Every finding on record at Life Care Center of Pueblo

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for one (#1) of three residents reviewed for accident hazards out of 19 sample residents.Resident #1 was admitted to the facility on [DATE]. Resident #1's comprehensive care plan revealed the resident was taking an anticoagulant (blood thinner) medication and goals included preventing abnormal bleeding and bruising as a result.On 12/24/25 at approximately 2:40 p.m. Resident #1 was being assisted to an activity in the dining room by the social services director (SSD) in her wheelchair without the foot pedals in place. Resident #1's left leg was bumped on her wheelchair when her leg dropped. At 5:41 p.m. Resident #1 complained of pain to her lower left leg. At 8:52 p.m. Resident #1 was found to have a large hematoma (a closed wound where blood collects and fills a space inside the body) on her left calf which measured 8 inches by 4 inches. Resident #1's physician was contacted and new physician's orders were received to hold the resident's anticoagulant medication and elevate the leg and ice as tolerated. Resident #1 was sent out to the emergency room on [DATE] and was treated with a splint, as-needed pain medication and orders to ice the hematoma as tolerated, and discharged back to the facility on [DATE].After the incident with Resident #1 on 12/24/25, education was provided to staff regarding the importance of transporting residents in their wheelchairs with foot pedals in place. However, observations during the survey (from 2/25/26 to 2/26/26) revealed staff continued to transport residents in their wheelchairs without foot pedals in place.Specifically, the facility failed to ensure staff transported Resident #1, who was on anticoagulant medication, in her wheelchair with the foot pedals in place, which resulted in a significant hematoma to the calf of the resident's left leg, causing the resident pain and requiring a trip to the emergency room for the resident.Findings include:I. Resident #1A. Resident statusResident #1, age [AGE], was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included cognitive communication deficit, history of falling, unsteadiness on feet, atrial fibrillation and personal history of transient ischemic attack (stroke).The 11/20/25 minimum data assessment (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was independent for most activities of daily living (ADL).The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident received an anticoagulant medication.B. Record reviewThe anticoagulant medication care plan, revised 12/26/24, revealed Resident #1 was receiving anticoagulant therapy. The goal of the care plan was to minimize abnormal bleeding and bruising for Resident #1. Pertinent interventions included administering anticoagulant medications as ordered and assessing Resident #1 for side effects, including muscle or joint pain and bruising each shift.The skin integrity care plan, revised 5/2/23, revealed Resident #1 was at risk for breaks in skin integrity due to her fragile skin, decreased mobility, incontinence and edema. Pertinent interventions included padding the doorway to Resident #1's bathroom and her roommate's wheelchair pedals, performing weekly skin checks and providing treatments as ordered.Review of Resident #1's December 2025 CPO revealed the following physician's orders:Apixaban (Eliquis) (anticoagulant medication) 5 milligram (mg) tablets, give one tablet by mouth two times a day for atrial fibrillation, ordered 7/15/24. The apixiban medication was placed on hold from 12/24/25 at 7:34 p.m. through 12/26/25 at 7:09 p.m. and again from 12/27/25 at 7:49 a.m. through 12/28/25 at 11:53 a.m.A progress note, dated 12/24/25 at 3:00 p.m., revealed the SSD was assisting Resident #1 into the dining room at approximately 2:40 p.m. to play bingo when her foot dropped and her left leg hit her wheelchair. The SSD immediately stopped and Resident #1 said her leg hurt. The SSD looked at Resident #1's leg and did not observe any marks. Resident #1 said she wanted to play bingo and the SSD continued assisting her into the dining room. The SSD told Resident #1 she would let the nurse know about the situation and proceeded to speak to Resident #1's nurse.A progress note, dated 12/24/25 at 5:41 p.m., revealed Resident #1 was administered an as-needed pain medication due to pain in her lower left leg.A progress note, dated 12/24/25 at 7:29 p.m., revealed Resident #1's apixaban order was held due to her recent hematoma.A progress note, dated 12/24/25 at 8:07 p.m., revealed Resident #1 received a new physician's order for an as-needed pain medication for pain to her left leg. Resident #1 was having severe pain from her left leg hematoma despite elevating the leg and repositioning.A progress note, dated 12/24/25 at 8:52 p.m., revealed Resident #1 was notably in pain while sitting outside her doorway and waving a facility nurse down. Resident #1 was noted to have a hematoma on her left lower leg which measured approximately eight inches by four inches. Resident #1 said she ran into another wheelchair when she was being assisted into the dining room by the SSD. Resident #1 was having severe pain. The physician was contacted and new physician's orders were obtained to elevate the resident's leg, ice the area as tolerated, and administer tramadol (a pain medication) every six hours. Orders were obtained to hold Resident #1's Eliquis for 48 hours and to measure and monitor the hematoma. The director of nursing (DON) and Resident #1's representative were both notified.-Review of Resident #1's electronic medical record (EMR) did not reveal any documentation of when and why the resident was sent out to the emergency room (see progress note below).A progress note, dated 12/25/25 at 12:30 a.m., revealed Resident #1 was admitted back to the facility from the emergency room. Resident #1's left lower leg was wrapped in a stretch wrap, and the resident reported pain in the affected leg with movement. Resident #1's foot of her bed was elevated and a pillow was placed under the affected leg for comfort and support. Resident #1 received an opioid pain medication (a pain medication used to treat moderate to severe pain) while in the emergency room. Resident #1's physician was called and informed of Resident #1's arrival back to the facility, and physician's orders were obtained to administer another dose of an opioid pain medication before continuing to give tramadol as scheduled and inform the physician of any changes.A progress note, dated 12/25/25 at 2:37 a.m., revealed Resident #1 received instructions from the emergency room to keep a splint on her left lower leg for protection for the following few days and the splint could be removed when swelling or pain improved. A progress note, dated 12/26/25 at 6:15 p.m., revealed Resident #1 was being monitored by the nursing staff for the hematoma to her left lower leg. An on-call nurse removed Resident #1's stretch wrap to visualize the leg, and saw the hematoma to her leg was large, bubbled and raised and dark purple in color. A splint was in place to the back of Resident #1's leg and the leg was re-wrapped for protection. Resident #1 reported having pain and an as-needed pain medication dose was administered. Resident #1 was assisted with repositioning. Resident #1's physician was contacted and requested the resident's apixaban be held until 12/28/25 when the physician could evaluate the resident. Resident #1's representative was in the facility at the time and was informed of the new physician's orders and plan.A progress note, dated 12/27/25 at 1:47 p.m., revealed Resident #1 complained of pain to her left lower leg. The nursing staff removed the stretch wrap to check her pulses and found her pulses were even and strong. The note documented Resident #1's hematoma was draining serous fluid. Resident #1's leg was re-wrapped with abdominal gauze pads and clean stretch wrap. Resident #1's representative was in the facility at the time and voiced concerns regarding Resident #1's lower left leg. A call was placed to Resident #1's physician and the nursing staff received physician's orders to send Resident #1 out to the emergency room a second time.A progress note, dated 12/30/25 at 12:42 p.m. (after Resident #1 was transferred to the hospital on [DATE]), revealed Resident #1 was assessed by a nurse and found to have an eight inch by five inch hematoma at approximately 5:30 p.m. on 12/24/25. Resident #1 was in pain, reporting a pain of 8 or 9 on a scale from 1 to 10, and would motion with her hand not to touch the hematoma site. Resident #1's physician was contacted to report the hematoma. Resident #1's representative was in the facility at the time and agreed to the physician's orders to attempt to treat the hematoma in house. Report was given to the oncoming night nurse, and as-needed and scheduled pain medications were administered.A progress note, dated 1/6/26 at 2:21 p.m., revealed Resident #1 was reviewed by the interdisciplinary team (IDT), 12 days after the incident which resulted in the hematoma to the resident's left leg. The note documented Resident #1 was a long-term care resident with decreased mobility, weakness, obesity and was on anticoagulant medication. Resident #1 was observed to have a large hematoma to her left lower leg and was in pain. Resident #1 said she hit the area with the hematoma on another wheelchair while being assisted by staff in her wheelchair. The area was assessed and all appropriate notifications were made. The nursing staff received orders from the physician to hold Resident #1's anticoagulant medication. The area with the hematoma continued to get larger and Resident #1 was sent out to the emergency room for evaluation. Resident #1 returned to the facility afterwards, but had to return to the hospital for further evaluation (on 12/27/25). Education was provided to all staff on transporting residents with foot pedals.A skin assessment, dated 12/25/25 at 4:30 p.m., revealed Resident #1 had a 10 inch by 6 inch hematoma to her left lower leg. The assessment documented the hematoma was noted several hours after Resident #1 was in contact with another wheelchair during assistance to the dining room. Resident #1 reported pain of 8 to 9 on a scale of 1 to 10. Resident #1's physician gave new physician's orders for cares but Resident #1 was eventually transported to the emergency room where the hospital wrapped her leg, gave her pain medications and returned her to the facility.