Every finding on record at Life Care Center of Greeley

Based on observations, record review, and interviews, the facility failed to ensure that the services it provided or arranged met professional quality standards for two (#39 and #29) of two residents out of 33 sample residents. Specifically, the facility failed to: -Follow physician's orders for the use of Resident #39's cervical collar; and,-Ensure Resident #29's medications were not left unattended in a medication cup on top of the medication cart. Findings include: I. Failed to follow physician's orders for the use of Resident #39's cervical collar A. Facility policy and procedure The Physician orders policy, revised 2/11/26, was received from the nursing home administrator (NHA) on 7/21/26 at 12:59 p.m. It revealed in pertinent part, A physician must personally approve in writing a recommendation that an individual be admitted to a facility. A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Upon admission, a written order approving the admission will be obtained from the attending physician. This may be done by telephone order. As a means of validation, any orders taken verbally or by telephone must be read back in their entirety to the person giving the orders. Any orders written by a consulting physician must be reviewed and signed by the resident's attending physician. This may be done by telephone order. B. Resident #39 1. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included traumatic subarachnoid hemorrhage (bleeding in the brain), dementia, congestive heart failure (CHF), fracture of the fifth, sixth, and seventh vertebrae, fracture of the right wrist, fracture of the left patella (small bone at the front of the knee), difficulty walking and muscle weakness. The 4/21/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The assessment indicated the resident was fully dependent on staff for oral hygiene, bathing and shower hygiene, chair-to-chair transfers, toileting hygiene, and lower body dressing. 2. Resident observations and interviews On 7/15/26 at 9:00 a.m. Resident #39 was sitting in her wheelchair in her room. She had on a neck brace (cervical collar). The resident said she was admitted to the facility because she had a fall at home. She said she had to wear the neck brace all the time. On 7/20/26 at 9:09 a.m. Resident #39 said she had to wear the cervical collar all the time. She said the nursing staff removed the cervical collar when she had a shower yesterday (7/19/26) to wash and dry her hair. She said the only time the staff removed the cervical collar was during her showers. She said she did not know of any special precautions she had besides wearing her cervical collar all the time. 3. Record review The activities of daily living (ADL) care plan, revised 4/16/26, revealed Resident #39 had a self-care performance deficit related to current health issues. Pertinent interventions included providing the resident with assistance from one staff member with bed mobility, providing total assistance with showers and bathing, and assisting the resident with transfers using her walker. -The ADL care plan failed to include the use of the resident's cervical collar. Review of Resident #39's July 2026 CPO revealed the following physician's orders: C-collar (cervical collar) in place at all times, even for showers, every shift for cervical vertebrae #5 to thoracic vertebrae #1 (C5-T-1) fractures, ordered 4/15/26. No bending or twisting. No lifting, pushing, pulling more than 10 pounds every shift for C5-T1 fractures, ordered 4/15/26. Spinal precautions every shift for C5-T1 fractures, ordered 4/15/26. A nursing progress note, dated 4/16/26, revealed Resident #30's C-collar was to be in place at all times. A nursing progress note, dated 4/17/26, revealed the resident was alert and oriented. The resident was to have her C-collar and lower left extremity immobilizer on at all times. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/20/26 at 10:21 a.m. CNA #1 said she worked full time at the facility during the day shift. She said her duties included obtaining residents' vital signs, dressing, bathing, and transporting residents to and from the dining room. She said she gave showers to Resident #39. She said she would remove the resident's cervical collar for 10-15 minutes while providing the resident with her shower. She said Resident #39 wore her cervical collar all the time, except when showering. She said she learned how to take off and put on the resident's cervical collar through past work experience. She said besides wearing the cervical collar, she was unsure of any special precautions for the resident. The occupational therapy assistant was interviewed on 7/20/26 at 10:37 a.m. The occupational therapy assistant said Resident #39 was supposed to wear the cervical collar all the time because she had fractures to her neck and back. She said the resident was on spinal precautions, which meant the resident should not do any bending at the waist, lifting more than 10 pounds over her head, or twisting at her waist. Registered nurse (RN) #1 was interviewed on 7/20/26 at 11:07 a.m. RN #1 said the resident needed to wear her cervical collar at all times. She said she would take off the cervical collar to check the resident's skin underneath the collar. She said she would apply foam under her collar to ensure the resident's comfort while wearing the cervical collar. The director of rehabilitation was interviewed on 7/20/26 at 11:20 a.m. The director of rehabilitation said he had worked for the facility for five years. He said he was responsible for ensuring therapy services were provided for the facility's residents as needed. He said Resident #39's cervical collar physician's orders were dictated by her outpatient physician. He said the outpatient physician would advise the facility on when to discontinue the resident's cervical collar and any special precautions needed. He said if the outpatient physician ordered Resident #39 to have the cervical collar on at all times, even with showers, he would expect the nursing staff to follow those physician's orders. The director of nursing (DON) was interviewed on 7/20/26 at 12:59 p.m. The DON said Resident #39 was admitted to the facility from the hospital because she had a fall at home. She said the resident was admitted with a cervical collar on her neck. She said the resident had physician's orders for the cervical collar to be worn at all times, including during showers. She said when Resident #39 was admitted to the facility (on 4/15/26), the facility's nursing staff added the shower instructions regarding the resident's cervical collar to the Kardex (a comprehensive tool utilized for providing consistent resident care) for the CNAs to reference. She said in addition to the Kardex, the facility nurses were supposed to give report to the CNAs regarding any special care instructions for Resident #39. She said the CNAs would give shift reports to oncoming CNAs. She said the CNAs were responsible for providing the residents with showers. The physical therapist (PT) was interviewed on 7/20/26 at 1:30 p.m. The PT said he had worked for the facility for 15 years. He said he was involved in reviewing physician's discharge orders from the hospital for the facility's residents and contributing to their plans of care. He said if Resident #39 had a physician's order to wear her cervical collar at all times, then that would include wearing the collar during showers. He said if Resident #39 did not wear her cervical collar as ordered, the resident would be at risk for compromised healing of the existing fractures to her vertebra. The DON was interviewed a second time on 7/21/26 at 10:41 a.m. The DON said she spoke with the neurosurgeon for Resident #39. She said she obtained a clarification order for the resident's cervical collar. She said the new physician's order indicated the resident could remove her cervical collar for showers and bathing. She said that when residents were admitted to the facility, there was always a second nurse to verify physician's orders to ensure accuracy. She said two facility nurses verified the physician's order for Resident #39's cervical collar upon her admission. -However, the clarification order indicating Resident #39 was able to remove the cervical collar for bathing was not obtained until after the concern was brought to the facility's attention during the survey, three months after Resident #39 was admitted to the facility. II. Failed to ensure Resident #29's medications were not left unattended in a medication cup on top of the medication cart. A. Facility policy and procedure The Storage of Medications policy, revised April 2024, was provided by the NHA on 7/21/26 at 3:34 p.m. It read in pertinent part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. B. Observations On 7/20/26 at 8:35 a.m. RN #1 was administering nine medications to Resident #29. The resident dropped two of the medications on the floor. RN #1 picked up the two tablets from the floor and disposed of the medications. RN #1 returned to the medication cart with the medication cup to refill the two medications that had been dropped on the floor by Resident #29. After RN #1 redispensed the resident's two medications into the medication cup, a CNA called out from another resident's room, asking for assistance. RN #1 locked the medication cart and went into the other resident's room to assist the CNA. RN #1 left the medication cup containing the two medication tablets for Resident #29 sitting on top of the medication cart. -RN #1 failed to ensure the medications were properly secured and not left unattended on top of the medication cart. C. Staff interviews RN #1 was interviewed on 7/20/26 at 8:40 a.m. RN #1 said she should not leave medication on top of the medication cart. She said she remembered to lock the medication cart when she went to assist the CNA, but she forgot that she had Resident #29's medications sitting in the medication cup on top of the cart. RN #1 said leaving medications unattended on top of the medication cart posed a risk that a resident could take the medications. The DON was interviewed on 7/21/26 at 8:25 a.m. The DON said the nurses should never leave medications unattended on top of the medication cart because a resident could walk by and take the medications.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for three of four medication carts. Specifically, the facility failed to:-Ensure medications, such as inhalers and nitroglycerin (a medication used to relieve chest pain), were dated when opened; and,-Ensure loose pills were not in the bottom of the medication cart drawers.Findings include:I. Professional referenceAccording to Healthcare Direct Pharmacy Services (6/22/26) RX Guides: Select Medications with Shortened Expiration Dates, retrieved on 7/23/26 fromhttps://www.hdrxservices.com/rx-guides-select-medications-with-shortened-expiration-dates/, An albuterol inhaler should be discarded 13 months after being removed from its packaging. Combivent Respimat should be discarded three months after the first actuation (triggering the device to release a single, measured dose of medication) or when the device locks out. According to The American Journal of Cardiology's Open-Label Study of the Stability of Sublingual Nitroglycerin Tablets in Simulated Real-Life Conditions (2018), retrieved on 7/22/26 from https://www.ajconline.org/article/S0002-9149(18)31750-8/abstract, Contemporary practice favors refilling sublingual (administered under the tongue) nitroglycerin every three to six months. High temperature storage resulted in the most rapid loss of potency. II. Facility policy and procedureThe Medications Storage and Administration Quick Reference Guide, undated, was provided by the nursing home administrator (NHA) on 7/22/26 at 1:10 p.m. It read in pertinent part, Medication carts are cleaned, stocked, and organized. Medication carts are locked when unattended. Ensure use-by dates of inhalers have not been exceeded. III. ObservationsOn 7/16/26 at 9:45 a.m., the #2 medication cart for the 200 unit hallway was observed with licensed practical nurse (LPN) #1. The following item was found: -One Combivent Respimat 20 microgram (mcg)/100 mcg inhaler was not labeled with the date the medication was opened.On 7/16/26 at 10:10 a.m. the [NAME] medication cart in the 100 unit hallway was observed with LPN #2. The following items were found: -Three albuterol sulfate 90 mcg inhalers were not labeled with the date the medications were opened; -One nitroglycerin sublingual 0.4 mg was not labeled with the date the medication was opened; and,-Seven loose pills were in the bottom of the second drawer of the medication cart.On 7/16/26 at 11:15 a.m. the [NAME] medication cart in the 100 unit hallway was observed with LPN #3. The following items were found: -Two albuterol sulfate 90 mcg inhalers were not labeled with the date the medications were opened;-One bottle of nitroglycerin sublingual 0.4 milligram (mg) tablets was not labeled with the date the medication was opened; and,-Four loose pills were in the bottom of the second drawer of the medication cart.IV. Staff interviewsLPN #1 was interviewed on 7/16/26 at 10:00 a.m. LPN #1 said the nurses cleaned the medication carts on each shift. LPN #1 said that when medications were opened, the open date should be written on the inhaler or box, so that the expiration date was clear. LPN #2 was interviewed on 7/16/26 at 10:45 a.m. LPN #2 said the nurses working the medication carts should clean the carts on their shift. LPN #2 said it was important to date the medications when opened in order to know when to dispose of the medications. LPN #2 said it was important not to administer expired medications because the medications could be ineffective.LPN #3 was interviewed on 7/16/26 at 11:35 a.m. LPN #3 said the risk of having loose medications in the medication cart drawers was that staff could not identify the medication and which resident it belonged to. LPN #3 said a loose medication tablet could drop on the ground and a resident could consume it accidentally. The director of nursing (DON) was interviewed on 7/16/26 at 10:50 a.m. The DON said the nurses cleaned the medication carts on their shift. The DON said she did not believe the medications observed in the medications were expired, according to the facility's policy. She said that facility policy was to use the medication fill date as the initial date the medication was opened. The regional director of clinical services was interviewed on 7/16/26 at 10:50 a.m. She said the facility policy did not require an open date for inhalers. She said she would use the manufactured expiration date.

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease on two of two units. Specifically, the facility failed to -Ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing care to residents who were on contact precautions and enhanced barrier precautions (EBP); and,-Ensure housekeeping staff washed their hands when cleaning residents' rooms and cleaned the high-touch areas daily.Findings include: I. Failed to ensure staff donned the appropriate PPE when providing care to residents who were on contact precautions and EBPA. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 4/2/24, retrieved on 7/26/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of a gown and gloves for high-contact resident care activities is indicated when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, or wound care. In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.According to the CDC's Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities (6/27/25), retrieved on 7/26/26 from https://www.cdc.gov/mrsa/hcp/infection-control/index.html, The use of contact precautions is recommended for MRSA-colonized or infected patients. Follow Contact Precautions when caring for patients with MRSA (colonized or carrying and infected).B. ObservationsOn 7/15/26 at 8:47 a.m. an unidentified staff member removed a meal tray wrapped in plastic and from Resident #48's room and placed it in the meal cart outside the resident's room. There was PPE outside the resident's room door, but no contact precautions signage outside of the room to indicate the resident was on contact precautions due to the resident having Clostridium difficile (C. diff.) -The unidentified staff member failed to don a gown and gloves prior to entering the resident's room and removing the resident's meal tray from the room. On 7/16/26 at 3:12 p.m. certified nurse aide (CNA) #3 entered the room of Resident #55, who was on contact precautions due to having active methicillin-resistant Staphylococcus aureus (MRSA) in her eye that was draining and she did not have a dressing over the eye. -CNA #3 failed to don a gown and gloves prior to entering the resident's room.On 7/16/26 at 3:15 p.m. CNA #4 entered the room of Resident #1, who was on EBP due to urine colonized with extended-spectrum beta-lactamase (ESBL - a bacteria that is resistant to common antibiotics and difficult to treat). CNA #4 proceeded to provide Resident #1 with an incontinent brief change.-CNA #4 failed to don a gown prior to changing Resident #1's brief. C. Staff interviewsThe infection preventionist (IP) was interviewed on 7/16/26 at 2:00 p.m. The IP said Resident #48 was on contact precautions due to a C. diff. infection. She said that the sign indicating the resident was on contact precautions was hanging in the resident's room on the back of the door. The IP said the resident's room was identified as an orange room, which indicated the resident had a C. diff infection. The IP said the facility used color coding to identify resident rooms with precautions due to the residents' right to privacy. She said staff understood the color orange indicated a resident had C. diff and was on contact precautions. The IP said the PPE for contact precautions were outside the residents' rooms, which indicated to staff and visitors that they needed to put on PPE.-However, a staff member was observed not donning PPE when removing a meal tray from Resident #48's room (see observations above). CNA #3 was interviewed on 7/16/26 at 3:14 p.m. CNA #3 said she went into Resident #55's room to turn off the call light. CNA #3 said the resident was on contact precautions and she should have put on a gown and gloves prior to entering the room. She said she just went in to turn off the resident's call light and so she did not put on PPE CNA #4 was interviewed on 7/16/26 at 3:26 p.m. CNA #4 said she went into Resident #1's room to change his briefs due to the resident being incontinent CNA #4 said the resident did not have a Foley catheter. She said she should have put on a gown and gloves before entering the room to provide the resident with incontinence care.Registered nurse (RN) #2 was interviewed on 7/20/26 at 11:30 a.m. RN #2 said she would put on a gown and gloves to provide care for Resident #55. She said the resident refused to wear a dressing over her left eye that was draining. RN #2 said she donned her gown and gloves before entering the room and doffed them in the room before exiting. II. Housekeeping failuresA. ObservationsOn 7/20/26 at 1:03 p.m. housekeeper (HK) #1 was cleaning room [ROOM NUMBER]. HK #1 cleaned the toilet then removed her gloves. Without performing hand hygiene, HK #1 put on a new pair of gloves and cleaned the bathroom counter and handrails, then removed her gloves. Without performing hand hygiene, HK #1 put on a new pair of gloves and proceeded to clean the resident's room with a clean disinfectant rag. After cleaning the room, HK #1 removed her gloves.-Throughout the entire room cleaning process, HK #1 failed to perform hand hygiene after removing her gloves and prior to donning a new pair of gloves. -HK #1 failed to clean the high-touch areas of the door knobs, call light, and the bed control. On 7/21/26 at 9:00 a.m. HK #2 was cleaning room [ROOM NUMBER]. HK#2 began cleaning the bathroom, after donning gloves and a PPE gown due to the resident having a Foley catheter. After cleaning the bathroom, including the toilet, she removed her gloves. Without performing hand hygiene, HK #2 donned a new pair of gloves to clean the resident's room.-Throughout the entire room cleaning process, HK #2 failed to perform hand hygiene after removing her gloves and prior to donning a new pair of gloves. -HK #2 failed to clean the entrance door knobs to the room.B. Staff interviewsHK #1 was interviewed on 7/20/26 at 1:20 p.m. HK #1 said she forgot to clean the door knobs, call light, and bed control in room [ROOM NUMBER]. HK #1 said she knew that the high-touch areas should be cleaned daily to reduce the spread of bacteria. She said she forgot to sanitize her hands before putting on new gloves. The housekeeping supervisor was interviewed on 7/20/26 at 2:00 p.m. The housekeeping supervisor said the HK #1 was nervous about being observed while she cleaned. The housekeeping supervisor said she did provide education to HK #1 about cleaning the high-touch areas in residents' rooms daily and performing hand hygiene when removing her gloves and donning new gloves. HK #2 was interviewed on 7/21/26 at 9:40 a.m. HK #2 said she sanitized her hands when she entered room [ROOM NUMBER] and again when she exited the room. HK #2 said she forgot to perform hand hygiene when she changed her gloves while she was cleaning the room. The housekeeping supervisor was interviewed a second time on 7/21/26 at 9:45 a.m. The housekeeping supervisor said she would provide education to HK #2 on performing hand hygiene when donning new gloves.

