15 -Multiple Minerals-Vitamins tablet by mouth once a day for wound healing, started 9/18/15 -Med Pass 2.0 three times a day, 120 milliliters (ml) between meals, started 7/31/15 The Turn and Positioning Program documentation was reviewed from 9/14/15 (the day the pressure ulcers were first identified) through 10/19/15, and revealed the resident was not turned or repositioned for longer than two hours on the following dates: -9/14/15 = Turned at 6:44 a.m. (over four hours since last turned) -9/16/15 = Turned at 3:32 a.m. (the documentation reflects that the resident was last turned at 3:43 p.m. on 9/15/15, for a total of over 11 hours since last turned) -9/18/15 = Turned at 1:22 a.m. (over five hours since last turned) -9/19/15 = Turned at 1:42 a.m. (over four hours since last turned) -9/20/15 = Turned at 2:35 a.m. (over eight hours since last turned) -9/21/15 = Turned at 1:49 a.m. (over 10 hours since last turned) -9/22/15 = Turned at 1:06 a.m. (over six hours since last turned) -9/23/15 = Turned at 12:28 a.m. (over eight hours since last turned) -9/26/15 = Turned at 7:17 a.m. (over four hours since last turned) -9/27/15 = Turned at 12:08 a.m. (the documentation reflects that the resident was last turned at 2:28 p.m. on 9//26/15, for a total of over nine hours since last turned) -10/1/15 = Turned at 2:15 a.m. (over four hours since last turned) -10/4/15 = Turned at 3:42 a.m. (over seven hours since last turned) -10/5/15 = Turned at 1:57 a.m. (over six hours since last turned) -10/8/15 = Turned at 12:52 a.m. (over 10 hours since last turned) -10/9/15 = Turned at 3:46 a.m. (over seven hours since last turned) -10/10/15 = Turned at 12:14 a.m. (the documentation reflects that the resident was last turned at 3:05 p.m. on 10/11/15, for a total of over nine hours since last turned) -10/11/15 = Turned at 3:51 a.m. (over four hours since last turned) -10/14/15 = Turned at 12:53 a.m. (over four hours since last turned) -10/15/15 = Turned at 12:41 a.m. (five hours since last turned) -10/16/15 = Turned at 3:03 a.m. (over five hours since last turned) -10/17/15 = Turned at 12:54 a.m. (over four hours since last turned) -10/18/15 = Turned at 12:19 a.m. (over four hours since last turned) -10/19/15 = Turned at 3:43 a.m. (over four hours since last turned) Resident Observation: On 10/15/15 at 4:24 p.m., resident #101 was observed sitting in her wheelchair in her room. She was wearing the hard-shelled AFO boots on her feet and the right boot was unfastened at the toe area and the foot was positioned incorrectly with her right heel touching the bottom of the device and was not off-loaded. At 4:41 p.m., the resident was observed again to be sitting in the same position and the boot remained improperly positioned on her right foot with her heel touching the bottom of the device. On 10/19/15 at 11:05 a.m., resident #101's heel pressure ulcers were observed with the DON, who was also the facility's certified wound nurse. The following was observed: -The resident was seated in her wheelchair in her room with her feet resting on a clean paper disposable pad on the floor. -The DON raised the resident's left heel and a small black, non-raised wound was observed that was approximately the size of an irregularly shaped pencil eraser. -The DON raised the resident's right heel and a black, raised scab was observed to be approximately the size of a nickel, and had dried, peeling edges around the wound. -The DON explained that there were no dressings for either of the wounds, and they were measured weekly on Wednesdays. -The DON was asked what caused the wounds, and she stated, Pressure. Staff Interviews: On 10/20/15 at 9:00 a.m., CNA #21 was interviewed and she confirmed that she routinely worked with resident #101. She was asked how much care the resident was able to provide for herself and she stated, None. We do everything. She explained that the resident was supposed to wear the AFO boots for her heels. The CNA was asked if the resident currently had a pressure ulcer and she stated, Not that I know of. The CNA was asked if the resident was supposed to be positioned in any particular way while she was in bed, and she said no. On 10/20/15 at 9:11 a.m., CNA #16 was interviewed and she confirmed that she routinely worked with resident #101. She explained that the resident was supposed to wear the AFO boots during the day when she is out of bed and they stay on but the Velcro tends to slide right off. It happens probably once or twice a shift. And then when we are doing a transfer and put her foot on the pedal, they tend to come un-Velcroed. -CNA #16 explained that she was assisting with resident #101's shower on 9/14/15 when the pressure ulcers were first identified and she observed her heels. She said she notified the nurse to check the heels and stated, That is when they got the air mattress, the (foot) cradle, the boots. They got all of that the same day. -The CNA explained that the resident required extensive to total assistance with bed mobility and said, At night we would turn her but not notice her feet. She was not moving because she is not mobile. In bed she won't move-we have to move her. We added the every two hours (repositioning) at night and do our checks, but at the time she didn't have an air mattress. She explained that the CNA documentation for each shift now required them to chart repositioning for resident #101which had not been in place prior to the development of the pressure ulcers. On 10/20/15 at 2:25 p.m., the occupational therapist (#7) was interviewed and she explained that resident #101's AFO boots were Podus boots for off-loading. She said, When the foot is properly positioned in the boot there should be no pressure on the heels. She explained that the wounds probably developed from the resident being in bed and moving her heels up and down from trying to assist herself when they are pulling her up in bed. She said she thought it was from friction. On 10/20/15 at 10:58 a.m., licensed practical nurse (LPN) #40 was interviewed and she confirmed that she routinely worked with resident #101. She confirmed that the resident had pressure ulcers on her heels and was asked what caused them. She stated, I think it is probably sheering in her bed. She is very sensitive to touch. She denied that the resident complained of pain in her heels. On 10/20/15 at 11:10 a.m., the DON was interviewed and she explained that skin assessments were performed once per week with a bath or shower. She said if a resident had a skin concern they were following it weekly on Wednesdays and it would be documented on a skin wound note. -The DON explained that resident #101 was admitted originally to the facility's rehabilitation unit with altered mental status and explained, We didn't know her and put her on an air mattress on rehab. She said the facility automatically does that on the rehabilitation unit and said, When we moved her to long term care we noted she could move herself and was toileted during the night. She explained that the CNAs reported she was mobile, so we put her on a regular mattress. Ten days later an aide spotted (the pressure ulcers) when she was putting her socks on. She said they put her on an air mattress at that time to reverse the pressure, and placed her on a repositioning schedule because she would not leave her feet elevated. She explained that when the CNAs would go in to reposition the resident, they would have to reposition her heels to have them elevated. -The DON explained that the resident wore the AFO boots during the day while she was up in the wheelchair and said, There is no opportunity for the heel to touch in those at all and she can't kick them off. -The DON said resident #101's suspected deep tissue injuries were due to pressure, possibly from not moving for some period of time during the nights. We have reversed the pressure and they are getting better and have not opened. -The DON explained that the pressure ulcers were first discovered ten days after she was moved over to long term care and stated, I felt like we made a judgment call taking her off of everything when we moved her off of an air mattress and we just didn't feel like she had the risk, but obviously she does. -The DON was asked if she felt that the pressure ulcers were preventable and she said, If we'd left her on an air mattress, yes. 2. Resident #13 Resident #13, age 79, was admitted to the facility originally on 5/12/11 and then readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The 14-day scheduled MDS assessment dated [DATE] included a BIMS score of 15, which indicated he was cognitively intact. He had adequate hearing, vision and clear speech, and no [MEDICAL CONDITION] or rejection of care. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. He had an indwelling suprapubic catheter and was occasionally incontinent of bowel. He was at risk for pressure ulcers and had no current or unhealed pressure ulcers and had pressure reducing devices for his chair and bed. Record Review: The resident's care plan initiated 5/30/11 and last revised on 10/15/15, identified the following problems, goals and interventions: Skin at risk for breakdown related to immobility and [MEDICAL CONDITION] with lower extremity [MEDICAL CONDITION]. Risk for bruising and skin tears related to poor self awareness. Has open area on left inner gluteal fold. -The goals included Resident will not have complications from infection through review date to left inner gluteal fold. -The interventions included Dressing changes as ordered by MD .Has pressure reducing cushion in wheelchair .(Resident #13) requires extensive assistance of 1-2 to turn/reposition every four hours, more often as needed or requested .Monitor wound for signs/symptoms of infection, increased drainage, odor, peri-wound redness and notify MD .Notify family, MD, of any change in wound status. Pressure reducing mattress to bed .Skin checks to be done by each nurse with each bath. Use yellow pad only for incontinence; no brief to be worn to prevent skin breakdown. The nurse's progress notes dated 8/10/15 documented (Resident #13) is an historical long term care resident who was recently readmitted status [REDACTED]. Resident is alert and oriented times three, skin is warm, pink and dry with no areas of concern .completes ADLs and transfers with one to two assist, resident does use the sit-to-stand lift for all transfers . The physician's progress notes dated 10/8/15 documented, (Resident #13) is a [AGE] year old male who presents for evaluation (of) a sacral ulcer that (name of facility) staff noticed over the past week. His nurse reports seeing some drainage .Skin: Left side of the (p)erineum with one cm ulceration with purulent/bloody drainage surrounded by five-six cm of firm, non-tender, nonfluctuant indurated tissue, two-three cm irregularly shaped area of superficial dermal breakdown just posterior to the scrotum .Assessment: 1) Left side stage II and III perineal pressure ulcers with purulent drainage due to inactivity related to dementia .Plan: 1) Continue daily dressing changes and continue to follow with the wound care nurse. Advised to call MD if ulcerations increase in size over two consecutive days, or if he develops fever or signs of localized infection. Consulted nutrition who recommended starting Vitamin C .and Zinc .Requested air mattress and improved cushioning for his wheelchair . The document had a hand-written signature below the Assessment section dated 10/9/15 by licensed practical nurse (LPN) #49 and included noted. The physician's telephone orders dated 10/8/15 included, .Measure wound daily-contact MD if increased size greater than

Based on observation, record review and interviews, the facility failed to have evidence that allegations of physical abuse involving one of 19 sample residents (#1) were timely reported, thoroughly investigated and that steps were taken to prevent the resident from further abuse. Specifically: On 4/1/13, resident #1 alleged a tall lady pushed her onto her 'pot,' (toilet), hit her in the head twice, and twisted her arm. The resident experienced fear and bruising to her face, arm, wrist and buttock. Record review and interviews revealed staff failed to timely report and respond to the resident's allegation of physical abuse, failed to thoroughly investigate the resident's allegations, and failed to protect the resident from further abuse. On 5/5/13, a resident slapped resident #1 in the face while in bed in her room, causing further bruising, when staff failed to implement planned safety interventions to prevent residents from entering resident #1's room. The findings included: I. Allegation of Abuse A. A complaint was filed with the Health Department alleging abuse of resident #1 B. Resident #1 Resident #1, an [AGE] year-old female, was re-admitted to the facility on [DATE] (six months after a prior stay) with [DIAGNOSES REDACTED]. The resident resided on the facility's secure unit. Review of the resident's 10/15/12 admission Minimum Data Set (MDS), revealed the resident was coded under mood, to have little interest or pleasure in doing things, tired or little energy. She was coded to be without signs or symptoms of delusion, [MEDICAL CONDITION], or hallucinations. She required extensive 1-person assist with activities of daily living (ADLs). She exhibited verbal behavior directed toward others, no physical behaviors and no other behaviors noted. No preferences for customer routines noted (section blank) Review of the resident's 1/15/13 quarterly Minimum Data Set (MDS), revealed she had a BIMS (cognition) score of 5 indicating severe cognitive impairment, and required extensive one-person assistance for activities of daily living (ADLs). She exhibited verbal behavioral symptoms directed toward others. Her mood and behaviors were as coded on the 10/15/12 MDS. She was not coded to exhibit [MEDICAL CONDITIONS] or hallucinations. Care plan review revealed plans for cognition, behaviors, vulnerability, mood, [MEDICAL CONDITION], safety, and activities of daily living. All these care plans, except cognition and [MEDICAL CONDITION], were revised after 4/1/13 (date resident alleged abuse). Pertinent care plans in effect prior to 4/1/13 included, in pertinent part: (1) A care plan for "Impaired cognitive function and impaired thought processes r/t dementia" initiated 9/27/12, revised 1/14/13. Goal: "will develop skills to cope with cognitive decline and maintain safety by the review date." Interventions: Administer meds as ordered. Communication: Use resident's preferred name (first name), identify yourself at each interaction, face resident when speaking and make eye contact. Keep resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, offer activities if resident becomes agitated, validation visits PRN. (2) A safety care plan, initiated 12/21/13, identified the resident was at "risk for falls r/t (related to) impaired cognition, use of [MEDICAL CONDITION] medications, impaired balances and hx (history) of falls." The goal was "will be free of injury from falls." Interventions included bed and chair alarm, proper footwear, 30 minute checks, call light and personal items in reach, secure unit placement. (3) A care plan for [MEDICAL CONDITION], (initiated 12/24/12, not revised), read in pertinent part: Resident receives daily antipsychotic and anti anxiety medication for dx of anxiety/agitation and senile dementia with depressive features. Potential for adverse effects and/or drug interactions r/t the use of medications." "Interventions: administer per MD orders, monitor & document behavior & moods q shift, CNA to notify nurse of any change in condition, nurse to eval, monitor for s/sx of adverse reactions q shift, nurse to report to md any changes in res condition and any side effects noted, pharmacist to monitor for potential drug interactions monthly, unmet needs team monthly." The care plan did not include a problem of hallucinations or [MEDICAL CONDITION]. Review of physician orders [REDACTED]. -[MEDICATION NAME] (anti-Alzheimer's medication) 2 mg M,W, Th, Sat for dementia w/ behaviors, order date 2/15/13. -[MEDICATION NAME] (benzodiazepine) 0.5 mg prn bid agitation & anxiety ordered 10/8/12. The only related dx on her dx list was senile dementia w/ depressive features. C. Allegations of Abusive Incident 4/1/13 and Post-Investigation Report of Injuries 1. Facility records and investigation reports were reviewed and resident #1, during interviews conducted with the social services director (SSD) and the police officer on 4/3/13, stated: -"She told me to sit on a pot in the middle of the room. I said I won't. She tried to push me down. She tried to break my arm. She tried to twist my arm and break it. She beat me with her fists ... She was pretty tall and pretty strong. She made me sit on the pot. She pushed me down on it ... I said I am not going to do it because the edges are sharp. I said, 'I'm not.'" (Interview with social services director 4/3/13.) -"The girl came in last night. She told me to sit on the pot. The pot was a tin can with sharp edges ... She pushed me down and I said 'hey, that hurts.' She said 'That's too bad.' ... She came in to beat me up with her fists after sitting on the can. She tried real hard to break my arm ... She twisted my arm really bad and tried to break my arm. She hit me in the head twice." (Interview with police officer and SSD on 4/3/13 at 9 a.m.) An incident description form, dated 4/2/13 and revised 4/10/13, documented, "Certified nurse aide (CNA) notified licensed practical nurse (LPN) of resident's bruises" (see below assessments of the resident's bruising to forehead, forearm, upper buttock, left hand near wrist). First statement to CNA was 'Someone beat me up.' Later stating 'The tin can got me.' 'My roommate beat me up.' 2. Resident #1, during an interview at 6:45 p.m. on 4/11/13 said, "That damn girl beat me up. I don't know which one or I would do something." She said (the girl) wanted her to sit on a coffee can with jagged edges, forced her to sit on the toilet, hit her on the head with her fist. The resident said she was "just getting ready to go to bed" and "she said you're going to sit on the potty 'cause I'm going to make you do it." The resident said the girl then grabbed her arm and twisted it, and she "got cut with the edges on that can." 3. Assessments 4/2/13 revealed resident bruising The facility's "Immediate Post Injury of Unknown Origin Investigation" form dated 4/2/13 at 10:42 a.m. documented injuries to the resident as follows: bruising 5x6cm to forehead, 6x5cm forearm, 2cm left wrist, buttock (wording cut off). The bruising was purple/blue/red, indicating new injuries. The physician's progress notes documented, in pertinent part, on 4/2/13, that staff reported the resident "has new bruises on her forehead, arm, and bottom that were not present on her most recent skin survey about 24 hours or so prior to this morning ..." The physician assessed the resident's injuries as "nickel to quarter sized flat round hematoma R lateral superior forehead, silver dollar sized round slightly raised hematoma on the distal dorsal aspect of her R forearm, irregularly rectangular shaped 3-4 cm flat hematoma on medial superior aspect of R buttock." II. Facility Failures in Response to Resident's Allegations A. Staff failure to timely report and respond to resident #1's allegation of abuse 1. Facility records, investigative reports, and interviews conducted during the complaint investigation revealed several staff members were aware resident #1 reported on 4/1/13 that she had been 'beaten up' but failed to notify supervisors and failed to ensure the resident was timely assessed for injuries. a. Evening shift (4/1/13) (1) Certified nurse aide (CNA #1) who worked with resident #1 during the evening on 4/1/13 and who had bathed the resident that evening and taken her to the bathroom, wrote (in pertinent part) in a statement on 4/3/13, that resident #1 "asked if I was the woman in here last night ... She stated that 'the woman was trying to beat me' & she was going to get a gun & shoot her & call her son. She was scared & very sure about finding the gun ... I informed the nurse (nurse #1) & told her I would pass it on to the next shift CNA that the resident was very upset and scared ... At end of shift, I informed night CNA (CNA #6) about resident & that resident has [MEDICAL CONDITION] quite frequently, but I myself have not seen resident scared & upset to that extent ..." (2) CNA #2, who also worked the evening shift 4/1/13, wrote in a 4/3/13 statement that on 4/1/13 at approximately 9 p.m., CNA #1 was in resident #1's room and when she came out said, "'Gee, I wonder if I should report to the nurse what (resident #1) just said to me ... (Resident #1) thinks some girl is going into her room at night & beating her up.' ... I said, 'Yes, go tell (the nurse #1) because whether it's true or not that's serious' ... (CNA #1) did go out of the unit to tell (nurse #1) ... I figured as long as she told (nurse #1) what her and (resident #1) talked about all was fine." CNA #2 did not indicate in her statement above that she followed up with nurse #1 to ensure the resident's allegations were reported or that she reported the resident's allegations to any supervisors. (3) Nurse #1 who worked the evening shift 4/1/13 stated in an undated interview conducted by the director of nursing (DON) and human resources director (HRD) that "she had already done her turnover (resident report and shift hand off) with the oncoming charge nurse. She was off the floor and CNA #1 came up to her and stated that she forgot to tell her that "(resident #16) may have hit (resident #1). I asked (CNA #1) if (resident #1) definitely said (resident #16) hit her and she said yes. I asked her if she checked on (resident #1) and she said she had just done her rounds and knew that (residents #1 and #16) were asleep ... She did not understand what (CNA #1) was saying or why." Nurse #1 did not indicate she assessed resident #1 or reported resident #1's allegations to the oncoming night nurse or to the nursing home administrator (NHA). Review of resident #1's record revealed no nurses' notes for the evening shift. b. Night shift and Day shift (4/1/13 - 4/2/13) (1) CNA #6, who per the staffing schedule worked alone on the secure unit the night of 4/1/13, reported to the HRD on 4/2/13 that "he did not see a bruise on (resident #1's) head last night/this morning ... She was asleep from the beginning of his shift at 10 p.m. until 3:00 a.m. when she woke up." CNA #6 did not indicate that resident #1's allegations had been reported to him or that, if aware of the allegations (per CNA#1's written statement that the allegations were reported to him), he followed up with his supervisors to ensure the resident's allegations were reported. (2) CNA #4, who reported to work on 4/2/13 at 5:30 a.m., and CNA #5, who reported to work on 4/2/13 at 6 a.m., revealed in statements obtained by the facility and in follow-up interview, that the resident's bruising was visible that morning and the resident told CNA #4 and CNA #5 about the bruising when asked. They reported she stated a tall lady had 'beat her up' during the night. She further told CNA #4 that it happened when "she took me to the toilet and I did not want to go." CNA #4 said she asked the night nurse (nurse #7) and "he answered that nothing had been reported." (3) Nurse #7 who worked the night shift 4/1 - 4/2/13, did not enter any nurses' notes for the night of 4/1/13. However, the nurse wrote in a nurses' "incident" note dated 4/2/13 at 8:31 a.m., in pertinent part, that "Resident noted to have bruises on forehead and on back of R hand ...She stated it happened after supper on 4/1/13." There was no documentation in the "incident" note by nurse #7 above that a comprehensive skin assessment was completed, that the resident was further interviewed about how the bruising occurred, or interviewed about the statements she had made to CNA #4 and #5. c. The director of nursing (DON) and NHA were interviewed at 3:30 p.m. on 4/14/13. -The DON said she was not notified of the resident's allegations and bruising until between 6 and 7 a.m. on 4/2/13, when she received a phone call at home. -The NHA stated facility policy required that the NHA be notified immediately of an abuse allegation, and that she was not notified immediately after the resident reported abuse, or immediately after the resident's bruising was observed. B. Failure to Thoroughly Investigate Resident #1's Allegations of Abuse The facility's "Immediate Post Injury of Unknown Origin Investigation" form dated 4/2/13 at 10:42 a.m., after documenting the resident's bruising (see above; bruising to forehead, forearm, left wrist and buttock), documented: -Under the question "Are there suspicions due to the injury type?" the documented answer was "No" and noted the resident took aspirin 81 mg. -Under "Explain and name final root cause determination by the team," the assistant DON wrote, "Bruise to R buttock is from resident transferring into w/c (wheelchair) and attempts to sit down too early, bumping bottom on w/c handle. Bruise to wrist is from bumping on toilet riser handle during transfer on 4/1 before bed. Bruise to R thumb/forefinger area is from grabbing toilet riser handle hard during transfer. Bruise to head may be from another resident." The resident's physician documented in pertinent part, "I looked over her bathroom, and I believe she could have received the injuries sitting down hard on the toilet. Banging her R arm on the metal wall mounted rail bar on the R side of the toilet, and banging her R forehead on a toggle-like switch mounted on the R side of the wall in the bathroom. . ." The conclusion of the facility investigation, dated 4/5/13, was, "Another (secure unit) resident was in the resident's room just prior to the resident alleging being beaten up. We cannot prove that the resident hit the victim prior to resident's allegation nor can we prove that resident found in her room had intent due to her own cognitive impairment. The resident's bruise to her right forearm is consistent with her aide's testimony of the resident's transfer to the toilet, being an uneasy transfer and her hitting her right forearm on the riser arm rests on her toilet." 