-However, the skin assessment was documented nearly 26 hours after Resident #1's initial incident occurred.Hospital notes, dated 12/24/25 at 8:58 p.m., revealed Resident #1 was evaluated in the emergency room for a hematoma to her left leg. Resident #1 said she was getting pushed in her wheelchair around the facility. Resident #1 reported she was accidentally pushed into another wheelchair and her bruise had gotten bigger. Resident #1 reported she had been having pain. Resident #1 was on a blood thinner. Xrays were taken of Resident #1's left lower leg and found no acute breaks or fractures, only soft tissue swelling. Resident #1 was discharged back to the facility on [DATE] at 11:52 p.m.The facility investigation of the incident, dated 12/24/25, was provided by the nursing home administrator (NHA) on 2/25/26 at 1:40 p.m. and revealed the following:Resident #1 had a hematoma to her left leg. Resident #1's physician was notified and new physician's orders were received to elevate the left leg, hold the resident's apixaban order, and ice the area as the resident would tolerate.A witness statement from the SSD, dated 12/24/25, revealed the SSD was assisting Resident #1 in her wheelchair into the dining room to play bingo at approximately 2:40 p.m. Resident #1's foot had dropped and hit her wheelchair while moving. The SSD immediately stopped and looked at Resident #1's calf and did not see any marks or bruising. Resident #1 said her leg hurt but told the SSD she wanted to play bingo. The SSD said she immediately informed Resident #1's nurse about the situation. The SSD said the resident hit her left calf.A summary of findings from the IDT, undated, revealed Resident #1 was a long-term care resident with decreased mobility, weakness, obesity and was on anticoagulant medication. Resident #1 was observed to have a large hematoma to her left lower leg and was in pain. Resident #1 said she hit the area with the hematoma on another wheelchair while being assisted by staff in her wheelchair. The area was assessed and all appropriate notifications were made. The nursing staff received orders from the physician to hold Resident #1's anticoagulant medication. The area with the hematoma continued to get larger and Resident #1 was sent out to the emergency room for evaluation. Resident #1 returned to the facility afterwards, but had to return to the hospital for further evaluation. Education was provided to all staff on transporting residents with foot pedals, conducted 12/30/25 through 1/9/26.-However, staff continued to transport residents in wheelchairs without foot pedals in place (see observations below).III. Observations of other residentsOn 2/25/26 at 11:47 a.m. the infection preventionist (IP) was assisting an unidentified resident with transportation in their wheelchair through the facility hallway. The resident had one foot situated on their wheelchair foot pedal, while the other foot was situated between the two wheelchair foot pedals and pointing at the floor.At 12:06 p.m. certified nurse aide (CNA) #5 began assisting an unidentified resident with transportation in their wheelchair through the facility hallway. The resident was holding their feet up so they did not drag along the ground, and no wheelchair foot pedals were present on the resident's wheelchair.At 4:38 p.m. CNA #4 was assisting Resident #10 with transportation in his wheelchair down the hallway. Resident #10 was lifting his feet up in the air so they would not drag along the ground, and no wheelchair foot pedals were present on the wheelchair. CNA #4 asked Resident #10 if he wanted him to keep pushing his wheelchair, to which Resident #10 said he did not.On 2/26/26 at 9:09 a.m. CNA #3 assisted Resident #9 in his wheelchair from one dining table in the dining room to another table. Resident #9 had foot pedals attached to his wheelchair, but the foot pedals were flipped up and not in a position for the resident to rest his feet on them. Resident #9's feet dragged along the ground as CNA #3 pushed him.At 9:10 a.m. an unidentified housekeeping staff member was assisting an unidentified resident with transportation in their wheelchair through the facility hallway. One of the resident's feet were situated on her foot pedals, while the other jutted between the foot pedals and pointed at the ground.IV. Staff interviewsCNA #1 was interviewed on 2/26/26 at 10:29 a.m. CNA #1 said she used foot pedals on residents' wheelchairs when assisting them with transportation so the residents did not hit their toes or so their legs did not bend back while moving. CNA #1 said she received education on using foot pedals the month prior (January 2026) but said she was not sure why.CNA #2 was interviewed on 2/26/26 at 10:39 a.m. CNA #2 said when assisting residents with transportation in their wheelchairs, she applied foot pedals to the resident's wheelchair and ensured their arms were tucked in while moving. CNA #2 said the nursing staff used foot pedals on the residents' wheelchairs so the residents would not drag their feet while moving or potentially fall out of their wheelchairs. CNA #2 said she had received education on using foot pedals for residents using wheelchairs the month prior (January 2026) after a resident bumped their foot while being assisted in their wheelchair.Registered nurse (RN) #1 was interviewed on 2/26/26 at 10:54 a.m. RN #1 said facility staff needed to use foot pedals when assisting residents with transportation so they would not bump their feet or fall. RN #1 said the facility's administration staff had done a lot of education on using foot pedals recently so all staff members, even kitchen and housekeeping staff, knew they needed to use foot pedals when assisting someone in a wheelchair.The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said facility staff should apply foot pedals to the resident's wheelchair if the resident was being assisted with transportation. The DON said the facility had done education on the subject recently. The DON said for Resident #1's incident on 12/24/25, the SSD had been assisting Resident #1 through a smaller door in the dining room. The DON said they did not believe Resident #1's foot pedals were being used at the time of the incident, which was why they educated all staff on using foot pedals. The DON said Resident #1 had moved her foot during the transportation but was not sure if she had hit something on her wheelchair or had bumped into the doorway. The DON said Resident #1 had a hematoma to her left calf. The DON said Resident #1 had not complained of pain that day and was sent out to the emergency room that night (12/24/25), and had been discharged from the hospital shortly thereafter.The DON said she did not do a root cause analysis for the incident involving Resident #1. The DON said the IDT had decided to do education with staff regarding the use of foot pedals based on the information they had about the incident. The DON said she did not conduct any audits of wheelchair foot pedal usage following the incident, and said the use of foot pedals had not been identified as a concern prior to Resident #1's incident on 12/24/25.The NHA was interviewed on 2/26/26 at 12:09 p.m. The NHA said the SSD had been escorting Resident #1 to bingo when her foot dropped and the resident hit her left leg. The NHA said the SSD asked if Resident #1 was okay, and the resident said she was and that she wanted to go play bingo. The NHA said the SSD alerted Resident #1's nurse, and the nurse evaluated her and did not see any marks. The NHA said Resident #1 developed a hematoma to her left leg a few hours later and was sent out to the emergency room. The NHA said the administration had educated all facility staff members on proper wheelchair transportation so residents' feet did not fall when they were being transported. The NHA said all staff members had been educated on the subject prior to their next shift, and had received additional education during an all-staff meeting on 1/15/26. The NHA said the documents in the facility investigation were the only information they had collected.-However, several staff members were observed during the survey process not using wheelchair pedals when assisting residents with transportation (see observations above).