Based on record review and interviews, the facility failed to ensure one (#6) of nine residents reviewed for accidents out of 32 sample residents remained as free from accident hazards as possible. The facility failed to prevent Resident #6's fall from a mechanical (hoyer) lift while transferring her. On [DATE] two certified nurse aides (CNA) #1 and #3 attempted to transfer Resident #6 from her bed to her wheelchair. During the transfer, Resident #6 fell from the sling attached to the mechanical lift's sling bar (a bar with two safety latches on each end the sling attaches to), onto the floor and hit her head on the mechanical lift. As a result, Resident #6 sustained head trauma (laceration) to the back of her head. Immediately after Resident #6's fall staff observed that one (right upper body) of the four sling handles had disconnected from the mechanical lift sling bar. Resident #6 was assessed at the facility and transported to the hospital where she was treated and received staples for the head laceration. She returned to the facility the same day at 9:00 p.m. On [DATE] Resident #6 complained of pain to her right shoulder. New orders for an x-ray for her right shoulder and arm were obtained. Imaging showed a fracture to Resident #6's right clavicle. The facility was unable to identify during their investigation how the sling could have come unhooked from the mechanical lift resulting in Resident #67 ' s fall. Due to the facility's failure to adequately supervise Resident #6 during her mechanical lift transfer, Resident #6 fell and sustained head trauma and a fractured right clavicle. The facility failed to identify during the course of their investigation a specific procedural failure that occurred during the transfer of Resident #6 on [DATE]. Findings include: Record reviews, observations and interviews confirmed the facility corrected the deficient practice related to Resident #6's fall prior to the onsite investigation on [DATE] to [DATE]. The deficiency was cited as past non-compliance with a correction date of [DATE]. I. Incident on [DATE] The nursing home administrator (NHA) provided an investigation on [DATE] at 9:15 a.m. regarding Resident #6's fall from the mechanical lift while being transferred by CNA #1 and CNA #3. A. Investigative report An investigative timeline that documented the initial reported incident on [DATE] and follow up actions of interviews, assessments, mechanical lift inspections, education and reporting. The investigation, action plan and facility wide education was completed [DATE]. The facility concluded Resident #6 fell from the sling attached to the mechanical lift's sling bar (a bar with two safety latches on each end the sling attaches to), onto the floor and hit her head on the mechanical lift. She sustained a laceration to her head requiring staples and a fractured right clavicle. B. Investigation timeline and mechanical lift inspection history On [DATE]: At 4:08 p.m. a CNA reported to the nurse that Resident #6 fell from the mechanical lift and the resident was assessed by two registered nurses (RN). At 4:15 p.m. the physician, the director of nursing (DON) and the resident's representative were all notified. At 4:18 p.m. orders were received from the physician to transfer Resident #6 to the emergency department for evaluation and treatment. At 4:35 p.m. Resident #6 transferred out to a local hospital via ambulance. At 9:00 p.m. Resident #6 returned from the local hospital emergency department. On [DATE]: At 9:00 a.m. staff and resident interviews were conducted, Resident #6 was assessed by a physician and she denied having pain. At 9:05 a.m. the interdisciplinary team (IDT) met to discuss the fall and interventions. On [DATE]: Resident #6 had no complaints of pain. On [DATE]: At 10:43 a.m. Resident #6 refused to use her right arm. Orders for immediate imaging were obtained. At 4:00 p.m. Resident #6's x-ray results were received and the physician was notified the resident had a right clavicle fracture. The facility's work history report documented monthly inspections of all facility mechanical lifts for the prior year from [DATE] to [DATE]. C. Resident and staff interviews CNA #3 provided a written witness statement on [DATE]. The statement read in pertinent part, CNA #1 and myself were getting Resident #6 up for dinner. While transferring her from her bed to her wheelchair, the sling slipped out of the hook of the hoyer (mechanical lift) and before we could realize, the resident slipped out of the sling and hit her head on the leg of the hoyer (mechanical lift). CNA #1 provided a written witness statement on [DATE]. The statement read in pertinent part, My coworker and I were getting Resident #6 ready to go down to the dining room. We were transferring her from the bed to the wheelchair with the hoyer lift. She was on the hoyer lift off the bed when one arm of the sling came off and she (Resident #6) fell on the floor. -Neither statement documented what kind of safety checks CNA #1 and CNA #3 performed prior to transferring Resident #6 from her bed to her wheelchair. Seven residents throughout the facility were interviewed on [DATE] by the social services director (SSD), two of which were transferred utilizing the mechanical lift. All of the residents denied concerns regarding their transfers during daily care. Nine CNA's were interviewed on [DATE] and [DATE] and they all denied concerns or issues with the mechanical lift and falls and knew what steps to take if a resident fell . The maintenance supervisor (MS) provided a written statement on [DATE]. It read in pertinent part, The NHA and I immediately went and found the lift (used for Resident #6's transfer) for an inspection to rule out a failure of the equipment in any way. The hoyer (mechanical) lift was working properly, wheels rolled, brakes locked, legs open and closed, mast went up and down, emergency stop was working, remote functioned and the sling safety latches were present on the swivel bar. This was corroborated by multiple department heads. We (the staff) tried to recreate the incident on our own as the staff members were present. We (the staff) could not recreate any failures. Out of an abundance of caution I (the MS) removed the lift from service until such time that the staff could show what happened. The lift was removed from use on the floor at around 10:00 a.m. on [DATE]. All other mechanical lifts were inspected at this time as well to assure all safety features are present and lifts are indeed in working order. The mechanical lift was out of service until the staff involved could show how the incident occurred. II. Facility plan of correction A. Immediate action to correct the deficient practice for Resident #6 Both CNA #1 and CNA #3 demonstrated the use of appropriate mechanical lift procedures on [DATE] immediately following Resident #6's fall. Both CNA's correctly demonstrated use of the lift separately and then together showing the procedure they used to transfer Resident #6. B. Identification of other residents The NHA reviewed care plans and assessments of all residents who required assistance with transferring via mechanical lifts first, and expanded the care plan review and examined residents with recliners in their rooms that might be a fall risk. C. Systematic changes All nursing staff were re-educated on proper mechanical lift procedures and provided a return demonstration of knowledge by [DATE]. D. Monitoring The NHA was interviewed on [DATE] at 5:41 p.m. The NHA said the facility discussed the [DATE] hoyer lift incident in the quality assurance program improvement (QAPI) meeting and were continuing to monitor. Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Facility policy and procedure The Limited Lift Program (Safe Patient Handling) policy, revised [DATE], was provided on [DATE] at 11:00 a.m. by the nursing home administrator (NHA). The policy read in pertinent part, The facility will assess residents for the need for assistance with transfer activities, mobility or repositioning utilizing a validated mobility assessment by either nursing or therapy. Associates will be responsible for utilizing mechanical lifting devices, transferring devices, proper body mechanics to lift, transfer and/or pivot non-ambulatory patients as indicated. The facility must ensure that the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents. The facility will provide education to residents and resident representatives on the use of a mechanical lifting device to ensure the safety of the resident and associate. IV. Mechanical lift manual The user manual for the Golvo 7000ES/7007ES mechanical lift was provided by the NHA on [DATE] at 11:00 a.m. It read in pertinent part, Before using always make certain that: -Persons using the equipment have received appropriate instructions and training; -All manuals have been carefully studied and understood; -The sling is securely locked into position on the sling bar and cannot accidentally unlock; -All lift components, material and seams are intact and show no signs of damage or wear; -The patient is positioned firmly and securely so that no part of the body can be injured; and, -The safety split or pin or nut is securely fastened in the bolt that holds the sling bar or other accessories. V. Resident status Resident #66, over the age of 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included metabolic encephalopathy (chemical imbalance in the blood affecting the brain), chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, dementia, weakness and difficulty walking. The [DATE] minimum data set (MDS) assessment revealed the resident had a memory problem and was severely impaired in her decision making abilities for everyday life based on the staff interview for mental status. She was dependent on care for toileting hygiene, transfers and rolling from left to right/right to left in bed, needed substantial assistance with dressing, bathing and personal hygiene and moderate assistance with oral hygiene and set up help only with eating. The MDS assessment did not indicate the resident had a fall. VI. Record review The fall care plan, revised [DATE], documented Resident #6 was at risk for falling and injuring herself due to her diagnoses of muscle weakness, difficulty walking and dementia. She required extensive assistance for most of her daily care. She used her wheelchair as her primary mode of locomotion in the facility. The care planned intervention on [DATE] included the use of a mechanical lift with the assistance of two staff members to transfer Resident #6. Resident #6's progress notes documented the following: On [DATE] two CNAs transferred Resident #6 with the mechanical lift. Resident #6 was in the sling and the CNAs proceeded to lift the resident off her bed and into her wheelchair when one of the sling's handles came off of the mechanical lift sling bar. Resident #6 then fell to the floor and hit her head. There was a laceration to the back of her head. The resident was transported by ambulance to a local hospital at 4:40 p.m. On [DATE] Resident #6 returned to the facility from the hospital at approximately 9:00 p.m. with a scalp laceration closed by staples. On [DATE] Resident #6's fall interventions were reviewed and remained unchanged. She was re-assessed for the correct sling size which also remained unchanged for the resident and she remained appropriate for the mechanical lift. On [DATE] Resident #6 refused to use her arm in a full range of motion and immediate x-rays were ordered. On [DATE] Resident #6 was non weight bearing on her right arm due her right clavicle (collarbone) fracture diagnosis. VII. Staff interviews The NHA and MS were interviewed together on [DATE] at 10:36 a.m. The MS said, on [DATE], the day after Resident #6's fall, he and the NHA utilized the same mechanical lift staff used during Resident #6's fall multiple times to complete a transfer with the mechanical lift and the sling stayed secure each time. The NHA said CNA #1 and CNA #3 demonstrated separately how to use the mechanical lift and the sling after Resident #6's fall and both CNAs provided a correct demonstration on how to use the lift for a resident transfer. The NHA said Resident #6's sling hung on the back of her bathroom door and was kept in her room. CNA #1 was interviewed on [DATE] at 3:15 p.m. CNA #1 said she assisted in Resident #6's transfer on [DATE] from the resident's bed to the resident's wheelchair. CNA #1 said she used the sling hanging on the back of Resident #6's door for the transfer. CNA #1 said she was trained to use the lift during her CNA training at the facility, and there was ongoing training and a reeducation after Resident #6's fall. CNA #1 said one of the four sling handles came off the lift itself and she noticed this after the resident fell . CNA #1 said she and CNA #3 placed the sling under Resident #6 while she was in bed. CNA #1 said Resident #6 fell from the lift during her transfer off her bed, and when the resident fell , she and CNA #3 noticed a sling handle was not secured on the hook. She said she did a visual inspection to ensure the sling was in the correct place prior to Resident #6's transfer. CNA #1 said she and CNA #3 followed the correct mechanical lift procedures during Resident #6's transfer. Registered nurse (RN) #1 was interviewed on [DATE] at 3:15 p.m. RN #1 said the right shoulder side of the sling detached from the mechanical lift during Resident #6's transfer. RN #1 said ongoing assessment occurred for CNA #1 and CNA #3 for four weeks and the staff were assessed at random five times a week for 12 weeks. She said staff monitoring started immediately after the fall on [DATE]. The DON and RN #1 were interviewed together on [DATE] at 11:00 a.m. RN #1 said when she entered the resident's room after Resident #6 fell , CNA #1 and CNA #3 had already unhooked the sling from the mechanical lift. RN #1 said one sling handle came unhooked and Resident #6 slipped out of the sling and fell , which resulted in a laceration on the back of her head. RN #1 said Resident #6 was transported to the hospital and assessed. RN #1 said the CNAs reported Resident #6 was in the mechanical lift and was lifted from her bed when she fell . RN #1 said the facility ordered and replaced all the mechanical lift slings in the facility. RN #1 said she did not work on the recreation of Resident #6's fall with the MS and the NHA. The DON and RN #1 said based on their interviews with CNA #1 and CNA #3, Resident #6's sling was connected correctly to the lift during her transfer. RN #1 said if the sling was not attached to the lift correctly Resident #6 would have fallen back onto her bed immediately after the staff began lifting her. RN #1 said Resident #6 was already lifted off the bed and was mid-transfer off the bed when she fell from the sling. The DON said she interviewed both CNA #1 and CNA #3 after Resident #6's fall. The DON said CNA #1 and CNA #3 both demonstrated the correct use of the mechanical lift to her and the MS after Resident #6's fall. The DON said if a sling was broken, frayed or staff were unsure if it was intact, the staff could bring the sling to a nurse on duty. She said the nurse on duty could then assess the sling. The DON said the facility assessed the sling used during Resident #6's fall and the sling was intact and had no deformities. CNA #4 was interviewed on [DATE] at 1:35 p.m. CNA #4 said she received mechanical lift training prior to starting work as a CNA. CNA #4 said two staff members should always be present to use the mechanical lift while transferring a resident. CNA #4 said after Resident #6's fall on [DATE], the staff were required to demonstrate their knowledge on how to use the mechanical lift. CNA #4 said before the mechanical lift slings were utilized in the facility, the slings were inspected by a nurse. CNA #4 said she knew the size of a resident's sling because there was a posted sign listing all residents' correct sling sizes which all staff had access to. CNA #4 said she checked the slings prior to use to see if the sling was frayed or torn and would tell a nurse if she observed damage to a sling. CNA #4 said while using a mechanical lift to transfer a resident, one staff member controlled the lift while the second staff member guided the resident. CNA #4 said guiding the resident involved holding the sling or the resident's legs to keep the resident from moving. CNA #4 said she was trained how to the lift's emergency button and, if the mechanical lift malfunctioned, the emergency button stopped the mechanical lift immediately. CNA #5 was interviewed on [DATE] at 1:40 p.m. CNA #5 said he had extensive training on how to use the mechanical lift and sit to stand hoyer lift. CNA #5 said mechanical lifts were always operated with two staff members attending. CNA #5 said he was shown how to use the mechanical lift, had demonstrated how to use the lift with a coworker and he himself had been in a lift for training. CNA #5 said he was trained and knew how to use the emergency button on a lift but had not had to use it. CNA #5 said the staff member guiding the resident during a transfer steadied the resident while in the sling. CNA #5 said one person operated the lift and both staff members should both be watching the resident during the transfer. CNA #5 said if he ever determined a lift was not safe to use he would tell a nurse for assistance. He said he had received training to use a mechanical lift prior to working as a CNA and received ongoing training and was observed using a mechanical lift. The NHA, DON and RN #1 were interviewed together on [DATE] at 1:45 p.m. The NHA said CNA #3's written statement (see above) indicated Resident #6 fell and then the CNAs looked up and saw a sling handle had come off the sling bar hook. The NHA said Resident #6 fell quickly. The NHA said the facility was unsure how the resident fell and the sling came unhooked if all the procedures were followed correctly. The DON said CNA #1 and CNA #3 reported all the sling hooks were attached to the mechanical lift prior to Resident #6's transfer on [DATE]. The DON said the resident was not over the chair but lifted and being transferred over the floor when she fell . The DON said when CNA #1 and CNA #3 demonstrated how they used the mechanical lift to recreate Resident #6's lift prior to her fall, she did not take notes or write down what the staff said or what they demonstrated. RN #1 said the sling was intact immediately after Resident #6's fall and it was not frayed or torn. CNA #3 was interviewed on [DATE] at 3:15 p.m. CNA #3 said she was one of two CNAs who transferred Resident #6 with the mechanical lift on [DATE]. CNA #3 said Resident #6 fell from the sling attached to the lift very quickly. CNA #3 said CNA #1 attached the sling to the hooks prior to the transfer and she (CNA #3) guided the resident by her legs. She said both she and CNA #1 gave a quick glance to ensure the sling was connected correctly and it was. CNA #3 said Resident #6 was lifted out of the bed and the CNAs started to turn the lift when Resident #6 slid out of the sling. CNA #3 said Resident #6 slid all the way out of the sling onto the floor. She said immediately after the resident fell , both CNAs saw the right shoulder sling handle was disconnected from the sling bar. CNA #3 said she went to get a nurse while CNA #1 stayed with the resident. CNA #3 said the additional training post-fall helped assure her that she used the right sling size for Resident #6 during her transfer on [DATE]. CNA #3 said she and CNA #1 transferred Resident #6 correctly. The NHA said the facility identified the incident, investigated, and put in place a plan of correction that included facility wide education that was fully completed by [DATE].

Based on observations, record review and interviews, the facility failed to ensure one (#67) of three residents reviewed for pressure-related skin conditions out of 32 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #67, who was at risk for developing pressure injuries due to paraplegia, weakness and the inability to move both legs, was admitted on [DATE]. The facility provided a pressure reducing mattress and wheelchair pad upon admission. The resident was able to make small movements to reposition herself, however, the staff did not provide the resident with consistent repositioning per the resident's needs On 7/4/24, a wound was observed on the resident's sacral area (bony area just above the tailbone). The nurse who observed the wound on 7/4/24 failed to notify the unit manager or the physician of the wound. On 7/11/24, the wound was again noted by a nurse and a specialty mattress was ordered for the resident (seven days after the initial identification of the wound). On 7/12/24 and 7/15/24, the facility's nurse practitioner (NP) and the resident's physician documented the resident had what appeared to be an early stage wound to her coccyx which would continue to be monitored, however, neither the NP nor the physician observed the resident's wound. On 7/15/24 (11 days after the initial identification of the wound) Resident #67's wound was observed by the wound team for the first time. The wound was classified as a Stage 3 pressure injury to the sacrum and wound care orders for treatment of the wound and nutritional supplement orders were obtained from the physician (11 days after the initial identification of the wound). Due to the facility's failures to implement timely interventions and obtain wound care orders after the initial identification of the wound, Resident #67 developed a Stage 3 pressure wound to her sacrum. The 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 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/6553d3440e18d57a550c4e7e/1699992399539/CPG2019edition-digital-Nov2023version.pdf on 7/17/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Injuries policy, revised on 7/9/24, was provided by the nursing home administrator (NHA) on 7/17/24 at 4:35 p.m. It read in pertinent part, Residents will receive a comprehensive skin assessment upon admission or readmission to the facility. The Braden Scale (a tool used for determining pressure ulcer risk) will be completed for each resident upon admission or readmission, weekly for four weeks, quarterly, and as needed based upon each resident's specific needs. Resident skin assessments will be performed weekly by a licensed nurse. Any changes or open areas noted by a certified nurse aide (CNA) will be reported to the nurse. CNAs will report to the nurse if a topical dressing is soiled, saturated or dislodged. The nurse will complete further inspection and provide treatment if needed. Measures to maintain and improve the resident's tissue tolerance to pressure will be implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development. Upon admission and throughout, a pressure redistribution surface mattress will be used with turning and repositioning as needed with care, assistance, and incontinent care. Skin barriers will be applied as needed and a preventative wheelchair cushion used if indicated. Measures to protect the resident against the adverse effects of pressure, friction, and shear will be implemented in the plan of care, including repositioning at least every two to four hours (per NPIAP standards) as consistent with overall patient goal and medical condition, utilizing positioning devices to keep bony prominences from direct contact, placing a pressure redistribution mattress under the resident and placing the resident on a pressure reduction device and repositioning the resident when in a wheelchair. Staff will educate the resident and significant others regarding the preventive skin care plan. If skin breakdown occurs, it requires attention and a change in the plan of care if indicated. III. Resident #67 A. Resident status Resident #67, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included acute infarction of the spinal cord (interruption of blood flow to the spinal cord), incomplete paraplegia (paralysis of the lower body), generalized muscle weakness, difficulty in walking and osteoarthritis. The 6/24/24 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. She was dependent on staff for bed mobility and transfers, needed substantial assistance with toileting and moderate assistance with bathing. The assessment indicated the resident was at risk for developing pressure ulcers but had none upon admission. B. Resident interview Resident #67 was interviewed on 7/10/24 at 10:37 a.m. Resident #67 said she woke up at 5:00 a.m. and waited for about three hours until someone could help her out of bed. She said at night, she spent a lot of time in her wheelchair before getting help transferring to bed. The resident said she had a wound on her bottom that was being treated with cream and a bandage. She said she thought the wound happened because she sat in her wheelchair so much and laid on her back when she was in bed while waiting for staff to get her up. On 7/11/24 at 1:16 p.m., the resident was overheard telling an unidentified therapist that staff did not get around to getting her out of bed until after 9:00 a.m. C. Observations On 7/15/24 at 3:10 p.m., Resident #67's wound was visualized with CNA #2 and LPN #2. CNA #2 and LPN #2 rolled Resident #67 onto her left side. LPN #2 peeled away the corner of the resident's dressing to reveal a sacral wound approximately the size of a nickel, which was red at the base and had slough (white, dead tissue) in the upper portion of the wound. The wound had no odor or drainage. D. Record review A Braden Scale assessment dated [DATE] at 9:54 p.m. revealed Resident #67 was at high risk for developing pressure ulcers due to very limited sensory perception, occasional moisture, being confined to bed and completely immobile and having the potential for friction and shear. A care plan, initiated 6/20/24, revealed Resident #67 was at risk for a break in skin integrity. Interventions to reduce risk of skin breakdown included cleaning and drying the resident's skin after incontinent episodes, using a pressure reducing mattress, providing treatments as ordered and conducting weekly skin checks. A care plan initiated 7/12/24 by registered nurse (RN) #2 and updated by the NHA on 7/15/24 (during the survey), revealed that the resident had a Stage 3 pressure ulcer to her sacrum. Weekly skin checks were already in place, and the resident had a specialty air mattress and gel wheelchair cushion placed on 7/11/24. Additional interventions, which were added to the care plan on 7/15/24 (during the survey) included encouraging the resident to offload her buttocks while in the wheelchair and providing the resident with supplements as ordered to promote wound healing. From 6/28/24 to 7/15/24, CNA documentation revealed that bed mobility assistance was given to Resident #67 between two and three times per 24- hour period. From 6/28/24 to 7/15/24, CNA documentation revealed Resident #67 was provided one or two-person transfer assist between the bed, chair, or wheelchair. The time stamps on the documentation indicated the resident received two to three transfers per day, in combination with assistance given to her while in bed. A weekly skin assessment, dated 6/27/24 at 11:09 p.m. by LPN #2, did not reveal any pressure injuries. A weekly skin assessment, dated 7/4/24 at 9:36 p.m. by LPN #2, revealed an open area to Resident #67's coccyx. It documented the resident was repositioned frequently for skin integrity and comfort, a dryness lotion was applied, and the finding was not new. -However, the 6/27/24 weekly skin assessment documented the resident did not have any open areas (see above). -No progress note was written and there was no documentation that a physician or unit manager was notified of the open area. A weekly skin assessment, dated 7/11/24 at 9:37 p.m. by LPN #2, revealed an area of blanchable redness to the coccyx (tailbone). A skilled nursing note, dated 7/6/24 at 9:29 p.m. revealed the resident had an open slit above the coccyx (tailbone). A nurse practitioner (NP) note, dated 7/12/24 at 8:31 a.m., revealed the NP had not seen the resident's wound, but noted it appeared to be an early stage coccyx wound. The wound development status was reviewed with the resident, the resident was educated on offloading, was to utilize the new mattress and seat cushion and the wound would be monitored. The resident informed the NP that she received the new mattress and gel seat cushion for her wheelchair. A skilled nursing note, dated 7/12/24 at 10:44 p.m., revealed the resident had an open slit above the coccyx that was covered with an intact, mepilex (a kind of foam) dressing. A physician's progress note, dated 7/15/24 at 10:33 a.m., revealed the physician (MD) had not seen the resident's wound, but noted it appeared to be an early stage coccyx wound. The resident was educated on offloading, utilizing the new mattress and seat cushion and the wound would continue to be monitored. A skilled nursing note, dated 7/15/24 at 1:36 p.m., revealed there were dressing changes ordered for a sacral wound. There were no signs of wound infection and the resident was now followed by the wound care team. -The note was documented during the survey investigation. A nursing progress note, dated 7/15/24 at 8:32 p.m. revealed that staff would continue to turn and reposition the resident frequently to prevent skin breakdown. An NP progress note dated 7/16/24 at 9:18 a.m., revealed the NP had not seen the resident's wound, but noted it appeared to be an early stage coccyx wound. The resident was educated on offloading. She was using the new mattress and seat cushion, and the wound would be monitored. The July 2024 CPO revealed the following physician's orders: Ensure air mattress is on and functioning every shift, ordered 7/12/24. Monitor the open area to the resident's sacrum and notify the physician for signs and symptoms of infection, ordered 7/13/24. Apply santyl ointment (to remove dead tissue from pressure wound) 250 units per gram to the sacrum, ordered 7/15/24. Cleanse the small open area to the sacrum with normal saline and pat dry. Apply nickel thick santyl and cover with mepilex. Change daily and as needed, ordered 7/15/24. Two Cal med pass oral nutritional supplement, ordered 7/15/24. -The dressing orders and the nutritional supplement orders were not obtained until 11 days after the initial identification of Resident #67's wound. A Wound Observation Tool was completed by the director of nursing (DON) on 7/15/24 at 6:24 p.m. (during the survey). It documented Resident #67 had a Stage 3 pressure injury to the sacrum. The wound was documented as round, with 70% slough tissue (yellow, tan, white, stringy) and dimensions of 1.2 centimeters (cm) length by 0.5 cm width by 0.2 cm depth. The wound had no drainage or signs of infection and was not painful to the resident. The DON documented that the NP, the resident, and the resident's representative were previously notified of the wound, on 7/12/24. The DON further documented that the current treatment plan included cleansing the wound with normal saline and patting dry, [NAME] Nickel thick Santyl, covering the wound with mepilex, and changing daily and as needed. Special equipment and preventive measures included a pressure reducing specialty air mattress and pressure reducing wheelchair cushion. The resident was to be repositioned as tolerated to reduce pressure on her buttocks and both heels. Daily skin care was to be provided. D. Staff interviews RN #1 was interviewed on 7/15/24 at 4:10 p.m. RN #1 said she treated residents'pressure related wounds. She said the wound team, which consisted of herself, RN #2, the registered dietitian (RD), and the NP, rounded on wounds every Wednesday. She said the NP measured the wounds and wrote the more complicated wound orders. RN #1 said residents at high risk for skin breakdown (and all residents upon admission), received a dietitian consultation and weekly skin assessments. She said those were standard interventions for residents who did not currently have a wound. RN #1 said all residents were originally given pressure-reducing mattresses. She said residents with a pressure wound or redness received a low-air loss mattress which had a pump to intermittently inflate and deflate. RN #1 said she did not know about Resident #67's wound because the resident was not on her assigned hallway. She said RN #2, who was on vacation, knew more about the resident. RN #1 said she had not seen the resident yet but the resident was on the list to be seen by the wound care team on Wednesday (7/17/24). She said RN #2 must have completed a referral form for the wound team to assess the wound the previous Friday, before she left. RN #1 said if a nurse noticed an open area on a resident's skin, they would let the unit manager know and they would proceed with notifying the physician and wound team. RN #1 said she did not know why wound care treatments for Resident #67 had not been initiated when the wound was initially identified. She said taking two weeks to get treatments into place after noticing an open wound was not good practice. CNA #2 was interviewed on 7/16/24 at 2:48 p.m. CNA #2 said upon admission, Resident #67 had a deficit in her right leg and needed two staff members to assist her with a mechanical lift. She said the resident moved around in bed and had, to some extent, been able to reposition both legs in bed, but she needed some help moving the right leg. She said the resident was consistent in pressing the call light to let staff know she wanted to be moved or repositioned. CNA #2 said Resident #67 never complained of pain at the site of the wound. She said since the wound developed, the resident had gotten a new air mattress, they repositioned her even more often than before, and were more diligent about making sure the site of the wound and the dressing were clean, especially after changing her brief. LPN #1 was interviewed on 7/16/24 at 3:02 p.m. LPN #1 said she was not usually on Resident #67's unit and had only known the resident for the past two days. She said the resident could move her left leg some, but not the right one. She said she needed a mechanical lift for transfers but she could move around on her own in her wheelchair using her upper body. She said the resident could not really roll in bed on her own. LPN #1 said if a new opening was noticed on a resident's skin, it would be documented in the skin assessment and the unit manager and wound care team would be notified for new interventions to be placed. She said, usually, the wound team nurse would stage and measure the wound. LPN #1 said since the wound developed, Resident #67 had received a new air mattress, they did daily dressing changes and she was on a supplement for wound healing. She said the resident did not complain of pain from the wound. The DON was interviewed on 7/16/24 at 4:44 p.m. The DON said upon admission Resident #67 could not do much. She said interventions to prevent wound development for Resident #67 had included offloading her bottom and repositioning the resident at least every two hours and whenever the resident requested repositioning. She said rounds for more independent residents were every two hours, so staff should round even more frequently for residents who could not reposition independently. The DON said residents at high risk for pressure injuries on the Braden assessment would have certain interventions in place, such as a specialty air mattress, a gel cushion for the wheelchair, and they would be placed on a check-and-change or frequent repositioning schedule. The DON said on 7/4/24 Resident #67's wound was open and on 7/11/24 it was closed again and had blanchable redness. She said the resident's mattress was changed and the treatments were changed as soon as the blanchable redness was noticed. The DON said she talked to LPN #2 about the wound. She said LPN #2 told her she had put barrier lotion on the wound and covered it with mepilex but she did not tell anyone about the wound when it originally developed. The DON said education about wound care documentation began on 7/15/24 (during the survey) for the nursing staff.

Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one resident (#44) of three residents reviewed for blood pressure management out of 32 sample residents. Specifically, the facility failed to assess and document Resident #44's blood pressure consistently prior to administering blood pressure medications. Findings include: I. Facility policy and procedure The Oral Medication Administration policy, revised 9/22/21, was provided by the nursing home administrator (NHA) on 7/17/24. It read in pertinent part, The facility will provide oral medication administration in accordance with professional standards of practice, as outlined by [NAME] through the procedures below: -Assess parameters, such as blood pressure and pulse, as needed, before administering a medication with dose-holding parameters. II. Resident #44 A. Resident status Resident #44, age 70, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included diabetes, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), ascites (fluid build up) and cirrhosis (liver damage). The 5/13/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment indicated he had a fluid build up (ascites) and was prescribed a diuretic medication. B. Record review The July 2024 CPO revealed a physician's order for furosemide (a diuretic medication) 40 milligrams (mg), give one tablet by mouth two times a day for fluid build up due to cirrhosis. Hold for a systolic blood pressure less than 90 millimeters of mercury (mmHg) and a diastolic blood pressure less than 60 mmHg, ordered 6/6/24. Resident #44's medication administration record (MAR) was reviewed for June 2024 and 7/1/24 to 7/16/24. The MAR revealed the resident was administered the medication on all days reviewed. -However, the resident's blood pressure was not recorded on the MAR and there was no documentation on the MAR to indicate the resident's blood pressure was assessed prior to the administration of the medication. The blood pressure (BP) records were reviewed from the vital signs section of the resident's electronic medical record (EMR) and revealed the following: On 6/21/24 at 9:49 a.m. the resident's BP was 89/58 mmHg. -However, according to the June 2024 MAR, the medication had been administered. On 6/15/24 at 4:23 p.m. the resident's BP was 83/57 mmHg. -However, according to the June 2024 MAR, the medication had been administered. On 6/11/24 at 3:24 p.m. the resident's BP was 90/52 mmHg. -However, according to the June 2024 MAR, the medication had been administered. On 6/9/24 at 2:47 p.m. the resident's BP was 92/58 mmHg. -However, according to the June 2024 MAR, the medication had been administered. On 7/1/24, 7/2/24, 7/3/24, 7/5/24, 7/6/24, 7/7/24 and 7/8/24, the resident's blood pressure was documented one time in the vital signs section. -However, the resident's blood pressure was to be obtained two times per day prior to the administration of the furosemide. On 7/4/24 the resident's BP was not documented in the vital sign section of the EMR. -However, according to the June 2024 MAR, the medication had been administered. II. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 7/15/24 at 2:45 p.m. LPN #3 reviewed Resident #44's EMR and said the resident's blood pressure was not consistently documented or taken. She said the resident was scheduled to receive medication at 8:00 a.m. and 1:00 p.m. every day, however the blood pressure on some days was documented only once. She said it was important to check blood pressure prior to the administration of furosemide to ensure that it was safe to administer the medication. She said if the blood pressure was too low and the medication was given, the resident's blood pressure could get critically low. LPN #3 said she would communicate the findings to the unit manager. She said she would correct the record to ensure the resident's blood pressure was documented on the MAR so all the nurses would have to document the resident's blood pressure before administering medications. The director of nursing (DON) was interviewed on 7/16/24 at 3:50 p.m. The DON said she was not aware that Resident #44 received furosemide when his blood pressure was below normal. She said the nurses should follow the physician's order and check the resident's blood pressure prior to medication administration. She said if the resident's blood pressure was below the recommended parameters, the medication should not be administered. The DON said she would provide education to all the licensed nursing staff to remind them about following the holding parameters for medications.

Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to: -Ensure licensed practical nurse (LPN) #3 followed proper infection control during medication administration; and, -Follow proper infection control procedures by sanitizing scissors pulled from a nurses pocket prior to their use for Resident #21's wound care. Findings include: I. Facility policy and procedure The Infection Prevention and Control Program policy, revised 5/19/23, was provided by the nursing home administrator (NHA) on 7/17/24 at 4:35 p.m. The policy read in pertinent part, General procedures include: Ensure staff follow the Infection Prevention and Control Program policy and procedures such as hand hygiene and appropriate use of PPE (personal protective equipment) and to the degree possible/consistent with the resident's capacity, provide supplies necessary to adhere to recommended infection prevention and control practices such as hand hygiene supplies, respiratory hygiene and cough etiquette, PPE and environmental cleaning and disinfection. Implementing strategies to achieve the goals include methods to reduce the risks associated with procedures, medical equipment and medical devices, including the following: appropriate storage, cleaning, disinfection and/or disposal of supplies and equipment, no resume of equipment designated by the manufacturer as disposable in a manner that is consistent with regulatory and professional standards, and the appropriate use of PPE. II. Failure to follow proper infection control during medication administration A. Observations On 7/15/24 at 9:59 a.m. licensed practical nurse (LPN) #3 was observed as she was administering morning medications to residents. LPN #3 dropped one pill on the medication cart. -LPN #3 picked the pill up with her ungloved hands and put it back in the medication cup. At 10:08 a.m. LPN #3 was observed administering topical medications in a resident's room. LPN #3 applied lotion to the resident's ankle using her left gloved hand. She was not wearing gloves on her right hand which she had used to remove the resident's sock. -LPN #3 did not wash her hands after touching the resident's ankle and before offering the resident the oral medications from a medication cup. B. Staff interviews The infection preventionist (IP) was interviewed on 7/16/24 at 11:45 a.m. The IP said all medications that came in contact with the medication cart surface should be disposed of because the medication cart surface was considered unclean. The IP said nurses should wash their hands when they removed gloves. She said LPN #3 should have washed her hands after she was finished applying lotion, after she removed her gloves and prior to offering the resident her medications. She said LPN #3's hands were not considered clean since they came in contact with the resident's feet when she helped the resident remove her sock. 47151 III. Failure to follow proper infection control procedures during wound care A. Observations On 7/15/24 at 10:50 a.m. registered nurse (RN) #1 and RN #3 were observed providing wound care to Resident #21 in his room. Resident #21 was seated in his chair while wound care was provided to his right lower leg. Resident #21's wound care supply container was set on his bedside table next to his chair. At 10:53 a.m. RN #3 began to unwrap the top of Resident #21's ace bandage from his right calf. RN #3 reached into her right pants pocket and removed a pair of medical grade bandage scissors with her hand. -Without cleaning or sanitizing the scissors, RN #3 cut the top of Resident #21's wound bandage around his right calf, touching the scissors to his skin. RN #3 then placed the scissors on the resident's bedside table and continued with Resident #21's wound care. -At 11:05 a.m. RN #3 placed the scissors back in her right pants pocket without cleaning or sanitizing the scissors. RN #1 was interviewed at 11:07 a.m. after the completion of Resident #21's wound care. RN #1 said RN #3 used her own personal scissors to perform wound care on Resident #21, but the facility had scissors in each resident's individual wound care supply container. B. Staff interviews RN #4 was interviewed on 7/16/24 at 10:39 a.m. RN #4 said if personal scissors were used to provide wound care, the scissors should be on top of the medication cart and not in a clothing pocket. RN #4 said if scissors were kept in a staff member's pocket, the scissors would need to be cleaned and sanitized prior to providing wound care and then cleaned again after use. RN #1 was interviewed again on 7/16/24 at 11:00 a.m. RN #1 said scissors were kept in each residents' container of supplies for wound care. RN #1 said if a nurse used their personal scissors for wound care, the scissors should be sanitized before and after providing a resident's wound care, and the scissors should also be kept in their own holster or package. RN #1 said she corrected RN #3 after completing Resident #21's wound care and told RN #3 that she should have sanitized her scissors prior to using them to cut the resident's wound dressing. RN #1 said RN #3 did sanitize her scissors after RN #1 instructed her to do so. RN #1 said RN #3 used her own scissors because the scissors usually in Resident #21's wound supply container were not present for his wound care on 7/15/24. The infection preventionist (IP) was interviewed on 7/16/24 at 4:10 p.m. The IP said wound care scissors pulled from a pocket in a nurse's clothing should be cleaned and sanitized before and after each use and the scissors should have their own holster to carry them in.

Based on interviews and record review, the facility failed to ensure one (#51) of five out of 29 sample residents were kept free from neglect and abuse. Specifically, the facility failed to ensure Resident #51, who required extensive assistance from two staff for toileting, was not left on the toilet commode for 70 minutes on 1/12/23. Findings include: Record review and interviews confirmed that the facility corrected the deficient practice prior to the onsite investigation completed on 2/9/23-2/14/23. The deficiency was cited as past noncompliance with a correction date of 1/15/23. No other incidents of resident neglect have occurred at the facility. I. Facility policy and procedure The Abuse and Neglect Prohibition policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 2/9/23. The policy read in part, Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. II. Resident #51 A. Resident status Resident #51, age 91, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, unspecified severity, without behavioral disturbances, hemiplegia (paralysis) and hemiparesis (weakness) affecting right dominant side following cerebral infarction (stroke), anxiety disorder, aphasia (loss of ability to understand or express speech), dysarthria and anarthria (motor speech disorder), difficulty in walking, arthritis, pain, and general muscle weakness. The 1/6/23 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status score of two out of 15. She required extensive assistance of two staff members with transfers and toilet use. B. Record review The care plan for activities of daily living (ADLs) last reviewed on 11/21/22 identified the resident had an ADL, self-care performance deficit related to dementia, and hemiplegia (paralysis)/hemiparesis (weakness) following a CVA (stroke) affecting the right dominant side. Pertinent care interventions include the extensive assistance of one staff member and use of stand-to-pivot disc when performing toilet use and transfers. The care plan for memory/cognition last reviewed on 11/21/22 identified the resident had an impaired cognitive ability and thought process related to dementia diagnosis. Pertinent care interventions include cue, reorient and supervise as needed. The care plan for communication last reviewed on 11/21/22 identified the resident had a communication deficit related to diagnosis of dementia, dysarthria and anarthria (motor speech disorder), and aphasia (loss of ability to understand or express speech) following a CVA (stroke). Pertinent care interventions include anticipating and meeting needs. Provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation. III. Facility investigation An investigation conducted by facility on 1/12/23 read Resident #51 was left on the toilet unattended for approximately 70 minutes. A description of the resident's response read, when found in the restroom by staff Resident #51 was tearful. A few minutes later when social services director (SSD) spoke with her she was smiling and when asked if she was okay resident responded 'yeah.' The immediate actions by the facility included suspending both certified nurse aides (CNAs) that were working with Resident #51, and conducting an audit of other vulnerable residents. The investigation concluded that Resident #51 was left on the toilet by morning CNA #4 due to miscommunication with oncoming CNA #1. CNA #4's understanding was that she would take resident to the bathroom and CNA #1 would assist the resident back from the bathroom. At the time of the incident, the resident's call light was not engaged, indicating that resident did not use the call light to call for help. The resident's skin was assessed immediately after the incident and no bruising or other injuries were observed. On 1/13/23 resident was assessed by her primary care physician, who documented, Facility asked me to evaluate the patient as she had inadvertently been sitting on the toilet for over one hour. (Resident) was smiling and jovial (cheerful, friendly) as always when I spoke to her and had completed her entire lunch. She stated she was 'fine' and the skin exam revealed no suspicious areas. Documentation continued to state, Mood and affect are appropriate and pleasant. The facility conducted an audit of all residents having similar deficits with cognitive and physical limitations and implemented corrective actions to not leave resident's unattended in bathrooms while toileting. Staff education and training for not leaving identified resident's unattended on the toilet began on 1/12/23 and was completed on 1/15/23. The facility did not substantiate neglect due to the investigation failed to prove the intent of neglect (see NHA interview below). IV. Staff interviews Certified nurse aide #2 was interviewed on 2/13/23 at 10:30 a.m. She said she approached Resident #51 to inquire on care needs. She said Resident #51 did not use a call light for assistance. CNA #3 was interviewed on 2/13/23 at 10:35 a.m. She said she approached Resident #51 to inquire on care needs. She said Resident #51 was inconsistent with using call light for assistance. Registered nurse (RN) #1 was interviewed on 2/13/23 at 10:45 a.m. She said Resident #51 initiated conversation and used her call light inconsistently. RN #2 was interviewed on 2/13/23 at 10:50 a.m. She said Resident #51 initiated conversation and used her call light inconsistently. CNA #1 was interviewed over the phone on 2/14/23 at 10:20 a.m. She said she arrived for work on 1/12/23 and received a report from the departing shift. She said she asked CNA #4 to toilet Resident #51 before they left for the day. She said that CNA #4 was in agreement of doing so. She said she witnessed CNA #4 go into room of Resident #51. She said she did not see CNA #4 exit room of Resident #51. She said later she was approached by wellness aide (WA #1) who told her Resident #51 was sitting on the toilet in the bathroom. She said the resident was crying upon arrival. She said the Resident was not able to stand up and hold on to the bar as she always did. The resident continued to lean to her right side. She said assistance from a second CNA was needed to transfer the resident from the toilet back into the wheelchair. She said on previous occasions Resident #51 needed only the assistance of one staff member when toileting. She said Resident #51 was not reliable to use call light appropriately. She said the resident was non-verbal and forgetful at baseline. She stated, I have always stayed with her because she's non-verbal and she usually doesn't take long in the bathroom. Wellness aide #1 was interviewed on 2/14/23 at 11:20 a.m. She said that upon entering room of Resident #51 she heard soft crying from the bathroom. She said she entered the bathroom and observed the resident sitting on the toilet. She said the resident was crying and leaning against the bathroom wall. She said her call light was not turned on. She said she left to find a CNA to assist Resident #51. The physical therapist (PT) was interviewed on 2/14/23 at 11:40 a.m. He said the most recent evaluation for the Resident #51 was completed in 2021. He said the resident was discharged from the therapy with recommendation of one person assistance for transfers and ADLs. He said to the best of his knowledge the resident's status had not changed since then and the resident was not working with therapy since 2021. He said in general, anyone with a diagnosis of stroke and one side weakness should not be left alone in the bathroom due to the risk of falls. The director of rehabilitation (DOR) was interviewed on 2/14/23 at 12:00 p.m. He said he worked with Resident #51 on transfers and toileting abilities. He said he observed the resident transferring with one person's assistance and she was deemed as safe to be left alone in the bathroom. He said the resident's inability to stand straight after the incident, when she required two person assistance, was indicative of emotional distress that she was in at the time of the incident. He said after the incident the resident did not show any signs of physical changes or decline. The social services director (SSD) was interviewed on 2/14/23 at 12:15 p.m. She said she talked to the resident on the day of the incident. She said the resident was not in distress. She said she did not conduct any formal assessment for the resident after the incident, but she spoke to her on several occasions and the resident appeared to be at her baseline. The nursing home administrator (NHA) was interviewed on 2/14/23 at 1:34 p.m. She said it's fair to say that Resident #51 uses call light inconsistently. She said this is the first occurrence of a resident being left unattended for an extended period of time. She said the physician and family were notified. She said the staff members involved were suspended, and ongoing skin assessment were conducted on Resident #51. She said the facility implemented a new practice and educated staff. She said the new practice included an audit that was completed to identify all residents with similar cognitive and physical impairment limitations and the interdisciplinary team provided input. She said the facility implemented a plan of correction for those identified residents who should not be unattended while toileting. She said the allegations of neglect were not substantiated as the investigation failed to prove the intent of neglect. The director of nursing (DON) was interviewed on 2/14/23 at 1:45 p.m. She said it was not appropriate for Resident #51 to be left unattended in the bathroom prior to the incident. She said, she's been here a long time and this is the first incident that occurred. She said after the incident the facility placed a plan of correction in place to make sure vulnerable residents with similar conditions were not left unattended in the bathroom. She said a list of identified residents was placed on every nursing station and all staff were educated on the new plan. She said care plans and Kardex were updated with new interventions for identified individuals. She said the education for all direct and indirect care staff in the facility was completed by 1/15/23.