1. Failure to thoroughly consider information provided by CNA #1 in her written statement on 4/3/13 during the facility's investigation. CNA #1's Statement: CNA #1 wrote in her statement that she assisted resident #1 with her shower on 4/1/13 "around 6:15, 6:30 ish," the resident watched TV in the TV area for a couple of hours, and "was looking tired so I assisted resident to her room to get ready for bed. -I brought resident into the bathroom and parked (the) wheelchair directly in front of toilet for transfer. Resident helped with transfer, but couldn't stand all the way up so I assisted with my hands on sides of hips/bottom to help turn around to toilet. Resident was struggling with turning and taking very little steps to try to turn, so I helped turn with little motion to turn resident. -The commode seat was not resting properly so while holding resident & trying to fix chair/commode resident was off balance as myself and sat slouching/leaning back on toilet chair. I tried to reposition resident & moved wheelchair closer to resident knees so she would not have chance of sliding off. -I then went to closet to grab new brief, came back into bathroom & resident was slouched back farther & legs stretched straight out in front. I tried repositioning to better sitting position & placed fastened brief on to pull up when standing. Resident's feet kept sliding forward & leaning back into commode. I put my left foot in front of resident's feet to help with sliding & to have resident's feet bent at 90 degree angle to help stand. -(I) helped resident up with resident right hand on transfer bar on wall & placed my hands on left arm & upper arm for support standing. Resident was struggling to stand so I did a quick pull up of brief to help with leverage to hold onto resident, but still having a hard time with standing & doing transfer safely, transferring resident in a quick turn causing brief to tear on left side. -Resident was in wheelchair but not sitting in a good sitting position, I then brought resident to the bed to lay down. I helped resident sit up so I could give her a bear hug, resident arms over my shoulders & mine under for a good safe hold position & rotated to the bed. I lowered resident to bed & left arm by back of shoulders & right hand under knees & spun/laid resident into a lying position. -I went to closet for another brief due to tearing the other one during transfer, helped resident roll to change into brief, having trouble rolling side to side. I got resident situated and covered up, put wheelchair by the dresser & turned on motion light. I turned off light by sink & took out trash in room. -"I came back 15-20 min(utes) later to close resident window & resident asked if I was the woman in here last night. I said I've been here all evening & helped her during bed time. She stated that 'the woman was trying to beat me & she was going to get a gun & shoot her & call her son. She was scared & very sure about finding the gun. I talked with resident about who it could of been or when & saying last night the woman came in her room. I then shut window by the head of the bed & turned alarm on ... I checked on resident after due to call light being on. Resident again saying she was going to kill that woman, I comforted resident & said we have someone here all the time if she needs anything ... I finished with report & ended the shift." (In a 4/3/13 addendum statement, CNA #1 described what she was wearing and that "my hair was down, I have long dark hair which was described by the resident.") Review of the facility's conclusion above - that another resident was in the resident's room just prior to the resident alleging being beaten up - was not consistent with CNA #1's written statement above. Review of the facility's investigation, moreover, revealed no evidence the facility investigated whether another resident had entered the resident's room [ROOM NUMBER]/1/13 through interviews with staff about the whereabouts of other residents on the unit that evening or about their own interactions with resident #1 on 4/1/13. Review of the facility's conclusion above - that the resident's injuries were consistent with CNA #1's report of an "uneasy" transfer - failed to reveal that the details of the transfer by CNA #1 were reviewed to determine whether the measures taken by the CNA were appropriate and did not involve mistreatment. See above; the CNA said the resident looked tired and couldn't stand up, yet proceeded with the transfer without assistance. The CNA further reported she left the resident unattended twice; once when she was slouched on the toilet chair and again after she had lowered the resident onto the bed. During an interview with the DON at approximately 3:30 p.m. on 5/14/13, the DON said CNA #1 worked PRN (as needed) and was one of their best and most experienced CNAs, so they had no concerns about her transfer skills. Review of the nursing schedule revealed CNA #1 was scheduled to work in the secure unit the next evening on 4/2/13. On the daily assignments schedule, 7.75 hours were penciled in next to her name, indicating she had worked that evening. 2. Failure to investigate staff's failure to timely report and assess resident #1 after she reported she had been physically abused Interview with the NHA and DON at 3:30 p.m. on 5/14/13 revealed nurse #1 had been counseled for failing to assess resident #1 when CNA #1 reported the resident she had been hit and for failing to report the resident's allegation to the NHA or designee. However: -There was no evidence that CNA #2's failure to ensure resident #1's allegations were reported to supervisor was investigated. -There was no evidence nurse #7 was interviewed about what information, if any, he received from nurse #1, what he observed and how he responded when CNA #4 reported resident #1's bruising and allegations and why he, too, had not made these observations and questioned the resident further about their cause. -There was no evidence the oncoming day nurse who was scheduled to arrive at 6 a.m. was interviewed about what s/he observed and interviews s/he may have conducted with the resident. III. Failure to protect the resident from abuse and injury during and after the investigation A. Facility Plan for Resident #1's Safety after 4/1/13 1. The facility revised the resident's "safety" care plan (see above) on 4/11/13 to include the following interventions: -2 assist with transfers, sit to stand PRN initiated 4/11/13 -2 persons to be in room for all cares initiated 4/10/13 2. The facility developed a "victim" care plan, that was initiated 4/5/13, and identified "potential for abuse from others due to her [DIAGNOSES REDACTED]." Interventions were: -Alarm on in doorway to signal someone going into room; -Extra staff placed outside of resident's room to keep away potential intruders; -Resident will be placed on 15-minute checks; -Stop sign with magnets to doorway to help keep wanderers out. B. Incident of Physical Abuse 5/5/13 On 5/5/13 at 11:01 p.m., a registered nurse (RN) documented in nurses' notes that she was "called to this resident's room at (8:30 p.m.). Resident was in bed with feet off of side of bed laying almost sideways. I asked her what had happened she said that lady (resident #15) slapped the s--- out of me. Exam noted a bruise starting above R eyebrow and a possible bruise forming by the bridge of nose by tear duct of eye ... Exam of (resident #15) was done also. (Resident #15) couldn't tell you what happened. CNA had said that when she heard this resident holler out and she entered room that (resident #15) was in (resident #1's) room and refused to leave at first, then she hollered out, threw her arms in air and walked out prior to them notifying myself. DON notified and she notified administrator ... At (9:35 p.m.) police were here and talked to this resident and CNA and myself. This resident is now in bed and resting. There is a CNA outside of her room for 1:1 for safety. Continue with care." -On 5/6/13 "Bruises noted on R eyelid and above R eyebrow" ... 1:1 CNA care provided t/o the night." -On 5/7/13 "CNA provided 1:1 monitoring t/o the night." The 5/5/13 police report documented resident #1 "did tell me that a lady she did not know came in and slapped her. I took a photo of (resident #1's) face where it was bruised and red near her right eye. ...(CNA #8) told me that she came out a nearby room and heard (resident #1) yelling. (CNA #8) told me that she opened the door and saw (resident #15) in the room. (CNA #8) told me that (resident #15) shut the door and (CNA #8) had to push it open. (Resident #1) was upset and (resident #15) was yelling. (CNA #8) told me that (resident #1) was sideways in the bed. (CNA #8) told me she was able to get (resident #15) out of the room ... (resident #1) had told her that lady slapped her." -"(Personal Care Provider/PCP #9) told me that she was with her client and saw (CNA #8) trying to get into (resident #1's) room and ... trying to get (resident #15) out of the room. (PCP #9) told me that (resident #15) was waving her arms and yelling ... (then) did storm out of the room and went down the hall. (PCP #9) told me that during this time she could also hear (resident #1) yelling." -"There is evidence of an assault with the marks on (resident #1's) eye and what she told the staff when they entered the room." Resident #1 was observed on 5/6 and 5/7/13 in the common area of the secure unit. She had purplish-blue and yellow, new and old, bruising to her face and forehead. C. Facility Failure to Implement Planned Safety Precautions 1. Review of the facility investigation revealed that resident #1's alarms were not engaged, her velcro stop sign was not up, and no facility staff were available on the unit to protect her. CNA #8 was giving a shower, and CNA #2 was taking out the trash. PCP #9 who worked for an outside agency and was monitoring a different resident sat in the hall but did not respond or assist. CNAs #2 and #8 received corrective actions on 5/6 and 5/7/13 respectively because they each "failed to follow a resident's care plan when she did not ensure that all alarms and other safety devices were in place after putting the resident to bed." 2. Observations On 5/7/13 at 2 p.m., resident #1's door alarm was not engaged. The resident was behind her closed door and the velcro stop sign was in place. The unit manager was notified, and immediately engaged the alarm, without first opening the resident's door to check on her. A few minutes later, the unit manager stated the alarm was not on because the resident was in the room with two CNAs who were providing care for her. On 5/9/13 at 2 p.m., upon approaching resident #1's room to interview her, it was observed that the resident's door alarm was not engaged. The green light was not flashing, the door was slightly ajar, the velcro stop sign was in place, the resident was alone in her room in her bed, and no staff were observed in the hallway or nearby. The unit manager was notified at 2:18 p.m., when the interview was completed. She engaged the alarm, confirmed it had not been on, and stated that it should have been. IV. Resident Decline CNA #2, interviewed at approximately 8 p.m. on 5/14/13. She said, pertinent part: -Resident #1 "was an extensive one-person assist, but after all her incidents she's kind of gone down a little bit. (Before the incidents) she could pivot herself, she needed a gait belt. She's now a two person assist with a gait belt. It seems that after her incidents she just went down. -When her first incident happened I assumed someone had hit her. She was with it pretty much. But after her second incident she (seemed more confused). Just from looking at her, she seemed a little subdued and scared. She looked like somebody beat her up. -In the second incident (on 5/5/13), "I walked in the door and the PCP told me (resident #15) just went in there. (Resident #1) was red and shaking ..." Nurse #10 was interviewed at approximately 9 p.m. on 5/13/13. She said, in pertinent part, regarding the 5/5/13 and resident #1's current status: -"The CNAs came and got me and I went to (resident #1's) room. (CNA #8) was with (resident #1). She was laying sideways in bed and said, 'That lady hit me.' Her face was red. I looked her over and saw a bruise. Then I went into my investigation of what happened. (Resident #15) had gone in there, shut the door, CNAs heard (resident #1) hollering, and then it took a few minutes to get (resident #15) out of the room. (Resident #1's) bruise was over her right eye and above the bridge of her nose. (Resident #1) kept saying, 'She slapped the s--- out of me. I had not seen (resident #15) hit anyone before. I've seen (resident #15) get aggressive and not be easily redirected ..." -(Resident #1) has needed a lot more care lately. She needs a lot of care now." Resident #1 was interviewed at 2 p.m. on 5/9/13. -She said, "I had a pretty bad bruise right here (pointing to her face). That old woman just hit me as hard as she could. I was in bed right here ..." She said something like this had happened before. She said, "I'm sorry, too, and I wasn't strong enough to fight her off ... I tried to point her out to the people who work here; they didn't pay any attention to me. They should have but they didn't. I do see her around, once in awhile; usually in the dining room." -She said, "I do feel fairly safe now. I didn't for awhile, but I do now. (My family) are here a lot. They take care of me. They have a couple of guards here now. I don't worry about it anymore. I told them about this girl and they said she's gonna be gone. We're gonna fire her. I know that." -She said, "Now they are (watching out for me). They weren't before ... I didn't feel safe for awhile but I'm okay now."

Based on observation, resident and staff interview, and record review, the facility failed to ensure seven of 30 sample residents (#5, #9, #30, #43, #49, #57 and #82) received the care and services necessary to attain and/or maintain their highest practicable level of well being. The facility failed to implement an effective pain management program for the above residents. Specifically: -Resident #30 had several painful [DIAGNOSES REDACTED]. The resident experienced frequent, severe breakthrough pain that was not thoroughly assessed, documented, treated, reported to the physician by nursing staff, or adequately relieved. -Resident #49 had chronic shoulder pain. Staff failed to comprehensively assess the resident's pain, review pain interventions or offer alternative interventions to address the pain. The resident stated her pain, which she had rated as high as a 9 (10 being the worst pain), was not relieved. -Resident #57 fell after eloping from the facility and sustained a fracture of his left elbow that was surgically repaired. The facility failed to monitor and document and evaluate the resident's behaviors to rule out pain, not dementia related behaviors as the trigger. -Resident #5 stated she hurt all the time. She indicated she hesitated to ask for pain medication because of staff's attitude and her fear of being seen as a drug seeker. -Resident #43 had neck pain documented at a level up to 8/10. The resident indicated the PRN pain medication was not effective. Facility documentation was inadequate to evaluate the effectiveness of the resident's pain medications. -Resident #9 complained of back pain that was recorded as high as a level 8/10. She indicated that when she asks for pain medication, her pain is "severe" and her current pain medication lasts for about five hours and then her back starts hurting again." She stated staff "wrinkle their nose when I say I'd like some more pain medicine." The resident was not receiving routine pain medication. -Resident #82 had a painful rash for which the treatment was not helping. Staff continued these treatments for more than five months before notifying the physician, involving the medical director, and receiving a new [DIAGNOSES REDACTED]. The findings included: A. Facility Policy Facility Policy and Procedure Related to Pain Evaluation and Management Policy: It is the policy ... that all residents have the right for appropriate pain assessment and pain management. All residents will be evaluated for indicators or a history of pain for the MDS 3.0 on admission, quarterly, with a significant change in status, and with the new onset of potential pain or discomfort. Data will be collected through resident interviews, staff interviews and observations. Purpose: To properly identify, treat and manage pain and discomfort. To determine what pain relief interventions can be utilized to aid resident in maintaining a comfortable level of function in activities of daily living, eating, sleeping, mobility, socialization and all other aspects of the resident's daily routine. Failure to identify and treat pain, however can have devastating results for residents including [MEDICAL CONDITION], decreased socialization, sleep disturbances, falls, depression, cognitive dysfunction, and other symptoms. This facility believes in providing teaching to the resident, family, and healthcare workers regarding attitudes and beliefs about pain treatment and the importance of proper identification. Procedure: 1. With any MDS scheduled assessments, data is collected related to resident's potential indicators. If the resident is experiencing unrelieved pain, refer to the interdisciplinary team, and the MD/GNP. 2. With Admission data collection and with 3 day data collection, resident will be interviewed and monitored for verbal and non-verbal indicators of pain. 3. On day 4 of admission, a 5 day pain data collection tool will be placed for data collection for verbal and non-verbal indicators of pain including quality, intensity and duration. The interventions and evaluations will also be noted on 5 day pain data collection. Upon completion and review of the 5 day pain data collection, the formal Pain Evaluation will be completed. 4. If a PRN pain medication is used routinely, for 3 consecutive days and/or greater than 6 times in a month, notify the physician for a possible routine management plan. 5. If the resident displays behaviors which could possibly indicate pain or discomfort, consult with Physician or Nurse Practitioner regarding a trial pain management program, implement charting and reassess to see if there is improvement with behaviors. 6. If the resident has a [DIAGNOSES REDACTED]. 7. Notify MD of pain assessment findings if pain is indicated to start or change pain management program as necessary with on going evaluation of effectiveness of medications prescribed. 8. Follow prescribed orders for pain management-documenting results on the pain control flow sheet for PRN medications using provided pain scale of 0-10. For residents on scheduled pain medications, document effectiveness routinely and notify MD or Nurse Practitioner if/when change in medication regimen is needed. 9. Initiate and/or update care plan to include type of pain, required monitoring including pain management plan and a measurable goal relating to the pain management plan. 10. Review pain assessment quarterly and as needed. Note any changes or revisions in current plan. Highlight any areas no longer applicable. 11. For the resident with pending discharge, address the need for pain control with discharge with the MD, resident and family. 12. After a single episode of pain is resolved with the pain management plan, any new occurrence of pain will initiate the process again. 13. Education to residents and their families/responsible parties regarding pain management will be individualized and provided as indicated. B. Resident Failures 1. Resident #30 Resident #30, a [AGE] year-old female, was admitted to the facility on [DATE]. She was re-admitted on [DATE] following abdominal surgery 1/5/13, then rehosptalized on [DATE] for urinary tract infection and dehydration. She returned to the facility 1/25/13. On 1/29/13, the resident was diagnosed with [REDACTED]. Other pertinent resident [DIAGNOSES REDACTED]. a. Resident Status Minimum Data Set (MDS): According to her 10/11/12 MDS, the resident had a BIMS (cognition) score of nine, indicating modified independence. (However, her BIMS scores were inconsistently documented: she was noted as 15 (cognitively intact) on 7/19/12, rarely or never understood with no interview conducted, but short-term memory intact per the 1/4/13 discharge assessment, and blank on the 1/9/13 entry record.) The 10/11/12 quarterly MDS noted the resident had experienced no acute onset mental status change. -No behavioral symptoms were identified. The resident needed extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. She used a wheelchair for ambulation. -Pain was noted as present, almost constant, rated 10/10, making it hard for the resident to sleep at night and limiting her day to day activities. The resident was noted to receive scheduled and PRN (as needed) pain medications. An interdisciplinary team (IDT) note in the resident's medical record documented by the social services director and dated 1/29/13, revealed a BIMS (Brief Interview for Mental Status) was completed that day, and the resident scored 15 (intact cognition). The note further stated, "Resident remains cognitively intact, able to make her needs known and participate in her cares ... No s/s (signs/symptoms) of [MEDICAL CONDITION]." b. History of Pain - Pain Management Plan Prior to Surgery 1/5/13 - Resident Response (1) Review of the resident's care plan revealed a plan for pain was initiated 2/17/12. The care plan identified "abdominal hernia causes pain/discomfort ... able to communicate/verbalize pain to staff." The goal was to "attempt to minimize pain on daily basis through next review." The interventions included: -Abdominal binder as she will allow. -Administer prescribed pain medication/treatments as ordered. Refer to MAR (medication administration record). Notify physician if not effective. -Allow to remain in bed in the AM longer when in pain. -Encourage resident to voice pain as soon as it begins. -Monitor for non-verbal signs/symptoms of pain. -Offer non-pharmalogical interventions. Resident prefers to be repositioned often. -Warm blankets PRN. (2) Review of the resident's IDT notes from 10/12 through 11/12, revealed evidence of ongoing abdominal pain. The notes revealed the resident's pain ranged from 6/10 - 5/10 on a scale of 1-10. Pertinent notes included: -On 10/17/12 at 1:55 p.m., the notes documented, "Pain review - resident dx are abdominal hernia, OA, scoliosis, [MEDICAL CONDITIONS] reflux, pain in joints (shoulder) ... medications-routine-[MEDICATION NAME] 10 mg PO every 12 hours ... MD notified of pain management issues, and request evaluation of routine medications. Asked if surgical consult desired by the MD." -On 10/23/12 at 10:17 a.m., the notes documented, "Appt with (physician) for possible surgery for [REDACTED]. -On 10/29/12, 11/4/12, 11/18 (x3), 11/21/12 and 11/24/12, the resident complained of and was medicated for abdominal pain, rated as high as 20/10 on 11/18/12. Medication was documented at times as providing positive relief, other times as providing some relief and yet other times as providing relief that was not sustained. (3) Review of the 12/1/12 through 12/31/12 medication administration record (MAR) revealed the resident had orders for the following pain medications: -Regularly scheduled [MEDICATION NAME], 10 mg tablet, every 12 hours daily for abdominal pain, ordered 5/22/12, to be given at 8 a.m. and 8 p.m. -PRN [MEDICATION NAME] HCl 10mg every 6 hours -PRN (as needed) APAP, 325 mg and -PRN APAP 650 mg. Review of the 12/1/12 - 12/31/12 MAR and IDT notes revealed the resident received PRN medications frequently for abdominal pain. December MAR: -The resident was noted to have received [MEDICATION NAME], 10 mg as scheduled, with the exception of refusals of all medications twice on 12/22, and once each on 12/25, 12/27 and 12/29/12. -The resident was noted to have received PRN (as needed) APAP, 325 mg, on 12/28/12 at 5:30 a.m. for a headache. -The resident was noted to have received 650 mg of APAP on 12/1, 12/10, 12/15 twice, 12/21, 12/26, 12/28 and 12/29/12 for headaches, general pain, hurting all over, and abdominal pain (on 12/28 at 1:30 a.m.) -The resident received 10 mg of [MEDICATION NAME], ordered every six hours PRN for breakthrough abdominal pain, on 12/3, 12/5, 12/8, 12/13, 12/15, 12/23 and 12/24/12, for abdominal pain. On the back of the MAR, the resident's pain was rated as "abdominal pain 20/10" on 12/3/12 with no notation of effectiveness; as "abd pain 12/10" on 12/13/12, and as "c/o abd pain 10/10" on 12/23/12. Abdominal pain was noted but not rated on 12/24/12. Pain medication was noted only as "eff" with no time or details on three of the four administrations noted on the back of the MAR. December IDT notes: -On 12/2/12, 12/3/12, 12/9/12, 12/23/12, 12/24/12 the IDT documented complaints of pain for which she received medication. A decline in her activity involvement was noted and on 12/13/12, the resident indicated this was "because her stomach hurts so bad." -On 12/31/12 at 12:04 p.m., "Upon review of pain issues: res has chronic complaints of pain in her abd r/t hernia, res continues on the same pain medication that she states is effective in treating her pain, res has had c/o pain on 8 occasions and received 7 PRN oxy 10 mg and 8 PRN APAP 650 mg. Res is scheduled for surgery to repair hernia on 1-4-2013, will continue with current plan of care." The resident was hospitalized for [REDACTED]. c. Pain and Pain Management Post-Surgery 1/5/13 - Facility Failures Documentation revealed resident reports of frequent, severe breakthrough pain as well as new onset of pain 1/25/13, that was not thoroughly assessed, documented, treated, and timely communicated to the physician by nursing staff. (1) Care Plans The resident's care plan for pain (see above) was reviewed 1/18/13. There was no evidence interventions were revised. The resident's 1/25/13 acute care plan identified pain control as an issue, noting her recent abdominal surgery, with interventions to monitor for signs/symptoms of