Based on observations, record review 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.Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene when handling residents' meal trays and water pitchers;-Ensure staff handled residents' drinkware and silverware in a sanitary manner; and,-Ensure staff donned (put on) face masks appropriately during a facility outbreak with COVID-19.Findings include:I. Failed to ensure staff performed appropriate hand hygiene when handling residents' meal trays and water pitchersA. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 3/3/26 from https://www.cdc.gov/cleanhands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings.B. Facility policy and procedureThe Resident Dining Services policy and procedure, revised 4/29/25, was provided by the nursing home administrator (NHA) on 2/26/26 at 1:17 p.m. It read in pertinent part, Staff involved in dining/food services will perform hand hygiene prior to distributing trays to the residents and when serving food to residents.C. ObservationsOn 2/25/26 at 12:07 p.m. certified nurse aide (CNA) #4 was going from room to room collecting residents' water pitchers, refilling them with ice water and returning the pitchers to the residents' rooms. CNA #4 entered an unidentified resident's room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 held the resident's straw with his bare hand so the resident could sip from the water pitcher. CNA #4 then returned the resident's water pitcher to her room, and continued going from room to room down the hallway refilling water pitchers. -CNA #4 did not perform hand hygiene between each resident's room or after handling the resident's straw.At 1:00 p.m. CNA #5 was assisting an unidentified resident in the dining room with putting her shirt back on. CNA #5 then went to look for the resident's lunch tray and moved several other residents' trays before finding the tray that belonged to the resident. CNA #5 assisted the resident with putting her shirt on again and oriented the resident to her meal tray. CNA #5 then continued passing out meal trays to other residents in the dining room.-However, CNA #5 did not perform hand hygiene after assisting the resident with putting her shirt on or between each resident's meal tray.At 1:09 p.m. CNA #5 entered an unidentified resident's room to deliver her room tray. CNA #5 oriented the resident to her meal tray and began to assist the resident with cutting up her food. CNA #5 then left the resident's room, grabbed another room tray and entered another resident's room.-However, CNA #5 did not perform hand hygiene between each resident when assisting with meal delivery.D. Staff interviewsThe infection preventionist (IP) was interviewed on 2/26/26 at 11:18 a.m. The IP said staff members should perform hand hygiene before handling room trays and after leaving residents' rooms, especially if they assisted the residents with handling their food or opening packets. The director of nursing (DON) was interviewed on 2/26/26 at 11:32 a.m. The DON said staff members should perform hand hygiene between each tray when delivering meal trays. The DON said the facility had identified concerns in this area and had been doing audits of meal hand hygiene a few months ago. The DON said the facility had provided education to the nursing and dietary staff at the time the concerns were identified, and put signs on the meal delivery carts as a reminder to perform hand hygiene. The DON said the facility's administration staff still saw occasional issues with hand hygiene during meals, but said the audits had decreased the rate of issues significantly. -However, observations conducted during the survey process revealed concerns with staff performing hand hygiene between tray deliveries and in filling water pitchers (see observations above).II. Failed to ensure staff handled residents' drinkware and silverware in a sanitary mannerA. ObservationsOn 2/25/26 at 12:07 p.m. CNA #4 was going from room to room collecting residents' water pitchers, refilling them with ice water, and returning the pitcher to the residents' rooms. CNA #4 entered an unidentified resident's room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 grabbed the outside of his mask and pulled his mask down to speak with the resident. Using the same bare hand, CNA #4 held the resident's straw so she could sip from the water pitcher. CNA #4 then returned the resident's water pitcher to her room, and continued going from room to room down the hallway refilling water pitchers. -CNA #4 did not perform hand hygiene before or after handling the resident's straw or after handling his mask.On 2/26/26 at 9:13 a.m. CNA #3 began assisting an unidentified resident with eating breakfast. CNA #3 unwrapped the napkin around the resident's silverware and held her fork and knife by the cutting surface and tines. CNA #3 grabbed the resident's coffee mug by the rim of the mug and handed it to her. CNA #3 then began cutting up the resident's food.At 9:16 a.m. CNA #3 grabbed the unidentified resident's mug by the rim and pulled it closer to himself to add a packet of sugar to her coffee. CNA #3 then used the handle of the resident's knife to stir her coffee. CNA #3 had previously used the knife to cut the resident's food.B. Staff interviewsThe IP was interviewed on 2/26/26 at 11:18 a.m. The IP said staff members should not touch the area on silverware where a resident's mouth would go. The IP said staff members should not grab mugs or cups by the top, and said it was not okay to grab areas where the resident's mouth would then touch.The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said staff should not handle the rims of residents' cups or the end of the residents' silverware that the resident would then put into their mouth.III. Failed to ensure staff donned face masks appropriately during a facility outbreakA. Facility policy and procedureThe Universal Source Control policy and procedure, revised 7/7/25, was received from the NHA on 2/26/26 at 1:17 p.m. It read in pertinent part, Source control is the use of respirators or well-fitting face masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing or coughing. Source control is recommended for individuals in healthcare settings who reside or work on an area of the facility experiencing an outbreak of respiratory infection. Healthcare professionals should be instructed that if they must touch or adjust their facemask they should perform hand hygiene immediately before and after.B. ObservationsOn 2/25/26 at 12:07 p.m. CNA #4 entered an unidentified resident's room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 grabbed the outside of his mask and pulled his mask down to speak with the resident. CNA #4 bent down and put his face beside the resident's ear while doing so. After speaking with her, CNA #4 pulled his mask back up and encouraged the resident to drink. CNA #4 repeated this process moments later.-CNA #4 did not perform hand hygiene after handling his mask, and his mask did not cover his mouth and nose while in close contact with the resident.On 2/26/26 at 9:09 a.m. CNA #3 was in the dining room assisting residents with getting to their seats for the breakfast meal service. CNA #3 was wearing a surgical mask which was pulled down below his mouth.At 9:13 a.m. CNA #3 sat next to an unidentified resident and began assisting her with eating. CNA #3 continued to wear his surgical mask under his mouth.C. Staff interviewsThe IP was interviewed on 2/26/26 at 11:18 a.m. The IP said the facility was in outbreak status at the moment for COVID-19, but did not have any current cases of COVID-19 in the resident population. The IP said their most recent positive case was a staff member who had tested positive for COVID-19 the week prior (week of 2/16/26). The IP said the facility's last day of outbreak status would be on 2/28/26. The IP said he had been enforcing surgical mask use for staff members, especially when they were in resident care areas. The IP said staff should wear their masks so they covered both their nose and their mouth. The IP said he had to provide spot-education to a few employees the day prior (2/25/26) to ensure their noses were covered by their masks. The IP said staff members should perform hand hygiene after handling the outside of their mask, as the mask was technically considered to be a contaminated surface.The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said staff members should be wearing face masks in the facility hallways and resident care areas during the facility's COVID-19 outbreak. The DON said staff members' masks should cover both their nose and their mouth. The DON said if a resident was having difficulty communicating and the staff member needed to lower their mask to communicate with them, the staff member should avoid pulling their mask down in a hallway. The DON said the staff member should try to bring the resident to a room or office to facilitate communication.