Based on record review, observations and interviews, the facility failed to ensure a safe environment, effective interventions and adequate supervision to prevent accidents for five (#50, #27, #42, #39 and #148) of eight residents reviewed out of 20 sample residents. The facility failed to implement effective interventions after the first fall to prevent a second fall with major injury for Resident #50. Due to the facility's failures to develop appropriate interventions to effectively anticipate cognitively impaired residents' needs resulted in several unwitnessed falls, it contributed to Resident #50's femur fracture and hospitalization . The facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple unwitnessed falls that ultimately resulted in major injury to Resident #27. Due to the facility's lack of supervision and effective interventions, it resulted in four unwitnessed falls in less than a month, in which she sustained fractures to her left hand; causing her pain, and requiring the application of a cast, resulting in limited use of her left hand. The facility further failed to: -Implement effective and appropriate interventions after each of three falls sustained within a four day period to prevent recurrent falls for severely cognitively impaired Resident #42; -Implement effective and appropriate interventions to prevent two falls sustained within one week for Resident #39; and, -Implement effective interventions to prevent a fall for cognitively impaired Resident #148, who was admitted with their left upper extremity immobilized after a fracture. Findings include: I. Resident #50 A. Resident status Resident #50, age 89, was admitted on [DATE] with diagnoses of concussions, polyneuropathy, heart failure, pain and repeated falls. The 9/21/21 minimum data set (MDS) assessment revealed the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. No hallucinations, delusions or rejection of care behavior were present. He required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use and personal hygiene, and was independent with eating. A history of falls and one fall with injury since admission were documented. B. Record review 1. Care plans The resident's care plan for activities of daily living (ADLs) documented: (Resident) has limited physical mobility which includes physical performance limitations affecting balance, gait, and limited strength due to deconditioning after hospitalization AEB (as evidenced by) muscle weakness, difficulty walking, and significant cognitive deficits, increased dizziness, lightheadedness, and balance difficulties due to a concussion, resulting in more numerous falls. Most recent fall resulted in a retroperitoneal (the tissue that lines the abdominal wall and covers most of the organs in the abdomen) hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space). He also has left leg, hip, and shoulder pain. Other comorbidities that may influence his mobility are: CAD ([CONDITION(S)]), OSA (obstructive sleep apnea), A fib ([CONDITION(S)]) on blood thinners, dementia, and [CONDITION(S)]. Date Initiated: 9/23/21 Interventions included: Staff to assist with all transfers and ambulation as needed. Provide supportive care and assistance with mobility as needed. The care plan for falls documented: (Resident) is at risk for injury due to falls r/t (related to) functional & mobility impairment, poor safety awareness and cognitive deficits AEB muscle weakness, difficulty walking, and significant cognitive deficits 2/2 (secondary to) increased dizziness, lightheadedness, and balance difficulties resulting in numerous falls. Only a month ago a fall resulted in a concussion. Most recent fall resulted in a retroperitoneal hematoma. He also has left leg, hip, and shoulder pain. Other comorbidities that may influence his mobility are: CAD, OSA, [CONDITION(S)] on blood thinners, dementia, and [CONDITION(S)]. Date Initiated: 9/17/21 Interventions included: A 'Call Don't Fall' visual aid on bathroom door. Assist with ADLs as needed. Call light in reach. Complete fall risk assessment. Educate on safety awareness and what to do if a fall occurs. Patient to wear nonskid footwear with transfers and mobility. Staff to encourage (resident) to use reacher to pick items off the floor. -The facility failed to assess the resident's several falls prior to admission to implement appropriate approaches to prevent falls in the facility. 2. Nursing notes revealed the resident suffered two falls, one with major injury, within nine days, as follows: Fall #1 -A 9/18/21 nursing note revealed: Summoned by front desk receptionist at approximately 0555 (5:55 a.m.) that nurse on 200 unit was in need of assistance r/t (related to) this resident being on floor. On entering room, noted resident lying on his right side. His legs were flexed. His walker was nearby, above his head. He was near the door to his bathroom. Noted open abrasion to left, upper, posterior arm (1.2 x 1.0 cm) and to distal left knee (2.0 x 1.5 cm) .Resident assessed by this RN (registered nurse) .Assisted off floor and onto bed with staff assist x 3 using mechanical lift. Cleansed abrasions to left arm and to left knee .Assisted resident with using urinal that was in reach at bedside. Assisted with positioning in bed for comfort. Pad type call bell placed in reach, clipped to front of shirt at chest. Resident stated he had difficulty finding his call bell prior to getting OOB (out of bed). Call bell was noted clipped to top of bedspread . -A 9/20/21 interdisciplinary team (IDT) note revealed: Fall huddle with IDT, direct care staff, and patient to discuss recent fall and recent added intervention of soft touch call light. This seems to be adding support for patient adequately per staff report, patient acknowledges need to use call light and is able to demonstrate how to use call light, however admits to not using 'all the time.' Continued education and encouragement by staff to have (resident name) use call light for assist. -A 9/22/21 nursing note revealed: Pt (patient/resident) displaying some confusion at HS (night). Pt was found attempting to self-transfer. Pt reminded the importance of calling for assistance and waiting for staff to arrive. -A 9/23/21 nursing note revealed: Prevention fall huddle with IDT and patient to discuss fall intervention strategies. Patient recently admitted for rehabilitation following hospitalization due to multiple falls, dizziness and weakness. Patient reports he has had at least 25 falls in the last year which 6 (six) of the falls happening the week of being hospitalized . Patient is A&Ox3 (alert and oriented to person, place and time) with confusion noted. He is however able to make his needs known; staff reports he is using call light appropriately. Patient is strongly encouraged to use call light due to safety concerns which he reports understanding. Bed is positioned along the wall per patient preference, and a visual reminder of a 'Call don't fall' sign is placed on closet door. Patient is educated on safety reminders and what to do if a fall occurs which he reports understanding. He wears glasses; staff is aware and glasses will be worn with transfers and mobility. He does wear nonskid footwear with transfers and mobility. His room is clutter free and with adequate lighting. Discussed high risk medications: [MEDICATION(S)] (Benzodiazepine, side effects include severe drowsiness and dizziness), [MEDICATION(S)] (opioid, side effects include severe drowsiness and dizziness), Aspirin, [MEDICATION(S)] (blood thinner) . Fall #2 -A 9/27/21 nursing note revealed: This nurse was at the nurses station when another patient approached me and notified me of another patient that had fallen in his room. Upon arrival, the patient was laying on his right side next to his bed. The wheelchair was near his feet and the brakes were locked. The walker was next to the wheelchair. Patient stated that he was trying to move a cord that was laying on the floor in front of him and he fell forward out of the chair . 2cm x 0.7cm skin tear noted to right elbow. Pt was Hoyer lifted back into bed and VS (vital signs) were obtained . Call light placed within reach. -A 9/28/21 nursing note revealed: Patient having AMS (altered mental status) and garbled speech this morning after unwitnessed fall yesterday. Pt (patient) reported he did hit his head. Neuros WNL (within normal limits). Pt c/o (complained) increased pain to pelvic area. Pt received first dose of [MEDICATION(S)] (blood thinner) yesterday. (Name) PA (physician assistant) notified and orders were received to send pt to ED (emergency department) for evaluation. Pt left facility at approximately 10 a.m. 3. Hospital record On 9/28/21 the emergency department physician documented: I performed a face-to-face diagnostic evaluation of the patient in the emergency department. I was present in the emergency department around 1015 hours (10:15 a.m.), just prior to the patient's arrival. EMS reported that the patient is an [AGE] year-old male with a past medical history that includes cardiac disease on systemic anticoagulation with [MEDICATION(S)] and dementia who was brought in from his nursing care facility to the (hospital) emergency department as a full trauma activation after reportedly sustaining a ground-level fall yesterday evening around 1800 (6:00 p.m.) hours .Secondary survey revealed age-indeterminate bruising of the right lateral chest, flank, and knee, as well as an approximately 2 cm in diameter superficial skin tear of the right elbow area . The patient was found to have a fracture of the right femur just below the femoral head . Diagnoses this visit: -Right proximal femoral (thigh bone) fracture -Bilateral pleural effusions (fluid buildup between the lungs and chest) -Fall on anticoagulation. From the emergency department, the resident was admitted for surgery. He did not return to the facility after hospitalization . C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 10/21/21 at 8:20 a.m. She said Resident #50 should have been checked by staff as frequently as every 15 minutes after his first fall. She said additional interventions should be implemented. She said it should not have been another resident alerting staff about Resident #50's fall. II. Resident #27 A. Resident status Resident #27, age 87, was admitted on [DATE] and readmitted on [DATE]. According to the October 2021 CPO, pertinent diagnoses included muscle weakness, difficulty in walking, cognitive communication deficit, attention and concentration deficit; and new diagnoses on 10/2/21 of non-displaced fracture of base of second metacarpal (bones between the wrist and fingers) left hand, and displaced fracture of shaft of third metacarpal bone left hand. The 9/15/21 MDS indicated Resident #27 was severely cognitively impaired with a BIMS score of three out of 15. She did not have mood or behavior symptoms. She required extensive assistance of two staff members for bed mobility, transfers and toilet use, and required extensive assistance of one staff member for personal hygiene and dressing. She was always incontinent of bladder and was occasionally incontinent of bowel. She was not on a toileting program. No restraints or alarms were used. No falls were documented. She was not steady when moving from a seated to a standing position, when transferring from surface to surface or when moving on and off the toilet, and was only able to stabilize with staff assistance. She used a wheelchair for mobility. B. Observations On 10/19/21 at 4:30 p.m. Resident #27 was seen in her room seated in her wheelchair in front of the television that was located beyond the foot of her bed. Her call light was clipped to the hem of her shirt. Both brakes on her wheelchair were in the locked position. She had a purple hard cast on her left arm that covered her hand, up to her mid forearm. She said she did not know how to call for help if she would need it. She was unaware of what the call light was for and did not know how to operate the brakes on her wheelchair. There were four white non-skid strips secured to the floor beside her bed. -At 4:57 p.m. Resident #27 was still seated in her wheelchair with both brakes locked on her wheelchair. She had scooted herself closer to the television and was slumped down in the seat of the wheelchair. On 10/20/21 at 8:15 a.m. Resident #27 was seen in her room attempting to propel her wheelchair toward the door of the room, while pushing the overbed table in front of her that had her breakfast tray on top of it. She had pulled her oxygen tubing from the portable tank that was lying on her bed. Her call light was clipped to the blanket on the side of her bed. An unknown CNA entered her room and positioned her wheelchair in front of her television. She did not place her call light within her reach. It remained behind her, clipped to the blanket toward the head of the bed. -At 8:40 a.m. Resident #27 was seated in her wheelchair, and had moved her wheelchair in her room again. The white strips, seen previously adhered to the floor beside her bed, were gone and a fall mat was seen folded underneath her bed. -At 12:29 p.m. Resident #27 was seen seated in her wheelchair in front of her television at the end of her bed with her lunch tray on the overbed table in front of her. Both brakes on her wheelchair were locked and her call light was clipped to the blanket behind her toward the head of the bed, out of her reach. On 10/21/21 at 8:20 a.m. Resident #27 was seen seated in her wheelchair in her room positioned in front of the television. Her breakfast tray was on the overbed table in front of her. Both brakes on her wheelchair were locked. Her call light was clipped to the top of her mattress at the head of the bed, under the blanket, out of her reach. -The resident was unable to independently lock or unlock her wheelchair brakes, per interview below. C. Record review The care plan, initiated 10/6/21, indicated Resident #27 had impaired cognitive skills related to short and long term memory loss, forgetfulness, poor recall, poor orientation to current time related to her diagnosis of dementia, attention and concentration deficit and cognitive communication deficit. Staff were to cue, reorient and supervise as needed. Per the care plan, initiated 10/6/21, Resident #27 was at risk for falling and injuring herself related to muscle weakness, and difficulty waking secondary to a diagnosis of dementia, [CONDITION(S)], polyneuropathy (malfunction of peripheral nerves), and right foot drop. She required extensive assistance for most activities of daily living (ADLs). Interventions included: -Anticipate and meet the resident's needs. -Call light within reach. -Nonskid strips to ground next to bed. -Offer toileting before and after meals to minimize risk of self transfers. -Staff to supervise and cue (Resident #27) when up in her wheelchair to not lean forward to pick items off the ground. -The care plan was not updated to indicate actual falls with injuries, and effective interventions were not added to the care plan after the resident's unwitnessed falls, including the fall mat and bed in low position. Per the care plan, initiated 10/6/21, Resident #27 had an ADL self care performance deficit related to muscle weakness and difficulty walking, and required extensive assistance with most ADLs. Interventions included: -Resident #27 used a wheelchair for mobility. -She required extensive assistance of one staff member for bed mobility, toilet use and transfers. -Encourage Resident #27 to use bell to call for assistance. Review of the September and October 2021 fall risk evaluations revealed the following scores of greater than 10, that indicated Resident #27 was at high risk for falls: -9/22/21 Status Post Fall-score 20 -10/1/21 Status Post Fall-score 18 -10/10/21 Status Post Fall-score 22 -10/18/21 Status Post Fall-score 24 D. Falls Fall #1, 9/22/21 unwitnessed fall: The 9/22/21 fall investigation and event note documented by certified nurse aide (CNA) #2 and registered nurse (RN) #4 at 7:30 p.m. read in part: (Resident #27) was crying for help in the bathroom. She was sitting with her back to the wall and her legs out in front of her. Her wheelchair was by the sink. Resident assessed, states pain to left knee when attempting to move her leg. Able to move right leg without difficulty, bruising noted to inner left knee. Able to move arms without any pain or discomfort. No injuries to head noted, continues to complain of left knee pain when palpated, just above the knee. The resident stated she was trying to get to the bathroom by herself, the call light was not on. The intervention for this fall was to place a sensory alarm on the bathroom door. -There were no interventions to conduct 15-minute checks, how to anticipate and provide the resident's needs, or a toileting plan. The 9/22/21 pain evaluation completed after this fall indicated Resident #27's pain level was eight (severe) out of 10 for pain to her left knee. The 9/22/21 plan of care note documented by the DON at 9:00 p.m. read in part: All fall interventions were reviewed and remain appropriate and current at this time. Additional intervention, sensory alarm placed to bathroom door. -This was not added to the resident's care plan. The 9/23/21 physician documentation indicated Resident #27 was seen related to a fall. Fall safety and prevention reviewed although considerably limited by patient's dementia. Fall #2, 10/1/21 unwitnessed fall: The 10/1/21 fall investigation documented by licensed practical nurse (LPN) #1 at 3:30 p.m. read in part: This nurse was in another room and walked into the hall to see two CNAs and another nurse lifting (Resident #27) off the floor with a mechanical lift. There was bruising above her right eyebrow, a small cut on her bottom lip and a skin tear to her right 'pinky' finger knuckle with bone exposure. Resident stated that her wrists hurt. The physician was notified and stated to continue to monitor. Skin tear dressed. The resident said she fell forward out of the wheelchair. She had been in the hall outside her room self propelling in her wheelchair. The cause of the fall was felt to be due to her diagnosis of dementia. The intervention for this fall was to do frequent checks on the resident and staff were to supervise and cue the resident when up in her wheelchair to not lean forward to pick items off the ground. -However, the DON did not provide documentation of frequent checks completed for Resident #27. Further, there was no documentation of how often the frequent checks should be conducted. -There was no pain evaluation completed after this fall. The 10/1/21 event note documented by the DON at 4:00 p.m. read in part: Ground level fall occurred at 4:00 p.m. Noted to have skin tear to lateral right hand, approximated skin and steri strips applied. Bruising noted above right eyebrow. Physician was notified with no new orders at this time. The intervention for this fall was to have therapy evaluate wheelchair size and resident's positioning in the chair. -However, the resident was not evaluated by therapy until 10/5/21. The 10/2/21 health status note documented by LPN#1 at 9:00 a.m. read in part: Noted bruising to right side of jaw this morning, as of yesterday after fall no bruising was noted, bruising is light purple in color. Moderate purple bruising noted to right forehead bump, slightly darker in color from previous day. Right hand down to mid forearm [CONDITION(S)] noted as previous date none was noted, moderate purple bruising noted to this area as well as previous date none was noted. Resident complains of pain with and without touch to her right wrist. Physician notified to obtain orders for right wrist x-rays. The 10/2/21 transfer to hospital summary, documented by RN #4 at 2:55 p.m., read in part: Resident with left hand blackened from fingertips to down below the wrist, hand deviated slightly outward and very painful, swollen and hot. Unable to manipulate joint as it was too painful. Resident was transferred to the hospital. She was alert but confused at time of transfer. The 10/2/21 emergency department x-ray result indicated Resident #27 had a minimally displaced spiral fracture along the left third metacarpal shaft and a nondisplaced fracture at the base of the second metacarpal with possible intra-articular (fracture that crosses a joint surface) extension at the carpometacarpal (CMC) joint (at base of thumb) with soft tissue swelling along the left hand and wrist. The 10/2/21 event note documented by RN #4 at 5:38 p.m. read in part: Spoke with the emergency department at the hospital, they state (Resident #27) has multiple fractures in her left hand that is splinted and will need follow up with orthopedic (ortho) specialist. The 10/2/21 health status note documented by RN #4 at 7:22 p.m. read in part: Returned from the hospital emergency department. Left hand is in splint. Orders to follow up with orthopedic surgeon in three days. -However, the resident was not seen by orthopedics until 10/12/21, 10 days later, and after she had yet another fall. The 10/6/21 health status note, documented by RN #1 at 12:26 p.m., read in part: Resident has splint on left wrist for wrist fractures which she frequently removes. The 10/7/21 physician documentation indicated Resident #27 was seen related to a fall with injury resulting in an ER visit and return to the facility with instructions to follow up with orthopedics. The patient is able to point to her most recent injuries sustained in a recent fall. Left hand and wrist splint in place and secured with an ace (elastic) bandage. Fall #3, 10/10/21 unwitnessed fall The 10/10/21 fall investigation, documented by LPN #4 at 3:30 p.m., read in part: CNA (#3) notified the nurse that (Resident #27) was on the floor. The nurse saw the resident sitting upright on the floor. She was unable to say how she got on the floor. She complained of pain to her left hand. She was assisted into her wheelchair with a mechanical lift. The intervention for this fall was to leave the door to her room open and apply non-skid strips next to her bed. -Leaving her door open, defined frequent checks, therapy assessments, and anticipating/meeting needs and how to do so were not added as interventions to the care plan. The 10/10/21 pain evaluation completed after this fall indicated Resident #27 scored a three out of 10 for pain to her coccyx and left hand. The 10/10/21 event note, documented by LPN #5 at 5:15 p.m., read: Resident was sent to the hospital for evaluation. The 10/10/21 event note, documented by LPN #3 at 9:52 p.m., read in part: Resident returned at this time via emergency medical services. No additional fractures to her left hand. The emergency department staff resplinted the left hand and rewrapped. Resident also has a urinary tract infection now being treated. The 10/11/21 plan of care note, documented by the DON at 10:20 a.m., read: Fall huddle with interdisciplinary team (IDT), direct care staff, and patient to discuss recent fall. All fall interventions were reviewed and remain appropriate and current at this time. Immediate intervention, patient was sent to emergency room (ER) for full evaluation, returned with no new fractures however was diagnosed with urinary tract infection ([CONDITION(S)]) and started on oral antibiotics. Long term intervention, non-skid strips to ground next to bed, this is effective at this time per staff report. The 10/11/21 health status note, documented by RN #4 at 7:39 p.m., read in part: Resident continues on neurologic (neuro) checks for unwitnessed fall, no new injuries noted. Continues to have left hand in splint from previous fall. Resident removes splint often and has to be rewrapped. Resident climbing out of bed (OOB) often this evening, has no safety awareness. The 10/11/21 physician documentation indicated Resident #27 was seen related to an ER visit on 10/10/21 for a fall. The patient was alert and sitting in her wheelchair in her room slightly agitated. Patient states she has no idea what's been going on. X-rays in ER confirmed wrist fracture and patient was started on antibiotic for apparent [CONDITION(S)]. Left brace in place but patient has been giving nurses a difficult time about wearing it. Fall safety and prevention reviewed although considerably limited by patient's dementia. The 10/12/21 health status note, documented by LPN#6 at 1:00 p.m., read in part: Alert charting for recent fall. Continues on neuro checks. Out for ortho follow up, pending results. Hand in splint for multiple fractures. The 10/14/21 health status note, documented by RN #1 at 11:37 a.m., read in part: Resident returned from ortho appointment with hard cast on left wrist. Fall #4, 10/18/21 unwitnessed fall The 10/18/21 event note documented by RN #4 at 9:50 p.m. read in part: Heard resident talking from her room, went into room and noted resident lying on the floor on left side next to her bed, head off the ground. Resident in bare feet. Resident states the floor is slippery and she was trying to stand up. Resident assessed and able to move all extremities without difficulty, no injuries noted. Short arm cast intact to left hand/wrist. Denies any pain or discomfort. Assisted back to bed with hoyer ( mechanical lift) and three person assist without difficulty. The intervention for this fall was to remove the non-skid strips from the floor next to her bed and place a fall mat beside the bed. -There was no evidence that therapy was included in the post-fall evaluation. The 10/18/21 pain evaluation completed after this fall indicated Resident #27 denied pain. The 10/19/21 physician documentation indicated Resident #27 was seen related to a fall. Patient states she doesn't remember falling from bed this morning (AM). She was in good spirits and pleasantly confused. Nursing reports patient rolled out of bed this AM with no injuries noted. Left wrist hard cast in place. Fall safety and prevention reviewed although considerably limited by patient's dementia. D. Staff interviews RN #1 and #2 were interviewed on 10/20/21 at 3:15 p.m. They acknowledged Resident #27 had frequent falls over the last few weeks. They said the resident was confused and current interventions included having her bed in a low position with a fall mat next to the bed because she had fallen from bed a few times. The staff were to anticipate her needs. They were to do frequent checks to look in on her whenever they were down that hall. They were to have her call light in reach. RN #2 said the resident did know how to use the call light but she was very forgetful. They were unsure if she was receiving therapy. CNA #1 was interviewed on 10/21/21 at 9:24 a.m. She said she usually worked on the rehab side of the facility but would help out on the long term side when needed, as she had done 10/18-10/21/21. She said she was unaware Resident #27 had fallen several times over the last few weeks and was unaware of what interventions were in place for her. She said Resident #27 required a sit to stand lift or a full body lift with the assistance of two staff members to transfer. She said when a resident had multiple falls the staff were to do frequent checks, every 15 to 30 minutes, if the resident was in their room, but those checks were not documented in their medical record. She said Resident #27 was very impulsive and would try to transfer herself and she did not use the call light to ask for help. She said Resident #27 would not be capable of locking the brakes on her wheelchair, especially since she had a cast on her left arm. III. Resident #42 A. Resident status Resident #42, age 89, was admitted on [DATE] with diagnoses of Alzheimer's disease, unspecified dementia with behavioral disturbance, anxiety and [CONDITION(S)]. The 9/22/21 MDS assessment revealed the resident sometimes was able to understand others and her cognitive skills for daily decision making were severely impaired. She required limited assistance with bed mobility and walking, extensive assistance with transfers, dressing, toilet use and personal hygiene, and supervision with eating. She was frequently incontinent of urine. She had one fall with no injury. She received antipsychotic and antidepressant medications daily. B. Record review 1. Care plans The resident's care plan for falls documented: (Resident) is at risk for injury due to falls r/t (related to) functional & mobility impairment, poor safety awareness and cognitive deficits. Date initiated 6/10/21 Interventions included: Anticipate and meet the resident's needs, call light within reach, adequate lighting in room/bathroom, clutter free pathway, non-skid foot wear with transfers and mobility, nonskid strips to ground at bedside. The following interventions were added after Resident #42's three falls, on 10/14/21, Therapy evaluation and treat, and staff to make frequent checks on (resident's name). The resident's care plan for antipsychotic medication use documented: (Resident) uses [CONDITION(S)] medications r/t (related to) behavior management. Date initiated 6/10/21. Intervention included: Observe for and report PRN (as needed) any adverse reactions of [CONDITION(S)] medications: unsteady gait, tardive dyskinesia, EPS (extrapyramidal symptoms), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [CONDITION(S)], social isolation, blurred vision, diarrhea, fatigue, [CONDITION(S)], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Consult with pharmacy, MD (physician) to consider dosage reduction when clinically appropriate at least quarterly. Discuss with MD (physician), family ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of [CONDITION(S)] medication drugs being given. The resident is on a behavior management program: distraction. The interventions were dated 6/10/21. -The facility failed to implement appropriate interventions to prevent falls for this resident with severely impaired cognitive status who was administered antipsychotic ([MEDICATION(S)]) and anti-anxiety ([MEDICATION(S)]) medications. 2. Fall risk evaluation The score 10 and above indicated high risk for falls. The following fall risk evaluations indicated Resident #42 was at high risk for falls: -9/26/21 score 22 -10/11/21 score 14 -10/13/21 score 22 -10/14/21 score 30 3. The resident's medical record revealed the following falls: Fall #1 A 10/11/21 nursing note revealed: CNA (certified nurse aide) notified this nurse that resident was on the floor. Observed resident sitting on her bottom in front of her chair in her room, legs straight out in front of her. Her shoes were on. Call light was not on. Assessed for injuries, none noted. Neuro assessment WNL (within normal limit). Denies pain. Assisted into chair with assist of two. Skin intact, no redness or bruising noted . Call light within reach. A 10/12/21 IDT note revealed: Fall huddle with IDT, direct care staff, and patient to discuss recent fall. All fall interventions were reviewed and remain appropriate and current at this time. New intervention, staff to make frequent checks on (Resident). The facility Incident Management Soft File review revealed the resident fell on [DATE] at 8:50 p.m. There was no fall investigation included in this document. It was f[TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Specifically, the facility failed to: -Ensure staff were following proper hand hygiene procedures; -Provide hand hygiene opportunities for residents; -Ensure staff were following proper personal protective equipment (PPE) guidelines. Findings include: I. Facility policies The Hand Hygiene policy, last revised March 2020, was provided via email by the nursing home administrator (NHA) on 3/31/2020. It read in part, Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Policy: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. The facility should provide education on hand hygiene routinely. Procedure: Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids. Using an alcohol-based hand rub (ABHR) is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, non intact skin, wound dressings; after removing gloves; and after contact with inanimate objects in the patient ' s environment. The Hand Hygiene for Residents policy, last revised August 2018, and last reviewed March 2020, was provided via email by the NHA on 3/31/2020. It read in part, Purpose: To decrease the risk of transmission of infection by enabling residents to perform appropriate hand hygiene. Policy: The shared living environment of a long term care (LTC) facility can allow the spread of easily [MEDICAL CONDITION] and bacteria leading to respiratory and gastrointestinal infections among both staff and residents. Handwashing/hand hygiene is generally considered the most important single procedure for preventing infections. Procedure: Staff will encourage and assist the resident as needed to ensure proper hand hygiene through hand washing or the use of an ABHR. Hand hygiene should be offered/performed upon waking, after toileting, after coughing/sneezing, prior to handling and/or consumption of food/drink, prior to leaving his/her room for therapy or shared activities, after ending therapy or shared activities, anytime hands are visibly soiled, and upon request. The Personal Protective Equipment (PPE) policy, last revised March 2020 was provided via email by the NHA on 4/6/2020. It read in part, Purpose: to reduce the risk and prevent the spread of infection to patients, visitors, and staff. The facility should train on PPE, this training should include but is not limited to: appropriate don/doff process and appropriate use, based on care activities. The use of PPE during resident care is determined by the nature of staff interaction and the extent of anticipated body, body fluid, or pathogen exposure to include contamination of environmental surfaces. Furthermore, appropriate use of PPE includes PPE appropriately discarded after resident care prior to leaving the room followed by hand hygiene. II. Failure to ensure staff were following proper hand hygiene procedures A. Observations On 3/31/2020 at 11:47 a.m. certified nurse aide (CNA) #3 was observed delivering a meal tray to Resident #4 in her room. The CNA set the tray down on the resident's bedside table, and left the room. The CNA used some ABHR to sanitize her own hands, however she had a brace on her left hand and was unable to effectively sanitize her left hand. At 11:51 a.m registered nurse (RN) #1 was observed delivering a meal tray to Resident #5 in her room. The RN placed the tray in front of the resident. The RN then went immediately over to assist the roommate, Resident #6, who had not received the correct meal tray. The RN did not perform hand hygiene in between assisting Resident #5 and Resident #6. B. Interviews The NHA was interviewed on 3/31/2020 at 12:15 p.m. She said that staff had been educated on hand hygiene. She also said that the facility was performing audits on hand hygiene. C. Record Review A copy of a staff education in-service that was conducted at the facility on 3/17/2020 was provided by the NHA via email on 3/31/2020. Review of the in-service revealed that it included education on hand hygiene and PPE. Review of the sign in sheets for the in-service revealed that RN #1 and CNA #3 had received the education. III. Failure to provide hand hygiene opportunities for residents A. Observations On 3/31/2020 at 11:33 a.m., CNA #1 was observed in the TV room where five residents were awaiting their lunch meal. CNA #1 assisted Resident #1 with putting on a clothing protector. At 11:35 a.m., Resident #1 received her meal from CNA #1. CNA #1 did not offer the resident the opportunity to perform hand hygiene prior to eating. At 11:35 a.m., Resident #2 received her meal tray from an unidentified CNA. The CNA did not offer the resident the opportunity to perform hand hygiene prior to eating. The resident was observed to begin eating. At 11:38 a.m., Resident #3 was assisted into the TV room by CNA #2. She informed the resident his meal would be coming and then left the room without offering the resident the opportunity to perform hand hygiene. CNA #4 brought the resident his meal tray, set him up to eat, and put a clothing protector on him. She also did not offer the resident the opportunity to perform hand hygiene prior to eating his meal. At 11:47 a.m., CNA #3 was observed delivering a meal tray to Resident #4 in her room. The CNA placed the tray on the resident's bedside table. She did not offer the resident the opportunity to perform hand hygiene prior to eating her meal. At 11:51 a.m. RN #1 was observed delivering a meal tray to Resident #5 in her room. The RN placed the tray in front of the resident, but did not offer the resident the opportunity to perform hand hygiene prior to eating her meal. B. Interviews The NHA was interviewed on 3/31/2020 at 12:15 p.m. She said that residents should be assisted to wash their hands or use ABHR prior to eating. She said that staff had received education on resident hand hygiene. C. Record review A copy of an education in-service that was conducted at the facility on 3/31/2020 was provided by the NHA via email on 3/31/2020. Review of the in-service revealed that it included education on hand hygiene for residents. Review of the sign in sheets for the in-service revealed that RN #1, CNA #1, CNA #2, CNA #3, and CNA #4 all received the education. IV. Failure to ensure staff were following proper personal protective equipment (PPE) guidelines A. Observations On 3/31/2020 at approximately 11:15 a.m., laundry aide (LA) #1 was observed pushing a covered cart in the hall, delivering clean personal folded laundry and laundry on hangers to resident rooms. The LA had gloves on both hands. She knocked on a resident's door, entered the room, placed a blanket on the resident's bed and left the room. The LA then went to the shared room of Resident #3 and Resident #7, removed clothes from the laundry cart and went into the room with the same gloves on. She opened the closet door, hung the clothes in the closet, removed empty hangers from the closet and left the room. She did not perform hand hygiene or remove her gloves upon exiting the room. The LA then got more clothes from the covered laundry cart and returned to the same room, opened the other closet door, hung the clothes in the closet, removed empty hangers from the closet, and exited the room again without performing hand hygiene or removing her gloves. The LA then proceeded to the room of Resident #8 still wearing the same pair of gloves. She removed Resident # 8's clothes from the laundry cart, entered the room, opened the closet door and hung the clothes in the closet, then left the room. Again, she did not remove her gloves or perform hand hygiene prior to exiting the room. B. Interviews LA #1 was interviewed on 3/31/2020 at 11:25 a.m. She said that she wore the gloves for her own protection when putting clothes away. She said that she would put all of the clothes on the laundry cart away in all of the residents rooms on the hall before she would change her gloves. She said she was trained on PPE, however she said she did not know that she had to change gloves and perform hand hygiene in between each room and resident. C. Record Review A copy of an all staff education in-service that was conducted at the facility on 3/17/2020 was provided by the NHA via email on 3/31/2020. Review of the in-service revealed that it included staff education on hand hygiene and PPE. Review of the sign in sheets for the in-service revealed that LA #1 had received the education. LA #1 received further education regarding hand washing and laundry distribution on 3/31/2020.