discomfort, use pain scale as applicable, and pain management plan interventions per nurse/physician. The resident's care plans were not updated on 1/25/13 when the resident developed new onset pain in her left lower extremity (see below). (2) Pain Assessments A pain evaluation and management report, dated 1/9/13 and signed on 1/18/13, by a registered nurse, was completed because of the resident's readmission from the hospital (1/9/13). The pain history section noted she had a history of [REDACTED]." -The resident stated she had new onset pain in the last five days, in her abdomen, which she rated as "20" on a scale of 0-10, which she experienced "frequently" and described as "severe" and "aching." -Potential pain indicators were the resident stating "That hurts," and "grimacing or distorted face." -Pain management was noted as scheduled pain medication, PRN pain medication, non-medication interventions, rest, changing positions, and relaxation. -The resident's pain scale goal was left blank. -The resident's individual comfort goals were noted as the ability to sleep comfortably, comfort with movement, to stay alert, and perform activities. -When asked to document "Has a pain management program been trailed?," the answer was "No." -The summary and management plan notes documented, "Res is alert and oriented, res has complaints of pain in her abdomen r/t hernia repair and received PO scheduled and PRN pain medication, res states that the medication is effective in treatment of [REDACTED]." However, there was no evidence the resident had said during this assessment that her pain was managed. Additionally, the note stating she had regularly scheduled medications was inaccurate as of 1/17/13, when routine [MEDICATION NAME] was discontinued (see MAR below). See below; IDT notes revealed the resident began complaining of left leg pain 1/25/13; there was no evidence that this pain was comprehensively assessed, although the resident complained of pain at levels 20-30/10. According to the resident's electronic medical record review on the afternoon of 1/31/13, the resident's pain evaluation and management assessment was "six days overdue - 1/25/13." (3) Pain Medications Pain medication orders on readmission included: -Regularly scheduled [MEDICATION NAME], 10 mg tablet, twice a day "AM/PM". This medication was discontinued 1/17/13. -PRN [MEDICATION NAME] HCl 10 mg every 6 hours -PRN [MEDICATION NAME] HCl 5 mg Review of the January MAR revealed at least daily administration of pain medications for abdominal pain at levels 8/10 - 10/10 (when rated) and beginning 1/25/13, complaints of left leg pain. MAR review revealed the nurses were not consistently documenting the resident's medication administration time and dosage, the reasons why it was given, pain level, effectiveness of the medication, or whether they were assessing her pain often enough or at least every shift as stated in her acute care plan. There was no evidence the resident was asked about her acceptable level of pain. Specifically: Review of the resident's January 2013 MAR showed that prior to 1/17/13 when it was discontinued, the resident received the regularly scheduled [MEDICATION NAME], 10 mg except in the AM on 1/11 (refused all morning meds) and 1/12/13. From 1/10 through 1/21/13, the resident received PRN [MEDICATION NAME]-[MEDICATION NAME], ordered as 10/650 mg as follows according to the back of the MAR: -1/10/13 at 4:40 a.m., 5/325 mg for "c/o abd pain" not rated, noted as "eff" with no time or details. -1/11/13 at 1:30 a.m., 5/325 mg for "c/o abd pain" noted as "eff" -1/11/13 at 3:20 p.m., 5/325 mg for "c/o abd pain" noted as "helpful" -1/12/13 at 3 p.m., 5/325 mg "x2" for "c/o abd pain 7/10" noted as "eff 2/10" -1/13/13 at 12:10 a.m., 5/325 "two" for "c/o 10/10 abd pain" noted as "eff" -1/13/13 at 4:45 a.m., 5/325 mg "two" for "c/o 10/10 abd pain" noted as "eff" -1/14/13 at 4:20 a.m., 10/650 mg given for "abd pain" noted as "eff" -1/14/13 at 11:30 a.m., 10/650 mg given for "c/o abd pain" noted as "eff" -1/15/13 at 4:45 a.m., 10/650 mg given for "8/10 abd pain" noted as "eff" -1/18/13 at 1 p.m., 10/650 mg was given for "abd pain 10/10" resulting in "abd pain 2/10" -1/19/13 at 5 a.m., 10/650 mg given for "abd pain, eff" -1/19/13 at 9:30 a.m., 10/650 mg given for "abd pain 10/10" resulting in "abd pain 3/10" -1/19/13 at 1:30 p.m., 10/650 mg given for "abd pain 9/10" resulting in "abd pain 2/10" -1/19/13 at 10:30 p.m., 10/650 mg given for "abd pain 9/10" noted as "eff" -1/20/13 at 5:30 p.m., 10/650 mg given for "abd pain 8" noted as "eff" -1/21/13 at 4:45 a.m., 10/650 mg given for "abd pain 9/10" noted as "eff" -1/21/13 at 8:40 a.m., 10/650 mg given for "abdomen" noted as "helpful." The resident received PRN [MEDICATION NAME]-[MEDICATION NAME], two 10/650 mg tablets, twice on 1/25/13 (4 p.m. and 8:15 p.m.), three times on 1/26/13 (12:30 a.m., 10 a.m., 2:15 p.m.), once each on 1/27/13 (6:15 p.m.), 1/28/13 (10:55 a.m.) and 1/29/13 (2 a.m.). Nurses documented on the back of the MAR that the two-tablet dose was given on the following dates for the following reasons: -1/26/13 at 12:30 a.m., complaint of left leg pain, no pain rating noted, result noted as "eff" with no time or details documented. -1/26/13 at 10 a.m., complaint of 8/10 left leg pain, "eff" with no time noted. -1/27/13 at 6:15 p.m., complaint of left leg 6/10 and abdominal pain, "effect" no time noted. The resident received [MEDICATION NAME]-[MEDICATION NAME], one PRN 5/325 mg tablet, once on 1/25/13 at 4 p.m. (duplicate documentation or duplicate medication, see above), twice on 1/26/13 at 10 a.m. (also a duplicate that was marked through as an "error") and 4:05 p.m., and on 1/29/13 at 7 a.m. Nurses documented on the back of the MAR that the one-tablet dose was given on the following dates and reasons: -1/25/13 at 4 p.m. - knee and abdominal pain - no pain rating and no effectiveness noted. -1/26/13 for left knee pain 8/10 - crossed out and marked "error". (4) IDT notes -1/9/13 at 3:56 p.m., "Res admitted s/p (status [REDACTED]." -1/9/13 at 8:43 p.m., "Meds taken as ordered and scheduled pain meds help with pain." -1/10/13 at 4:48 a.m., "Resident c/o pain with repositioning. [MEDICATION NAME] administered at (4:40 a.m.)." -1/10/13 at 9:34 a.m., "(Resident) was admitted to rehab after surgery for [REDACTED]. From physician reports it appears that she was considered high risk, however the hernia was bothering her enough that she opted to have it repaired. Prior to surgery she experienced some weight loss that may have been related to the discomfort she was experiencing from the hernia. Her meal and fluid intake continues to be poor..." -1/10/13 at 1:21 p.m., "Res has some complaints of pain in her abd and is treated with PO PRN pain medication." -1/11/13, "Two [MEDICATION NAME] given at (1:30 a.m.) for c/o 10/10 pain to abdomen r/t recent ventral hernia repair." -1/11/13 at 9:18 p.m., "Given PRN pain medication at (3:20 p.m.) for pain 7/10, had fair results." -1/12/13 at 2:31 a.m., "Resident stated pain 8/10 to her abdomen r/t hernia repair surgery. PRN [MEDICATION NAME] administered at (12:15 a.m.) ... Resting quietly at this time." -1/12/13 at 8:09 p.m., "Voices c/o pain of 6/10, given PRN pain meds, reports she had good results." -1/14/13 at 10:21 a.m., "Res has some complaints of pain in her abd and is treated effectively with scheduled and PRN pain medication." -1/14/13 at 7 p.m., "Pt received a shower this eve. We were unable to get a weight. Pt has c/o pain 10/10, pt given scheduled pain meds and reports relief." -1/15/13 at 8:17 p.m., "Scheduled pain meds given and helped with pain in abd." -1/16/13 at 9:44 a.m., "Res has some complaints of pain in her abd r/t recent surgery and is treated effectively with PO scheduled and PRN pain medications throughout the day." -1/16/13 at 11:59 a.m., "Upon review of res pain management, res has complaints of pain in her abd r/t recent surgery. Res does wear an abd binder when up OOB (out of bed). Resident is a difficult historian and is unable to use pain scale appropriately at times. Res has rated the pain as high as 20/10 on occasion." -1/16/13 at 1:31 p.m., "She expressed a significant decrease in pain following surgery but continues to experience fatigue and some pain appropriate to the healing process." -1/16/13 at 9:39 p.m., "Resident continued to have abd pain at times. Schedule pain med helped..." -1/17/13 at 12:21 p.m., "Res has some complaints of pain in her abd r/t surgery and is treated effectively with PO scheduled and PRN pain medications." -1/17/13 at 6:51 p.m., "Res has remained in bed thus far this shift. Taking her scheduled po pain meds, no requested prn meds." -1/17/13 at 9:13 p.m., "Res rec new order per signed fax, from (physician), d/c [MEDICATION NAME] and cont with the [MEDICATION NAME] for pain management needs." -1/18/13 at 1:36 p.m., "Res has some complaints of pain and is treated with PO PRN pain medication, res continues to wear abd binder while OOB." -1/19/13 at 2:35 p.m., "Pt. has c/o abd pain, given PRN pain meds and reports relief and that the pain is tolerable." -1/21/13 at 11:12 p.m., "Resident had two large clear yellow emeses ... Medicated for c/o abdominal pain from surgery ... Placed in protective isolation." -1/22/13 at 2:58 a.m., "Resident had large coffee ground emesis at (1:15 a.m.)... Orders received to send via ambulance to (hospital emergency room ) for eval & tx." -1/25/13 at 1:57 p.m., "(Resident) was admitted today from (hospital) ... Res admitted s/p UTI, dehydration..." -1/25/13 at 2:38 p.m., "Res has c/o L knee pain and does not want to stand or have knee touched." -1/25/13 at 2:47 p.m., "Res reports that she has severe pain in her L knee and reports that she started having this pain in (hospital) on Monday" ... (The resident had fallen in the hospital and X-ray orders were obtained with negative results for fracture or dislocation). -1/25/13 at 9:22 p.m., "Resident was medicated for c/o severe L leg pain x2. L knee appears swollen and is elevated on pillow. States pain is 20-30/10 but pain pills help. Pain appears spasm like." -1/25/13 at 11:31 p.m., "c/o severe pain L knee." -1/26/13 at 3:40 a.m., "c/o L knee pain, [MEDICATION NAME] 5/325 mg 2 po given with a good effect." -1/26/13 at 12:19 p.m., "Res c/o 10/10 left leg pain, gave PRN pain medication. Res reports 3/10 tolerable pain on reassessment." -1/26/13 at 11:06 p.m., "Had two [MEDICATION NAME] @ (2 p.m.) which partially relieved pain and spasms in left leg. Pain level was 15/10. Unable to reach MD, DON was notified of continued pain ... Warm pack prn pain." -1/27/13 at 11:33 p.m., "Medicate for c/o right leg pain with 2 [MEDICATION NAME] which was effective." d. Failure to Assess and Adequately and Timely Address Resident #30's Pain 1/28/13 - 1/31/13. Resident Observation and Interview 1/28/13: Resident #30 was interviewed at 4:00 p.m. on 1/28/13. When asked if she had discomfort or pain with no relief, she said, yes, that there was an incision in her lower abdomen that "hurts now." She stated her last pain medication was given five or six hours before. The resident was observed to have a pained facial expression, her face was distorted, and she grimaced as she shifted her weight in her bed. The resident's call light was activated and a certified nurse aide (CNA) entered the room. The CNA said she would get the nurse. At approximately 5:20 p.m. (over an hour later), the nurse entered the resident's room, and told the resident she had one pain pill for her, before asking the resident her pain level. When she did ask, the resident said her pain level was "ten." The nurse did not ask her where she was having pain. When approached a few minutes later, the nurse said she thought the resident told her "8-10," then said she was not sure if the resident said what her pain level was. Asked where the resident was having pain, the nurse said she "typically had leg pain and abdominal incision pain." Review of the Resident MAR revealed: -The resident had received PRN [MEDICATION NAME]-[MEDICATION NAME] two 10/650 mg on 1/28/13 at 10:55 a.m. Nurses documented on the back of the MAR that two tablets had been given for "abd." There was no pain rating. The medication was noted as "helpful." There was no pain rating. -The resident had received [MEDICATION NAME]-[MEDICATION NAME] one 5/325 mg tablet at 4:15 p.m., for knee and abdominal pain 8/10. But see above; observations revealed the medication was given at 5:20 p.m. There was no documentation on the effectiveness of the medication. Review of the IDT notes revealed one note written at 11:17 a.m., documenting "Res has some complaints of pain in her abd and is treated with PO pain medication." Further review of the resident's IDT and MAR for 1/29/13 and 1/30/13 revealed in pertinent part: -1/29/13 at 2 a.m., complaint of left leg pain. There was no pain rating noted. "eff" without a time noted. -1/29/13 at 4:53 a.m., "c/o L leg pain @ (2 a.m.) [MEDICATION NAME] 5/325 mg 2 po given with a good effect." -1/29/13 at 3:02 p.m., "She just returned from (hospital) for US (ultrasound) of the L leg...res has some complaints of pain her L groin area, res denied pain in her abd." -1/29/13 at 4:36 p.m., "No weight bearing status on L LE r/t [MEDICAL CONDITION]." -1/30/13 R 10:32 a.m., "Res has some complaints of pain in her L leg and groin r/t [MEDICAL CONDITION]. -1/30/13 at 11:27 a.m., "Per nursing res newly diagnosed with [REDACTED]. Res does have some complaints of pain in the leg and is treated with PO PRN pain medication." -1/30/13 at 2:53 p.m., "C/o LLE pain rated 20/10 stabbing pain during movement. Receives PRN [MEDICATION NAME] 5/325 mg..." Staff Interviews: A certified nurse aide (CNA) who provided care for resident #30 was interviewed at 2:47 p.m. on 1/30/13. Asked about pain management, she said, "(Residents) complain about pain but usually the nurses are right on top of it." A licensed practical nurse (LPN) who provided care for resident #30 was interviewed on 1/30/13 at 3 p.m. When asked about the resident's pain, she said, "(Resident #30) has complained of more breakthrough pain within the last week. She returned from the hospital in a significant amount of pain. I took care of her last night and she didn't want any pain meds at all. She said her legs don't hurt if she's in bed or her wheelchair. We're pre-medicating her before transfers now. That is a fairly new thing for her. She does tend to refuse care a lot and refuse her meds." The director of nursing (DON) was interviewed at 1 p.m. on 1/30/13, about resident #30's pain. She was asked if the resident's ongoing breakthrough pain, frequent use of PRN medications, the ineffectiveness of these medications, as well as the lack of routine medication (since 1/17/13), had been reported to the physician. The DON said they had been collecting pain data on resident #30, and asked a nurse to provide a copy of the report they were working on. Review of the report, titled "Pain Control Issues" for resident #30 was dated 11/29/12, with a note in the upper right corner stating "ventral incisional hernia repair 1-4-13." A note in the upper left corner stated, "Charted 11/30/12 - no labs requested - pre-op consults." The "describe pain" section was completed as follows: "Res has chronic c/o abdominal pain r/t hernia." The form included the following questions and answers: -Was comprehensive assessment done? Yes - last pain assessment 10/11/12 -UA done? No 1/7/12 -TSH recently? Yes - 11/16/12 TSH 4.63 -B-12 recently? No -Care plan updated? Yes -IDT note written? Yes -72 hour pain assessment started? Yes ? No ? (question marks were written by both answers) -Pain control flow sheet on MAR? Yes "11/2012 - Surgery consult for hernia" -Therapy interventions were noted as: warm blankets, abd binder, repositioning, medications [MEDICATION NAME] 10 mg po q 12 hrs, [MEDICATION NAME] and tylenol prn, PRN medications were noted for November as follows: 9 PRN doss of Tylenol 650 mg and 10 PRN doses of [MEDICATION NAME] 10 mg. There were no notes for December or January. At the bottom of the form was noted, "Res has inconsistent c/o ab pain through month of Nov - pain on all shifts as high as 10/10. Most days charted with no pain." Diversional activities were listed but not noted as provided for the resident. Team assignments were listed for week one, week two, week three and week four, and for IDT members weeks one through four. However, weeks two through four were blank for team assignments, and all weeks were blank for IDT member assignments. Under "week one" was noted, "(illegible) charts of pain 8, 8 PRN APAP 650 mg, 7 PRN Oxy 10, charted 12/31/12." Contrary to facility policy, there was no evidence in the resident's "Pain Control Issues" report above that indicated the physician had been notified of the resident's ongoing breakthrough pain, frequent use of PRN medications, and the ineffectiveness of these medications or that routine pain medication had been requested. (1) 1/31/13 Resident Observations and Interview: At 9:00 a.m. on 1/31/13, the resident was observed sleeping in her bed. At 10:00 a.m. on 1/31/13, the resident was lying in bed, and said she was having pain. She was observed attempting to reposition herself for comfort, said her leg hurt, and called the CNA to tell the nurse. The CNA left the room and returned to say, "The nurse gave her a pain med 12 minutes ago." The resident asked the CNA to "Tell (the nurse) it's not working, please tell her now." Upon interview, the nurse said she had given the resident one [MEDICATION NAME], "that was all she could have," and she "would let the doctor know her pain meds aren't holding her." The nurse said she would go in to help the resident reposition for comfort. At 11:15 a.m. on 1/31/13, the resident was observed lying in bed. When asked about her pain, she said she was "still hurting," but was glad to hear that the nurse was going to call the doctor about her pain medication not holding her, because "it's not." At 12:30 p.m. on 1/31/13, the resident was sitting up in her wheelchair in her room. She said she was hungry and was waiting for her lunch. A follow-up interview with the resident's nurse revealed she had given the resident a second [MEDICATION NAME], and had contacted the resident's physician (see fax to physician below). Record Review 1/31/13 revealed: -1/31/13 at 12:57 p.m., the IDT note read: "Res has some complaints of pain in her L leg and is treated with PO PRN pain medications, MD faxed by ... nurse in regards to res c/o pain..." -1/31/13 at 12 noon, a FAX communication to the resident's physician, dated 1/31/13 at 12 noon, requested as follows: "Pt given 2 perc 5/325 (PRN Q4hrs) for abd. pain 10/10 after 1 hr. pt states pain is 20/10. Pt refused all meds except antibiotic & PRN pain med. Pt

Based on resident and staff interview and record review, the facility failed to provide adequate assistance to maintain or restore continence for two of 30 sample residents (#49 and #82). Both residents stated they did not receive adequate, timely assistance with toilet use. Both residents had experienced declines in continence status since their admission to the facility, and had ongoing incontinence associated [MEDICAL CONDITION] with resulting discomfort. Cross-reference F 309; care and services and F 353; nurse staffing The findings included: 1. Resident #49 Resident #49, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS): According to her 11/10/12 MDS, resident #49 had a BIMS (cognition) score of 13, indicating she was cognitively intact. No behavioral symptoms were noted. The resident needed extensive assistance with bed mobility, toilet use, dressing, and personal hygiene. -The resident was noted as frequently incontinent of bladder, which was a decline in continence status since her previous MDS on 8/10/12 when she was occasionally incontinent. Care Plan: The resident's care plan, initiated on 8/15/12 and revised on 1/18/13, identified, "The resident has potential for skin breakdown r/t (related to) immobility and occasional incontinence." The goal was for intact skin, and interventions included pressure relieving cushion in wheelchair, turn and reposition at least every two hours. The care plan also identified, on 11/10/12, "Alteration in bowel and bladder function, r/t functional incontinence, d/t (due to) limited mobility, r/t DM and [MEDICAL CONDITION]." The goal was to maintain skin integrity, and for the resident to be "dry, clean, comfortable, and odor free, next 90 days." The interventions included to report any signs/symptoms of urinary tract infections, and "offer toileting every two hours while resident is awake, and check and change as needed." -No specific toileting schedule, bladder assessment, or voiding assessment was mentioned. The care plan was contradictory, in that the resident was noted both as occasionally incontinent and functionally incontinent. Resident Observation: The resident was observed at 5:15 p.m. on 1/28/13. She was sitting in her recliner in her room, and asked the surveyor to help her into her wheelchair. The resident was asked to activate her call light and staff would assist her. The resident activated her call light, then continued trying to transfer from her recliner to her wheelchair. No staff were observed in the hallway. -The medical records director (MRD) was asked to get assistance for the resident, and said she was a certified nurse aide (CNA) and could assist her, and went to do so. -By the time, the resident was standing up, holding onto her wheelchair. The staff person rushed in to assist her. The resident had needed assistance to the bathroom, but there were no other staff available to assist her. Resident Interview: The resident was interviewed at 2:00 p.m. on 1/29/13. She said, "I have to wait for so long to get help ... I can hold it but I'm a nervous person anyway, so that really makes me upset. I wait and wait until they help me (to the bathroom) because I can't walk." The resident said she had a sore on her bottom. Bladder Assessments: a. The resident's initial bowel and bladder evaluation, noted as effective on 7/16/12 and signed on 7/25/12, documented the resident could identify the need or urge to void, and was able to use the call light and ask for help. At that time she was occasionally incontinent, her incontinence started before admission, she awoke at night to void, and had problems with urgency. -It was noted that a toileting program was currently being used, and that the resident was always continent of bowel. She was noted to have [MEDICAL CONDITION], dementia, and [MEDICAL CONDITION]. She used diuretics and beta blockers, required assistance to transfer, the date of her last urinary tract infection was unknown, and she required extensive assistance for toilet use. -A three-day voiding assessment was noted as done, and patterns of urinary continence were noted. However, the urinary patterns were noted as follows: "AC, PC, HS and PRN" (before and after meals, at bedtime, and as needed). It was noted that a trial toileting program was not assessed, and the resident's response was not assessed. Two plans were selected for the resident from this assessment: -Scheduled/Habit Toileting Plan to match the resident's voiding habits, and -Training to return to previous pattern/retraining. The analysis and summary of data noted: "Resident is occasionally incontinent of bladder. Continent of bowel. Toileted on a schedule (every) AC, PC, HS and PRN (before and after meals, at bedtime and as needed). Continue current plan of care." However, no plan of care was developed to assist the resident to improve continence status (see care plan above). Instead, the resident had an incontinence care plan that was not tailored to her individual needs. Moreover, her individual voiding patterns and needs were not thoroughly assessed. b. An 11/9/12 Bowel and Bladder Quarterly Review identified the resident was reviewed for changes since her last assessment. It was noted "Resident makes needs known frequently incontinent." The final comments were: "Resident uses call light for toileting needs but is frequently incontinent of bowel and bladder r/t urgency. 