Based on record review and interviews the facility failed to ensure residents were treated with dignity and respect for three (#1, #12 and #9) of four residents out of 13 sample residents. Resident #1, who was non-weight bearing on his right leg due to a broken ankle required staff assistance to transfer from his wheelchair to and from the toilet. According to Resident #1, certified nurse aide (CNA) #1 was rude to him when he requested assistance with transferring to the toilet and told him he could use the bathroom himself. CNA #1 did assist the resident onto the toilet, however when Resident #1 requested assistance to transfer back to his wheelchair after using the bathroom, CNA #1 entered the resident's room and refused to assist him. CNA #1 informed the resident we are not doing this again and left the resident's room without assisting him. Resident #1 said he had to remain on the toilet until another CNA responded to his call light and came to assist him from the toilet back to his wheelchair. Resident #1 said the experience made him feel humiliated. On another occasion, Resident #1 said CNA #1 approached him in the dining room and when he did not respond to her, she laughed at him and rudely said What's the matter with you, you don't have a mouth now and That's right, you're mad at me. Resident #1 again said the experience with CNA #1 humiliated him. Resident #1 said CNA #1 entered his room to answer his call light and he asked her to leave because he did not want to receive care from her due to his past experiences with her. The resident said he told CNA #1 he was going to report her behavior to the nursing home administrator (NHA) and CNA #1 responded by saying I've already told therapy about you. Resident #1 said her statement made him feel scared. Resident #1 said he was afraid other staff would treat him poorly if CNA #1 was bad-mouthing him. Resident #1 said he reported CNA #1's behavior to the NHA, however, he said nothing had changed and CNA #1 now snickered at him and heckled him in the hallway when he passed by. He said she sometimes stood outside his room and stared at him or laughed at him. He said he had started to keep his door closed when CNA #1 was working but he preferred to have his door open. Due to the facility's failure to ensure Resident #1 was treated with respect and dignity by CNA #1 and the facility's failure to follow up effectively with CNA #1 to ensure CNA #1's behaviors toward Resident #1 were corrected, Resident #1 suffered psychosocial harm due to feelings of humiliation from the treatment he received and fear that other staff would also treat him poorly. Additionally, Resident #12 and Resident #9 reported they were not treated with dignity and respect by staff on occasion. The residents felt staff were rude, degrading and did not care for them. Findings include: I. Facility policy and procedure The Dignity policy and procedure, dated September 2023, was provided by the nursing home administrator (NHA) on 8/7/24 at 3:12 p.m. It read in pertinent part, Each resident has the right to be treated with dignity and respect. Interactions with staff must focus on maintaining and enhancing the resident's self-esteem and self-worth, as well as honor and value their input. The facility must protect and promote the rights of the resident. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included fracture of upper and lower end of right fibula, closed fracture with routine healing, lack of coordination, muscle weakness, difficulty in walking and pressure ulcer of the right ankle. The 6/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff assistance for toilet transfers. The assessment revealed the resident was strictly non-weight bearing on his right extremity related to his fractured fibula. B. Resident interview Resident #1 was interviewed on 8/5/24 at 4:31 p.m. Resident #1 said he was admitted to the facility for rehabilitation after breaking his ankle. He said he was unable to bear any weight on his right ankle related to the surgery. He said because of his surgery, he needed staff assistance to get on and off of the elevated commode that was placed over the toilet in his bathroom. Resident #1 said he had used his call light to request assistance transferring from his wheelchair onto the commode. He said CNA #1 was rude and refused to help him. Resident #1 said CNA #1 told him he could go to the bathroom by himself. Resident #1 said he told her he could not because he was non-weight bearing and weak. He said CNA #1 told him that it was (expletive language) that he needed assistance. Resident #1 said while he was seated on the commode after having a bowel movement he used the call light to request assistance to transfer back to his wheelchair. Resident #1 said CNA #1 entered his bathroom in response to the call light, said we're not doing this again and exited the room. He said she left him seated in the bathroom soiled. He said he felt humiliated. Resident #1 said he had to continue to push the call light until another CNA came to the bathroom to assist him. Resident #1 said he was approached on another occasion in the dining room by CNA #1. He said she was rude and hateful toward him. Resident #1 said CNA #1 aske him What's the matter with you, you don't have a mouth now? He said she then laughed at him and said That's right, you're mad at me and walked away. Resident #1 said again he felt humiliated. Resident #1 said he no longer wanted to receive care from CNA #1. He said CNA #1 came into his room another time, after he pushed the call light. He said he asked her to leave and he would wait for another CNA or nurse to come assist him. He said CNA #1 argued with him about leaving. Resident #1 said he told CNA #1 that he was going to report her behavior to the NHA. Resident #1 said, in response, she told him I've already told therapy about you. He said CNA #1's statement made him feel scared. Resident #1 said he was afraid other staff would treat him poorly if CNA #1 was bad-mouthing him. Resident #1 said he reported CNA #1 to the NHA, however, he said her behavior toward him had not changed. Resident #1 said after he reported CNA #1's behavior to the NHA, she began to bully him in the hallways. He said she snickered and heckled him while passing him in the hallways. Resident #1 said CNA #1 had begun to stand outside his doorway and stared or laughed at him. He said he had begun to keep his door shut during her scheduled shifts, however, he said he preferred for his door to remain open. C. Record Review Review of Resident #1's August 2024 CPO revealed a physician's order that indicated the resident was to 7/26/24 continue strict non-weight bearing to his right lower extremity for four more weeks. D. Staff interviews The NHA and the director of nursing (DON) were interviewed together on 8/5/24 at 5:35 p.m. The NHA said he remembered receiving a complaint from Resident #1 about CNA #1. The NHA said Resident #1 had been upset with CNA #1 because she had been rude. The NHA said the resident was unable to express an exact allegation and had reported the complaint to him in the hallway. The NHA said he had not spoken with CNA #1 because he had been unsure exactly what to speak to her about. The DON said she had spoken with CNA #1. The DON said Resident #1 had reported that CNA #1 had been rude to him on a Friday, however, she said CNA #1 did not work on Fridays. The DON said when she approached CNA #1 about Resident #1's complaint, CNA #1 told her she had no issues with the resident. The DON said it may be easy for a resident to become confused as to the day of the week. The NHA said CNA #1 had been told not to provide cares to Resident #1 unless it was necessary, such as when another staff member could not provide assistance to the resident. The NHA said the facility did not change the hallway assignment for CNA #1 so she would no longer be providing care for Resident #1 because she had been told not to answer his call light. The NHA said he did not investigate or file a grievance on Resident #1's behalf because it had appeared to be a customer service issue. -However, per Resident #1's interview, he continued to have problems with CNA #1 (see resident interview above). The NHA was interviewed again on 8/7/24 at 10:15 a.m. The NHA said a Resident's Rights training had been attended by every employee during their orientation and then annually thereafter. III. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), dependence on oxygen, weakness and difficulty in walking. The 5/22/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required assistance with activities of daily living (ADL). B. Resident interview Resident #12 was interviewed on 8/7/24 at 2:00 p.m. Resident #12 said most staff treated her with dignity and respect. However, she said today (8/7/24) the bath aide (CNA #7) was an (expletive language) to her. She said CNA #7 refused to put lotion or ted hose (compression stockings) back on her after her shower. She said CNA #7 told her she did not have time. She said this morning (8/7/24) her breakfast tray came late and her coffee was cold. She said this happened frequently so she asked when her tray was picked up to have two cups of hot coffee brought to her. However, Resident #12 said, this morning (8/7/24) CNA #8 told her she did not have time to go get the hot coffee so she would have to wait until lunch. Resident #8 said it made her feel like she was not important and it was degrading to her. She said she tried not to bother the staff unless she needed to. She said she had complained in the past, but it did not do any good. Resident #12 said the CNAs gossiped about residents who complained. C. Staff interview The NHA was interviewed on 8/7/24 at 2:30 p.m. The NHA said he was informed of the above interview with Resident #12. He said the resident should have received the care she requested. He said he would investigate the situation and go talk to Resident #12. He said the facility staff could use some training on customer service. He said he would talk to the dietary manager about the coffee being cold. IV. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included COPD, type II diabetes mellitus with neuropathy, heart failure, neurocognitive disorder with Lewy bodies and hemiplegia and hemiparesis (weakness to one side of the body). The 5/10/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. B. Resident interview Resident #9 was interviewed on 8/6/24 at 9:05 a.m. Resident #9 said licensed practical nurse (LPN) #1 did not treat her with respect and dignity. She said LPN #1 was rude and would not listen to her. She said when she had chest pain LPN #1 would not believe her. Resident #9 said LPN #1 just did not care for her. She said she tried to avoid her when she was the nurse for the day. C. Staff interview The social service assistant (SSA) was interviewed on 8/6/24 at 9:30 a.m. The SSA spoke with Resident #9 about her concern and told the resident she would investigate. The SSA said the staff were to treat residents with respect. She said Resident #9 was able to make her needs known. She said she would check in with the resident periodically to see how she was doing.

Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for one (#3) of three residents reviewed for abuse out of 13 sample residents. Resident #3 was admitted to the facility on [DATE] with a diagnosis of constipation. On [DATE], in the early morning hours, Resident #3 called for assistance. The resident told the staff that she was constipated and needed assistance or she wanted to go to the hospital. Registered nurse (RN) #1 came to her room. Certified nurse aide (CNA) #5 assisted Resident #3 to roll over. RN #1 began to insert a suppository and felt a hard stool in the resident's rectum. As RN #1 removed the stool from Resident #3's rectum, the resident was crying and yelling in pain and asking RN #1 to stop. However, RN #1 continued to proceed with the removal of the stool, while the resident was crying in pain, which caused mental anguish, emotional distress and fear for Resident #3. Additionally, the facility failed to document any information related to Resident #3's fecal impaction and the procedure that occurred in Resident #3's electronic medical record (EMR). Findings include: I. Professional references According to Setya A, [NAME] G, Cagir B. (2023). Fecal Impaction. National Institutes of Health, retrieved on [DATE] from https://www.ncbi.nlm.nih.gov/books/NBK448094/, Fecal impaction is a significant but preventable problem in the elderly population within hospitals and other institutions. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The treatment options are the rectal administration of stool softening agents, usually enemas or suppositories or a digital evacuation of the impacted fecal mass.The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger. Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), pages ,d+[DATE], retrieved on [DATE], read in pertinent part, Position patient on left side which helps with medication retention because the descending colon is on the left side, it also helps relax the external anal sphincter (rectum). The patient should not experience pain during the administration of a suppository, but they will feel pressure. Encourage deep breathing to aid in relaxation of the sphincter. Pushing a suppository through a constricted sphincter causes discomfort. II. Facility policy and procedure The Abuse and Neglect policy and procedure, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:11 a.m. It read in pertinent part, Nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. It is the policy and practice of this facility that all residents will be protected from all types of abuse. Prohibiting and preventing all forms of abuse. Identifying what constitutes abuse. Reporting abuse. III. Physical abuse by RN #1 toward Resident #3 on [DATE] The [DATE] facility investigation was received from the nursing home administrator (NHA) on [DATE] at 12:45 p.m. The investigation was related to an allegation of sexual abuse on [DATE]. Resident #3 was interviewed by the facility on [DATE] at 4:00 p.m. Resident #3 said she had been feeling constipated and had requested a suppository. Resident #3 said RN #1 had inserted more than three fingers inside her rectum, moving them around, during the medication administration. Resident #3 told RN #1 that it was hurting and to stop, but RN #1 did not stop. Resident #3 said she was told by RN #1 not to push her call light again after the incident. Resident #3 said she did not feel safe in the facility. The roommate of Resident #3 was interviewed by the facility on [DATE] at 9:15 a.m. The roommate reported that RN #1 said she had come off of her break to deal with Resident #3. The roommate said Resident #3 had repeatedly yelled for RN #1 to stop. The roommate said RN #1 had hurt Resident #3 and she had heard her scream. The roommate said she had begun to pray for Resident #3. RN #1 was interviewed by the facility on [DATE] at 11:15 a.m. RN #1 said she administered a suppository after digitally removing stool from the Resident #3's rectum. RN #1 said the care only lasted 15 to 20 seconds. RN#1 said Resident #3 never told her to stop. The facility unsubstantiated Resident #3's sexual abuse related to the resident's emergency department (ED) visit had not noted trauma to the resident's rectal area. -However, according to the ED visit documentation, the resident's rectum was mildly red (see record review below). IV. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged to home on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented the resident was receiving renal dialysis. V. Resident's representative interview The resident's representative was interviewed on [DATE] at 12:55 p.m. The representative said Resident #3 resided at the facility, until she moved her from the facility on [DATE]. She said her mother had experienced a traumatic event at the facility. She said her mother had a history of constipation. She said Resident #3's mother had died at an early age of a bowel obstruction and so Resident #3 was very cautious about her bowels. She said Resident #3 told her she was held down while RN #1 gave her a suppository. She said Resident #3 was crying out to stop and RN #1 did not stop. She said the resident was afraid to stay in the facility. The resident's representative said Resident #3 was a religious woman and she felt she was rectally assaulted to the extent that she continued to have nightmares about the abuse. She said the resident was humiliated and embarrassed and that was why she did not report the abuse the night the incident occurred. She said Resident #3 told the social worker at the dialysis center of the abuse. The representative said the dialysis center social worker (DSW) reported the incident to adult protective services. VI. Record Review The admission record dated [DATE] revealed Resident #3 admitted to the facility with a medical diagnosis of a history of constipation. A [DATE] emergency department report for Resident #3 documented there was a small external hemorrhoid at the 11 o'clock position of the resident's rectum that was not bleeding and there were no overt tears, trauma, bleeding or bruising. The note documented the rectum did not appear to be irritated but was mildly red inside. A [DATE] facility nursing progress note documented a facility RN got a report from the emergency department that Resident #3 was alright and did not have bleeding or tears from the rectum. Another [DATE] facility nursing progress note documented Resident #3 had come back from the emergency department and was hungry. The [DATE] nurse practitioner note documented the nurse practitioner followed-up regarding the resident's sexual assault allegation. The note said the resident voiced to the nurse practitioner that she was constipated and the nurse forcefully digitally stimulated her. The note documented the resident was seen at the hospital and no evidence of trauma was noted on the exam. The note documented an investigation of the incident was in progress with nursing staff. A review of the resident's EMR did not reveal other documentation regarding the procedure that was done on [DATE] that prompted the resident to go to the emergency department, the allegation made, or any psychosocial harm on [DATE]. VII. Staff interviews RN #1 was interviewed on [DATE] at 7:24 p.m. RN #1 said Resident #3 had requested a suppository (laxative). RN #1 said she entered Resident #3's room with CNA #5 to administer the suppository. RN #1 said she had explained the need for digital disimpaction (procedure of removing stool from the rectum with the index finger) to Resident #3. RN #1 said the resident was educated that the stool needed to be removed for the suppository to work properly. RN #1 said she had heard the resident moaning as stool was removed from the rectum. RN #1 said the resident did say to stop, but it had been after the disimpaction and after her finger had already entered the rectum to administer the suppository. RN #1 then said she had never heard the resident say to stop. RN #1 said after the event she had heard from others that the resident had said to stop. RN #1 said the resident may have said stop, but she did not hear it until she was done. RN #1 said she may have forgotten to chart the administration of the suppository. Certified nurse aide (CNA) #5 was interviewed on [DATE] at 7:24 p.m. CNA #5 said Resident #3 had complained of constipation and had been turning her call light on every fifteen minutes asking for something to help her with her constipation. CNA #5 said Resident #3 had told her that the day shift nursing staff had not given her anything to relieve her of her constipation. CNA #5 said Resident #3 said she had been passing hard little balls of feces throughout the day and evening shifts. CNA #5 said she told RN #1 and that it took her a while to come into Resident #3's room to give her the suppository. CNA #5 said that Resident #3 understood the procedure. CNA #5 said once RN #1 came in to give the suppository, she helped roll Resident #3 onto her right side and held Resident #3's hand with her right hand and had her left hand on Resident #3's hip. CNA #5 said RN #1 did explain the procedure to her, that she needed to get the feces out for the suppository to work. CNA #5 said Resident #3 was crying and yelling for RN #1 to stop because the digging was painful. CNA #5 said RN #1 did not stop. CNA #5 said RN #1 was really digging the bowel movement out