Based on record review and interviews, the facility failed to have an appropriate reason to issue an involuntary discharge for one (#2) of three out of 18 sample residents. Specifically, the facility failed to issue an appropriate discharge letter containing the required information to Resident #2 and failed to have an appropriate reason for issuing the discharge letter. Findings include: I. Facility policies and procedures The Discharge Plan policy, dated 5/6/19, was provided by the nursing home administrator (NHA) on 10/24/19 at 1:49 p.m. It documented in pertinent part, The interdisciplinary team participate in developing an effective discharge planning process based on the patient ' s active participation in determining his;her discharge goals to effectively transition him/her to post-discharge care and reduce factors leading to preventable readmissions. The discharge plan will identify the discharge destination and ensure it meets the residents ' health and safety needs as well as preferences. The Discharge Summary policy, dated 5/6/19, was provided by the NHA on 10/24/19 at 1:49 p.m. It documented in pertinent part; -The Social Services and Nursing staff, as members of the interdisciplinary team, participate in developing a discharge summary when a resident is discharged to a private residence, nursing facility or another type of residential facility. -The discharge summary provides a recapitulation of the resident ' s stay and the resident ' s status at the time of discharge to ensure continuity of care. -The following information along with the discharge summary is sent to the receiving provider of care and will include the following: contact information of the practitioner responsible for the care of the patient; resident representative information including contact information; advance directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; and any other documentation to ensure a safe and effective transition of care. I. Resident #2 [NAME] Resident status Resident #2, age 85, was admitted on [DATE] with readmission 5/21/19. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/30/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. He required extensive assistance from staff with his activities of daily living (ADL), with no behaviors exhibited and he was discharged from the facility on 9/30/19. B. Family interview The resident representative was interviewed on 10/24/19 at 12:34 p.m. She said the resident, herself and her sister had been given a notice for their father to discharge from the facility due to his behaviors and the facility not being able to care for him. She said the facility told her that it was not locked and with his wandering, the facility could not keep him safe. She said it was abrupt since in previous care conferences the family were told that he could stay long term. She said she did not understand when issued the 30 day notice by the facility that they appeal the decision and it was not conveyed in subsequent meetings about his discharge. She said on the day of his discharge 9/30/19 that the facility was supposed to arrange transportation and have his discharge paperwork ready but that did not happen because her sister had to take the resident to his new facility at 8:00 p.m., without the discharge paperwork and was only provided his medications. C. Record Review 1. Notification of discharge The 9/3/19 notification of discharge letter addressed the daughters of the resident documented the resident was required to discharge on 10/3/19 and if a facility could not be found then he required to be discharged to the care of his daughters. It documented that due to the resident exit-seeking behavior and risk of elopement that the resident required secure unit placement. The resident had a right to appeal the facility ' s decision by appealing with the social service director or the health department within 14 days of the letter issuance. 2. Care plan The discharge plan that documented the resident was anticipated to stay long term, initiated 12/19/18 and revised on 10/3/19 had interventions for nursing and therapy to work with resident to meet goals and set discharge to home, nursing to set up home health care prior to discharge if appropriate, social service department to provide outside referrals and work with the resident on adjustment to rehab stay and new placement. The elopement care plan, revised on 10/3/19 documented the resident was at risk for elopement due to his attempt to leave through the exit doors, confusion and language barrier. Interventions documented were an elopement book, and on the elopement risk assessments, included to encourage the resident to participate in activities and frequent monitoring. 3. Nursing documentation The 8/1/19 nurse progress note documented, Pt. (patient) has been exit seeking this morning has been pushing and making the door alam sound. Pt. (patient) required constant redirection and monitoring. -The subsequent nursing notes on 8/3/19, 8/4/19 and 8/5/19 documented the resident had no exit seeking behaviors and that 15 minutes checks were being discontinued. -The resident had no exit seeking behaviors after the 8/1/19 documented in the nursing progress notes, however the 30 day notice was issued on 9/3/19. The 8/21/19 elopement risk evaluation documented the resident was at risk for elopement due to attempting to leave through exit doors, confusion and language barrier. Interventions were to have the resident in the elopement book and frequent monitoring. The 9/30/19 discharge summary documented the resident was discharged due to being an elopement risk, actively exit-seeking and he required placement at a facility with a memory care unit. It documented the resident mood and behavior he was pleasant towards others, outgoing and friendly with periods of confusion. -The discharge summary indicated that the information was reviewed with the resident, who had severe cognitive impairment. The 10/2/19 nurse progress note documented the resident discharged on [DATE] at 8:00 p.m. to a memory care assisted living facility. -The nurse progress note was documented two days after the resident discharged from the facility and failed to document who was responsible for the resident at the time of discharge, review of the discharge summary or any other pertinent documentation was sent with the resident. 4. Social service documentation a. Behavior tracking The (MONTH) 2019 behavior tracking documented targeted behaviors of exit seeking, confusion and wandering. -There were no documented behaviors documented in (MONTH) 2019. The (MONTH) 2019 behavior tracking documented the resident wandered into another room on 7/6/19 and he had increased confusion on 7/7/19. The (MONTH) 2019 behavior tracking documented that the resident was exit-seeking on 8/3/19 into a different hallway. The (MONTH) 2019 behavior tracking could not be located by the facility when requested from the social service director (SSD) on 10/24/19 at 2:00 p.m. b. Social services progress notes The 9/18/19 [MEDICAL CONDITION] interdisciplinary progress note documented that medications and the resident ' s expression of distress were reviewed. There were no recommendations from the meeting and no documentation for him to be reviewed the next quarter. Review of the social service progress notes from 8/1/19 to 9/30/19 revealed no documentation of the resident and family receiving a 30 day notice for discharge, the family meetings that were held after the notice of discharge provided, the discharge plan and any other services required for discharge. 5. Physician documentation The 8/2/19 physician assistant progress note documented in part the resident ' s dementia was at baseline with no increased confusion. The 9/13/19 physician progress notes [REDACTED]. Arrangements were being made for the resident to be transferred to a secured facility and that family was informed earlier in the month and working on arranging appropriate transfer for him. The 9/27/19 physician progress notes [REDACTED]. The resident was tentatively scheduled to be transferred to a memory care unit at an assisted living the following week. The 9/30/19 physician discharge summary documented in part, he assessed the resident on the day of discharge and that his family had been notified that the resident would be best served in a secured unit due to his attempts to leave the building on occasion. It further documented, The family had been quite involved with many concerns for his welfare and at other times quite remote and difficult to engage his care. -The discharge summary, history and physical and lab results were sent to the assisted living. The 9/30/19 physician order [REDACTED]. D. Staff interviews The social service director (SSD) and social services assistant (SSA) were interviewed on 10/24/19 at 11:38 p.m. They said Resident #2 was admitted to the 100 unit when he first arrived at the facility and he did not do well with a roommate and was moved in (MONTH) 2019 to the 200 hall in order for him to have a private room. They said his behaviors of exit seeking and aggression lessened after that and in (MONTH) 2019 they had a care conference with the family and informed them he could stay long term care. They said due to his increased behaviors of exit seeking that started in (MONTH) 2019 he was at risk due to the facility not being secured. They said the resident would exit seek into another hallway that was closed off. They said he did not exit out of the building, however they felt the facility was being proactive by issuing the 30 day notice on (MONTH) 3, 2019 and they said the family could appeal the decision as indicated in the letter. They said the family never appealed the decision for discharge and the notice was submitted to the health department. They said they had a meeting on (MONTH) 10, 2019 with the daughters, resident, director of nursing, NHA and a frequent visitor. They discussed a facility in town with immediate placement but the daughters declined to move to the facility. They said the frequent visitor subsequently met with daughters after the (MONTH) 10, 2019 meeting and it was reported to them by the frequent visitor that the family felt like the facility was forcing their dad to leave. They said there was limited documentation in Resident #2 ' s electronic medical record regarding the notice of discharge provided to the resident, documentation of the meetings held before his discharge and of his exit-seeking behaviors. They said the day of discharge on 9/30/19 the facility was supposed to arrange transportation from a medical appointment to the assisted living facility. They said the transportation coordinator did not contact the family to make arrangements for the transportation to his appointment and to his new facility. They said the family ended up moving the resident on 9/30/19 at 8:00 p.m. They said the issuant of the notice, discharge planning and discharge process were not seamless for the resident and the family when reviewing the lack of documentation in his chart. The NHA and DON were interviewed on 10/24/19 at 1:13 p.m. The DON said that when a resident discharged from the facility the discharge summary was filled out by the interdisciplinary team to review what the required needs were to take care of the resident at the new facility. She said the discharge summary was reviewed by the nurse on shift and he/she documented on the form who the information was reviewed with whether the resident or family member. She said the nurse on shift documented the discharge in the nursing progress notes of who the resident discharged with, the time, the receiving facility and other pertinent information. The DON said for Resident #2 the discharge summary was reviewed with the resident on the form which he would not be able to comprehend the information due to having severe cognitive impairment. She said the discharge progress note should have been completed on the day of his discharge on 9/30/19 and not on 10/2/19 which was two days later. She said it was important to document any pertinent information at the time of discharge in order to ensure the resident was provided continuity of care and ensure it was a safe discharge. The NHA said herself and the interdisciplinary team met with the residents daughters several times about the resident exit seeking and that the facility was not appropriate since it was not locked. She said she drafted the notice of discharge and provided it to the daughters on 9/3/19. She said that her expectation was for the interdisciplinary team to have more documentation regarding his behaviors of exit seeking, their meetings with the family, when the notice was provided and the discharge process. The frequent visitor was interviewed on 10/24/19 at 1:52 p.m. She said she met with the family on several occasions previous to the discharge and was involved with the discharge. She said when the resident first arrived at the facility he was wanting to get on a bus and tried to leave the facility. She said he had been living independently previously, had come to the facility for therapy rehabilitation and required time to settle in to the facility. She said his behaviors of exit seeking had subsided due to him settling in to the facility and he was going to remain at long term care since he required 24 hour nursing care. She said she was present during the initial meeting when the 30 day notice was provided to Resident #2 ' s daughters. She said she did not recall the facility reviewing with the daughters they had a right to appeal the decision determined by the facility. She said she understood why the daughters felt his discharge was inappropriate since his behaviors lessened and he required long term care but the family was still given the discharge notice.