1 assist with toileting." Although the resident had a decline in continence status, the resident's assessment was incomplete, no voiding pattern assessment was done, either upon admission or after her decline in continence status. Body Audits: Review of the resident's weekly body audits revealed that from 11/7/12 to 1/2/13, the resident had "IAD (incontinence associated [MEDICAL CONDITION]) on sacral area, open area that is treated per wound nurse with angle paste" and "yeasty rash to right groin, dr. notified." Staff Interview: The occupational therapy assistant (COTA) was interviewed on 1/31/13 at 9:30 a.m. about the resident's decline in activities of daily living (ADLs) (cross-refer to F 311, Activities of Daily Living). The COTA said she was not aware of the resident's ADL decline, but that she would follow up with nursing. The director of nurses (DON) was interviewed at 1:00 p.m. on 1/30/13. She said they did not have a restorative nurse but were in the process of hiring one. 2. Resident #82 Resident #82, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS): According to his 12/14/12 MDS, the resident was receiving hospice care, and had a BIMS (cognition) score of 14, indicating he was cognitively intact. He required extensive two-plus-person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He used a wheelchair for mobility. He was frequently incontinent of bowel and bladder. According to his 8/14/12 admission MDS, the resident was admitted with an indwelling catheter and was frequently incontinent of bowel. According to his 9/2/12 PPS 30-day MDS, there was no catheter and the resident was "occasionally" incontinent of bladder and bowel. According to his 9/21/12 significant change MDS, he declined to "frequently" incontinent of bowel and bladder, and was on a toileting program without improvement. According to his 12/14/12 quarterly MDS, the resident's continence status was "frequently" incontinent of bowel and bladder, with no current toileting program. Care Plan: The resident's "bowel and bladder" care plan, initiated on 8/27/12 and revised on 1/1/13, identified "frequent bladder incontinence r/t prostate enlargement." The interventions included: "Brief use: Wears large disposable briefs. Staff to offer to toilet or change briefs every two hours and during night rounds." No bowel program was listed, and no specific toileting schedule was documented to meet the resident's individually assessed needs. Bowel/Bladder Assessments: Review of the resident's assessments since his admission revealed he never had an comprehensively assessed voiding pattern or schedule. The nurse noted that he took diuretics and other medications that affected continence status, also noted a "yeasty groin rash," and that the resident's toileting program consisted of "Q2hrs and PRN, AC and HS." This was not an individualized toileting plan based on assessment of the resident's voiding patterns. The resident's most recent assessment, dated 12/14/12, documented "continent of bowel 90% of the time, uses BSC with 1 to 2 assist ... no changes needed with present care plan ... res is continent and incontinent of both bowel and bladder ... wears depends due to incontinence of both bowel and bladder, no changes with resident's bowel and bladder in the past 90 days." -Although the resident was noted as "continent and incontinent" of B&B, there was no documentation of a voiding assessment or actual schedule. Body Audits: The resident was repeatedly noted on his weekly body audits, reviewed since his admission and up to 1/31/13, to have IAD and rashes to his groin and buttocks. (Cross-reference F 309, Care and Services regarding ongoing pain/discomfort from these rashes.) Resident Interview: Resident #82 was interviewed on 1/29/13 at 9:30 a.m. He said, "They're understaffed. They also don't have enough staff to train other people ... From what I see, they're understaffed and there isn't anybody to help. Sometimes when I have to go to the bathroom, (I can) only wait so long, and that's kind of the big thing. You try to hang on and wait for them ..." The resident said he had had incontinence accidents "because they don't come fast enough - these incontinence briefs hold a little bit, you know ..." physician progress notes [REDACTED]. A physician progress notes [REDACTED]. Is incontinent of urine ... Status: Poor hygiene biggest factor, pt needs more frequent peri care as he only gets his attends changed BID. Will increase freq to 5 times a day ..." The physician wrote a telephone order for the resident to receive peri care five times daily. Although this was added to the treatment sheets, the care plan was not updated. 3. Staff Interviews A certified nurse aide (CNA) was interviewed on 1/30/13 at 2:30 p.m. She said, "Sometimes call lights go off for a long time. (Resident #49) will fall asleep holding her call light, so sometimes it goes off for extended periods. What I do is wake her and ask if she's okay and she'll say she didn't know she had the call light going off." The CNA said she worked as a float and did not "know the routines for each resident." Asked where she was floating, she said, "Today, I'm floating on Gold, Lime, Peach and Rehab." (These were all the hallways except the secure unit.) A second CNA was interviewed at 2:45 p.m. on 1/30/13. Asked how often she assisted residents #49 and #82 to the toilet, she said, "(Resident #82) pretty much rings when he wants us, so there's not a time for toileting assist. He averages once an hour to every two to three hours. He is incontinent, extremely, but on my shift he gets cleaned regularly. I assist him with peri care probably four times per shift ... We help (resident #49) every hour sometimes, and after dinner. It depends on if she's anxious or not; it just varies. The other night I helped her to the bathroom ten times." A third CNA was interviewed at 11 a.m. on 1/31/13. She said resident #82 "rings when he has to go; if he doesn't ring I go in every two hours ... I typically find him wet ... (Resident #49) will let us know - she rings when she needs to go - she's not typically wet. The past couple days she's been more confused, but she hasn't been incontinent for me during the day - I don't know about the other shifts." The CNA said she had not noticed a decline in resident #49's ADL status. She said, "During the day she does pretty good. She said she slept good last night. She has a sore spot - like a chapped kind of area, and we have cream that we put on it." A licensed practical nurse was interviewed on 1/30/13 at 3 p.m. Regarding resident #82, she said, "The nurses were doing his cream five times a day - I believe he's on the check and change program. He calls when he wants to go to the restroom so we can put him on the bedside commode. The one thing I hear from (resident #82) is anxiety - if you're not very prompt on answering him, I can see he'd feel like his needs weren't being met ... I think (resident #49's) is more of a memory issue - I'm by that room for the majority of the shift. I was toileting her Friday night and she told me she felt useless and wanted to die because she required help, so she may have some of those feelings about being helped. The other night (resident #49) was dry both times I toileted her. I don't know about (resident #82)." The wound nurse was interviewed on 1/31/13 at 12 noon. She said resident #82 had skin issues since admission due to urinary incontinence. The director of nurses was interviewed at 1:00 p.m. on 1/30/13. She said they did not have a restorative nurse but were in the process of hiring one. Regarding the residents' reported concerns about lack of assistance, she indicated that both residents were anxious and confused. The DON and nursing home administrator were notified of the findings above during a late afternoon interview on 1/31/13. They acknowledged the concerns but did not comment further. In summary, the nursing staff gave conflicting responses about the residents' need for assistance. Although both residents were cognitively intact and experienced declines in continence status, nursing staff attributed their complaints, in part, to confusion and anxiety, and did not adequately assess their needs in order to ensure they received the necessary assistance.

Based on observation, family and staff interview, and record review, the facility failed to provide monitoring and supervision to prevent accidents with injury for one of 30 sample residents (#57). These failures contributed to resident #57 eloping from the facility, suffering a fall, a fracture, and a hospitalization with surgery. Upon his return to the facility, the resident continued to fall from his wheelchair and bed. The facility further failed to prevent accident hazards regarding use of critical care equipment and anti-skid floor strips. The findings included: A. Resident #57 Resident #57, an [AGE] year-old male, was admitted to the facility 9/4/12 and readmitted [DATE] following a fall with fracture on 10/14/12. [DIAGNOSES REDACTED]. a. Resident Status on Admission On 9/4/12, nurses' notes documented the resident was assessed at moderate risk for falls. He had no history of falls at home and was able to ambulate independently. The admission Minimum Data Set ((MDS) dated [DATE], documented, in part, that the resident had short and long-term memory problems, his memory recall ability was that he knew the location of his room, current season, and that he was in a nursing home. He was coded with poor decision making ability and disorganized thinking. He did not exhibit physical behavioral symptoms directed towards others, did not have verbal behavioral symptoms directed towards others, and did not reject cares. -The resident required supervision and oversight with bed mobility, transfers, walking, eating, toileting, and personal hygiene. -The resident did not receive antipsychotic, antidepressant or antianxiety medications during the past 7 days, was not on a scheduled pain medication, did receive as needed (prn) pain medication, did not have a fall in the past 6 months (ambulatory with no history of falls). The resident's care plan, initiated 9/24/12, documented in part: -Problem-At risk for falls related to wandering and unsteady gait. -Goal-Resident will be free of injury from falls over the next 90 days. -Approaches-Resident walks with hand hold assist and gait belt, pressure alarm when sitting in a chair, ensure that the bed alarm is on the bed, place walker in front of the bed and use fall mat. Review of physician orders [REDACTED]. -Order dated 9/4/12, for Ativan, an anti-anxiety medication, 0.5 mg prn (as needed) for agitation. Ativan is a sedative/hypnotic, with potential side effects that include drowsiness, ataxia, confusion, blurred vision, slurred speech, hypotension, headache, paradoxical central nervous system restlessness, excitement in elderly/debilitated. (See Saunders Nursing Drug Handbook 2010 page 690-691) -Order dated 9/13/12 for bed alarm at night for safety b. Incident 9/30/12 - Facility Response - Failures in Facility Response Review of nurses' notes/progress notes revealed the resident was documented on 9/27/12 at 5:11 a.m. as very anxious and agitated, thinking there were men and children in his room. Review of the nurses' notes/progress notes on 9/30/12 at 8:31 p.m. revealed the resident followed a staff certified nurse aide (CNA) out of the secure unit with a fire extinguisher in hand, threatening staff. The resident was redirected back to the unit. The resident refused Ativan. The CNA reported the resident had been delusional and paranoid during the shift. According to a physician communication/FAX on 9/30/12 at 9:20 p.m., the resident sustained [REDACTED]. Facility Response: According to the physician's communication/FAX 10/1/12, nursing wrote 'Resident with increased agitation, paranoia and anxiety, on 9/30/12 he was swinging the fire extinguisher at staff, would you like to make medication adjustments? Physician response was: Begin Haldol (antipsychotic) 1 mg po BID (twice a day.) Potential side effects of Haldol include blurred vision, constipation, and orthostatic hypotension. Haldol has a "Black Box" warning of increased risk of mortality in elderly patients. According to the nurses' notes/progress notes dated 10/4/12, the facility requested a medication review with the pharmacist. A psychological consult also was obtained. A pharmacy medication review dated 10/9/12 revealed the pharmacist suggested Depakote (anticonvulsant) trial to get the resident off Haldol. Failure in Facility Response: On the morning of 2/5/13 the Director of Nurses was asked how the resident had access to the fire extinguisher and she said the door, which had a keyed lock, had been left unlocked. Review of the resident's comprehensive care plan revealed no care plan updates on staff interventions to address the resident's anxiety and agitation, on the initiation of an antipsychotic in addition to the prn sedative/hypnotic Ativan, or on the potential side effects to be monitoring the resident for in order to maintain his safety. Review of the nurses' notes/progress notes revealed no documentation the facility followed up to ensure the physician responded to the pharmacist's recommendation of a Depakote trial. c. Incident 10/14/12 - Facility Response - Failures in Facility Response Review of physician orders [REDACTED]. He was transferred to the emergency room [DATE]. Specifically: PO and FAX 10/14/12 read: Resident found outside he had fallen, found 2 skin tears and bruises to bilateral shins. A mobile x-ray was completed of the left elbow. NN 10/14/12 read: resident was found outside. The CNA heard someone outside calling out. Resident was found at 4:45 a.m. sitting in the parking lot, on his bottom with hand behind him and legs bent in front of him. Resident was quite shaky, the nurse made a head to toe assessment. Half hour later, the resident had swelling in the left inner elbow and he could not move it without pain. Facility Response: Review of the facility fall investigation report dated 10/14/12 at 4:45 a.m. read - elopement, fall, fracture outside the building. Medication in the last 8 hours prior to fall included Haldol, mental status confused. The NN 10/14/12 documented "Safety Intervention:" Immediate intervention - the secured unit door code was changed and all windows and doors checked. Physician, family, DON notified. PO on 10/14/12 at 1:45 p.m. read "splint today and follow up with physician. If cannot splint, send to emergency room ." Another PO read: "mobile x-ray of left inner below to rule out possible fracture." PO on 10/15/12 read: "May have chair alarm for resident safety." Failures in Facility Response: (1) Failure to address resident #57's safety needs Record review revealed no review of the resident's medication regimen and no follow-up on pharmacist's report to trial Depakote to get the resident off Haldol. Review of the resident's medication administration record 10/1/12 - 10/14/12 revealed the resident received Haldol 1 mg twice a day. He also received Ativan 0.5 mg 5 out of these 14 days. In addition to the care plan failures identified above, further review of the resident's care plan revealed no update referencing the resident's elopement and no revision of interventions to keep the resident safe. (2) Failure to ensure the secure unit remained secure The Director of Nurses (DON) was interviewed on the morning of 2/5/13 related to the resident's elopement. The DON said that following the 10/14/12 incident, the facility had placed safety latches so the resident room windows could be partially opened but could not be opened wide enough for a resident to exit. The DON said the management team investigated to find out how the resident was able to get outside of the secured unit. She said they felt he was able to key in the code for the lock on the door and he walked down the hallway near the physical therapy department and he left out that door. She said he had set his oxygen tank, hat and eye glasses down on his way down the hall and next to the exit to the outside. She said the facility changed the code number immediately and checked all the windows and doors. However, observations in the morning on 1/7/13 of the secure unit, including resident rooms, revealed one side of the hallway opened up to the secured court yard and the other side of the hallway had windows that opened up to the outside yard that was not secured. The residents' bedroom windows were observed not to have safety latches, creating the potential for a resident to open the window wide enough to exit out the window. d. Resident Status on Readmission PO and FAX revealed the resident was readmitted to the secure unit 10/17/12 following an open reduction internal fixation (ORIF) of his left elbow. -Orders on 10/17/12 included bed alarm and the following pertinent medications: Haldol 1 mg tid (three times a day) and as needed (PRN) medications Haldol 1 mg PO (by mouth) BID (twice per day) PRN, APAP 325 mg 1 tab po q 4 hours PRN, APAP 325 mg or 2 tabs po q 6 hours PRN. -Orders on 10/18/12 included chair alarm and the following pertinent medication orders: 5 mg (5.0 mg) Haldol intramuscular injection (IM) one time, Percocet 5/325 mg tablets give 1 or 2 tablets every 4 hours as needed for pain. The N/N on 10/17/12 documented in part: Resident readmitted to the facility at 12:45 p.m. The 10/18/12 N/N documented in part: Resident was very anxious and agitated, thought people were outside after him and that the staff worked for the government ... he was delusional and combative, resident was offered food, fluids, toilet and pain medication-declined all. The physician was called and provided new orders and Haldol 5 mg IM was administered. Review of the October Medication Administration Record was void of any documentation the resident received medication between his readmission on 10/17/12 at 12:45 p.m. and the time he received the Haldol 5 mg IM on 10/18/12 at 1:45 a.m. A significant change of condition MDS was completed 10/24/12, and documented, in part: -The resident had a brief interview of mental status (BIMS) score of three, indicating had severe cognitive impairment. He did not have physical behavioral symptoms directed towards others, did not have verbal behavioral symptoms directed towards others, and rejection of care behavior was not exhibited. -The resident had received antipsychotic medication for the past 7 days, no antidepressant, and one day out of 7 days, he had received an antianxiety medication. He was not on a scheduled pain medication, did receive as needed (prn) pain medication. He was unable to answer questions on the pain assessment interview. -The resident was coded as having no falls since admission or his prior MDS assessment (But see above - fall with fracture on 10/17/12). -The resident required extensive assistance with bed mobility, transfer, to walk in corridor, dressing and toileting. There was no evidence the resident's care plan was updated to reflect the significant changes identified in the MDS. e. Additional Falls - Facility Response - Failures in Facility Response Review of the facility fall investigation reports (IR), PO/FAX physician communication (PO/FAX) and nurses' notes (NN) documented the resident fell on [DATE], 11/3/12, 11/14/12, 11/27/12, 12/15/12, 1/5/13, and 1/6/13. Review of these records revealed: -10/14/12 at 4:45 a.m. elopement, fall, fracture. -11/3/12 at 9:20 a.m. - IR documented fall from his recliner chair onto floor in his room -11/14/12 at 11:10 p.m. staff assisted to toilet resident slipped and was lowered to floor by staff, gait belt was in use, medication in the last 8 hours prior to fall included antipsychotic, mental status confused. -11/15/12 at 6:55 a.m. - the PO/FAX documented resident slipped down wall on 11/14/12 in the bathroom with CNA and PCP standing by. -11/27/12 at 7:30 p.m.- staff assisted to sit down in a chair, resident slipped and was lowered to floor by staff, gait belt was in use, medication in the last 8 hours prior to fall included antipsychotic, mental status confused. -12/15/12 at 2:45 p.m. resident attempted to self transfer from his bed, the alarm sounded and staff went to room to provide assistance, resident fell to floor landing on his buttocks, medication in the last 8 hours prior to fall included antipsychotic, mental status alert times one. NN on 12/15/12 at 2:45 p.m. documented the resident was found leaning on the bedside table after the alarm sounded. He lost his balance and slowly fell to floor, on the way down he bumped his left elbow on the table and scraped the left upper outer arm skin tear and left inner elbow 1 cm skin tear, steri strips applied. -1/5/13 at 7:30 p.m. resident was in his wheelchair in the commons area and slipped from the wheelchair to the floor, resident was agitated and had increased confusion, medication in the last 8 hours prior to fall included antipsychotic (decreased dose of haldol) and antianxiety. A NN on 1/6/13 at 1:24 a.m. late entry for 1/5/13 read that the resident slid out of his wheelchair, did not hit his head, hyperventilating, lungs clear, pulse irregular at times, blood pressure 121/75, temperature 98.4, pulse 160, respirations 52. Physician notified per FAX at 12:45 a.m. PO/FAX 1/6/13 read at 12:45 a.m., resident slid out of his wheelchair and was lowered to the floor, appears to be hallucinating, resident was anxious and restless and required one on one most of the shift, haldol and ativan were not effective. -1/6/13 at 6:45 a.m. Bed alarm sounded, resident rolled from bed landing on the floor with body pillow, medication in the last 8 hours prior to fall included antipsychotic, mental status - asleep prior to fall. A NN at 6:45 a.m. documented pupils equal, reactive to light, resident lethargic, blood pressure 122/96, pulse 159, respirations 20. -1/6/13 (no time) resident was witnessed rolling out of bed. NN read at 1/6/13 (void of time) resident was witnessed rolling out of bed. Facility Response - Failures in Facility Response: (1) Medication Changes Review of a PO/FAX dated 11/14/12 documented the resident had a significant decrease in behaviors, increasing lethargy/sleepiness during the day time hours. Decrease Haldol dose to twice per day. However, review of a PO/FAX dated over two weeks later indicated the mid day Haldol was not discontinued until 12/6/12. Specifically, a PO/FAX dated 12/6/12 read: "Resident has had fewer behaviors and paranoia with medication changes. He is increasingly sleepy on day shift. Resident's mid day haldol was held yesterday with positive results. Per physician may discontinue the mid day haldol." Review of a monthly pharmacy report dated 11/12/12 revealed "awaiting response to previous." There was no indication the pharmacist's suggestion (to change from Haldol to Depakote) was considered and/or pursued on the resident's behalf. While on 12/28/12, Haldol was changed to 0.5 mg every night for one week, then discontinue (order for Haldol 1 mg po every day worsening agitation or paranoia remained in effect), this change followed a care conference on that date and the family's request for a trial off Haldol. Specifically, the 12/28/12 FAX to the physician read, in pertinent part: "Resident's daughters both concerned over resident's declining condition and both daughters feel the haldol is making resident lethargic daily. The daughters would like to trial resident off haldol. Resident is still having periods of agitation, paranoia and delusions approximately every other day." (2) Vital Signs Review of the vital sign for resident #57 revealed abnormally low blood pressures and elevated pulse at intervals as follows: -10/28/12 Pulse= 120 -11/3/12= 116/78, Pulse= 112, Respirations= 28. -11/16/12 = 83/40 -12/9/12= 93/57 -12/16/12= 94/49 -12/19/12= 93/54, Pulse= 122 -12/30/12= 96/51 -12/31/12= 95/56 -1/6/13 Pulse= 120 -1/7/13= 90/50 See above potential side effects of Haldol. Review of the medical records and staff interviews (10/17/12 through 2/5/13) revealed the facility did not report the abnormal vital signs to the physician. The facility did not evaluate the resident's abnormal vital signs as potential adverse side effects of medication use. (3) Care Plan Review of the resident's care plan for falls revealed it was most recently reviewed 1/7/13. There was no indication that the resident's fall interventions were re-evaluated and/or revised as the resident continued to fall. f. Interviews On 1/31/13 at 9:20 a.m. a certified nurse aide (CNA) who was scheduled regularly to work on the secured unit was interviewed about resident #57. She said the resident slept more after his return from the hospital (10/17/12). She said after he returned, staff used a body pillow, chair alarm and bed alarm to try and keep him safe. She said the resident was up often sometimes every hour. On the morning of 2/5/13 the secured unit Nurse Manager (NM) was interviewed. She (NM) said the resident was having a decline in his condition; he had dementia with behavioral problems. She said he would get agitated at times and was hard to redirect. He would refuse his medications at times and he was very confused. She said the facility had hired a one on one staff to sit with the resident for about two weeks because the resident was confused and required more help. g. Observations On the afternoon of 1/7/13, observations were made of resident #57 sitting in a recliner chair in the commons area. His eyes were closed and his body at times made jerking movements. Two staff came over to reposition the resident in his recliner; they spoke to the resident but he did not respond to the verbal communication. Staff repositioned the resident, however, he did not open his eyes. He made slight moaning sounds then became quiet again. His eyes remained shut. B. Environmental Hazards 1. Critical Care Equipment An observation of the facility environment during survey (1/28/13 - 2/5/13) revealed numerous residents at the facility required oxygen concentrators in their room. Review of these rooms revealed that many oxygen concentrators were plugged not into a direct electrical plug in the wall, but rather into a multi-use power strip. These power strips were observed attached to the wall, sideways, near or behind the residents' nightstands. All observed power strips had numerous plugs attached, not just the oxygen concentrators. The oxygen concentrator and nebulizer for resident #43 were both observed on 1/29/13 at 11:41 a.m. to be plugged into a power strip against the wall. The resident was observed at that time using his oxygen at 4 liters per minute. The oxygen concentrator for resident #60 was observed on 1/29/13 at 11:43 a.m. to be plugged into a power strip against the wall. The oxygen concentrator for resident #70 was observed on 1/29/13 at 11:44 a.m. to be plugged into a power strip against the wall. 2. Nonskid Strips An observation of resident #82's room on 1/29/13 at 9:27 a.m. revealed nonskid tape stuck to the floor in rows to provide grip for the resident so that he would not fall when getting out of bed. The tape was observed dirty and in poor condition. An interview with resident #82 on 1/29/13 at 9:27 a.m. revealed that the nonskid tape used across the floor in front of the resident's bed was dirty, collected dirt and lint, and had slippery spots that required the resident "to be careful that his feet don't slide." 3. A tour of the environmental concerns was completed with the maintenance director on 2/5/13 at 11:50 a.m. -The maintenance director spoke with resident #82 who confirmed that the nonskid strips on the floor near the 'fireman's pole' were very slippery. He said he has a hard time with them and would like them fixed. The maintenance director stated it would be taken care of. -The maintenance director observed the oxygen concentrators in numerous rooms that were plugged into power strips. He stated that he had been told by Life Safety individuals that it was okay to use power strips because they had a proper breaker system. However, he stated that he could not confirm if the Life Safety inspectors had told him it was okay to use power strips for critical care equipment for the residents. He said he understood the concern related to critical care equipment not being plugged directly into the facility electrical system.