and RN #1 should have stopped when Resident #3 was yelling for her to stop. CNA #5 said she did not feel comfortable asking RN #1 to stop because she was a new CNA and also because RN #1 was the charge nurse on duty. A frequent visitor (FV) was interviewed on [DATE] at 9:24 a.m. She said she got a phone call from the resident's representative the morning of [DATE]. The FV said the resident's representative told her Resident #3 had been receiving a suppository and was digitally probed to the point where it felt as if she had been sexually assaulted, so much so that the representative took her to the emergency department for a sexual assault examination. The FV said the resident's representative told her that Resident #3 was fearful and traumatized from the experience. The NHA and the director of nursing (DON) were interviewed together on [DATE] at 10:15 a.m. The DON said RN #1 should have applied lubrication to her gloved finger before she inserted her finger into Resident #3's rectum. The DON said RN #1 should have removed as much stool as required to administer the suppository. The DON said RN #1 should have stopped when told to stop by the resident. The DON said if a resident said stop, it was their right and it did not matter what care was being performed at the time. The DON said RN #1 should have stopped the procedure and provided education to the resident. She said RN #1 should have provided options (continuing with the disimpaction, stopping the procedure completely or calling a provider) and allowed the resident to decide how they proceeded. The DON said there should be documentation in the resident's electronic medical record (EMR) of the digital stool removal. The NHA said he was the abuse coordinator for the facility. The NHA said on [DATE] he was notified of a sexual abuse allegation by Resident #3's dialysis center. The NHA said after he had received a notification of sexual abuse, he contacted the DON and the regional director. The NHA said he did not remember who notified him. The NHA said he called the DON, the regional team, the ombudsman and the police. He said he then reported Resident #3's allegation of rape to the State Agency reporting site. The NHA said the investigation had begun immediately upon the facility's notification of the allegation. The NHA said RN #1 and CNA #5 were placed on administrative suspension for approximately five days during the investigation. The NHA read aloud the facility-conducted interview of Resident #3's roommate. The NHA said he had seen and read the interview before. The NHA said his first instinct would have been that there had been potential abuse. The dialysis center social worker (DSW) returned a phone call (placed during the survey) and was interviewed on [DATE] at 9:33 a.m. The DSW said on [DATE] Resident #3 arrived for dialysis appearing disheveled, tearful and her demeanor was out of character. The DSW said as the dialysis staff attempted to calm down Resident #3, she had begun to shake and had cried. The DSW said Resident #3 told the dialysis staff that a CNA held her down and a nurse forced a suppository inside her. The DSW said Resident #3 said she had told them to stop, never mind, she did not want the suppository anymore, she just wanted to go to sleep. Resident #3 said the nurse did not stop. The DSW said Resident #3 used the words, fearful, scared, and retaliation. 51163

Based on record review and interviews, the facility failed to have evidence that all alleged abuse were thoroughly investigated for one (#3) of three residents reviewed for abuse of 13 sample residents. Specifically, the facility failed to thoroughly investigate an allegation of abuse. Findings include: I. Facility policy and procedure The Abuse and Neglect policy and procedure, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:11 a.m. It read in pertinent part, The facility must develop and implement written policies and procedures to investigate any such allegations. Have evidence that all alleged allegations of abuse are thoroughly investigated. II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged to home on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident's representative interview The resident's representative was interviewed on [DATE] at 12:55 p.m. The representative said Resident #3 resided at the facility, until she moved her from the facility on [DATE]. She said her mother had experienced a traumatic event at the facility. She said her mother had a history of constipation. She said Resident #3's mother had died at an early age of a bowel obstruction and so Resident #3 was very cautious about her bowels. She said Resident #3 told her she was held down while registered nurse (RN) #1 gave her a suppository. She said Resident #3 was crying out to stop and RN #1 did not stop. She said the resident was afraid to stay in the facility. The resident's representative said Resident #3 was a religious woman and she felt she was rectally assaulted to the extent that she continued to have nightmares about the abuse. She said the resident was humiliated and embarrassed and that was why she did not report the abuse the night the incident occurred. She said Resident #3 told the social worker at the dialysis center of the abuse. Cross-reference F600 for failure to keep a resident free from abuse. C. Facility investigation of incident between RN #1 and Resident #3 The [DATE] facility investigation was provided by the nursing home administrator (NHA) on [DATE] at 12:45 p.m. The investigation was related to an allegation of sexual abuse in the early morning hours of [DATE]. The roommate of Resident #3 was interviewed by the facility on [DATE] at 9:15 a.m. The roommate reported that RN #1 said she had come off of her break to deal with Resident #3. The roommate said Resident #3 had repeatedly yelled for RN #1 to stop. The roommate said RN #1 had hurt Resident #3 and she had heard her scream. The roommate said she had begun to pray for Resident #3. RN #1 was interviewed by the facility on [DATE] at 11:15 a.m. RN #1 said she administered a suppository after digitally removing stool from the Resident #3's rectum. RN #1 said the care only lasted 15 to 20 seconds. RN #1 said Resident #3 never told her to stop. On [DATE] at approximately 3:00 p.m. the facility interviewed certified nurse aide (CNA) #5. CNA #5 said she helped RN #1 administer the suppository by rolling Resident #3 onto her side. CNA #5 said the nurse had to remove feces to get the suppository placed inside Resident #3. CNA #5 said RN #1 told Resident #3 I can't stop because I am trying to pull feces out so I can put the suppository in. Resident #3 was interviewed by the facility on [DATE] at 4:00 p.m. Resident #3 said she had been feeling constipated and had requested a suppository. Resident #3 said RN #1 had inserted more than three fingers inside her rectum, moving them around, during the medication administration. Resident #3 told RN #1 that it was hurting and to stop, but RN #1 did not stop. Resident #3 said she was told by RN #1 not to push her call light again after the incident. Resident #3 said she did not feel safe in the facility. The investigation revealed the facility interviewed one additional staff member who was working the floor at the time of the incident. -However, the two additional staff members who were working at the time of the incident were not interviewed as part of the investigation. According to review of the facility's investigation, three additional staff members from different shifts were interviewed and asked if they had ever witnessed staff members being sexually inappropriate with residents and if they had any concerns about the way staff members handled residents. The facility interviewed five additional residents, asking each of them the following questions: -Has a staff member ever been sexually inappropriate with you; -Are you fearful of any staff members; -Do you feel safe; and, -Is there anything else you want the facility to know? -However, the facility failed to ask the residents any questions related to if any of them had ever experienced any care from staff that they felt had been provided in a forceful physical way. The facility unsubstantiated Resident #3's sexual abuse related to the resident's emergency department (ED) visit had not noted trauma to the resident's rectal area. -However, the facility failed to investigate the potential that physical abuse occurred due to the forceful way RN #1 administered the suppository to Resident #3, despite Resident #3 asking the nurse to stop. D. Record Review An emergency department (ED) visit progress note, dated [DATE] at 3:23 p.m., documented Resident #3 appeared to be nervous. Resident #3 said she had been rectally assaulted, possibly for disimpaction, but against her will. The note documented the resident had a small external hemorrhoid at the 11 o'clock position of the rectum that was not bleeding and there were no overt tears, trauma, bleeding or bruising. The note further documented the rectum did not appear to be irritated but was mildly red inside. III. Staff interviews The NHA and the director of nursing (DON) were interviewed together on [DATE] at 10:15 a.m. The NHA said he was the abuse coordinator for the facility. He said he was notified of a sexual abuse allegation on [DATE]. The NHA said he followed the investigation procedure for a sexual abuse allegation. The DON said the facility had not substantiated the sexual abuse allegation because the emergency room discharge stated no signs of trauma or assault. The DON said RN #1 had been interviewed by a CNA who was helping out the social services department and was not a licensed social worker. The DON said she had not conducted the interviews because RN #1 was the DON's sister, so she had removed herself from the investigation. She said she did not think the assistant director of nursing (ADON) had conducted an interview with RN #1 in her place when she removed herself from the investigation. The NHA said the interviews during the investigation should have been conducted by a qualified social worker or someone from the management team, and not the CNA who was not a licensed social worker. During the interview, the NHA read aloud the interview that the facility had conducted with Resident #3's roommate. After reading the interview, the NHA said his first instinct would have been that there had been potential physical abuse, however, he said he did not recognize it at the time of the incident. The NHA said every staff member who was working on the shift when the incident occurred should have been interviewed. 51163