Based on observations, record review and interviews, the facility failed to provide care and services to prevent pressure ulcer development and promote healing for one (#5) of three residents reviewed for pressure injury out of the 18 sample residents. Specifically, the facility failed to: -Have a system in place to ensure staff identified, accurately documented and treated pressure ulcers in a timely manner for Resident #5; and -Notify the physician and registered dietitian (RD) timely when Resident #5 developed wounds. Findings include: I. Facility policy and procedure The Skin Integrity and Pressure Ulcer Prevention and Management Policy and Procedure, last revised 10/3/19, was provided by the nursing home administrator (NHA) on 10/28/19 at 11:45 a.m., included in pertinent part, A skin assessment occurs on admission/readmission. Skin observations also occur throughout points of care provided by certified nurse aides (CNAs) during activities of daily living (ADL). Any changes or open areas are reported to the nurse. The nurse will complete further assessment and provide treatment if needed. -A skin assessment should be performed weekly by a licensed nurse. -Measure to maintain and improve the patient's tissue tolerance to pressure are implemented in the plan of care. Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care. -When skin breakdown occurs, it requires attention and change in the plan of care to appropriately treat the patient. II. Resident #5 [NAME] Resident status Resident #5, age less than 65, admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/16/19 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was at risk for pressure ulcer development and had a surgical wound. The resident required extensive assistance of two people for bed mobility, transfers, personal hygiene and toileting. B. Resident interview and wound observation 1. Resident #5 was interviewed on 10/17/19 at 12:15 p.m. She said she had a sore on her bottom that was painful. She said as far as she knew the facility was not doing anything about it except putting cream on her they had been using since she was admitted . 2. Resident #5 was interviewed again on 10/24/19 at 10:30 a.m. She said she had been having a lot of loose stools because she had received a laxative for her constipation and now the wound on her bottom was a lot worse. She said the facility put a dressing on it but it had been several days since it had been changed. Resident #5 said she was having increased pain because of the wound and it was hard for her to find a position that was comfortable when she was sitting up in her wheelchair or lying in bed. She rated her pain five on a one to ten scale. She said it was very difficult for her to make position changes in her bed and wheelchair because she was not supposed to use her left arm. She said the staff only came in to reposition her when she called for assistance. The resident was sitting up in a reclining electric wheelchair with a cushion in place. She said the cushion was a pressure relieving cushion that she had brought from home. 3. On 10/24/19 at 1:45 p.m. the resident's wound were observed with the unit manager (UM). The allevyn dressing removed from the wound was undated, partially soiled with feces and had a small amount of drainage on it. There was a large wound to Resident #5's coccyx and left buttock which was measured by the UM. She said it measured 6.9 cm (centimeters) x (by) 6.0 cm. There was yellow slough (dead tissue) which covered approximately 60% of the wound bed on the left buttock and the inferior coccyx and a small dark purple area to the wound bed of the superior coccyx. The surrounding tissue was red and nonblanchable. The wound had scant serosanguineous (thin watery pink or red fluid that contains red blood cells) drainage with no signs of infection. The UM said she had spoken with the physician prior to coming in to the room and received orders to change the wound care and dressing to the area to a [MEDICATION NAME] dressing (duoderm) if the area had deteriorated. The UM proceeded to cleanse the area with normal saline, patted dry, applied skin prep to the periwound and applied a duoderm dressing to the wound. III. Family interview The resident's family member was interviewed on 10/24/19 at 4:15 p.m. She said the resident had a small amount of redness on her bottom when she was admitted to the facility from the hospital. She said she was concerned about her sister's skin and requested the nurse to look at her bottom for any breakdown. She said that was when they found she had three small black areas on her coccyx and buttocks. She said the facility had contacted her earlier on 10/24/19 to tell her they were changing the wound care orders and the physician's assistant (PA) was going to look at the wounds on Monday 10/28/19. IV. Record review According to the 10/9/19 Admission/readmission Collection Tool, the resident had blanchable redness to her coccyx. The care plan, initiated 10/9/19, revealed the resident was at risk for break in skin integrity. Interventions included: -Clean and dry skin after each incontinent episode; -Treatment as ordered; -Pressure reducing mattress; and -Weekly skin checks. According to the (MONTH) 2019 CPO, orders included therashield (a skin protectant) to bilateral buttocks twice a day and as needed for skin integrity. According to the 10/12/19 skilled note, an air mattress was delivered and set up on pulsate mode. The resident required two person assist with a mechanical lift for transfers from her electric wheelchair. She required maximum assistance of two person for bed mobility. According to the 10/16/19 weekly skin integrity data collection, the resident had blanchable redness to the right and left buttocks with shearing in between the anus and coccyx that measured 1.5 cm length x 3.0 cm width x 0.1 cm depth that was blanchable. The care plan was updated on 10/17/19 to include: -Encourage to limit sitting to one hour at a time; -Encourage to off load while in electric wheelchair by reclining back for at least 15 minutes every hour; and -Low air loss mattress. According to a 10/18/19 skilled note, the resident's air mattress was on pulsate mode and the resident was positioned toward her right side to off load weight from her buttocks and coccyx. Therashield cream applied to open area near coccyx. The 10/21/19 Wound Observation Tools revealed the following: -An unstagable pressure area to the inferior coccyx appearing as a deep tissue injury (DTI) measuring 1 cm by 1 cm. The wound was circular in shape with no drainage or odor and dark black in color; -An unstagable pressure area to the superior coccyx appearing as a DTI and measured 1.2 cm by 1.2 cm. The wound was circular in shape with no drainage or odor and dark black in color; and -An unstagable pressure area to the left buttock appearing as a DTI and measured 2 cm by 1 cm. The wound was circular in shape with no drainage or odor and dark black in color. The treatment plan included: air mattress, wheelchair cushion, and frequent incontinence care, skin care daily, cleanse wounds with normal saline, pat dry, and apply a sacral alleyvn dressing. The dressing was to be changed every three days and as needed (PRN). A telephone order was received on 10/21/19 for wound care to the left buttock and coccyx wounds to include: cleanse with normal saline, pat dry, and apply a sacral allevyn dressing. Change every three days and PRN. The care plan was updated on 10/21/19 to include the resident had a DTI pressure ulcer to the coccyx and left buttock related to immobility. No new interventions were initiated. According to the 10/21/19 nutrition/dietary note, the resident was seen by the registered dietician. She documented the resident's skin was frail without pressure at that time. According to the 10/21/19 skilled note, the air mattress was on pulsate mode, the resident was positioned toward the right side to relieve pressure to the coccyx and therashield was applied to the coccyx. There was no mention of the wound care or dressing that had been ordered by the physician that day. According to the 10/22/19 skilled note, therashield was applied to the peri-area and buttocks for skin protection. There was no mention of the wound care or dressing ordered by the physician. According to the 10/22/19 PA progress note, the resident was currently on an air mattress due to possible pressure area on her coccyx. The resident requested a different mattress but there was concern she may develop a pressure wound on her coccyx. According to the 10/23/19 Weekly Skin Integrity Data Collection, the resident had blanchable redness to the right and left buttocks. This assessment had no documentation of the three DTI pressure areas identified on 10/21/19. According to the 10/24/19 Skin/Wound note, the left buttock, superior coccyx and inferior coccyx wound were assessed and all three wounds remain unstageable. Measurements of the entire wound bed area measured 6.9 cm length x 6.0 cm width. Twenty percent slough adhered to the wound bed towards the left buttock, ten percent DTI dark purple colored tissue was noted to the coccyx area and 70 percent of the wound was [MEDICATION NAME] tissue. A small amount of serosanguinous drainage with no odor was noted to the old dressing. The peri-wound had slight [DIAGNOSES REDACTED] but was blanchable. She continued to use an air mattress and had a pressure relieving cushion in her power wheelchair. Her up/down schedule was revised and she continued to tilt in her power wheelchair when up. Prior to wound assessment the physician ordered to start new treatment with duoderm if the wound had worsened. This documentation differed from the observation of the wound conducted on 10/24/19 at 1:45 p.m. The resident's up/down schedule was not added to the care plan. According to the 10/24/19 PA progress note, nursing reported an open area on the resident's buttocks with a foul smelling green discharge. The UM dressed the wound earlier and stated she saw no evidence of drainage from her wound and not much change in overall appearance (the wounds were now open and did have drainage according to the wound note). The plan was to continue with the current wound care regimen and the PA would inspect her wound during her dressing change on Monday 10/28/19. She was encouraged to change her position frequently. The care plan was updated 10/24/19 to include the following interventions: -Administer medications and treatments as ordered; -Assess wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician; -Educate the resident/family/caregivers as to causes of skin breakdown; -Follow facility policies/protocols for the prevention/treatment of [REDACTED].>-Weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, type of tissue and exudate. V. Interviews and observation The PA was interviewed on 10/28/19 at 11:58 a.m. She said she was aware the resident had an open area on her bottom but the physician had not put the resident on her schedule to be seen that day. She said possibly the physician was going to look at it. The physician was interviewed on 10/28/19 at 12:06 p.m. He said he was aware the resident had an open area on her coccyx but did not plan on looking at it that day. He said he looked at wounds whenever requested by the nursing staff and referred residents to outpatient wound clinics if wounds were not healing. He said the resident was not compliant with relieving pressure to the area when she was first admitted and that probably led to the development of the wound. After discussion about the wound observation on 10/24/19, the physician agreed to look at the wound. Observation of Resident #5's wounds on her bottom on 10/28/19 at 12:51 p.m. revealed an open area to the coccyx and left buttock that measured 7.6 cm x 6.7 cm with yellow slough covering 40% of the wound bed. The peri-wound was red and non-blanchable. According to the 10/28/19 physician progress notes [REDACTED]. There was concern that she would have adverse effects as a result. She was placed on an air mattress immediately and she was being monitored. [MEDICAL CONDITION] initially appeared around her sacrum one week ago and she went on to have skin breakdown over the next few days. Nursing had been monitoring and applying dressings. The resident had an approximate 7.0 cm x 6.0 cm shallow ulceration over the sacrum. There was a small amount of slough present but no inflammation or evidence of infection. By report, the wound was improved from late last week when it was seen by the nurse who did the dressing that day and the P[NAME] (The documentation of the wound differed from the observation made by the surveyor and the wound had not been seen by the PA). The sacral wound had progressed as expected. The wound was unavoidable since they were not able to force her into bed when she arrived. The resident had been compliant with her schedule since that time. The wound should heal without further difficulties with continued aggressive local care. The 10/28/19 Wound Observation Tool revealed an unstageable pressure wound to the coccyx with twenty percent yellow colored slough that measured 6.7 cm x 7.6 cm. The peri-wound had slight [DIAGNOSES REDACTED] noted but remained blanchable. There was a scant amount of serosanguinous drainage with no odor. The wound bed was 80 percent [MEDICATION NAME] tissue and twenty percent slough with the slough areas being concentrated to the furthest bottom left of the wound bed and at the apex. (This documentation of the wound differed from the observation made on 10/24/19 at 1:45 p.m.). The 10/28/19 Nutrition/dietary note revealed the skin was frail with pressure wounds to coccyx and buttocks. Protein foods and high protein supplement options were discussed with the resident. VI. Staff interviews The UM was interviewed on 10/24/19 at 2:15 p.m. She said the wound team for her unit consisted of the dietician, the MDS coordinator and herself. She said they met on Wednesday to look at all pressure areas, [DEVICE] and other skin issues that the nursing staff had concerns about. She said she did not keep a list or record of the resident's with wounds, she just knew who had issues and needed to be seen. She said Resident #5 had blanchable redness to her bilateral buttocks when she was admitted and had a history of [REDACTED]. She said the night nurse told her on 10/15/19 the resident had an open area but it was only shearing when she looked at it. The nurses told her on Monday the wound was worse so when she assessed it she found the DTI's. She said she got an order for [REDACTED]. The RD was interviewed on 10/28/19 at 9:28 a.m. She said she was in the facility on Mondays, Wednesdays and Fridays. She said she found out the resident had pressure ulcers that morning when she read it in the resident's chart. She said she had not been notified by the UM or any other staff. She said she was part of the wound team that did the rounds on Wednesdays but she was not there the previous week. She said she was placing the resident on supplements and increasing the protein in her diet to assist with wound healing. Registered nurse (RN) #1was interviewed 10/30/19 at 10:55 a.m. She said skin assessments were done upon admission and weekly. She said any break in skin integrity should be documented on the assessment, including incisions, wounds and bruises. She said an incident report was made for all new skin issues and the unit manager was notified. The director of nursing (DON) was interviewed on 10/30/19 at 11:55 a.m. She said the unit manager for each unit was responsible for measuring and staging all wounds for their unit to provide consistency. She said skin assessments should be done every seven days. She said the assessment should include temperature, color, any irregular areas and any new areas. She said the previous week assessment should be looked at and any areas identified needed to be addressed, whether it was better, worse or healed. She said an incident report should be completed for any new skin concerns, including bruises and the UM should complete a wound tool. She said the care plan should be updated with any new skin concerns with new interventions. She said the nurses and MDS were responsible for updating the care plan. She said wound rounds were done weekly on Wednesdays by the UM, MDS and the dietician and occasionally she would join if needed. She said the UM knew their people on their units and would create a list weekly of who needed to be seen by the wound team that week. She said she got a report weekly to send to the corporate office. She said the weekly skin assessment done on 10/23/19 was inaccurate. She said the areas identified on 10/21/19 should have been documented on this assessment. She said she was going to provide wound care education to that nurse.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#2 and #5) of three residents reviewed out of 18 sampled residents. Specifically, the facility failed to: -Obtain physician orders [REDACTED].#5; -Follow physician orders [REDACTED]. -Ensure Resident #2 had transportation to an outside medical appointment causing a delay in treatment. Findings include: I. Facility policy and procedure The Transportation Services Policy, revised 8/30/19, was provided by the nursing home administrator (NHA) on 10/24/19 at 3:57 p.m. It documented in pertinent part, During a patient's inpatient stay in a skilled nursing facility, transportation to and from medically necessary doctor's visits, [MEDICAL TREATMENT], and other services provided by the skilled nursing facility are included. II. Resident #5 [NAME] Resident status Resident #5, age less than 65, admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/16/19 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had a suprapubic catheter. B. Observations and interview On 10/24/19 at 10:30 a.m. Resident #5's suprapubic catheter insertion site had a partially urine soaked washcloth under the catheter. The skin around the insertion site was slightly pink. The resident said she had the catheter for at least [AGE] years and the last [AGE] years, and it had chronically leaked. She said she preferred to have the wash cloth instead of a dressing because she could change it out when she needed to. On 10/28/19 at 12:51 p.m. the resident's suprapubic catheter insertion site did not have any type of dressing, pad or washcloth to absorb the urine leaking from the site. C. Record review According to the (MONTH) 2019 CPO, orders included: -Suprapubic catheter 18 Fr. 10 ml - catheter care with warm water and soap every shift, ordered 10/10/19; -Change catheter bag one time a month, ordered 10/10/19; and -Suprapubic catheter site - cleanse with normal saline, pad dry, apply interdry to sides of site under abdomen then apply drain sponge around the catheter. Change daily and as needed (PRN). According to the 10/11/19 physician assistant (PA) progress note at 4:06 p.m. the resident had a suprapubic catheter which leaked chronically. Nursing was to try to place a poise pad around the catheter to contain leakage. (No orders were written for this treatment). The 10/11/19 skilled note at 10:23 p.m. revealed the suprapubic catheter site was cleansed and a moisture wicking Kotex pad was cut to fit around the catheter to absorb moisture leakage and keep the skin dry. The 10/18/19 skilled noted revealed an ABD pad was placed around the suprapubic catheter after catheter care due to chronic leakage of urine. According to the 10/19/19 health status note at 12:50 a.m., the resident was having increased urine leakage from around suprapubic catheter insertion site with minimal urine in drainage bag. The suprapubic catheter was flushed with 30 milliliters (ml) sterile water and a new drainage bag was applied. Immediate return of a moderate amount of cloudy urine was obtained with a small amount of sediment noted in the tubing. There was decreased urine leakage noted around the insertion site. (The resident did not have an order to irrigate the catheter). According to the 10/19/19 skilled note at 3:25 p.m., the suprapubic catheter was clogged. Irrigation was attempted but remained clogged. Per the resident's request, the suprapubic catheter was changed with the same size catheter with the balloon inflated with 30 ml of normal saline. (The size of the balloon ordered was 10 ml and the resident did not have any orders to irrigate or change the catheter). On 10/21/19 a telephone order was obtained to change suprapubic catheter as needed for obstruction. This was two days after the catheter had already been changed. No orders were received for irrigating the catheter if needed. D. Staff interviews Registered nurse (RN) #1 was interviewed on 10/30/19 at 10:54 a.m. She said orders were required to irrigate and change urinary catheters. She said she always irrigated with normal saline. She said if the resident did not have orders, the physician needed to be contacted to obtain them. She said Resident #5 preferred to have a washcloth under her catheter and said the treatment orders needed to be clarified with the physician. The director of nursing (DON) was interviewed on 10/30/19 at 11:10 a.m. She said if a catheter was obstructed and needed to be irrigated the physician needed to be notified and orders received for the type and amount of solution to be used. She said orders were also required to change a urinary catheter. She said the nurses should be following physician orders [REDACTED]. The DON presented a copy of the facility's Standing Orders for the physician of Resident #5 on 10/30/19 at 1:07 p.m. She said the nurse that changed the catheter was going by the standing orders; however, according to the standing orders, signed 7/25/19, all orders would be written on a telephone order and sent to the attending physician for signature. The orders should state it was an approved Standing order. The DON acknowledged the order for the catheter change was not written for two days after it was done and it did not state it was an approved standing order. III. Resident #2 [NAME] Resident status Resident #2, age 85, was admitted on [DATE] with readmission 5/21/19. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/30/19 MDS assessment revealed the resident was severely cognitively impaired with BIMS score of one out of 15. He required extensive assistance from staff with his activities of daily living (ADL) and had a catheter. B. Resident representative interview The resident representative was interviewed on 10/24/19 at 12:34 p.m. She said the resident was scheduled to go to a urology appointment on 9/30/19 at 9:00 a.m., and her sister was going to meet him at the urologist office. She said her sister called the facility when the resident had not arrived at the urologist office at 9:00 a.m., and she was told by the nurse that he was still at the facility. She said she called the driver, who said she could not take the resident to the urologist appointment since she was with another resident at their appointment. She said she had to reschedule his urologist appointment in (MONTH) since he was not taken to his appointment by the facility transportation. She said in a meeting with facility a week previous to the appointment and the social service assistant (SSA) and NHA said they were going to arrange transportation for his urology appointment since he had refused to go to the urologist previously but had agreed to see the urologist on 9/30/19 since he wanted his catheter to be removed. C. Record review The 12/19/18 catheter care plan documented the resident had an indwelling catheter due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Pertinent interventions were catheter care every shift, observe and report any signs or symptoms such as urinary tract infection, observe for discomfort on urination and frequency and educate the president and family regarding the indwelling catheter and care. The 8/2/19 physician progress notes [REDACTED]. The 8/8/19 physician orders [REDACTED]. The 9/30/19 transportation calendar documented the resident had a 9:00 a.m., appointment with the urologist with a 8:30 a.m., pick up time and the family was to take him to the appointment. The facility was supposed to arrange transportation and take the resident to his appointment (see nursing home administrator interview below). D. Staff interviews The transportation coordinator/driver was interviewed on 10/24/19 at 11:13 a.m. She said oversaw the transportation to the residents residing at the facility. She said she called the medical office to arrange the appointments and coordinated their transportation to the appointments. She said if she had two medical appointments at the same time she coordinated with an outside transportation company. She said that family members of residents provided transportation to medical appointments and she indicated that on her calendar. She said she called the family members at least a couple weeks prior to ensure that transportation was set up and remind them of the time and location of the appointment. She said for Resident #2, he had an appointment to see the urologist on 9/30/19 at 9:00 a.m. She said she wrote on her calendar that the family was transporting the resident to his appointment. She said on 9/30/19 she talked to a family member on the phone who said Resident #2should have been at his appointment at 9:00 a.m. She said she tried to call the urologist office to see if he could be seen that day due to a mishap with his transportation but it had to be rescheduled for October. The SSA and NHA were interviewed on 10/24/19 at 2:00 p.m. They said the facility and family had a meeting on 9/20/19 with the resident and his two daughters. They said during the meeting they informed the daughters that the facility would arrange transportation to his urologist appointment since he had agreed to see the urologist. The SSA said she had contacted the transportation coordinator right after the meeting on 9/20/19 to call the family to arrange transportation to his appointment on 9/30/19. She said the transportation coordinator did not contact the family which caused a delay with him seeing the urologist to remove his catheter. -She said in the future she would follow up with the transportation coordinator when she was informed by a family that transportation was required for a medical appointment prior to the appointment to ensure it was scheduled.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, in three out of four medication carts and one out of two medication rooms. Specifically, the facility failed to: -Label inhalers and insulin with open dates; and -Ensure [MEDICATION NAME], a schedule IV controlled substance, was securely double-locked. Findings include: I. Facility policy and procedure The storage and expiration dating of medications policy, last revised 4/5/19, was provided by the nursing home administrator (NHA) on 7/23/19 at 2:00 p.m. The policy read in pertinent part, Facility should store schedule II to V controlled substances in a separate compartment within the locked medication carts and should have a different key or access device. Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. II. Manufacturer's recommendations A. The package insert for [MEDICATION NAME] (2018) revealed: -Unopened 3 ml (milliliter) [MEDICATION NAME], not refrigerated, should be discarded after 28 days. -Opened 10ml vial should be discarded after 28 days. B. The package insert for Breo Ellipta (2018) read in pertinent part, Breo Ellipta should be stored inside the unopened moisture-protective foil tray and only removed from the tray immediately before initial use. Discard Breo Ellipta 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. III. Observations and interviews related to medications stored improperly A. Cart #1 On 7/18/19 at 8:25 a.m. the first medication cart on the 200 unit was inspected with licensed practical nurse (LPN) #3 present. The following observations were made: -An unused [MEDICATION NAME] was not refrigerated and was not labeled with the date it was placed in the medication cart (out of refrigeration). -A used Breo Elipta 100 milligram (mg)/25 microgram (mcg) inhaler was not labeled with an opened date. -A used Breo Elipta 200 milligram (mg)/25 microgram (mcg) inhaler was not labeled with an opened date. LPN #3 said she did not know why the medications were not labeled or dated and said the medications were not opened on her shift. B. Cart #2 On 7/18/19 at 8:45 a.m. the second medication cart on the 200 unit was inspected with LPN #2 present. The following observations were made: -A used [MEDICATION NAME] vial was not labeled with the date it was opened. LPN #2 said she did not know why the [MEDICATION NAME] vial needed to be labeled. C. Cart #3 On 7/18/19 at 9:16 a.m. the first medication cart on the 100 unit was inspected with registered nurse (RN) #3 present. The following observations were made: -A used Breo Elipta 200 milligram (mg)/25 microgram (mcg) inhaler was not labeled with an opened date. RN #3 said she was not aware that the medication needed to be labeled. The medication storage room on the 200 unit was observed on 7/23/19 at 11:12 a.m. with RN #2, the nurse unit manager. A vial of [MEDICATION NAME] liquid solution 1 mg /1 ml was in a metal medication storage box with a lock that was not locked (the lid was able to be lifted without a key). RN #3 said she did not know why the box was unlocked, and said she believed the medication was used earlier in the day. She pointed to the lock on the box and said the lock was in the locked position, but the box was unlocked. IV. Additional staff interviews The consultant pharmacist (PSC) was interviewed on 7/23/19 at 9:30 a.m. in the presence of the director of nursing (DON). The PSC said he looked at medication storage carts and medication rooms as part of his routine visits to the facility. The PSC said the [MEDICATION NAME] and vial should have been dated as good for 30 days. The PSC said he was not aware the Breo Ellipta needed to be labeled as the medication was used in 30 days after opening and did not meet the six week mark. The DON was interviewed on 7/23/18 at 1:18 p.m. The DON said the [MEDICATION NAME] should be stored under double-lock, and the lock box in the medication storage room would be checked to ensure it was not broken. The DON said going forward the Breo Ellipta would be labeled for 30 days as there was the chance the medication may not be used up in 30 days depending on their physician's orders [REDACTED]. The DON said the nurses would be re-educated on proper medication storage and labeling.