Based on record review and staff interview, the facility failed to ensure five of 25 sample residents (#13, #31, #51, #77, #109) received adequate respiratory care and services. Specifically the facility: - Failed to adequately assess, identify and respond to resident #31's decline in [MEDICAL CONDITION] status. The facility delayed obtaining timely emergency care for this resident who was subsequently hospitalized . - Failed to adequately and consistently assess, develop care plans and provide appropriate interventions to meet the respiratory needs of residents #13, #51, #77 and #109. The facility nurses were titrating the residents' oxygen levels without physician orders, or above the flow rates for oxygen delivery ordered by their physicians. The findings include: Professional References regarding Respiratory Therapy Hypoxemia According to the website www.mayoclinic.com/health: "Hypoxemia, or low blood oxygen, describes a lower than normal level of oxygen in your blood. In order to function properly, your body needs a constant level of oxygen circulating in the blood to cells and tissues. When this level of oxygen falls below a certain amount, hypoxemia occurs and you may experience shortness of breath . . . An approximate blood oxygen level can also be determined using a pulse oximeter - a small device that clips on your finger. Though the pulse oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. Cyanosis The National Library of Medicine of the National Institute of Health's website Medline describes: "Cyanosis is a bluish color to the skin or mucus membranes that is usually due to a lack of oxygen in the blood . . . Lips - bluish; Fingernails - bluish; Cyanosis; Bluish lips and fingernails; Bluish skin . . . Blood that has lost its oxygen is dark bluish-red. Bluish skin (cyanosis) can be a sign of many serious medical problems and should be taken seriously. Call or visit your health care provider. For adults, call your doctor or 911 if you have bluish skin and: Your breathing is getting harder, faster, or you cannot get a deep breath. You need to lean forward when sitting to breathe. You are using muscles around the ribs to get enough air . . ." 1. Resident #31 Resident #31, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized the day after his admission on [DATE] and returned to the facility on [DATE]. The resident expired in the facility on [DATE]. The re-admission minimum data set (MDS) assessment dated [DATE], revealed the resident was moderately impaired in daily decision-making skills, required one-person physical assistance with all activities of daily living except dining, used a wheelchair propelled by others for mobility, had an indwelling urinary catheter, was incontinent of bowel, exhibited shortness of breath upon exertion, received oxygen therapy, was six feet one inches tall and weighed 134 pounds. The undated "Temporary Care Plan - Respiratory Function" assessed the resident's problem as: "Ineffective airway clearance, impaired gas exchange, or ineffective breathing pattern related to pneumonia. As evidenced by non-productive cough, 02 sats at 93% on 2LPM and abnormal lungs sounds." The approaches included: "Elevate HOB (head of bed), medication per MD, encourage fluid intake, monitor lung sounds daily, neb treatments per MD, provide instruction for proper use of inhalers, observe for changes in respirations, lab/diagnostic work per MD, chest x-ray per MD, monitor sputum for color changes, monitor for increased dyspnea (difficulty breathing), oxygen at 2LPM, 02 sats above 90%, monitor for discomfort and the need for [MEDICATION NAME], encourage frequent rest periods." The admission physician orders [REDACTED]." The facility's nursing staff failed to clarify this order with the resident's physician to obtain the liter flow (dose) of oxygen that the staff should deliver to the resident. The resident was admitted at 2:45 p.m. on [DATE]. The progress notes revealed the following in pertinent part: [DATE] - 3:20 p.m. "Resident admitted at 2:45 p.m. from (local) medical clinic via facility van. Resident admitted with pneumonia . . . 02 97% on 2LPM via nasal cannula. Shortness of breath noted. Breathing even and labored . . ." - 7:00 p.m. "Resident resting in bed. Labored breathing. Breath sounds diminished and tight." - 9:00 p.m. "Resident sitting up on the side of the bed having difficult time breathing. PRN (as needed) neb (nebulizer) treatment given at this time." - 11:00 p.m. "Resident noted to be sitting in his chair in his room . . . Vital signs obtained by nurse . . . respirations - 24 (normal range ,[DATE]), 02 sats 88% on 3LPM . . . B/P ,[DATE] (on lower side of normal) . . ." - 11:32 p.m. "Resident reassessed. Lung sounds clear to auscultation throughout except diminished in bases. Resident lying back in bed." - [DATE] - 12:45 a.m. "Resident noted to be laying on his right side on the floor in front of the door to his room with his head against the closet wall. Nasal cannula was off . . . pulse 43 (normal range ,[DATE]), respirations 24 (normal range ,[DATE]), B/P ,[DATE] (low diastolic (bottom) pressure), 02 sats 51% (normal range is >90% on room air . . ." Resident Failures After this incident, the facility failed to document that his oxygen cannula was put back in place, failed to notify the physician and family of the resident's change in vital signs and failed to assess and identify the seriousness of his change in condition. Moreover, the nursing staff continued to fail to respond to his decline in condition and call 911 for several more hours as evidenced by the continuing progress notes: [DATE] - 3:15 a.m. "Vital signs very difficult to obtain throughout the night. Blood pressure very faint. Pulse weak and thready. O2 sats bouncing from 50's to 80's . . ." - 4:16 a.m. "[MEDICATION NAME] administered via mask. Oxygen continued to jump around. Sats (oxygen) maintained in the 80's on 3LPM." - 5:28 a.m. ". . . respirations 24, B/P ,[DATE], 02 sat 74% at 3LPM. Nail beds cyanotic. Extremities dark in color." - 6:15 a.m. "Patient lying in bed. A&OX1 (alert and orient only to himself.) Very pasty looking skin. Lips a bit blue. Fingernail beds blue. Skin on fingers looking to have a bluish tint to them. 02 sat is bouncing from low 70's to 90% on 3LPM. Tried to titrate 02 but the sat would crash and stay low. Patient lungs very tight bilaterally. Left lower lobe has inspiratory and expiratory wheezes. Patient also working very hard to breath. Respirations around 30 per minute. Doctor called by night nurse. - 6:50 a.m. "(Doctor) notified by phone and orders received at 630 to send via ambulance to (local hospital) for evaluation and treatment . . . Resident transported via ambulance at 0650." - 9:44 a.m. "ER doctor called to notify that resident is being sent to (regional medical center). 'He is very sick.' (Local hospital) will notify family." The (local hospital's) emergency room Report dated [DATE] stated in pertinent part: "- Chief complaint: difficulty breathing, respiratory distress. - History of present illness: . . . The patient's oxygen saturation was notably low at the nursing home facility. The patient's oxygen was recorded between 50%-80% on 3 liters nasal cannula . . . The patient's nurse noticed his nail beds to be blue and he had some perioral (around the mouth) cyanosis. She noticed inspiratory and expiratory wheezing on lung exam . . . - Physical Examination findings: Vital Signs: Blood pressure is ,[DATE], pulse 109, respirations 38, which is consistent with tachypnea (rapid breathing), temperature 98 and pulse oximetry of 79% on 12 liters nasal cannula, which is consistent with [MEDICAL CONDITION] . . . Cardiovascular: [MEDICAL CONDITION] (rapid pulse), regular rhythm . . . Respiratory: decreased breath sounds bilaterally - Final Diagnosis: [REDACTED]. . [MEDICAL CONDITION] exacerbation . . . - Condition: Stable, yet critical. - Emergency Department Course: . . . The patient will be transferred to (regional medical center) for further treatment . . ." Interviews The registered nurse (RN) who came on duty and wrote the progress note dated [DATE] at 6:15 a.m. (see above) was interviewed at 1:15 p.m. on [DATE]. When asked when would it be appropriate to notify the physician if a resident's oxygen saturations were dropping, the RN replied, "I would check the concentrator to make sure it was on and the connections were good, make sure 02 tubing wasn't kinked and titrate him to keep level greater than 90%; it depends on the patient, sometimes their normal is a little lower than that. If that was all good and it still was low I would call the doctor . . . Yes, those are my notes. The only other thing I remember is that we had to work hard to get 02 sats on him; we had to wrap his hands . . . No, we try to get one but we don't need a doctors order to call 911 . . . we do have to let them know though." The director of nursing (DON) was interviewed at 10:00 a.m. on [DATE]. She was asked to review the progress notes from the resident's admission on [DATE] to his discharge to the hospital on [DATE]. After reviewing them she was asked if she would have done anything different than her staff had done. The DON responded, "With those vital signs and the 02 sats I would have called the doctor at the time (of the fall) and definitely he should have been sent (to the hospital) between 1:00 and 3:00 a.m. . . . They (nursing staff) notified me on the form in the mornings . . . That's why I now want them (nursing staff) to notify me day or night." An attempt was made to interview the resident's physician on [DATE] at 10:42 a.m. A message was left requesting a return call. A return call was never received. Policy and Procedure The facility's policy on "Oxygen Administration" dated 2010 stated the following in pertinent part: "Purpose: To safely administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Policy: Oxygen administration will be carried out only with a physician's orders [REDACTED]. . ." "Procedure: 1. Check physician's orders [REDACTED]. . ." 2. Resident #51 Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for resident #51 revealed a physician order [REDACTED]. Record review for Resident #51 revealed no care plan related to oxygen saturation levels or monitoring for the resident on file. Record review for the [DATE] Treatment Administration Record (TAR) revealed multiple shifts not documenting any O2 sat levels. The [DATE] TAR also showed multiple shifts where the O2 sat level was either at 90% or only stated "RA" for room air, and no O2 sat levels monitored. Record review for the [DATE] TAR revealed multiple shifts not documenting any O2 sat levels. The [DATE] TAR also showed multiple shifts where the O2 sat level was either at 90% or only stated "RA" for room air, and no O2 sat levels monitored. Record review for the February 2012 TAR revealed multiple shifts not documenting any O2 sat levels. The February 2012 TAR also showed multiple shifts where the O2 sat level was either at 90% or only stated "RA" for room air, and no O2 sat levels monitored. Record review for the [DATE] TAR revealed multiple shifts not documenting any O2 sat levels. The [DATE] TAR also showed multiple shifts where the O2 sat level was either at 90% or only stated "RA" for room air, and no O2 sat levels monitored. Record review for the [DATE] TAR revealed multiple shifts not documenting any O2 sat levels. The [DATE] TAR also showed multiple shifts where the O2 sat level was either at 90% or only stated "RA" for room air, and no O2 sat levels monitored. 3. Resident #13 Resident #13 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Resident record review for resident #13 revealed a physician order [REDACTED]. This order was continued upon readmission on [DATE]. Record review of the [DATE] TAR revealed the physician order [REDACTED]. Record review of the [DATE] TAR showed the physician order [REDACTED]. Record review of the February 2012 TAR showed the physician order [REDACTED]. Record review of the [DATE] TAR showed the physician order [REDACTED]. Record review of Resident #13's care plan revealed concern for risks related to [MEDICAL CONDITION]. The goal specified was to improve health status and prevent the patient from having shortness of breath, chest pain, [MEDICAL CONDITION], or high blood pressure during their stay. The approaches included monitoring lung sounds daily and prn, monitor oxygen saturation levels every shift and prn, and to notify the physician of any significant changes. These care plan approaches were not followed as developed. 4. Resident #77 Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on [DATE]. A hospital discharge summary report on [DATE], provided to the facility during facility admission, stated "was also asked to keep her oxygen above 90% with 2 liters on a nasal cannula." Record review for resident #77 revealed a progress note on [DATE] that stated "suspected pneumonia." Record review for resident #77 revealed a progress note on [DATE] that stated "improving pneumonia." A physician order [REDACTED]." Record review for Resident #77 revealed no care plan related to oxygen saturation levels or monitoring for the resident on file. Record review of the [DATE] TAR revealed "oxygen at 2 liters nc to keep sats above 90%." Review on [DATE] revealed the resident receiving 3 liters of oxygen on the ,[DATE] shift. The order was discontinued after [DATE]. A new order was started on [DATE] which stated "titrate O2 to maintain sats above 90%." Multiple documentations on the [DATE] TAR revealed the resident given 2.5 liters with much documentation of 90% saturation levels. Record review of the February 2012 TAR revealed that the physician order [REDACTED]." Review of the February 2012 TAR showed multiple documentations of the resident receiving 1,1.5, 2.5, and 3 liters of oxygen. There was no documentation of oxygen saturation levels on [DATE] and [DATE] during the evening shift. Record review for resident #77 revealed a physician order [REDACTED]. Another physician order [REDACTED]." Record review of the February 2012 TAR also showed on [DATE] that the second shift was not documented. Record review for resident #77 revealed a physician order [REDACTED]." Interviews: An interview with a registered nurse (RN) on [DATE] at 12:44 p.m., revealed that the nurses titrate resident oxygen according to the physician order. When asked how the RNs would know what oxygen liter to put a resident on, the RN stated that they would start conservatively. "If they are at 87%, I'll start at about a liter." The RN stated they check oxygen levels once a shift. When asked about oxygen monitoring for residents with [MEDICAL CONDITION] the RN stated that they would provide oxygen to "the level of comfort." When asked if the RN felt it would be beneficial to have the physician set parameters for the residents' oxygen care, the RN stated she "would not feel more comfortable" and that "if it's very specific then you are more limited in what you can do." When the RN was asked how to determine a resident's baseline, the RN stated, "I don't know how to answer that." The RN was asked how they would handle it if a resident's oxygen saturation levels were dropping. The RN stated they "would go by the order to titrate it up to increase the liters per minute." When the RN was asked when they would inform the physician they stated "if it was a significant change to their norm," which the RN clarified as "if they are normally at 90% on 2 liters and then if they went to the mid 80's and couldn't titrate it back up. A lot depends on if the doctor wants to be called or not." When asked how they get the oxygen saturation levels for the residents, the RN stated that the CNAs are given a list to do assessments for residents on oxygen. When the RN was asked how the CNAs know when oxygen is low, the RN stated "I don't know how they know" and that the aides "know to bring it to me if less than 90%." An interview with a licensed practical nurse (LPN) on [DATE] at 1:02 p.m., revealed that "if they are at 90% or above, then it is okay. If they are below that we increase their oxygen until we get the saturation levels up again." When asked if the LPN had any training on titrating oxygen, the LPN stated "no." When asked if there was a limit on how much oxygen to give a resident with [MEDICAL CONDITION] the LPN stated, "I don't know. I would probably ask the doctor what limit they would like us not to exceed." When the LPN was asked if oxygen parameters would be beneficial, the LPN stated "I do." The LPN was asked what to do for a resident who had an order to stay above 90%, and what would they do if it dropped below 90%. How would they know what the baseline would be to get the resident back to 90%. The LPN stated "I don't have an answer to that one." The LPN was asked if a resident had dropping sats, when would they notify the physician? The LPN stated "if it was a continuous dropping in like maybe a day period with decreasing sats I would let the doctor know, so through 3 shifts." The LPN stated they try to get the CNAs to provide the oxygen levels for their residents by 10:00 a.m. and that they know that anything below 90% is considered low. The LPN stated that if a resident is documented as on room air they should also document the residents' oxygen saturation levels. An interview with a certified nursing assistant (CNA) on [DATE] at 9:38 a.m., revealed that the CNAs were handed vital sheets to check oxygen levels for the nurses. The CNA stated that they would tell the nurses right away of any concerns with resident oxygen if it was observed below 90%. The CNA stated the oxygen saturations for the residents was not normally found to be below 90%, but they would look for sleepiness as a symptom of low oxygen levels. 5. Resident #109 Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the [DATE] MDS, resident #109 was admitted to the facility from the hospital, had a BIMS (brief interview for mental status) score of 13 (cognitively intact). The resident required extensive assistance of two persons with bed mobility, transfers, and toilet use. He required set-up help and supervision for eating meals, had an indwelling catheter (including suprapubic), had a fracture other than hip, had a personal history of falling, height 74", weight 238 pounds, no pressure ulcers, received oxygen, and received Occupational and Physical Therapy services. Care Plan The Individual Resident Care Plan, which noted "Initiate within 24 hrs of admission," documented in part: "Oxygen 2 liters per minute." No other oxygen instructions were documented. Record Review Review of the hospital Physician Discharge Instructions/Progress Note dated [DATE] documented in part as follows: Oxygen - titrate to keep O2 sats > 90%. The [DATE] TAR in part read: Oxygen titrate to keep sat's > 90% every shift, dated [DATE]. Review of the [DATE] TAR revealed from ,[DATE]-,[DATE] there were 9 times out of 30 possible times the resident did not have an O2 sat level recorded; 3 times out of 30 possible times the O2 sat was 90%. (The physician order [REDACTED]. The [DATE] TAR revealed from ,[DATE]-,[DATE] there were 8 times out of 30 possible times that the resident did not have an O2 sat level documented, and 5 times that the resident had sat levels that were 90%. Review of the Progress Notes revealed in part: - [DATE] documented in part: resident had apical heart rate of 104 and regular, lungs noted to be coarse throughout bilaterally, resident was coughing, afebrile, resident expressed his lungs felt like they were burning, physician was notified by FAX. - [DATE] documented in part: resident expressed that he is still coughing at times but denies any production of mucous with the cough. - [DATE] documented in part: resident had clear lung sounds through out bilaterally, had slight dry cough without production, no oxygen demand, on room air and able to maintain O2 sats > 90%. - On [DATE] a FAX to the physician documented: Resident having increased cough and expressed his lungs burn, lung sounds were course, O2 sats > 90% on room air, no production with the cough, and no temperature. - A [DATE] FAX response from the Physician was noted: [MEDICATION NAME] treatments q 4 hrs prn for shortness of breath documented on the April TAR. The TAR was void of documentation to indicate the resident received a [MEDICATION NAME] inhalation treatment. Interview On the morning of [DATE], the staff medication nurse on the Rehab Hall was interviewed about resident #109 and his oxygen levels. The medication nurse expressed that resident #109 did not use his oxygen, his O2 sat levels had remained above 90% and was turned off. When the staff nurse was asked if the facility had a policy or guideline for discontinuation of oxygen and resident specific monitoring the staff nurse expressed he did not think there was a written policy, that it was nursing judgment on how often to monitor before and after turning off the oxygen. Review of the medical record revealed no evidence of physician orders [REDACTED].