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents reviewed for discharge planning out of 13 sample residents. Specifically the facility failed to assist Resident #3 in the development of a safe and appropriate discharge plan. Findings include: I. Facility policy and procedure The Against Medical Advice (AMA) Discharges policy and procedure, August 2023, was provided by the nursing home administrator (NHA) on 8/7/24 at 2:30 p.m. It read in pertinent part, If a resident wishes to be discharged prior to the completion of medical treatment or against the advice of the attending physician to a setting that does not appear to meet their needs or appears unsafe, the facility will treat this a refusal of care. The facility will complete the required documentation and provide written discharge instructions as with any discharge. If a discharge AMA cannot be prevented, a practitioner must evaluate the resident's mental capacity to be sure that the resident can understand the condition, the nature and effect of the proposed treatment, and the inherent risk/benefit in pursuing the treatment and not pursuing the treatment. Documentation should include the resident's decision-making capacity, disclosed risks, and the resident's understanding of those risks. As with any discharge, the facility is required to provide written discharge instructions, including follow-up with practitioners, medication management, the need for continued therapy, and any durable medical equipment necessary. Notify the resident practitioner, the facility's social services department, and a facility administrator of the resident's desire to leave the facility AMA. The AMA documentation includes: decision-making capacity, discussion of treatment goals (risks of not completing goals with resident understanding those risks), date and time the practitioner was notified of residents desire to discharge AMA, discharge arrangements made with caregiver/family member, written discharge instructions provided, person to whom resident was discharged , signed copy of the AMA form, physical assessment findings and education provided to resident and family (with understanding of that teaching). II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged to home on 6/7/24. According to the June 2024 computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The 4/24/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required a hoyer lift for transfers related to a recent left leg below the knee amputation. The MDS assessment did not indicate the resident had an ongoing discharge plan. B. Resident's representative interview The resident's representative was interviewed on 8/7/24 at 12:55 p.m. The resident's representative said her mother had informed her of an incident which occurred in the early morning of 6/5/24. She said her mother had told her later in the morning (6/5/24) that she was scared and did not want to continue to live at the facility. The resident's representative said she spoke with the NHA to inform him of the abuse allegation. The resident's representative said Resident #3 went to dialysis on 6/5/24 and then to the hospital to be examined for a sexual assault allegation. The resident's representative said Resident #3 returned to the facility on [DATE] so the family could have time to obtain a Hoyer lift (mechanical lift) and a medical bed in order to make preparations so Resident #3 could be discharged from the facility to live with her. The resident's representative was a certified nurse aide (CNA) and an emergency medical technician (EMT). The resident's representative said she had told the facility she wanted Resident #3 to discharge home with her, however, she needed time to prepare. The resident's representative said the NHA told her if she was taking Resident #3 out of the facility it would be AMA and he had forced her to sign the AMA paperwork on the discharge date of [DATE]. The resident's representative said the facility did not send any discharge instructions, medications or a list of the current medications that Resident #3 was currently prescribed. She said Resident #3 went nearly two weeks without her blood thinner medication and other medications. The resident's representative said the facility did not send any paperwork with the resident. The resident's representative said the facility did not provide any assistance with the discharge planning process. C. Record review The AMA form, dated 6/7/24, was signed by the resident's daughter, the ombudsman and a registered nurse (RN). The discharge form documented, in pertinent part, I am being discharged against the advice of the attending physician and the facility administration. I acknowledge that I have been informed of the risks involved and hereby release the attending physician and the facility from all responsibility for and from anything that may result from such discharge. I am also aware that I will be responsible for any costs incurred tha my insurance company refuses to cover. -Review of Resident #3's electronic medical record (EMR) did not reveal documentation indicating the facility had assisted the resident with discharge goals. -The EMR failed to document the reasons for the AMA discharge, who had made the decision for the AMA discharge or if the interdisciplinary team (IDT) was involved with the decision to discharge the resident AMA. -The EMR failed to document if the resident's physician or the medical director (MD) was notified of Resident #3's AMA discharge. -A review of Resident #3's June 2024 CPO did not reveal a physician's order for the resident's discharge. -The EMR did not reveal documentation to indicate that a discharge summary or any discharge documentation was sent with the resident. III. Staff interviews The NHA and the director of nursing (DON) were interviewed together on 8/7/24 at 10:15 a.m. The DON said it was not been safe for Resident #3 to discharge home with family. The DON said the family had told the facility they were unable to care for the resident at home. The DON said the resident did return to the facility after dialysis and the emergency department on 6/5/24 and was not discharged AMA until 6/7/24. The DON said the facility had wondered why Resident #3 had come back to the facility after her emergency department visit if the family had not wanted her there. The DON said when the resident was first admitted to the facility she had planned to return home with her family. The DON said the resident's representative and the resident had made the decision to stay at the facility, as it was going to be difficult for the resident's representative to care for the resident at home. The DON said the facility made the decision to discharge Resident #3 AMA due to the fact that the resident's representative had told them she could not take care of her at home but was insisting on taking the resident home anyway. The DON said the resident's physician had not been notified prior to Resident's #3's discharge or that the resident left AMA. The DON said Resident #3's EMR should have included documentation that she had been discharged home. The DON said it was standard practice for the facility to notify adult protective services (APS) when a resident was discharged AMA, however, the DON said APS had not been contacted by the facility regarding Resident #3's AMA discharge. The social services director (SSD), and the DON were interviewed together on 8/7/24 at 2:45 p.m. The SSD said a discharge summary should have been written and given to the family upon discharge. The SSD said she did not know why a physician's discharge order was not obtained. The SSD said although she was newly employed and was not hired at the time of Resident #3's discharge, she said the practice was for the social worker to lead the discharge planning process. She said the social worker was to offer services and make referrals when needed. The SSD said the IDT was to complete a summary of the resident's stay. The SSD said she reviewed Resident #3's EMR and said there was not any documentation or evidence which showed the resident was offered any services or discharge planning assistance. She said pertinent phone numbers, such as advocacy contact numbers, were not provided. The MD was interviewed on 8/7/24 at 3:19 p.m. via telephone. The MD said there should have been a physician's discharge order when Resident #3 was discharged from the facility. The MD said the attending physician should have been notified and participated in the AMA discharge process. The MD said he was not notified that Resident #3 had been discharged AMA. The dialysis center social worker (DSW) was interviewed on 8/15/24 at 9:33 a.m. via telephone. The DSW said the facility had not completed a safe discharge for Resident #3. The DSW said the facility left the resident's representative on her own with the discharge. The DSW said the facility did not provide discharge instructions, a medication list or the necessary equipment for Resident #3 to successfully discharge. The DSW said she picked up oxygen supplies at a medical supply company for Resident #3. 51163