Based on observations, record review and interviews, the facility failed to ensure two (#41 and #28) of two residents with limited range of motion received appropriate treatment and services out of 37 sample residents reviewed. Specifically, the facility failed to: -Assess, and continually monitor Resident #41's right hand contracture; and -Provide restorative nursing services, including walking the resident to meal, for Resident #28. Findings include: I. Facility policy and procedure The Restorative Nursing policy and procedure, dated 5/16/19, was provided by the nursing home administrator (NHA) on 7/22/19 at 12:15 p.m. It read in pertinent part: The facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome. To promote the resident's optimum functioning, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessment and indicators. Accurate and thorough assessment of the patient is fundamental in determining the patient's need for restorative services. A licensed nurse will conduct a monthly evaluation to include progress towards goal and response to the program. Any changes will be documented in the medical record. The restorative care plan and care directive will be reviewed/revised as well. II. Failure to monitor contractures and reassess for Resident #41 A. Resident status Resident #41, age 78, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 6/12/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required assistance of one person with bed mobility, transfers, toilet use and personal hygiene. He required set-up assistance with walking in his room and throughout the facility and dressing. The resident did not have any rejections of care over the seven day look back period. The MDS documented the resident had functional limitation in range of motion in one side of his upper and lower extremities. It indicated the resident did not receive services from the restorative nursing program. B. Observations The resident was observed on 7/17/19 at 11:42 a.m. with a contracture of the right hand and wrist. The resident was not wearing a splint and his hand was in a closed position with his fingers touching the palm of his hand. The resident was observed on 7/18/19 at 4:35 p.m., he was in the lobby of the facility talking with the business office staff. He was not wearing a hand splint to the right hand and the position of his fingers were in the same position as mentioned above. C. Record review The activities of daily living (ADL) care plan, initiated on 4/2/19, revealed the resident had an ADL self-care performance deficit related to a history [MEDICAL CONDITION], right sided [MEDICAL CONDITION]. The goal was for the resident to continue to ambulate with his quad cane independently. The interventions included: encourage/supervise/assist the resident with bathing, bed mobility, dressing, eating, personal hygiene, toilet use and transfers. Observe and report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course decline in function. The ADL care plan did not include goal or interventions for restorative therapy. A review of the resident's complete care plan revealed there was not a care plan for restorative therapy. A review of the resident's 1/16/19 care plan progress note revealed there was no documentation of a discussion about the resident's current restorative therapy program during his annual care conference. D. Staff interviews A registered nurse (RN) #3 was interviewed on 7/22/19 at 9:27 a.m., she said the resident had suffered a stroke a long time ago and hand right sided weakness as a result. She said the resident had a contracture on the right hand, and was unable to open his hand. She said the resident did not have a brace, and was not receiving any treatment for [REDACTED]. An occupational therapist (OT) was interviewed on 7/22/19 at 9:29 a.m., he said the resident was not currently on a therapy program, and the last time he had worked with the resident was when he was first admitted in (YEAR). He said back in (YEAR), the resident did not want staff working on his right hand, and the OT was unsure if the resident had been reassessed since (YEAR). The therapy service director (TSD) was interviewed on 7/22/19 at 10:42 a.m., she said the resident was not currently on any type of therapy or restorative program for the upper extremity contracture. She said when she walked by the resident in the hallway, she would see him opening and closing his hand on his own, and working on his own passive range of motion. The TSD said nurses should be assessing and evaluating the resident's need for a restorative nursing program. The director of nursing (DON) was interviewed on 7/23/19 at 11:41 a.m., The DON said she was the nurse responsible for overseeing the restorative therapy program in the facility. She said residents were typically referred for a restorative therapy program after they had been discharged from therapy. The DON said Resident #41 was on a restorative program for his lower extremities, but was not currently on a program for his upper extremities. She said was unsure the last time the resident had been evaluated for a restorative program for the upper extremity and the right hand contracture. The DON said the activities of daily living (ADL) care plan is where a resident's restorative therapy program would be listed. She said resident's restorative programs should be discussed during care conferences, but she was unsure if that was occuring. The (TSD) was interviewed a second time on 7/23/19 at 1:18 p.m., she said the resident had been evaluated by OT yesterday after it had been noted that the resident had not been evaluated since his last therapy evaluation in (YEAR). The TSD said thankfully there had been no deterioration to the resident's skin or mobility with his hand. He was offered a splint device and well as restorative therapy, and the resident declined both. The TSD said they would monitor the resident's contracture more closely to ensure he did not have any unnecessary decrease in mobility. III. Ambulation (walking) program failures for Resident #28 A. Resident status Resident #28, age 68, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 5/22/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required assistance of one person for all activities of daily living (ADLs) including bed mobility, transfers, toilet use, personal hygiene and locomotion throughout the facility. The resident did not have any rejections of care over the seven day look back period. The MDS documented the resident did not receive services from the restorative nursing program. A. Resident interview The resident was interviewed on 7/17/19 at 10:55 a.m., she said she was currently on a program, where a certified nurse aide (CNA) was supposed to walk her to all three meals walk to dine. She said she had been occasionally walked to meals, but more often than not, she was assisted by staff in her wheelchair. The resident pointed to a sign on her door, which stated she was on a walk to dine program for all three meals. She said the sign had been up for several months. The resident was interviewed a second time on 7/23/19 at 10:15 a.m., she said she had not been offered by staff to walk to any meals in the past week. She said it was important to her to continue to walk to meals as it made her feel better when she walked. B. Observations On 7/17/19 at 11:16 a.m., the resident was observed propelling her wheelchair to the dining room, an unidentified nurse was observed offering to push the resident to the dining room. The nurse did not offer to walk the resident to the dining room. On 7/22/19 at 8:53 p.m., licensed practical nurse (LPN) #4 was observed offering to take the resident to the dining room for breakfast. The LPN did not offer to walk the resident to the dining room, and instead assisted the resident in her wheelchair. C. Record review The 4/1/19 Rehabilitation/Restorative Transfer Form revealed the resident was on an ambulation program two to three times a week. The (MONTH) 2019 Restorative Record revealed the resident had no minutes of restorative therapy documented for the month. The (MONTH) 2019 Restorative Record revealed the resident had no minutes of restorative therapy documented for the month. The (MONTH) 2019 Restorative Record revealed the resident had five days of restorative therapy documented for the month. The (MONTH) 2019 Restorative Record revealed the resident had seven day restorative therapy documented for the month. D. Staff interview The DON was interviewed on 7/23/19 at 11:41 a.m., the DON said the current restorative program had one certified nurse aide (CNA). She said they had two in the past, but for the last six months only had one CNA to run the program. The DON said there were currently 32 residents in the facility on a restorative program. The DON said if the facility was short of CNAs to provide cares, the restorative CNA would work the floor, and that could make it difficult to complete the restorative programs for all of the resident's. The DON said Resident #28 was currently on an ambulation (walking) program, and the restorative program was responsible for making the sign that was hung on the resident's door. The DON said any nurse or CNA assisting the resident to the dining room should have been offering to walk the resident to the dining room as part of her restorative therapy program.

Based on record review and staff interviews, the facility failed to ensure one (#129) resident reviewed out of 37 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Notify the physician on 7/15/19 and 7/16/19 for BS levels above 400 for any recommendations or changes to current orders. I. Facility standards A copy of the Standing orders was provided by the director of nursing (DON) on 7/23/19 at 11:00 a.m. In pertinent part, it read: (MONTH) obtain blood glucose level as needed. Always notify physician for blood glucose greater than 400 or less than 60. Monitor for signs of hyper/[DIAGNOSES REDACTED]. II. Resident #129 A. Resident status Resident #129, age 80, was admitted on [DATE], and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/10/19 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with all activities of daily living (ADLs). B. Family interview Resident ' s daughter was interviewed on 7/17/19 at 1:14p.m. She said she was concerned with the treatment of [REDACTED]. She said her mom knew very well and communicated to the physician what medications she was taking for diabetes. C. Resident interview Resident was interviewed on 7/23/19 at 11:18 a.m. She said her blood sugars were not managed well. She said I talked to the doctor, but he did not listen to me. D. Record review The resident's care plan, last revised 6/13/19, revealed the resident was at risk for developing hypo and [MEDICAL CONDITION] due to [DIAGNOSES REDACTED]. According to the discharge summary from the hospital, dated 7/10/19, resident had a [DIAGNOSES REDACTED]. The physician note dated 7/11/19, revealed that resident was assessed by physician and she was started on eight units of long acting insulin every day at bed time and glucose checks to be done twice a day. On the 7/14/19, residents blood glucose level was 423 at 7:30 a.m. There were no nurses progress if physician was contacted. The review of the MAR indicated [REDACTED]. Physical therapy progress note dated 7/15/19 revealed, that resident was supine in bed and difficult to arouse. Resident was not to actively engage in skilled activities during the day. On the 7/16/19, at 4:30 p.m. resident ' s blood sugar level was 493, there were no corresponding nurses notes whether the physician was contacted or not by staff. In the morning of 7/17/19, nurses note at 7:50 a.m. read resident BS indicated HI (high) on glucometer, resident in bed, sluggish with response, able to weakly squeeze nurses finger upon request, mild facial grimacing when name called, did open eyes then closed. MD (medical doctor) here, notified, order to give 7 units of Humalog now. III. Staff interviews Registered nurse (RN) #1, was interviewed on 7/22/19 at 3:36 p.m. She said they had standing orders from the physician to contact him when one of the residents has a blood sugar level above 400 or below 60. She was able to recall proper signs and symptoms that one would experience with a low and high level of insulin in blood. RN #4, was interviewed on 7/22/19 at 3:46 p.m. She said normal blood sugar levels in individual should be between 90 and 120. She said they physician should be called if blood sugar levels were above 350. Licensed Practical Nurse (LPN) #1 was interviewed on 7/22/19 at 4:15 p.m. She said when she approached resident in the morning on 7/17/19, would not speak, she asked her to squeeze her hand and resident weakly squeezed her hands. She said she checked her blood sugar levels and glucometer read high it did not show the exact number. In that case high meant that blood sugar level was above 500 or 600. She said she called physician and obtain order for short acting insulin. The DON was interviewed on 7/23/19 at 5:19 p.m. She said she did not know why the physician was not contacted on the days when resident ' s blood glucose level was above 400. She said it was important to notify physician and administer insulin timely because it was dangerous and harmful for an individual to have blood sugar levels in 400.

Based on observations, interviews and record review, the facility failed to ensure the resident had the right to choose activities and schedules consistent with their interests, assessments and care plans for one (#33) of one resident reviewed for choices out of 37 sample residents. Specifically, the facility failed to honor Resident #33's preferences regarding food choices. Findings include: I. Facility policy review The dignity policy, last revised 5/6/19, was provided by the nursing home administrator (NHA) on 7/22/19 at 2:00 p.m. The policy read in pertinent part, Each resident has the right to be treated with dignity and respect. Staff must respect the resident's individuality as well as honor and value their input. Examples of treating residents with dignity and respect include considering the resident's lifestyle and personal choices identified through their assessment processes to respect and accommodate his or her individual needs. II. Resident status Resident #33, age 60, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/29/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was usually understood and able to understand others. She was receiving a therapeutic diet. She required extensive assistance with one assist for transfers and bed mobility, and required supervision and set-up help for eating. III. Record review The (MONTH) 2019 CPO revealed the resident was on a consistent carbohydrate diet. The care plan, revised 1/14/19, read that the resident required supervision with decision making and encouragement to make healthy decisions at times, such as with food and beverage choices related to her [DIAGNOSES REDACTED]. The consistent carbohydrate menu extension for 7/18/19 revealed the meal served was three ounces pork and vegetable stir fry, a half cup of rice, a half cup of broccoli, one piece of egg roll and six fresh orange slices for dessert. III. Observations The kitchen tray line was observed on 7/8/19 at 12:10 p.m. A dietary aide was observed to enter the kitchen and inform the cook that Resident #33 wanted another egg roll. The cook responded no without giving an explanation to the dietary aide. The dietary aide said okay and walked out of the kitchen. IV. Interviews The cook was interviewed on 7/18/19 at 12:13 p.m. The cook stated Resident #33 was not able to have another egg roll as she was on a consistent carbohydrate diet and was only allowed to have one. Resident #33 was interviewed on 7/18/19 at 2:10 p.m. Resident #33 said she was told by a staff member that the kitchen had run out of egg rolls which was why she was not able to have seconds. Resident #33 said if she was told the facility still had egg rolls, she would have wanted one. Resident #33 said she was on a special diet for her diabetes. She said the staff member had offered her other foods to eat but she did not want to eat any of them. She said staff had not provided her with any education regarding healthy food choices. The registered dietitian (RD) was interviewed on 7/22/19 at 4:00 p.m. The RD said if a resident was on a consistent carbohydrate diet and wanted a food item not congruent with their diet order, staff should remind the resident of their diet order, educate the resident on why it was not the best option, and offer the resident healthy alternatives. She said if the resident still wanted the food item, they should be allowed to eat it and the education and resident's refusal should be documented in the resident's medical record. The RD said the resident's refusal should also be communicated to herself so it can be assessed if the diet order should be liberalized. The RD said Resident #33 should have been educated on her diet order and making healthy choices, and allowed to eat the extra egg roll rather than told the facility was out of the egg rolls. The RD said staff would be re-educated on this. The director of nursing (DON) was interviewed on 7/23/19 at 11:58 a.m. The DON said if the resident was alert and oriented, staff should explain the resident's diet order to them and educate the resident on the consequences of having the additional food item. The DON said staff should have educated Resident #33 and provided her the egg roll if she still wanted it after being educated.

Based on observations, record review, and interviews, the facility failed to follow an infection control procedure designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Follow proper housekeeping and resident care protocols to prevent cross-contamination; -Follow personal protective equipment (PPE) (wearing and removing gloves) protocol after performing tasks; -Follow dwell times per manufacturer recommendations for disinfection; and -Maintain proper storage of oxygen equipment (nasal cannula). Findings include: I. Facility's policies and procedures The Personal protective equipment policy, revised 4/1/15,was provided by the director of nursing (DON) on 6/28/18 at 11:38 a.m. The policy included, All employees using PPE must observe the following precautions: Follow hand hygiene recommendations immediately or as soon as feasible after removal of gloves, remove gloves after it becomes contaminated and before leaving the work area. Never wash disposable gloves for reuse. The Oxygen administration/safety/storage/maintenance policy, revised 11/29/17, was provided on 6/28/18 at 11:00 a.m., by the staff development coordinator (SDC). The policy included, Infection control: Store oxygen and respiratory supplies in a bag labeled with resident's name when not in use. II. Disinfectant Dwell Time-Manufacture Label On 6/27/18 at 12:05 p.m., the Housekeeping Manager/Laundry provided information on solution Virex 256 one-step disinfectant cleaner and deodorant and Crew non-acid (Crew NA) bowl and bathroom disinfectant cleaner used to disinfect resident's room daily. The label directions stated for use as a disinfectant included, Pre-clean heavily soiled areas. Apply use solution to hard, non-porous environmental surfaces. All surfaces must remain wet for 10 minutes. Wipe surfaces and let air dry. III. Room cleanings A. Observations of improper room cleanings On 6/25/18 at 11:14 a.m., Housekeeping assistant (HA) #1 was observed to clean room [ROOM NUMBER]. She went into the bathroom with gloved hands and a bottle of Crew NA disinfectant cleaner and deodorant solution. She sprayed the toilet seat, the toilet bowl, the bathroom railings and the bathroom sink with the Crew Na solution. She then immediately wiped off the solution without allowing the disinfectant to remain on the surfaces per manufacturer's dwell time. At 11:17 a.m., HA#1 was observed to splash water with gloved hands (the gloved hands used to clean the bathroom and the toilet seat) on the surface of the bathroom mirror, she wiped off the water with a paper towel without changing her gloves. At 11:20 a.m., HA#1 was observed to walk outside of the bathroom while her contaminated gloves remained on, to her cleaning cart placed outside of the room and retrieved the mop and dustpan. She walked back into the bathroom to mop the floor. She returned to the cleaning cart to retrieve a bottle of Virex 256 one-step disinfectant cleaner and deodorant with the same contaminated r gloves remained on. At 11:25 a.m., HA#1 was observed to spray the Virex 256 solution on the resident's bedside table, TV (television) stand, and the window frame. She wiped off the Virex 256 solution immediately without allowing the solution to remain on the surface per the dwell time. She sprayed the mirror in the room with glass cleaner solution and wiped off the solution with a paper towel. She went outside to her cleaning cart to retrieve the broom and dustpan. She swept the floor, changed the trash bag, mopped the floor and bagged the dirty linen in a trash container bag. She walked out of the room and in the hallway with the dirty linen bag to the dirty utility room with same contaminated gloves on. On 6/25/18 at 11:40 a.m., HA#1 observed to move her cleaning cart from room [ROOM NUMBER] to room [ROOM NUMBER] wearing the same gloves in the hallway and to go into the next room. She removed the dirty linen bag and tired the bag to her cleaning cart. At 11:44 a.m., HA#1 observed to push her cleaning cart outside room [ROOM NUMBER]. She removed her gloves and put on clean gloves without washing her hands nor did she use hand sanitizer in between changing her gloves. She went into the bathroom with gloved hands and a bottle of Crew NA disinfectant cleaner and deodorant solution. She sprayed the toilet seat, the toilet bowl, the bathroom railings and the bathroom sink with the Crew Na solution, and she immediately wiped off the solution without allowing the disinfectant to remain on the surfaces per manufacturer's dwell time. Still, in the bathroom, she splashed water with gloved hands) on the surface of the bathroom mirror and wiped the water off with a paper towel without changing her contaminated gloves. She walked out of the room with gloved hands, retrieve broom, dustpan, and mop. She swept the bathroom with the broom and mopped the bathroom floor. At 11:55 a.m., HA#1 sprayed Virex 256 solution on the nightstand, bedside table and TV stand, she immediately wiped off the solution. B. Staff interviews HA#1 was interviewed on 06/25/18 at 12:03 p.m. She said she cleaned the resident bathroom with Crew NA and wipe off the solution immediately. She said she wiped off the solution so the resident could use the bathroom. She acknowledge there was no resident in room [ROOM NUMBER] when she cleaned the bathroom, so there was no immediate need to wipe the cleaning solution off before the recommended dwell time. She said she sprayed Virex 256 solution on the bedside table; dresser and TV stand wipe the solution off immediately to keep the surfaces dry. She said she used glass cleaner for the mirror in the resident room only and water to clean the mirror in the bathroom. She said she was taught to the Crew NA and Virex 256 solution, but forgot about the dwell time on the surface. HK/Laundry director was interviewed on 6/27/18 at 11:10 a.m. She said the HA is to clean the resident room daily and deep clean whenever a resident was discharged . She said the HA had been trained on the dwell time when using the Virex 256 and Crew NA solution on any surface areas. She said the HA are trained to allow the solution to stay on the surface for 10 minutes so the solution could penetrate and kill the germs on the surface. She said the HA supposed to follow the manufacturer specification dwell time. She said the HA supposed to use Sani cloth bleach to wipe the rails and door handles. She said the HA should wipe off the solution off with pre soaked washrags mixed with a chemical in their bucket. She said those rooms cleaned by HA #1 were not cleaned and disinfect properly; she said she would provide an in-service immediately. SDC was interviewed on 6/27/18 at 11:31 a.m. She said the staff were not allowed to wear gloves walking in the hallway. She said the only exception was when staff were caring trash in the hallway. She said the staff were to remove their gloves and wash hands or use hand sanitizer before leaving the resident room. HK/Laundry director was interviewed again on 6/27/18 at 11:45 a.m. She said the HA was to remove their gloves when moving from to another room. She said the proper way was to remove gloves and wash hands or use hand sanitizer in between cleaning. HA#2 was interviewed on 6/28/18 at 11:30 a.m. She said the proper way to spray the Crew NA solution on the toilet seat, bathroom rails and let the solution sit for 10 minutes. She said while the solution was on the surface, she would change the trash bags in the toilet and the resident room. She said she would remove her gloves and rub hand sanitizer on her hands before donning another pair of gloves. She said the HA should use glass cleaner to clean all the mirrors in the resident room. She said the HA is not to wear gloves in the hallway. She said she was taught to change her gloves in between cleaning, use hand sanitizer and wash her hands before entering another room. IV. Oxygen tubing A.Observations of oxygen (O2) nasal cannula ( NC) on the floor: On 6/25/18 at 9:15 a.m., in room [ROOM NUMBER], the resident O2 tubing was running on the wall, the end of the tubing (with the NC) laid on the floor. Unknown certified nurse aide (CNA) was in the room with the resident and did not pick up the NC off the floor. There was no storage bag to store the O2 tubing with the NC in when it was not in use. On 6/26/18 at 2:15 p.m., unknown CNA went to room [ROOM NUMBER] to take the resident to the shower room. The resident's O2 NC was still on the floor and the unknown CNA walked passed the NC on the floor and did not pick it up. On 6/26/18 at 3:11 p.m., in room [ROOM NUMBER]b, the resident was observed sitting at the edge of the bed, his O2 NC was on the floor. The resident was not wearing the O2 NC. There was no storage bag to store the tubing with the NC. On 6/28/18 at 10:41 a.m., in the presence of the staff development coordinator (SDC) in room [ROOM NUMBER]. The resident O2 NC was observed hanging on the side partition divider in the room. The O2 tubing was not in use and there was no storage bag to store the tubing in the room. B. Staff interviews SDC was interviewed on 6/28/18 at 10:38 a.m. she said the O2 tubing is supposed to be stored in a storage bag when not in use. She said the nursing staff was to change the O2 tubing weekly. She said it was not acceptable to hang the O2 tubing on the wall or to allow the NC to touch the floor. She said the resident might pick up a respiratory infection if the resident reused the contaminated NC.