Based on observations, record review, family interviews, and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for six (#59, #52, #36, #28, #43, and #38) of 41 sample residents. Specifically: -Resident #59's signs and symptoms of pain were not adequately addressed. The resident was observed in pain when staff was present; staff did not report or respond to the resident's pain. -Resident #52's skin tear was not reported, monitored, or treated appropriately. The skin tear became infected and caused the resident pain. -Resident #36's wheelchair positioning was not addressed in a timely manner. -Resident #28's seatbelt was not routinely assessed to ensure it was the most appropriate device and to ensure the resident was getting periods of release. -Resident #43's pacemaker was not adequately cared for. -Resident #38 did not receive adequate intervention to prevent self-injury from scratching. The findings include: 1. Resident #59 Resident #59, age 88, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of senile dementia, [MEDICAL CONDITION] with [MEDICAL CONDITION], and behavioral disturbance, anxiety, and [MEDICAL CONDITION]. The 11/23/10 annual minimum data set (MDS) assessment documented the resident was severely impaired with daily decision-making and had short- and long-term memory problems. She exhibited disorganized or incoherent thinking, poor appetite, and trouble concentrating. She also wandered and was resistive to care. The resident was usually able to make herself understood and usually able to understand others. She was independent with bed mobility and required limited assistance by one staff member with transfers and ambulation. She required extensive assistance with toilet use, personal hygiene, and dressing. The resident used a wheelchair as her primary mode of locomotion. She was continent of bowel and bladder. The resident did not experience pain and was not on a pain medication regimen. An 11/17/10 pain evaluation, the most recent evaluation in the record, documented the resident verbalized she was not in pain. a. Fall with fracture 12/17/10 A 12/17/10 progress note documented the resident had fallen onto her right side and was complaining of "very bad pain" near her pelvis. The resident was unable to move her right leg. She was transported to the hospital where she was admitted for a fractured pelvis. A 12/17/10 post fall assessment documented the resident had fallen on 12/17/10 in the dining room while getting up from her wheelchair. The resident sustained [REDACTED]. A 12/27/10, 3:30 p.m. progress note documented the resident was readmitted to the facility. On readmission, the resident complained of pain when assessed but was unable to offer more information due to her dementia. b. Pain management plan after fall with fracture (1) Orders 12/27/10: The computerized physician orders [REDACTED]. -[MEDICATION NAME], 5 milligrams (mg) to 10 mg every hour as needed; -[MEDICATION NAME], 5 mg four times daily -[MEDICATION NAME], 200 mg every day; -[MEDICATION NAME], 325 mg to 650 mg every four to six hours as needed 1/11/11: -A 1/10/11 progress note documented the resident was moaning in pain at 10:30 a.m., 11:45 a.m., and 2:00 p.m. All three instances, the nurse attempted to administer oral medications and the resident was combative, refusing to open her mouth and fighting attempts to administer medication. The note documented the resident's physician ordered a [MEDICATION NAME] as the resident was refusing oral medications. -A 1/11/11 physician's faxed order documented the following new pain medication order: [MEDICATION NAME], 12.5 micrograms (micrograms) applied every 72 hours. 1/14/11: A 1/14/11 physician's faxed order documented the resident was "comfort care." The corresponding 1/14/11 comfort measures care plan documented the resident had a terminal Diagnosis: [REDACTED]. The goal of the care plan was, "Less Physical Discomfort." The approaches included: assess for pain/discomfort, provide pain medications as ordered, hold medications for comfort, provide assistance with food and fluids, provide frequent repositioning, provide oral care every shift, and provide support to family and significant others. 1/24/11: -A 1/24/11 progress note documented the resident's family member requested her [MEDICATION NAME] dosage be "cut back and then discontinued." The resident continued using a [MEDICATION NAME]. -A 1/25/11 physician's faxed order documented an order to change the resident's [MEDICATION NAME] dosage from every hour as needed to every six to eight hours as needed in response to the family member's request on 1/24/11. (2) Pain evaluation Record review revealed no new pain evaluation in the resident's medical record after she was readmitted with a fractured pelvis 12/27/10. (3) Review of the pain assessment flow sheets revealed: 12/10: The 12/10 pain assessment flow sheet documented the resident had no verbal or non-verbal signs and symptoms of pain throughout the month until she returned from the hospital on [DATE]. From 12/27/10 to 12/31/10, the resident exhibited grimacing, moaning, verbal complaints of pelvic pain, and restlessness. 1/11: The 1/11 pain assessment flow sheet documented the resident exhibited verbal complaints of pelvic pain, moaning, restlessness, and grimacing almost daily, typically during the evening shift. (4) Progress Notes A 12/27/10, 8:37 p.m. progress note documented the resident was complaining of pain and received scheduled [MEDICATION NAME] and scheduled [MEDICATION NAME]. However, there was no documentation of the effectiveness of the medications. A 12/28/10, 1:47 a.m. progress note documented the resident was "groaning in pain" and "cried out in pain." The note documented as-needed [MEDICATION NAME] was administered, but did not document the effect. A 1/2/11 progress note documented the resident complained of pain and was administered [MEDICATION NAME]. However, the effectiveness was not documented. A 1/5/11 progress note documented the resident was moaning in pain and received pain medication. However, the effectiveness was not documented. A 1/8/11 progress note documented the resident's family reported she had "very poor pain control." The note documented, "Attempted to reassure family person this would be addressed." A 1/9/11 progress note documented the resident was moaning but denied pain. A 1/11/11 progress note documented the resident was moaning in pain and received [MEDICATION NAME] sulfate. There was no effectiveness documented. (Progress notes between 1/11 to 1/22/11 did not document pain, although, see below, the resident was receiving as-needed [MEDICATION NAME] during this time.) A 1/22/11 and 1/23/11 progress notes documented the resident was refusing medications. A 1/25/11 progress note written at 3:57 p.m. and 4:03 p.m. documented the resident was moaning and would not verbally respond when asked if she was in pain. The nurse attempted to administer scheduled [MEDICATION NAME] but the resident clenched her mouth and turned away. A 1/27/11 progress note documented the resident was moaning but refused to take liquid [MEDICATION NAME] sulfate. (4) Medication Administration Records (MARs) for 1/11 revealed: -The resident refused her scheduled [MEDICATION NAME] two to three times daily for most of the month. The resident did not receive any as-needed [MEDICATION NAME]. -The resident received one to two doses of as-needed [MEDICATION NAME] almost daily, and received up to four doses of 10 mg per day at times, until the order was changed on 1/25/11. Specifically: As-needed [MEDICATION NAME] was administered on 1/1/11 ( 3:30 a.m., 5:40 a.m., and 8:00 p.m.), 1/2/11 (1:45 a.m. and 2:15 p.m.), 1/3/11 ( 9:55 a.m.), 1/4/11 (1:20 a.m. and 6:15 p.m.), 1/5/11 (6:25 a.m. and 3:40 p.m.), 1/7/11 (5:30 p.m.), 1/8/11 (1:55 p.m. and 3:10 p.m.), 1/9/11 (1:20 a.m., 7:00 a.m., 9:45 a.m., and 9:00 p.m.), 1/10/11 (10:30 a.m., and 11:45 a.m.), 1/11/11 (9:45 a.m., 10:45 a.m., and 4:20 p.m.), 1/12/11 ( 7:00 a.m., 8:00 a.m., 1:00 p.m., and 5:00 p.m.), 1/13/11 (11:00 a.m.) 1/16/11 (8:10 a.m.), 1/18/11 (9:45 a.m.), 1/20/11 (10:15 a.m.), 1/21/11(12:35 p.m., 10:30 a.m. and 3:35 p.m.) and 1/23/11 (9:30 a.m.). -1/23/11 at 9:30 a.m. After 1/25/11, the resident received one dose of as-needed [MEDICATION NAME] on 1/26/11 (12:10 a.m.). c. Facility Failures (1) Observations of staff's failure to respond to the resident's pain. The resident resided on the facility's secure unit. Fourteen residents resided on the unit which was staffed by two certified nurse aides (CNAs). A licensed nurse was on the unit during medication pass. On 1/24/11 during lunch from 12:15 p.m. to 1:20 p.m., the resident was observed seated in her wheelchair at the assisted dining table. She was crying, whimpering, writhing, and moaning in her wheelchair throughout the meal. The resident refused to eat any food or drink. There were two certified nurse aides (CNAs) in the dining room during the meal, each assisting four residents to eat. The nurse was not in the dining room and had already passed noon medications. At one point, a CNA asked the resident, "Where do you hurt?" but did not fetch the nurse to ask her to assess the resident for pain. The resident sat at the table through the whole meal without eating until she was wheeled into the activity area at 1:20 p.m. The two CNAs then began to assist residents with toileting after the meal. Neither of them went to report the resident's signs of pain to the nurse. On 1/25/11 at 9:55 a.m., the resident was observed lying in bed with her arm on her forehead. She was moaning, crying, and writhing, but was unable to answer questions regarding whether she was in pain. The nurse was not in the secure unit at the time. The two CNAs were assisting residents with activities of daily living (ADLs). The CNAs were not observed to intervene when the resident was exhibiting these signs and symptoms of pain. On 1/25/11 at 10:40 a.m., the resident was observed lying in bed with a visitor holding her hand. She was crying, whimpering, and writhing while in bed. A CNA was in the resident's room assisting her roommate. The nurse was not in the unit. The CNA was not observed to intervene when the resident was exhibiting these signs and symptoms of pain. On 1/25/11 at 2:19 p.m., the resident was observed lying awake in bed. She was whimpering and writhing in the bed. The nurse was not in the secure unit. The CNAs were not observed to intervene when the resident was exhibiting these signs and symptoms of pain. On 1/26/11 from 8:30 a.m. to 11:30 a.m., the resident was lying in bed in her room. She would intermittently moan and cry while in bed without any staff interaction. The nurse was not observed in the secure unit during this time. The CNAs were not observed to intervene when the resident was exhibiting these signs and symptoms of pain. On 1/27/11 from 11:50 a.m. to 2:30 p.m., the resident was observed lying in bed awake with the music turned off. She was intermittently observed moaning, crying, and writhing while in bed. The nurse was not observed in the secure unit from 12:30 p.m. to 2:30 p.m. The CNAs were not observed to intervene when the resident was exhibiting these signs and symptoms of pain. (2) Record Review Review of the progress notes 1/24/11 to 1/27/11 revealed no documentation that either the resident's physician or the facility medical director was notified of the resident's signs of pain (moaning, crying, and writhing). Review of the progress notes 1/25/11 to 1/27/11 revealed no documentation that the resident was refusing pain medications, beginning 1/25/11. Review of the progress notes revealed no documentation that the resident's physician was made aware of her patterns of [MEDICATION NAME] use (more frequently than every six to eight hours - see above - on 1/1/11, 1/2/11, 1/4/11, 1/8/11, 1/9/11, 1/10/11, 1/11/11, 1/12/11, and 1/21/11) prior to the order to change the frequency of the [MEDICATION NAME] administration on 1/25/11. Review of the resident's care plan addressing the resident's pain, revised 1/24/11, documented the approaches: reposition the resident to eliminate pain, administer pain medication per physician orders, give as-needed medications for breakthrough pain and note the effectiveness, and look for non-verbal signs and symptoms of discomfort. The care plan did not direct staff to implement non-pharmacological approaches, such as ice, heat, massage, etc., to address the resident's breakthrough pain. Also, the care plan did not address interventions regarding the resident's refusal of oral medications. (3) Staff Interviews On 1/25/11 at 10:28 a.m., the resident's nurse (licensed practical nurse (LPN) #1) stated the resident was exhibiting signs and symptoms of pain, probably related to the pelvic fracture. She stated she attempted to administer pain medication to the resident, but the resident refused all oral medication. The LPN stated the resident's family had wanted to wean her off the [MEDICATION NAME], so there was "not a lot we can do." The nurse did not indicate she contacted the resident's physician or facility medical director to report the resident's refusal or signs and symptoms of pain. On 2/3/11 at 8:30 a.m., the director of nursing (DON) stated she had spent time with the resident's family member to educate her on the risks versus benefits of weaning the resident off [MEDICATION NAME]. At the family member's request, the physician had decreased the frequency of administration. -The DON stated the resident got to the point "last week" where she would not take any medications orally, so the routine [MEDICATION NAME] to address pain was continued. The DON stated she was unsure whether the resident's physician was contacted regarding the resident's refusal to take her scheduled oral pain medications and whether other routes of medication administration were attempted. -The DON stated the nurses conducted pain assessments once per shift during medication pass, documented on the pain assessment flow sheets (see above). She stated since the nurses were usually on the secure unit only during routine medication pass, the CNAs were expected to report any signs and symptoms of pain to the nurses for further assessment. The DON confirmed as-needed pain medications would not usually be administered unless the CNAs fetched a nurse because they noticed signs and symptoms of breakthrough pain. She stated when the resident was observed crying, moaning, writhing, and whimpering, the CNAs should have asked the nurse to assess the resident for need of pain interventions. On 2/3/11 at 9:57 a.m., the physician filling in for the resident's primary physician stated his practice was alerted by fax when the resident refused medication. He stated he was unsure whether different pain medication routes, other than oral, were tried. The physician stated he was not personally alerted to the resident ' s signs and symptoms of pain from 1/24/11 to 1/27/11, such as crying, moaning, and writhing. On 2/3/11 at 2:30 p.m., in a follow-up interview, the physician filling in for the resident's primary physician stated his office had been alerted to the resident's signs and symptoms of pain. However, there was no documentation in the progress notes of physician contact, physician response, or facility follow-up with the physician's office. Moreover, there was no documentation that the facility medical director was contacted about the resident's unrelieved pain. 2. Resident #52 Resident #52, age 89, was admitted to the facility's secure unit on 10/27/08 with diagnoses, according to the face sheet, of senile dementia, hypertension, [MEDICAL CONDITION] obstruction, depression, [MEDICAL CONDITION], and [MEDICAL CONDITION] reflux. The 1/7/11 significant change MDS assessment documented the resident had memory problems and severely impaired with daily decision-making. She was able to make herself understood and usually understood others. The resident required extensive assistance with transfers, dressing, toilet use, and personal hygiene. The resident had a non-pressure wound. A 9/3/10 care plan addressing the resident's risk for skin breakdown documented the pertinent approaches: evaluate the resident's skin daily, encourage the resident to reposition frequently for skin protection, and the resident was "independent with mobility and repositioning." a. 12/27/11 Skin Tear (1) Record Review A 12/27/10 progress note documented, "(Certified nurse aides) heard the piano and another resident holler for help. (The resident) was noted to be sitting on the floor with her (right) leg straight out and her (left) leg bent in. She was assessed ... to have a skin tear on her (right) arm below the elbow 4 (by) 5 cm (centimeters). It was cleaned with (saline), as much of the skin as possible pulled back over and 5 steri-strips were applied with (antibacterial ointment) and then covered with a water-resistant dressing ...(Two) Tylenol were given for pain. The resident was cooperative and tolerated the procedure with no complaints." There were no progress notes or skin assessments in the resident's record addressing the skin tear to the right arm from 12/27/10 to 1/3/11. There was no evidence an incident report was completed on 12/27/10 when the wound was first observed. A 1/3/11 physician's progress note documented the resident "complains of right forearm hurting. (Resident) does not know how this happened." The note documented the resident had a 4.5 cm long by 0.75 cm wide laceration on her right forearm and a wound infection with greenish exudate. The wound had slight induration and [DIAGNOSES REDACTED] extending outward approximately 3 cm from the wound and was tender. The steri-strips over the wound were "saturated and not attached to skin." The overlying gauze dressing was "marked 12/29/10 (6 days old)." The physician called the facility and spoke to the supervising nurse. The resident was prescribed Keflex, 500 milligrams, four times daily for seven days to treat the wound infection. A 1/3/11 progress note documented, "Received telephone call from (resident's physician regarding) resident who is at her office today. States resident has dressing on right forearm which is dated 12-29-10. States wound is (filled with pus), bleeding, and indurated. Steri-strips in place and then coming off. States wound has been forgotten and she is upset. Would like to know how wound became forgotten and why not monitored. Sending (the resident) back on antibiotics. No skin sheet found on resident. Will talk with nurse involved. Talked with CNAs and stated she fell off stool 12-29-10 and obtained skin tear right forearm. Bruising noted between 2nd and 3rd fingers right hand. fell on evening shift." A 1/3/11 non-pressure skin condition record was filled out, and documented the resident received a 4 centimeter (cm) long by 5 cm wide skin tear to her right arm below the elbow. The record documented the onset of the skin tear was 1/3/11, though progress notes (above) identified the wound on 12/27/10. An undated acute care plan addressing a skin tear to the resident's right arm documented the approaches: clean the area, monitor the wound for infection, monitor the site daily, document the wound's progress on the Medication Administration Record, [REDACTED] A 1/3/11 physician's telephone order (TO) documented an order to treat the resident's right forearm wound with a wet to dry wound dressing change twice daily until the wound was well-healed. (2) Staff Interviews On 2/2/11 at 11:15 a.m., the director of nursing (DON) stated a skin sheet in the MAR indicated [REDACTED]. She stated the 12/27/10 skin tear should have been documented on the skin sheet on 12/27/10, when the skin tear was found. The DON stated there was no investigation done into the lack of wound care identified by the resident's physician and said, "I can't tell you why she didn't (change the dressing)." She stated the nurse responsible for caring for the skin tear between 12/27/10 and 1/3/11 did not receive any counseling or education on proper treatment of [REDACTED]. The DON stated she was not in the facility between 12/27/10 and 1/3/11, so she did not know about the skin tear at the time. On 2/2/11 at 2:15 p.m., the staff development coordinator (SDC) stated there was no further information regarding the skin tear the resident sustained [REDACTED]. The SDC stated the nurse should have been provided one-to-one counseling to prevent the incident from recurring. On 2/3/11 at 1:37 p.m., the resident ' s physician stated she planned to write a letter to the facility's medical director regarding the facility ' s failure to adequately treat the resident ' s skin tear, but she had not had time yet. She stated she had called and spoke with the nurse supervisor on 1/3/11. The physician stated, "I told her I was very unhappy and this could not happen. I said they needed to figure out why that happened. I don ' t know if they followed up, I haven't heard anything. I was really mad. The bandage was six days old. They probably forgot about it." Cross-reference F157: Notification of Change - The facility failed to notify the physician of the resident's injury. b. Skin Tear Observed 1/25/11 (1) Observations On 1/25/11 at 9:06 a.m. and 1/26/11 at 10:13 a.m., the resident was observed with an approximately one-inch long skin tear over a large circular bruise on her right wrist. On 1/25/11 at 9:06 a.m., the resident was holding her wrist and stated it hurt. (2) Record Review There was no non-pressure skin record in the resident's medical chart addressing a skin tear to her right wrist. Review of the medical record revealed no documentation of the skin tear. The resident body audit documented the resident received a full body skin audit and bath on 1/24/11 and 1/29/11. The 1/24/11 audit documented the resident complained of pain to her right arm, but did not document a skin tear or bruise. The audit documented, "Skin ok." The 1/29/11 audit documented the resident had old bruises on her left arm, but did not document a skin tear or bruise on the right arm. c. Staff Interviews On 2/2/11 at 8:52 a.m., the licensed practical nurse (LPN) #1 stated she was unaware of a skin tear to the resident's right wrist. On 2/2/11 at 11:00 a.m., the LPN #1 was observed, with the resident's permission, as she treated the resident's skin tear on the right wrist. The skin tear was scabbed and the bruise had faded somewhat. The LPN asked the resident if she knew what had happened, but the resident said "no." The LPN stated she had not seen or known about the skin tear before today. The nurse cleaned the skin tear, and then applied antibiotic ointment and a bandage. During the treatment, the resident stated the skin tear hurt. On 2/2/11 at 12:34 p.m., the DON stated LPN #1 denied seeing the skin tear on the resident's wrist last week. She stated she was unable to find any documentation regarding the skin tear. The DON stated an incident report should have been completed, a skin sheet should have been initiated, the resident's physician and family should have been notified, and an investigation into the origin of the injury should have been conducted. On 2/3/11 at 1:37 p.m. the resident's physician stated she was aware of the skin tear on the resident ' s right wrist because she noticed it during a visit on 2/1/11. 3. Resident #36 Resident #36, age 79, was admitted to the facility's secure unit on 5/16/07 with diagnoses, according to the face sheet, of [MEDICAL CONDITIONS], convulsions, dementia with behavioral disturbance, [MEDICAL CONDITION] disease, [MEDICAL CONDITION], and panic disorder. The 12/23/10 quarterly MDS assessment documented the resident had short- and long-term memory problems and severely impaired decision-making skills. She was usually able to make herself understood and usually able to understand others. The resident did not exhibit any behavioral symptoms, but exhibited a depressed appearance and little energy. She required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, and personal hygiene. The resident received a mechanically-altered diet. a. Record Review A 10/27/10 care plan documented the resident required total assistance with activities of daily living (ADLs) related to dementia and limited mobility. The approaches included: assist the resident to use the toilet, reposition the resident every two hours, assist the resident with bathing and dressing, and provide total assistance with transfers. A hand-written approach, dated 1/25/11, documented "Neck support per husband's request." The care plan did not address the resident's tendency to lean to the side (cross-reference F279: Comprehensive Plan of Care). A 4/5/10 referral for resident change documented the resident was leaning to the side in her wheelchair. A note at the bottom documented the resident was placed in a high-back wheelchair and the resident was sitting well in the wheelchair. It also documented, "Will monitor via nursing for further needs." A 10/4/10 physician's note documented the resident was seen sitting in her wheelchair, "slumped to the right." A 12/7/10 physician's note documented the resident was frail and was seen sitting in a wheelchair, leaning to the left. A 12/28/10 care conference summary documented, "We have concerns about (the resident) leaning in the (wheelchair), her necks (sic) appears to be uncomfortable. Will have OT (occupational therapy) do eval(uation) on her chair (and) leaning." There was no evidence of an OT evaluation following the 12/28/10 care conference. A 1/25/11 physician communication form documented, "No head control (and) leans to side (with) sitting in (wheelchair)." The physician ordered an OT consult. A 1/25/11 TO documented an order for [REDACTED]. b. Observations On 1/24/11 from 12:15 p.m. to 1:15 p.m., the resident was observed during lunch. She was leaning to the right in her wheelchair. Staff began to assist the resident to eat but did not reposition her or provide devices to aid in positioning. The resident was assisted by a CNA to eat, but only ate bites of food. The resident's family member came into the dining room at 12:50 p.m. carrying a bolster and neck support. He placed the bolster in the right side of the wheelchair and neck support on the resident's neck. The resident was seated upright, and began to eat more food as the family member fed her. On 1/25/11 at 8:30 a.m., the resident was observed in the activity area on the secure unit seated in her wheelchair. She did not have the neck support on. -During dinner on 1/26/11 from 5:30 p.m. to 6:30 p.m., the resident did not have her neck support on. Her head was leaning to the right at approximately a 60 degree (?) angle. The neck brace was hanging on the back of the wheelchair. The resident was fed by a CNA, but the neck support was never applied and the resident was never repositioned. -After dinner, the resident was wheeled in front of the television. She remained seated there in her wheelchair with her head leaning to the right, without the neck support on. During breakfast on 1/27/11 beginning at 7:20 a.m., the resident was observed seated at the dining table in her wheelchair. She did not have her neck support on, and her head was leaning to the right at approximately a 60? angle. At 7:45 a.m., the resident was assisted to eat by a CNA. The CNA did not attempt to reposition the resident or apply the neck support. On 1/27/10 from 11:15 a.m. to 12:15 p.m., the resident was observed seated in her wheelchair with the neck support on. She was not leaning to the side. c. Family Interview On 1/25/11 at 11:58 a.m., the resident's family member stated the resident often leaned to the side while seated in her wheelchair, making her uncomfortable and making it hard for her to eat. He stated he asked the facility about the resident's positioning, but nothing was done, so he provided a bolster and a neck support for the resident to use. The family member stated when he came in "yesterday" and found the bolster and neck support had not been applied to the resident and her wheelchair, he was very upset. He stated as long as he was there, she was positioned correctly, but he was worried about what happened when he was not there. The resident's family member stated he would like the resident to wear the neck support and use the bolster at all times while in her wheelchair when he was not visiting. d. Staff Interviews On 1/27/11 at 12:30 p.m., the resident's hospice nurse stated the resident had been leaning in her wheelchair for approximately four to six months now. She stated the resident had a wedge cushion for pressure relief, but did not have any positioning devices. The nurse stated the resident was no longer able to hold her own head up straight. On 1/27/11 at 2:15 p.m., the SDC stated she did not know if any changes were made to the resident's seating other than the high-backed wheelchair on 4/5/10. She stated the resident's husband had just brought the neck support in "this week" and he would like her to wear it all the time in the wheelchair. She stated therapy staff agreed the neck support was beneficial to the resident. On 1/27/11 at 2:28 p.m., the OT stated the resident had not been seen by the therapy department prior to the evaluation on 1/25/11. He stated the resident was evaluated and a request was sent to hospice for orders to treat the resident. On 1/27/11 at 4:35 p.m., the SDC stated during a hospice and interdisciplinary care conference on 12/28/10 (see above), the team discussed obtaining an OT evaluation for the resident's wheelchair positioning. She stated the evaluation never occurred after the 12/28/10 meeting until it was ordered on [DATE], but was unsure why it was not ordered in a timely manner. On 2/2/11 at 9:46 a.m., the OT stated the therapy staff usually did not attend care conference meetings unless the resident was already on the therapy case load. He stated the therapy department did not receive information from the care conference meeting on 12/28/10 regarding an OT evaluation for the resident. The OT stated after the care conference, hospice staff would have to write an order for [REDACTED]. 4. Resident #28 Resident #28, age 81, was admitted to the facility on [DATE] with diagnoses, according to the computerized [DIAGNOSES REDACTED]. The 12/16/10 quarterly minimum data set (MDS) assessment documented the resident was moderately impaired with daily decision-making. She was usually able to make herself understood and usually able to understand others. The resident was independent with mobility and transfers. She used a wheelchair as her primary mode of locomotion. The resident exhibited physical behaviors toward other residents and staff, resisted care, exhibited behavioral symptoms not directed at others, and wandered. a. Observations On 1/26/11 at 10:40 a.m., the activity director (AD) and activity assistant (AA) began a balloon toss activity. The resident was participating in the activity with a seatbelt on, though the AD and AA were standing near her, leading the activity. They did not offer to remove the seatbelt during the activity. At 11:00 a.m., the AD began a seated exercise group. The resident was in the group; her seatbelt remained fastened. During dinner on 1/26/11 from 5:30 p.m. to 6:30 p.m., the resident's seatbelt was on during the whole meal. Staff did not offer to remove it. During bre

Based on observations, record review, and staff interviews, the facility failed to immediately consult with the physician of one (#52) out of 41 sample residents when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention. Specifically, the resident's physician was not notified of two skin tears in a timely manner, one of which became infected before the physician became aware of it. The findings include: Resident #52, age 89, was admitted to the facility's secure unit on 10/27/08 with diagnoses, according to the face sheet, of senile dementia, hypertension, [MEDICAL CONDITION] obstruction, depression, [MEDICAL CONDITION], and [MEDICAL CONDITION] reflux. The 1/7/11 significant change minimum data set (MDS) assessment documented the resident had memory problems and was severely impaired with daily decision-making. She was able to make herself understood and usually understood others. The resident required extensive assistance with transfers, dressing, toilet use, and personal hygiene. The resident had a non-pressure wound. A 9/3/10 care plan addressing the resident's risk for skin breakdown documented the pertinent approaches: evaluate the resident's skin daily, encourage the resident to reposition frequently for skin protection, and the resident was "independent with mobility and repositioning." 1. 12/27/11 Skin Tear a. Record Review A 12/27/10 progress note documented, "(Certified nurse aides) heard the piano and another resident holler for help. (The resident) was noted to be sitting on the floor with her (right) leg straight out and her (left) leg bent in. She was assessed...to have a skin tear on her (right) arm below the elbow 4 (by) 5 cm (centimeters). It was cleaned with (saline), as much of the skin as possible pulled back over and 5 steri-strips were applied with (antibacterial ointment) and then covered with a water-resistant dressing...(Two) Tylenol were given for pain. The resident was cooperative and tolerated the procedure with no complaints." There were no progress notes or skin assessments in the resident's record addressing the skin tear to the right arm from 12/27/10 to 1/3/11. There was no evidence an incident report was completed on 12/27/10 when the wound was first observed. A 1/3/11 physician's progress note documented the resident "complains of right forearm hurting. (Resident) does not know how this happened." The note documented the resident had a 4.5 cm long by 0.75 cm wide laceration on her right forearm and a wound infection with greenish exudate. The wound had slight induration and [DIAGNOSES REDACTED] extending outward approximately 3 cm from the wound and was tender. The steri-strips over the wound were "saturated and not attached to skin." The overlying gauze dressing was "marked 12/29/10 (6 days old)." The physician called the facility and spoke to the supervising nurse. The resident was prescribed Keflex, 500 milligrams, four times daily for seven days to treat the wound infection. A 1/3/11 progress note documented, "Received telephone call from (resident's physician regarding) resident who is at her office today. States resident has dressing on right forearm which is dated 12-29-10. States wound is (filled with pus), bleeding, and indurated. Steri-strips in place and then coming off. States wound has been forgotten and she is upset. Would like to know how wound became forgotten and why not monitored. Sending (the resident) back on antibiotics. No skin sheet found on resident. Will talk with nurse involved. Talked with CNAs and stated she fell off stool 12-29-10 and obtained skin tear right forearm. Bruising noted between 2nd and 3rd fingers right hand. fell on evening shift." A 1/3/11 physician's telephone order (TO) documented an order to treat the resident's right forearm wound with a wet to dry wound dressing change twice daily until the wound was well-healed. b. Staff Interviews On 2/2/11 at 11:15 a.m., the director of nursing (DON) stated the skin tear should have been documented on 12/27/10, when it was first found, on a non-pressure skin issue record. She stated the resident's physician should have been notified immediately of the skin tear for treatment orders, if necessary. On 2/2/11 at 2:15 p.m., the staff development coordinator (SDC) stated there was no documentation the resident's physician had been notified of the skin tear first observed on 12/27/10. On 2/3/11 at 1:37 p.m., the resident's physician stated she first learned of the resident's skin tear on 1/3/11 during an office visit with the resident. She stated the resident complained of her arm hurting, and she looked at the arm and found the skin tear covered with a dirty, six-day-old bandage and infected. She stated she had not received notification from the facility between 12/27/10 and 1/3/11 regarding the injury. The physician stated, "I would expect they would at least call or fax to let me know. This is unacceptable." 2. Skin Tear Observed 1/25/11 a. Observations On 1/25/11 at 9:06 a.m. and 1/26/11 at 10:13 a.m., the resident was observed with an approximately one-inch long skin tear over a large circular bruise on her right wrist. On 1/25/11 at 9:06 a.m., the resident was holding her wrist and stated it hurt. b. Record Review There was no non-pressure skin record in the resident's medical chart addressing a skin tear to her right wrist. Review of the medical record revealed no documentation of the skin tear. c. Staff Interviews On 2/2/11 at 8:52 a.m., the licensed practical nurse (LPN) #1 stated she was unaware of a skin tear to the resident's right wrist. On 2/2/11 at 12:34 p.m., the DON stated LPN #1 denied seeing the skin tear on the resident's wrist last week. She stated she was unable to find any documentation regarding the skin tear. The DON stated an incident report should have been completed, a skin sheet should have been initiated, the resident's physician and family should have been notified, and an investigation into the origin of the injury should have been conducted. On 2/3/11 at 1:37 p.m. the resident's physician stated she was aware of the skin tear on the resident's right wrist only because she noticed it during a visit on 2/1/11. She stated she was not notified by the facility of the skin tear prior to 2/2/11.

Based on observations, staff interviews and record review, the facility failed to provide adequate pressure ulcer prevention and management to prevent the development and promote healing of a pressure ulcer for one of 41 sample residents (#97). Specifically, resident #97 was at risk for pressure and shearing to his left foot when he would use a trapeze bar to reposition himself in the bed. The facility failed to identify the resident's risk and assess, monitor, and implement timely interventions to ensure pressure relief to the resident's left heel. These failures contributed to the resident's development of an unstagable (Stage IV) left heel ulcer. The findings include: Resident #97, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Status on admission Resident #97's Minimum Data Set ((MDS) dated [DATE], documented in part as follows: Brief Interview for Mental Status (BIMS) was scored 11/moderate cognitive impairment, short- and long-term memory no problems, had appetite problem, moderate depression, weight 158 pounds (his ideal body weight was 161-195 according to the facility Nutrition History Form), no pressure ulcers, not a risk for pressure ulcers, frequently had pain, no fall since admission, required setup and supervision for eating, required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was continent and had a Foley catheter. The resident's care plan care dated 12/15/10 documented in part as follows: Bed alarm, special air mattress, reposition every two hours, meal assistance independent, assist with bed mobility and repositioning. The Braden Scale dated 12/22/10 documented the Braden score risk of 15 points with a score of 15 - 18 points being a mild risk. Review of the facility Body Audit dated 12/15/10 documented foot, toes, and heel clear and intact. 2. Weight loss and Skin breakdown after Admission a. Weight loss - Cross-reference F325; nutrition, for further details. Review of the resident's vital sign sheet revealed the resident's weights were documented as follows: 12/15/10=162.5, 12/16/10=162.3, 12/17/10=158.4, 12/31/10=149.2, 1/10/11=144.6, 1/18/11=143.5, No weights documented on 1/19/11 through 2/1/11. However, at the surveyor's request, the resident was weighed on 2/2/11. Resident #97's weight on 2/2/11 was 138.9 pounds. Review of the Medication and Treatment records revealed orders for fortified strawberry shake twice per day was ordered on [DATE] and the resident was taking 100% daily. Review of the resident's meal intakes for 12/10 and 1/11 revealed multiple meals refused and poor intake at most meals. (Cross-refer F325; nutrition, for more details.) On 1/25/11 the progress note related to nutritional follow up documented in part: "resident loves the homemade fortified milkshakes and takes them well, dietary will offer milkshakes up to three times per day if resident prefers, dietary to continue to offer favorite foods, nursing monitoring area of left heel, continue with nutrition plan of care and routine monitoring." b. Skin breakdown Review of a FAX notification (for your information) to the physician dated 1/21/11, documented resident had approximately 1.2 cm round red area on his left heel. Will float heels and monitor, the physician signature was dated 1/25/11 without new physician orders. Record review revealed the facility developed a care plan related to skin 1/24/11. It read: -Problem/Focus - Risk for skin breakdown related to decreased mobility and disease process. -Goal - Resident will have intact skin, free of redness, blisters or discoloration through next review date -Interventions/approaches - Resident to use trapeze bar, and U-bar to assist with turning, turn and reposition every two hours and more often as needed, moisturizer to skin. Review of physician orders [REDACTED]. Record review also revealed an unsigned acute care plan that read: -Problem - Old blood blister on left heel. -Goal - Skin problem to be resolved and/or reduced in size within 14 days. Approach - Monitor site every shift and the dressing treat per physician orders, wound pressure sheet, wound team evaluate weekly on wound rounds, float heel, bootie on in bed and recliner. Although the acute care plan was undated, the reference in the plan to "dressing treat per physician orders" indicated the acute care plan was developed on or after 1/27/11, the date of the treatment orders (see above). 3. Observations On the evening of 1/27/11, the resident's wound was observed with the assistance of staff. The resident was observed while in his bed; above his bed was a trapeze bar for positioning. A dark red area, slightly smaller than a dime size, was observed on the bottom of the resident's left heel. A large purple bruise on the instep of resident's left foot approximately 4 x 4 inches and covering most of the instep area of his left foot also was observed. The staff present expressed she did not know how he got the bruise or reddened area. On 2/2/11 at 9:40 a.m., resident #97 was observed in bed with the head of the bed up and the breakfast tray was on the bedside table in front of him. The resident was leaning toward his right side; his left leg was on a flat bed pillow and the rubber foam bootie on his left foot pressed into the air mattress. The resident's heel was not being floated. On 2/2/11 at 10:00 a.m. resident #97 was observed again. He remained in bed with his left leg on a flat bed pillow with his rubber foam bootie pressed into the air mattress. On 2/2/11 at 2:30 p.m., the nurse was observed during wound measurements and dressing change. The nurse removed the rubber foam bootie. At this time, the resident's left leg and foot were over the bed pillow and his left heel was slightly above the mattress. The bruise over the left foot instep area (see above) was still visible. The nurse measured the heel wound to be a round black area, unstagable, measuring 1.2 cm. The nurse cleaned the area and applied [MEDICATION NAME] dressing, and applied a new air filled "non-pressure" bootie (per the nurse) to the resident's left foot. According to MDS Assessment 3.0, Section 0700, black tissue on a wound is staged as a Stage IV wound. 4. Facility Failures a. Failure to timely address the resident's risk of skin breakdown. Record review revealed the facility failed to develop a care plan to address the resident's risk for skin breakdown until after a blood blister had developed on the resident's left heel (see care plans above). Although the resident's Braden Scale for pressure sore risk documented he was at mild risk for breakdown, there was no indication that staff considered the risk imposed by the resident's right knee amputation. The Director of Nursing (DON) stated during an interview on 1/27/11 in the evening that because the resident has only one foot and was an above the knee [MEDICAL CONDITION] (AKA) on the right side, he used the left foot to reposition and push up in his bed, creating the potential for sheering and pressure on his left heel. Review of the resident's skin care plan dated 1/24/11 revealed it did not incorporate the interventions (float heel and bootie) noted on the acute care plan in order to ensure consistent implementation of pressure relieving interventions. Moreover, there was no direction in the care plan for staff to monitor to ensure the resident's heel was floated. The resident used the trapeze bar to reposition. To float his heel on a bed pillow required staff intervention to reposition the pillow each time he used the trapeze bar. Review of the resident's skin care plan dated 1/24/11 revealed it failed to address the risk imposed by the resident's weight loss. b. Failure to implement pressure relieving measures. See observations above; there was no documentation that staff was monitoring the resident's left heel every shift. The nurse, during wound observation on 1/27/11, stated she was unaware of the red area and the bruise covering the resident's instep. See observations above; the resident's heels were not being floated, as ordered, when observed on 2/2/11. 5. Interviews On the evening of 1/27/11, the DON was interviewed about the pressure sore and bruise on resident #97's left foot. -The DON expressed she did not think he had a pressure ulcer and she would look into the issue. Later that evening the DON said she did look at resident #97's left foot and it looked like an old blood blister. -The DON said she also had observed the bruise on resident #97's left foot instep area. The DON expressed that she had assessed it for soreness and the resident said it was not sore to the touch. -The DON at 4:35 p.m., said she had called the resident's wife and the wife did not know about the bruise on the resident's foot and did not know how it happened. The DON expressed that the physician was notified about the bruise and that an investigation had been started.