Based on observations, resident and staff interviews and record review, the facility failed to act promptly upon the grievances and recommendations of resident council and the food committee concerning issues of resident care and life in the facility that were important to the residents. Specifically the facility failed to: - Act on the resident council members repeated complaints regarding their wishes to utilize clothing protectors that were once supplied by the nursing facility. - Act on the residents repeated concerns with long wait times during dining room services in both resident council, food committee and independently through the grievance process. These failures affected the residents who participated in resident council over the past four months and residents who ate in the dining room. Findings include: Facility Policy The Grievance Procedures policy, provided by the nursing home administrator (NHA) on 6/28/18 last revised on 11/19/16, included: Resident rights should be protected when voicing complaints to maximize the quality of life for each individual and to promote satisfaction with facility care and services It read that the social service staff was responsible for the following: -follow up with the resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction . It read the NHA was responsible for overseeing the facility's overall grievance program. I. Group interview Residents #12, #17, #44, # 27, #23 , #15, # 38 , #5, and #19 were interviewed on 6/27/18 at 1:34 p.m. The group interview had grievances with clothing protectors and long dining room wait times. --Resident #5 said about six months ago the staff in the facility took away their clothing protectors. She said they told all the residents it was a new corporate rule and therefore had to follow it. She said they told resident council it was a dignity issue and they ordered large cloth napkins which had to be shoved down their shirts instead of the nice, comfortable, black back fastening clothing aprons which they had prior. Resident #17, #27, # 12 and #23 all agreed they have been complaining that they wanted the old clothing aprons as they do not like the napkins that replaced them. Resident #23 said there were other residents (not in the group) that has said they want them back. Resident # 23 said they were going to keep bringing up the issue until they could get a resolution and that something like a piece of clothing the resident want to wear should not have to be such a big fight. -Resident #17 said she did not like how long she had to wait to get her meals in the dining room. She said she had diabetes and the nurse would give her an insulin injection and then send her to dinner where she had to wait for long periods of time to get her meal. She said it was dangerous and it worried her because she felt like her blood sugar would get low at times. She said there were other residents in the facility with diabetes that would tell her they worried about that as well. -Resident #12 said she too was upset about how long it took to get her meals in the dining room. She said lunch and dinner were the worst and she had complained to the kitchen staff, the dietary manager and the CNA's before and nothing changes. She said it is because it is first come first serve but no one was ever around to see who actually came first. All of the other residents agreed with her statement. -None of the residents in the interview filled out a grievance regarding the meal times or the clothing protectors. They said they felt like they each told staff about the issues each month in resident council and food committee and thought that should have covered it. Resident #5 and #23 said it was brought up every month during their meetings. -Resident #12 said she felt that the complaints voiced in resident council were not addressed in regards to the long wait times and the clothing protectors. II. Dining room wait times A. Observations On 6/25/18 at 11:34 a.m. The dining room started serving the residents who were able to eat independently. Table 15 observation Resident #63 was observed sitting at table 15 at 11:18 a.m. Her table mate, resident #12 entered the dining room at 11:24 a.m. Resident #63 received her food at 11:35 a.m. - At 11:55 a.m. resident #63 offered resident #12 a bite of her food because she was still waiting to eat. - At 12:09 p.m. another unknown table mate entered the dining room. A kitchen staff went over and took her order and resident #12's order at the same time even though resident #12 had been waiting there for over a half an hour. Resident #12 was smiling and talking to her table mate during the beginning of meal services, however, by 12:10 p.m. she was looking around the room at everyone eating with an irritated look on her face. - At 12:18 p.m. both resident's #12 and her tablemate were served their meal together, even though resident #12 waited 40 minutes for her food while her table mates waited no more than 10 minutes for theirs. Table 20 Observation -At 11:30 a.m , three residents were sitting at the table. - One of the residents was served her meal at 11:37 a.m. while the other two were sitting at the table falling asleep. One of the other table mates received their food at 11:48 a.m. and only one resident was left without a meal in front of her while her two table mates were eating. -The resident without any food at the table was resting her hands on her head and falling asleep again at the table. She shifted in her chair several times while she waited and would readjust her hands on her head. -At 11:53 a.m. a staff member came and took the order of the resident that was sitting without food while her table mates had already been eating. She was also sitting there as long as they had been. - At 11:54 a.m. the first resident that started eating had finished her meal and left the dining room. - At 12:00 p.m. the other table mate was finished eating and a staff assisted her out of the dining room. - At 12:05 p.m. a staff member came by with the last resident's food. She started setting the food up and sat with her to help her eat it. The resident who waited the longest for her food, needed assistance to eat it and was waiting on the staff member to get her food and help her with it. On 6/26/18 at 11:30 a.m. dining observation Table 12 --At 11:30 a.m., table 12 had two residents sitting together. The male resident already had his food in front of him and he was eating. The other resident was a female and she had a glass of water in front of her. -At 11:46 p.m. the female did not have her food while her table mate was almost finished with his food. She was falling asleep at the table and would wake up every few minutes and scrunch her face and adjust in her chair as if she were uncomfortable. - At 11:53 a.m. a dietary staff took her order. She had been sitting at the table for at least 23 minutes before her order was taken. The male resident was finished with his meal and they cleared his area. - At 12:03 she was served her meal. She immediately pushed away the main dish of pureed spaghetti and only took a few bites of food before falling back asleep at the table. Table 19 - At 11:30 a.m. table 19 had resident #35 and resident #55 seated together. - At 11:40 a.m. resident #35 was served his meal while resident #55 had not received his. - At 11:45 a.m. resident #55 was just served a soda. - Resident #55 received his meal at 12:07 p.m. He waited at the table for 37 minutes while his table mate waited ten to get his meal. Table 15 Resident #63 and resident #12 got to the dining room at 11:40 am together. The dietician had assisted in the dining room and did not take the residents orders until 11:58 a.m. There meals were not served until 12:13 p.m. Resident #63 was interviewed at approximately 12:00 p.m. He said it was ridiculous how long they had to wait to get their food even when they tried to come to the dining room late. Resident #12 interviewed at approximately 12:00 p.m. She agreed with Resident #63 and it was something they better learn to live with because complaining had not done any good. Both residents said they had complained but no one ever wrote the complaint up on a grievance for them. B. Record review Food committee minutes (FCM) The FCM were provided by the NHA on 6/28/18. The FCM dated 3/6/18 revealed 12 residents were present and it was brought up that they felt it took too long for food to get to the tables during meal service The FCM dated 4/4/18 read that the resident's had brought up the concern about waiting too long to receive their food again in the dining room. It also revealed they did not like that when sitting with their table mates they were no all served at the same time. Resident grievance forms There were two grievance forms provided by the NHA on 6/27/18 at 2:22 p.m. regarding long waits for meal service in the dining room. - The first grievance was dated 5/4/18 and written for resident #55 and resident #35. The description of the concern read: resident #55 told a nurse he and resident #35 feel the kitchen staff were serving other resident's before them because they were Mexican. They like to get to the dining room early but get served after a lot of other people. - Under person designated to follow was the dietary manager (DM). - On 5/5/18 at 11:15 a.m. it read, both residents agreed they are first to come to meals but other residents are served first. They also gave the DM specific dates and times the other residents received meals and the times while they waited. - The response from the DM read that she re-educated the residents about when they go into the dining room before there are dietary staff then they had no way of knowing who is first. Then she added that the residents nurse reported they are back to their rooms before other residents so they must be served close to first. The resident's response to this noted that they said, Okay, I see. They marked that the resident was pleased that an appropriate plan had been identified and implemented. However, the response did not reveal a plan to implement. Residents #35 and #55 were interviewed 6/27/18 at 3:50 p.m. Resident #55 said he was still upset about how long it took for him and his tablemate/roommate to have to wait at the table to eat. Resident #35 agreed, he said complaining did not help because they say it's their fault. They said they don ' t want to start going to the dining room any later because they would never get their food. The complaint written on 4/4/18 regarding the wait time in the dining room was from unidentified resident and their spouse. The complaint read they waited 45 minutes in the dining room to get their meal and that it had happened more than once. It read, the table behind was waited on two times before he was waited on and he wanted to talk to the NHA about it. The resolution went to the DM and her response read that she explained that meal service was first come first serve. It read that the NHA called the resident's spouse and spoke about it and it was signed on 5/7/18 by the NHA that the resident was cautious but optimistic about the resolution. Interview The dietary manager (DM) was interviewed 6/28/18 at 1:25 p.m. She said the residents were served on a first come first serve basis because that was the way they preferred it. She said she told the residents she could either do it that way or they could serve in sections and even if the resident was in the dining room first they could get served last with the other option. She said she was addressing the resident's concerns with the long wait times in the dining room by educating the resident's if they came in the dining room early then it would feel like they were waiting a long time and by documenting when the resident's first meal was served in the dining room and then again when the last meal was served. She said the entire process had only been taking an hour to an hour and a half so they could not have been waiting too long. She said she would hope they were not waiting more than twenty minutes in the dining room to get served their food, but it would be longer if they came in before staff were in the dining room. She said they try to take everyone's order as soon as they come into the dining room and she felt they had been doing a good job of catching residents as they entered the dining room. III. Clothing protectors A. Resident council minutes (RCM) Resident council minutes were provided by the activity director on 6/27/18. -The RCM dated 3/6/18 read, Shirt protectors were discussed again. It read, resident #24 said that the napkins the facility provided as a replacement were too small and resident #25 agreed and said the food runs off of the napkins and they did not help. It read that resident #23 asked why the other clothing protectors were discontinued. It read, We lose more dignity with food on our clothes than with a bib. -The RCM dated 5/2/18 revealed the residents brought up the same concern regarding the clothing protectors. They repeated the same concerns that the napkins that were provided in place of their old clothing protectors did not work to keep food off their clothing. The response to the concern was addressed by the ombudsman. It read that she told the resident's they could wear what they wanted in the dining room and they could get their own clothing protectors and put their names on them, or they could make them in activities with their own names. - The RCM dated 6/2/18 revealed the residents had brought the issue up regarding the clothing protectors again. It looked as though the issue was cut and copied from the 5/2/18 RCM because there was no changes in the residents concern or the response from the ombudsman. B. Interviews The social service director (SSD), social service assistant (SSA) and the nursing home administrator (NHA) were interviewed on 6/28/18 at 2:30 p.m. The NHA said their grievance process was to automatically write up any concerns voiced by a resident or their family on the facility concern forms. The NHA and SSD did not know why the resident's concerns had not been getting written on the resident council concern forms. The NHA said the activity director was responsible for writing the resident's concerns voiced in resident council on a concern form so it had appropriate follow up. However, The NHA and SSD acknowledged that they received copies of the resident council minutes each month and they were the ones responsible for the grievance/concern form process and follow up. Regarding the clothing protectors that the residents would like to have back, the NHA said the corporation and department head team decided months ago that the clothing protectors did not display the type of restaurant style culture that the facility wanted to portray and that was why they got rid of the clothing protectors. She said they had told the residents they could start bringing in their own or have family bring them one. The SSD said none of the resident had come to her saying they would like a clothing protector and that was why none of them had one yet. However, she received a copy of the resident council notes that documented which residents continued to complain that they would like one each month. Regarding the wait times in the dining room the NHA said the dietary manager (DM) was keeping logs of the dining start to finish process in order to help with the residents ' concerns regarding their long wait times in the dining room. She understood that because of the first come first serve process that documenting when they sent out their first dish and when they sent their last dish may not have been accurately portraying each resident's wait times. She said they would look into these processes further to come up with better solutions.

Based on observation and staff interviews, the facility failed to promote care for residents in their room and common area in a manner and in an environment that maintained or enhanced the residents dignity. This affected one (#142) of 20 sample residents and sixteen residents (#54, #7, #2, #42, #71, #37, #36, #21, #9, #47, #77, #13, #28, #69, #6) on the assisted dining room schedule out of 78 residents in the facility. Cross reference 565. Findings include: I. Resident #142 Resident #142, age 63, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physicians orders (CPO), [DIAGNOSES REDACTED]. The 6/16/18 minimum data set (MDS) assessment indicated the resident did not have a short or long term memory problems, modified independence with daily decision making and no inattention, disorganized thinking or altered level of conscience behaviors present. A. Record review The care plan initiated on 6/26/18 read that the resident was verbally responsive but her speech was primarily incomprehensible related to her [DIAGNOSES REDACTED]. The care plan read she did understand and was able to reply to simple and direct yes, no questions. B. Observation During the beginning of an interview conducted with resident #142 on 6/25/18 at 2:28 p.m. The occupational therapist (OT) #1 entered the room and interrupted the interview and said, just to let you know she is aphasic so she won ' t be able to communicate with you. The resident looked upset as she had a worried look on her face and was trying to say something. The resident needed to use the bathroom and staff helped her ending the interview. C. Interviews The OT returned at 3:21 p.m. She said she was sorry she interrupted the interview but she knew the resident would not be able to communicate with the surveyor. The resident and her son were interviewed on 6/25/18 at 3:35 p.m. Her son said that resident #142 told him about the interaction that occurred when the OT came in to her room and said the resident would not be able to communicate. He said that that really upset her because she understands everything and she can communicate perfectly when people take their time with her. The resident agreed that that statement from the OT upset her. She said she did not feel like the staff take their time trying to understand what she was saying sometimes and it did not make her feel like they are treating her with respect and dignity. The physical therapy director (PTD) was interviewed on 6/28/81 at 1:00 p.m. He he did not think the OT meant to make Resident #142 feel bad. He said it was her intention to help facilitate the communication and it did not come across the way it should have. He said speaking that way in front of the resident was not the right way to have provided assistance and he said he already spoke with the OT about the incident and he felt she understood. The director of nursing (DON) was interviewed on 6/28/18 at 3:33 p.m. The DON said she understood why resident #142 would have been upset over the incident with the OT. She said she wanted all of the residents in the facility to be comfortable and feel they were treated fair. She said these issues were not the type of culture she would like to see in the building and she would work to make it better. II. Dining room/ resident observations On 6/25/18 at 12:23 p.m. The dietician was observed in the dining room, she asked an unidentified male resident if he wanted more coffee. He had a confused look on his face and said he thought he couldn ' t have any. She replied by saying, you are right, that was a test because you are on a fluid restriction, good job you passed the test. She then left the room and the resident left the table a few minutes later. The facility ' s dining schedule was displayed in the facility for all to see. The times for which resident ' s may eat in the dining room were separated by the residents ability to eat independently and for the residents that needed extra assistance. The residents who were able to eat independently was 7:30 a.m., 11:30 a.m. and 5:00 p.m. The dining schedule for the resident ' s that needed extra assistance, was labeled assisted dining and included residents (#54, #7, #2, #42, #71, #37, #36, #21, #9, #47, #77, #13, #28, #69, #6) who were scheduled to eat at 8:30 a.m., 12:30 p.m. and 6:00 p.m. They were always scheduled one hour later than the residents who did not need extra assistance to eat. On 6/25/18 at 12:20 p.m. a staff member assisted three residents (#28, #13 and #71) out to table 13 that was designated for residents who needed extra assistance with eating. They were observed to sit at the table without being offered any drinks. - At 12:30 p.m. the residents were observed falling asleep at the table. Then two more staff assisted resident #7 and #47 to the table. - At 12:34 p.m. a staff member came out and brought all of the resident ' s drinks and silverware and sat with them. Resident #7 asked for food and the staff told him it would be out soon. Residents # 28, #47, #13 and #28 were sleeping at the table. - At 12:54 p.m. the residents were served their food and were prompted at that point to wake up and eat. The CNA started helping resident #7 eat right away as he was excited to have his food and said he was hungry. On 6/26/18 at 8:25 am, resident #71 was brought into the dining room and taken to table 13. She was placed at the table alone, without a beverage offered. - At 8:27 and 8:30 p.m. staff assisted residents # 28, #7, #47 and #13 to the table. - At 8:45 am, resident #71 was served her breakfast. - At 8:52 am, seven minutes after resident #71 was served, the other residents at the table received their breakfast. - On 6/26/18 at 9:49 a.m. resident #47 was in the hallway outside of her room. She said she wanted to go to the dining room, she was approached by a staff member who told her that no one was at her table yet and they took her back to her room and positioned next to the TV. She was brought to the dining room [ROOM NUMBER] minutes later. On 6/26/18 at 12:10 pm. A staff member assisted residents (#28, #13) to table 13. They were sat at the table without any beverages in front of them or a staff to assist them. - At 12:29 p.m. a staff assisted resident #7 to the table and took his order. - At 12:43 p.m. A CNA brought out beverages for the resident ' s and sat with them. - At 12:50 p.m. resident # 28 and 13 received their food. Resident # 7 received his food two minutes later even though residents #28 and #13 waited 40 minutes, he only had to wait 20 minutes. On 6/26/18 at 3:00 p.m., resident #9 was observed coming out of her room, the resident was observed to tell staff that she was hungry and that she wanted to go to the dining room. An unidentified staff member told the resident it was too early to eat and asked the resident if she would like to go back to her room. - At 3:30 p.m., resident #9 was observed coming out of her room again and told an unidentified nurse that she was hungry. The nurse told the resident it was too early to eat, and assisted the resident back to her room. Resident #9 is one of the resident ' s that eats at the assisted dining tables and was not scheduled to go to the dining room until 6:00 p.m. while residents that can eat on their own were scheduled until 5:00 p.m. On 6/27 p.m. at 6:03 p.m. resident #7 was sitting at table 13 and was calling out for help. Two of the dining room staff walked passed him as they were cleaning up the tables of the residents that ate independently and had finished eating. Then a CNA stopped told him he was their to eat dinner and he just needed to wait until all of his tables mates got to the table before they would start serving him. III. Resident council interview A group interview was held with eight alert and oriented residents on 6/27/18 at 1:34 p.m. None of the resident ' s that sit at the assisted dining tables attends resident council. However, the resident ' s that did attend resident said they did not think it was right that the residents that needed assistance had to eat after them. Resident #5 said she felt sorry for the residents that had to sit at the assisted dining tables. She said the staff brought them in early and they have to sit there and watch them eat. Resident #12 said the residents at the assisted table get confused and anxious and usually start trying to wheel themselves back out of the dining room while they wait and the staff just wheel them right back to the table and lock the breaks on their wheelchair. She said they can not tell them if it bothered them but she said if it were her it would bother her. Resident #17 said some of the other resident ' s did not like eating at the same time as the residents that sat at the assisted dining room tables and they was why they were supposed to eat after them. She said it did not bother her, but she felt like the problem was that the CNAs assisted the residents into the dining room too early and that made it worse because then they get disoriented while they wait for everyone else to finish eating. IV. Staff interviews The dietician was interviewed 6/28/18 at 2:00 p.m. regarding the observation of her offing coffee to the unidentified resident and then telling him it was a test. She said that was a normal practice of hers to test the residents and make sure they understood their restrictions. She said she was surprised he remembered and passed his test. She said she did that with all residents on food or fluid restrictions. She said she didn ' t know if it bothered residents when she tested them that way. She said she had never asked them if it was okay because it never occurred to her it would bother them. The dietary manager was interviewed on 6/28/18 at 1:25 p.m. She said that the residents who needed assistance with eating have had to eat an hour later than everyone else for at least the last five years. She said the other residents did not like eating with the residents that needed assistance so they started separating them by bringing them out an hour later. She said the CNAs realized it made their jobs easier as well because they were the ones that had to help the residents eat, so it just stayed that way. She said it was the nursing department that decided the dining room schedule. The director of nursing DON was interviewed on 6/28/18 at 3:33 p.m. She said she was new to the building and the dining room schedule was already established, so she was unsure if it were the nursing department that established it.She said she was going to work on the dining schedule with the dietary staff. She also said the dieticians way of teaching the residents about their restricted diets was not an appropriate tactic and she did not know that had been a practice of hers. She said she would talk to her about other ways of helping residents with their diet choices. She also said she understood why resident #142 would have been upset over the incident with the OT. She said she wanted all of the residents in the facility to be comfortable and feel they were treated fair. She said these issues were not the type of culture she would like to see in the building and she would work to make it better.