Based on observation, interviews and record review, the facility failed to ensure one of 41 sample residents (#97) maintained acceptable parameters of nutritional status. Specifically: Resident #97 experienced a significant, unplanned weight loss after admission. Although the facility recognized the resident's weight loss, no nutritional plan was developed that identified the resident's weight loss and preferences and no interventions were developed to ensure the resident received his food preferences and that staff consistently assisted, cued and encouraged the resident to eat and drink. These failures contributed to the resident's weight loss. The findings included: Resident #97, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Status on admission Resident #97's Minimum Data Set ((MDS) dated [DATE], documented in part as follows: Brief Interview for Mental Status (BIMS) was scored 11/moderate cognitive impairment, short- and long-term memory no problems, had appetite problem, moderate depression, weight 158 pounds, no pressure ulcers, not a risk for pressure ulcers, frequently had pain, no fall since admission, required setup and supervision for eating, required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the Hospital 12/10/10 History and Physical and the facility 12/14/10 Discharge Plan, resident #97 was admitted to the facility from the hospital after a fall at home where he was living with his wife. He came to the facility for rehabilitation services and pain control with discharge plan to return home with his wife. The Nutrition History Form dated 12/17/10 documented, in part: ideal weight range 161-195 pounds, admit weight 158.4, diet order for regular, no recent weight loss or gain, wears dentures, dentures fit properly, no chewing or swallowing problems, appetite fair, prefers regular size food portions, resident expressed he was a meat and potato person and was not picky, likes most foods. On 12/21/10 the facility Nutritional Full Assessment documented, in part: Resident #97's appetite fairly good, staff to routinely encourage food and fluid intake, continue nutrition plan of care and routine monitoring. 2. Weight loss - poor intakes after admission Review of the resident's vital sign sheet revealed the resident's weights were documented as follows: 12/15/10=162.5 (first recorded weight), 12/16/10=162.3, 12/17/10=158.4, 12/31/10=149.2, 1/10/11=144.6, 1/18/11=143.5, No weights documented on 1/19/11 through 2/1/11. However, at the surveyor's request, the resident was weighed on 2/2/11. Resident #97's weight on 2/2/11 was 138.9 pounds, a loss of 23.6 pounds since admission 12/15/10. Review of the December 2010 and January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An antidepressant was started 1/5/11. He was not receiving any diuretics. Review of resident #97's January 2011 intakes documented three meals daily breakfast, lunch, and dinner (93 meals total). No intake/refusals were documented for many meals. The documentation read: 1/1/11= 50%, 50%, 25%, 1/2/11 = 100%, 50%, 0% 1/3/11 = 0%, 0%, 50% 1/4/11 = 0%, 0%, 0%, 1/5/11 = 0%, 0%, 50%, 1/6/11 = 0%, 0%, 50%, 1/7/11 = 50%, 0%, 0%, 1/8/11 = 50%, 0%, 0%, 1/9/11 = 50%, 0%, 0%, 1/10/11 = 0%, 100%, 0%, 1/11/11 = 50%, 0%, 0%, 1/12/11 = 15%, 50%, 0%, 1/13/11 = 25%, 50%, 0%, 1/14/11 = 100%, 50%, 0%, 1/15/11 =0%, 0%, 0%, 1/16/11 =0%, 75%, 0%, 1/17/11 = 10%, 0%, 0%, 1/18/11 = 20%, 0%, 0%, 1/19/11 = 50%, 0%, 0%, 1/20/11 = 25%, 50%, 0% 1/21/11 = 25%, 50%, 0%, 1/22/11 = 0%, 0%, 0%, 1/23/11 = 75%, 0%, 75%, 1/24/11 =100%, 0%, 0%, 1/25/11 = 0%, 0%, 0%, 1/26/11 = 0%, 0%, 0%, 1/27/11 = 50%, 0%, 0%, 1/28/11 = 75%, 100%, 0%, 1/29/11 = 0%, 0%, 0%, 1/30/11 = 100%, 30%, 50%, 1/31/11 = 100%, 30%, 50%, Record of intakes of the milkshake twice per day documented 100% intake from 1/12/11 through end of the month. 3. Facility Response to Weight Loss Review of the progress note related to nutritional follow up dated 1/11/11, documented, in part, as follows: -Resident with recent decline in oral intake, resident admitted under hospice care as of 1/5/11, resident [MEDICATION NAME] on 12/28/10 was 3.8 (within normal limits), resident with [MEDICAL CONDITION] improvement since admission, resident with noted weight decrease, staff to routinely monitor resident's tolerance of regular diet/regular texture and refer any problems appropriately, staff to provide assistance with meals and encouragement as needed, staff to encourage fluids and oral intake as appropriate while honoring residents wishes for hospice care, resident claims his appetite is not the best, discussed the option for Ensure or homemade fortified shakes with the resident, resident claims Ensure is okay but would prefer homemade fortified ice cream shakes. Dietitian discussed resident with dietary manager and resident had already been moved to an assist table for minimum assist as needed and maximum encouragement, continue multiple vitamin supplement and continue nutrition plan of care and routine monitoring. Review of the Dietitian notes dated 1/25/11, documented the resident's weight on 1/18/11=143.5 pounds down 1.1 lbs in past 8 days, resident continues on hospice care, resident loves the supplemental ice cream fortified milkshakes, taking these well, resident primarily eats in his room with average intakes 51-100% at meals, desire dietary to continue to offer favorite foods, nursing monitoring red 1.2 cm circular area of left heel, no open area reported at present, nursing to monitor skin routinely and refer any problems appropriately, continue with nutritional plan of care and routine monitoring. 4. Observations On 2/2/11 at 9:40 a.m. resident #97 was in his room, in bed. The head of the bed was up and there was an over-the-bed table in place in front of the resident with his breakfast tray on the bedside table. The food tray had three sausage links, two pieces of toast, coffee, milk, bowl of cereal/cheerios. -The resident was sitting in bed leaning to his right side. He had a spoon in his right hand and had not eaten the food. When asked if he needed some help, the resident said, "I need my teeth. I have already asked three times (for them)." -The certified nurse aide (CNA) came into the room and said to the surveyor that the resident refused to go into the main dining room for breakfast. The resident told the CNA, "I need my teeth," and the CNA went to the sink to get the dentures. -At 10:00 a.m. the resident was observed again in his room. He was eating his cereal, but not his sausage. The CNA was in the room assisting resident #97's roommate. The CNA was not overheard encouraging resident #97 to eat. 4. Facility failures in addressing weight loss Even though nutritional progress notes and dietitian notes revealed resident preferences and a number of directives for staff (see above: To monitor resident's tolerance of regular diet/regular texture; to provide assistance with meals and encouragement as needed; to encourage fluids and oral intake as appropriate while honoring residents; to offer favorite foods, to seat at the assist table), review of the medical record revealed the record void of a nutritional care plan to ensure staff offered these identified preferences and consistently implemented these interventions. Moreover, documentation revealed resident #97 came out of his room to the main dining area for his meal for 14 meals out of the 93 meals served, thereby frequently missing staff cueing and encouragement to eat the meals and drink fluids served. See observations above; resident statements indicated staff failed to provide the resident the set up necessary to promote meal and fluid intake. 5. Interview On 2/2/11 resident's wife was in room visiting during the noon meal and expressed that the resident had lost weight and the resident's leg prothesis no longer fit. The wife expressed that the resident's appetite was not good. She said he had lost a little weight over the past few months at home but not anything near what he has lost in the nursing home. On 2/2/11 at 12:35 p.m. the Dietary Manager was interviewed about the nutritional status and care plan for resident #97. The Dietary Manager expressed the resident was offered foods he preferred at meals and supplemental ice cream fortified milkshakes. She expressed he takes the milkshakes real well - 100%. She also stated that he can make his needs known and he feeds himself. She expressed she had been informed someone was looking for the nutritional care plan and she also looked and did not find one. She said it was overlooked; she had just missed it.

Based on observation, family and staff interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and that one out of 41 (#100) sample residents received adequate supervision and assistance devices to prevent accidents. Specifically: -The facility failed to develop and implement interventions to address resident #100's known risks for falls which included visual impairment, gait/balance problems, history of falls, and, after admission, her known tendency to self-transfer. The resident fell three times, experiencing pain and was diagnosed with [REDACTED]. -The facility failed to ensure hazardous materials were stored in a secure manner. The findings include: A. Resident #100 Resident #100, an [AGE] year-old female, was admitted to the facility on [DATE] for a respite stay while her daughter/caregiver underwent surgery. [DIAGNOSES REDACTED]. An additional [DIAGNOSES REDACTED]. The resident was discharged from this facility to another long-term care facility on 1/26/11. The resident was hosptalized on [DATE] and 1/25/11, the first two days of survey. She was readmitted briefly to the facility before her transfer on 1/26/11 to another long-term care facility. While it was not possible to observe the resident during the survey, it was noted the resident had been in room 3 on Peach Hall at the time of her falls. This room was located approximately midway down the hall from the commons area and two doors down from the director of nursing (DON) and rehabilitation nurse's office. 1. Resident's status on admission Fall Risk Assessment: A Fall Risk Assessment completed on 1/5/11, identified that resident #11 was receiving hypoglycemic medication, that she had inadequate/impaired vision in adequate light with glasses on and that she was continent. She was identified as confined to a chair and disoriented, although (see below), the resident was ambulatory. -A gait analysis identified that she "exhibits loss of balance while standing" and "uses short discontinuous steps and/or shuffling steps." -Internal risk factors included "had had falls 30 days prior to admit, falls past 31-180 days, unsteady gait, joint pain, impaired vision with corrective lenses and anxiety." "Lighting" was identified as an extrinsic risk factor. -The analysis summary of risk factors stated, "Daughter states she needs to be told to pick up her feet when she walks. She loses her balance while she is walking. Daughter recommends we leave the bathroom light on at night. Daughter agrees to bed alarm. Daughter will bring cane; we discussed fall mat and she may trip over it, so will not place fall mat at this time. Reviewed use of call light." Physician's Progress Note: A progress note for resident #100's visit to her physician on 12/1/10 was faxed to the facility on her admitted . It stated, in pertinent part, "LE (lower extremity) weakness - will start rehab but hoping for a bed to open up soon at n.h. (nursing home)/rehab. Memory - remote memory seems good though very difficult to get reliable information as she either avoids or is unable to recall Hx (history)." Care Plan: An acute care plan, initiated on 1/5/11, identified that the resident was at risk for falls, that she was independent with ambulation, used a cane or walker, and had poor balance and poor vision. These risks were to be addressed by a bed alarm, special mattress and repositioning every two hours. Other interventions that were penciled in with no initiation date were: "eyeball" every hour and low air loss, perimeter defining mattress. Entries on the back of the acute care plan read that on 1/8/11, interventions put in place were low bed, remind to call for assistance when tired, have her use the walker, PT (physical therapy) to assess mobility devices, and interventions as needed. Family interview: On 1/31/11 at 3:10 p.m. the resident's family member reported the facility "had me sign for a night buzzer (bed alarm). I filled it out right away." The family member stated the facility staff said the resident "just gets up and walks all over the place." The family member stated that "skid runners" were placed on the floor after the fourth day of the resident's stay. The family member stated no fall mat was in place as it was considered a tripping hazard for the resident. 2. Unwitnessed falls (3) after admission - 1/9/11, 1/12/11, and 1/19/11 a. Family Interview On 1/31/11 at 3:10 p.m. the resident's family member reported to the surveyor, via telephone, that the resident had fallen three or four times during her stay at the facility. The family member stated, "Every time I went over (to the facility) (the bed alarm) wasn't on." The family member said staff had stated the buzzer was "too noisy." The family member further stated that at night, toward the end of the resident's stay in the facility and after the resident's fall with injury on 1/19/11 (see below) the alarm was on. The family member stated that on the day of the resident's third fall, the resident had been to physical therapy and complained of pain that night. The family member stated the resident was taken to the emergency roiagnom on [DATE], and x-rays confirmed a pelvic fracture. b. Record Review (1) Two Incident Reports were provided in response to a request for all incident reports related to resident #100's stay from 1/5/11 - 1/26/11. The director of nursing (DON) was interviewed on 2/2/11 at 10:15 a.m. The DON stated she believed there were three incident reports for falls, and she would have medical records provide the third; these reports read, in pertinent part: -An incident report dated 1/11/11 stated that at 11:30 a.m. on that date, "CNA found resident sitting on bottom on floor - assisted her back to wheelchair. Upon questioning stated she was getting up to take herself to bathroom, slid to floor. Denied hitting her heard, socks in place. Told (nurse) right arm hurt. Denied pain to me. Problems with vision noted. Bubble implant (illegible) eye." The report stated the resident complained of fight pain. The comments section stated, "Talked with daughter. Stated has Bumm implant in left eye. Vision impaired. Wants safety measures implemented." The follow-up section stated, "Resident has problems - vision, needs assistance and refused to ask even when prevention (of) injury discussed. Impulsive. Resident to have gripper socks or shoes on.. Colored tape to call light. Evaluate the resident for appropriateness of hipsters. Continue with therapy." -An Incident Report dated 1/12/11, stated the resident reported to a certified nurse aide (CNA) on 1/12/11 at 1:25 p.m. that she "fell on her knees while trying to get into bed, got up by herself and called for help." The fall was unwitnessed. No medical attention was required. Page two of this report, stapled to page one, read that a fall occurred on 1/9/11 at 1:00 a.m. The resident's left knee was noted to be bruised and swollen. The follow-up section read, "X-rays were negative - monitor bruise for healing and ask maintenance to check brakes on w/c." It was unclear if these reports were from two different falls or if dates were entered in error. However, a fax communication between the facility and the resident's physician dated 1/12/11, that read in pertinent part, "Pt fell again today. Family thinks she gets dizzy. . .", indicated the fall on 1/12/11 represented a repeat fall in the facility. -An Incident Report dated 1/20/11 stated, "Resident reported at 7:00 a.m. this morning that she had fallen last night and gotten herself up." The incident occurred in the resident's room. The follow-up section stated, "Did an assessment & resident was sent to ER for evaluation of pain." The investigation was conducted by the social services director, the nursing home administrator and the restorative nurse. (2) Neuro(logical) Check Assessment Flow Sheets were initiated, per facility policy, following the resident's unwitnessed falls. These flow sheets revealed: -A flow sheet initiated on 1/11/11 noted that neuro checks were completed from 11:20 a.m. on that day through the day shift on 1/12/11, although page 2 of the incident report dated 1/12/11 (see above) indicated a fall had occurred 1/9/11 at 1:00 a.m. (see above). The remainder of this flow sheet was crossed off. -A second flow sheet was initiated with 15-minute checks on 1/12/11 at 1:25 p.m. This flow sheet was completed through 1/15/11. -A third flow sheet was initiated on 1/20/11 at 7:30 a.m. and completed when the resident was in the facility through her hospitalization on [DATE]. (3) Physical Therapy Progress Notes revealed: -1/12/11 "Pt experienced a fall yesterday and is unable to recall details" -1/13/11 pt limited r/t (related to) R (right) shoulder pain from another fall. Pt reporting she pulled herself up off floor. Still unable to recall why she fell . Pt unable to be compliant with use of call light due to decreased cognition, therefore recommend use of alarm. -1/20/11 Pt with pelvic fx due to recent fall. Daughter requesting PT hold reassessment until next week due to pain. D/c (discharge) pt at this time. (4) Review of the Hospital History & Physical dated 1/21/10, revealed it read, in pertinent part: "Pt...has fallen several times in the past 2 days. Yesterday she fell and was brought to the emergency room , where it was found she had a superior and inferior pubic rami fracture on the left. She was sent back to the nursing home, as this is a nonsurgical problem. They returned to the ER today with concerns that she was having urinary retention. They have been unable to control her pain using Ultram, and there was some concern of sending her back to the nursing home without her pain well controlled; therefore, it was determined that she would be best served by hospital admission." Based on the documentation above, the resident sustained [REDACTED]. c. Interview. A CNA who provided cares for resident #100 was interviewed by telephone on 2/2/11 at 11:30 a.m.; the CNA stated the resident had not complained of leg pain until after her third fall. The CNA stated she worked the day shift on 1/20/11. When she arrived at the facility, the night shift CNA reported to her that the resident had complained that her legs hurt when she went to bed on the previous night, but staff thought this was likely related to physical therapy she received that day. When the day shift CNA attempted to assist the resident with dressing, the resident was unable to stand without assistance and kept stating her legs hurt. The charge nurse entered the room at that time, and the resident was subsequently transported to the ER (emergency room ) for evaluation. She said that she had not heard the resident complain of pain prior to that morning. She said the resident expressed her pain that morning by moaning and stating her legs hurt. 3. Failures in facility's response to first and second unwitnessed falls. Record review and interview revealed the facility failed to comprehensively address resident #100's known risk for falls and failed to provide adequate supervision after she sustained at least two unwitnessed falls at the facility. a. Incident reports Review of incident reports above revealed no additional interventions were noted on the incident report for the fall 1/9/11 or the fall 1/12/11. The family's concern about the resident's dizziness referenced in the fax was not noted after the 1/12/11 fall and no safety interventions to address it were identified. Neither report contained information on whether the resident's bed alarm was working. b. Care plan Review of the resident's care plan for fall risk revealed it was initiated on 1/12/11, but interventions were not added until on 1/21/11, after the resident's fall with pelvic fracture was identified: -Gripper strips in front of bed and toilet and sink -Staff to do 30 minutes vision checks -Bed to be kept in lowest position d/t (due to) resident's short height -Bed and w/c (wheelchair) alarm in place, -Put color tape on the call light and keep within reach -Resident to wear Hipster as she will allow -Resident likes to remove her shoes. Staff to monitor that she has non-slip socks on -Reminders to wait for assist to ambulate. c. Staff Interviews (1) CNA interview The CNA familiar with resident #100 who was interviewed by telephone on 2/2/11 at 11:30 a.m. stated CNAs tried to check on the resident frequently and offer assistance. She said the resident refused to use or was unable to use the call light to request assistance. She said that, due to the resident's visual impairment, staff wrapped the call light in bright-colored tape and made certain it was within reach of the resident. She said the resident was very independent and would transfer and ambulate without requesting assistance. She further stated she knew the resident would try to ambulate without assistance and that she had falls, so she would "look in and check on her each time I passed her room." However, she was not aware of specific orders for CNAs to frequently check on the resident. (2) DON interview The DON was interviewed again on 2/2/11 at 1:40 p.m. Regarding the acute care plan of 1/5/11, she stated the handwritten (penciled) care plan was put into place at admission and added to as needed until the full care plan was completed. She stated the entry "eyeball check Q hour" (see above) was added after the resident's fall with pelvic fracture (1/19/11). She provided "Documentation of Frequent Checks" forms for both RNs/LPNs and CNAs. The resident was checked every hour by nurses and every half hour by CNAs from 1/20/11(after the resident's 1/19/11 fall) through discharge on 1/26/11, with the exception of the times she was out of the facility. The medical record was void of documentation that a care plan intervention to provide frequent supervision or scheduled visual checks was initiated after her first two falls and prior to the fall on 1/19/11 with pelvic fracture. The DON reported on 2/3/11, that she had, in fact, instructed nursing staff, prior to the fall on 1/19/11, to check on the resident at specific intervals. She said she had provided staff with a calendar to record these checks, but that documentation was missing. As of this writing (2/7/11), no additional documentation has been provided. (3) Nursing Home Administrator (NHA) interview The NHA was interviewed on 2/1/2011 at 5:30 p.m. She stated resident #100's daughter was very angry about resident's fall and pelvic fracture. The NHA said records were reviewed and staff interviewed to try to determine when the injury occurred. She stated the resident was ambulatory and frequently self-transferred without waiting for assistance. She said the resident would report to staff she had fallen but could not always provide details. The NHA said the facility was never able to determine when the pelvic fracture occurred, as it could have been from a fall or could have been a stress fracture from ambulating or receiving physical therapy. B. Hazardous Materials - Secure Unit The secure unit of the facility was a designated locked unit for residents with progressed dementia who exhibited wandering, behavioral symptoms, and poor safety awareness. Throughout the survey from 1/24/11 to 2/3/11, the secure unit residents were observed to wander into rooms other than their own, attempt to open drawers and cabinets, and put items in their mouths (such as food wrappers) that were inappropriate. 1. Zinc Oxide Cream On 1/25/11 at 8:54 a.m., two tubes of zinc oxide cream were observed in the bathroom of room 3 in the secure unit on a shelf above the toilet. Two residents with severe dementia resided in the room, one of whom was able to ambulate and use the restroom independently. The creams were in a plastic bin with an un-lockable drawer, but the drawer was open. The tubes of cream documented, "Keep out of reach of children." They both contained 2.1% dimethicone and 2% zinc. The warnings on the tube included: "Avoid contact with eyes" and "If swallowed, get medical help or contact poison control." On 1/26/11 at 12:06 p.m., the nurse stated the zinc oxide cream stayed in the resident's bathroom in the plastic bin and was to be applied by staff. She stated one of the residents in the room was able to ambulate into her room independently, but she did not think she was able to reach the cream on the shelf in the bathroom. The nurse stated she was unsure how the staff monitored to ensure the residents did not use the cream inappropriately. On 1/26/11 at 12:15 p.m., a certified nurse aide stated there were several residents on the secure unit who wandered into rooms other than their own and had a tendency to rifle through others' drawers and cabinets. On 1/26/11 at 2:40 p.m., the zinc oxide creams were observed in the plastic bin in the residents' bathroom during the environmental tour with the director of housekeeping (DH) and the director of maintenance. The DH stated it was all right for the cream to be stored in the resident's room, as long as it was kept in the plastic bin with the drawer closed. She stated if the drawer was not closed, the residents could grab the cream and use it inappropriately. On 1/26/11 at 6:20 p.m., the zinc oxide cream was again observed in the plastic bin in the residents' bathroom. On 1/27/11 at 8:30 a.m., the zinc oxide cream was observed in the plastic bin in the residents' bathroom. The bin's drawer was open. On 1/27/11 at 10:40 a.m., the nursing home administrator (NHA) stated she was unsure what the facility's policy was regarding storage of medications on the secure unit. She stated she would follow up with the director of nursing (DON). On 1/27/11 at 1:14 p.m., the DON stated there was no written policy on the storage of medications. She stated she had thought the medications were safe while in the plastic bins, but realized "anything was possible" and residents on the secure unit were at risk of accessing the medication. The DON stated she had contacted the pharmacy, which directed the zinc oxide should be locked up or on a top shelf in the closet if kept in the residents' room, especially on the secure unit. The DON stated the cream was removed from the room and would be locked up. On 2/2/11 at 11:12 a.m., the zinc oxide creams were again observed in the plastic bin in the residents' bathroom. At 11:15 a.m., the DON stated removing the zinc oxide ointment from the residents' bathroom was on her list of things to do. She stated she did not realize the ointment was still there. 2. Unsecured Hazardous Materials On 1/26/11 at 6:13 p.m., an unlocked cabinet in the activity area was observed with a bin full of orange sticks, nail clippers, nail polish and remover, glue, alcohol pads, and body spray. Another bin contained hair spray and a curling iron. On 1/27/11 at 10:40 a.m., The NHA stated the storage in the cabinets in the secure unit should be locked at all times.