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#3) of three residents reviewed for quality of care out of 13 sample residents. Specifically the facility failed to: -Follow the physician's standing orders for bowel management for Resident #3; -Document the bowel medications that were administered to Resident #3; -Document the nursing medication reassessment; -Document the nursing abdominal and peri-rectal assessment; and, -Document the digital fecal disimpaction (procedure of removing stool from the rectum with a finger) procedure for Resident #3. Findings include: I. Professional reference Setya A, [NAME] G, Cagir B. (2023). Fecal Impaction. National Institutes of Health. Retrieved on [DATE] from https://www.ncbi.nlm.nih.gov/books/NBK448094/. It read in pertinent part, Fecal impaction is a significant but preventable problem in the elderly population within hospitals and other institutions. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The treatment options are the rectal administration of stool softening agents, usually enemas or suppositories or a digital evacuation of the impacted fecal mass. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger. Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), page 2065 was retrieved on [DATE]. It read in pertinent part, A health record permanently documents: the care, in chronological order, performed by healthcare providers, responses to medications, interventions, and procedures. Document the medication, time, dose, and route given, preadministration assessments, and your signature. Document all therapeutic and adverse effects of the medication. Also document your nursing interventions and teaching of potential adverse effects. Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), pages ,d+[DATE] was retrieved on [DATE]. It read in pertinent part, Position patient on left side which helps with medication retention because the descending colon is on the left side, it also helps relax the external anal sphincter (rectum). The patient should not experience pain during the administration of a suppository, but they will feel pressure. Encourage deep breathing to aid in relaxation of the sphincter. Pushing a suppository through a constricted sphincter causes discomfort. II. Facility policy and procedure The Bowel Protocol policy and procedure, dated [DATE], was provided by the NHA on [DATE] at 8:44 a.m. It read in pertinent part, Provide effective interventions for signs and symptoms of constipation. Nursing staff will record, in the electronic health record (EHR), each time a resident has a bowel movement. The Nursing Facility Standing Orders and Constipation policy and procedure, dated [DATE], was provided by unit care coordinator (UCC) #1 on [DATE] at 12:12 p.m. It read in pertinent part, The nurse may order the following if no bowel movement for three days: milk of magnesia; dulcolax suppository, fleets enema or senna. If standing orders are followed and not effective, report assessment of impaction, bowel sounds, vital signs, last BM (bowel movement) quality and quantity, presence of blood in stool, recent administration of narcotics and fluid intake. III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged home on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed dependent status required two staff assistance with hoyer for transfers. B. Resident's representative interview The resident's representative was interviewed on [DATE] at 12:55 p.m. The representative said Resident #3's mother died at an early age from a bowel obstruction and therefore she was always concerned about her bowel regimen because she was fearful of an obstruction. C. Record review The [DATE] CPO revealed the following physician's order for bowel management: -Standing order/protocols, ordered on [DATE]; -Colace 100 mg (milligrams) (laxative) oral capsule as needed, ordered on [DATE]; -Fleet enema ,d+[DATE] grams (g) per 118 milliliter (ml) enema as needed, ordered on [DATE]; -Miralax (3350 powder) 17 g with 120 to 240 ounces (oz) of fluid as needed, ordered on [DATE]; -Bisacodyl 10 mg suppository as needed, ordered on [DATE]; -Miralax (1450 powder) 17 g with eight oz ounces of fluid was ordered daily, ordered on [DATE] (started after the disimpaction procedure on [DATE]); and, -Senna-docusate sodium 8XXX,d+[DATE] mg oral tablet was ordered nightly, ordered on [DATE] (started after the disimpaction procedure on [DATE]). The bowel and bladder elimination tracking record ([DATE] to [DATE]) revealed the following: On [DATE], the resident had a large bowel movement. On [DATE], it was documented a response was not required. On [DATE], it was documented a response was not required On [DATE], there was no documentation. On [DATE], it was documented a response was not required. On [DATE] at 12:55 a.m., it was documented a response was not required On [DATE] at 5:39 p.m., it was documented the resident had a small bowel movement. On [DATE], it was documented a response was not required. On [DATE] at 12:51 a.m., it was documented the resident had a medium bowel movement. -According to the [DATE] medication administration record (MAR) the resident did not receive any as needed laxatives, softeners or enemas after she had gone four days ([DATE] to [DATE]) without any bowel movement. -The facility failed to follow the standing physician's orders for bowel management. -Review of Resident #3's electronic medical record (EMR) did not reveal documentation regarding RN #1's assessment of the resident's bowel status or the procedure for the fecal disimpaction and suppository administration in the early morning hours of [DATE] (see interviews below). IV. Staff interviews Unit care coordinator (UCC) #1 was interviewed on [DATE] at 12:00 p.m. UCC #1 said all medications that were administered needed to be documented as administered in the resident's EMR. UCC #1 said there was a standing order list (a list of common medical issues with steps and medications for the nurses to utilize). UCC #1 said constipation was one of the common issues that occurred with residents that was included on the standing physician's orders. The director of nursing (DON) was interviewed on [DATE] at 3:48 p.m. The DON said residents' bowel movements were charted by the certified nurse aides (CNA). The DON said the standing physician's orders for bowel protocol began with the most gentle laxative and increased in strength if it was found to be unsuccessful. The DON said the nurses would give a stool softener, then milk of magnesia (laxative), then a suppository or enema. The DON said registered nurse (RN) #1 did not document in Resident #3's EMR that she performed a fecal disimpaction or administered the suppository on [DATE]. RN #1 was interviewed on [DATE] at 7:24 p.m. RN #1 said Resident #3 had complained of constipation on the previous day ([DATE]). RN #1 said she had given Resident #3 milk of magnesia (laxative) and miralax (laxative) which helped the resident have a few small bowel movements. RN #1 said the resident had requested a Bisacodyl suppository (laxative). -However, RN #1 did not document that she had administered the resident milk of magnesia, miralax or the suppository (see record review above). RN #1 said as part of her assessment, she had listened to bowel sounds, palpated her stomach and verified that the resident was able to pass gas. RN #1 said she had explained to the resident that there was a need for digital fecal disimpaction. RN #1 said the resident was educated that stool needed to be removed for the suppository to work properly. RN #1 said she lubricated her finger and massaged the lubrication around the edge of the rectum. She said some small stool exited the rectum with the lubrication and palpation around the resident's rectum. RN #1 said there were many little, hard, shaped balls of stool in different sizes from small to quarter sized. RN #1 said she may have forgotten to chart the administration of the suppository and the fecal disimpaction. The DON was interviewed a second time on [DATE] at 10:15 a.m. The DON said RN #1 should have documented the abdominal and rectal assessment, digital stool removal and the fecal disimpaction. The DON said all medications and treatments given to residents should be documented on the MAR when given.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #1, CNA #2, CNA #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #1 (hired on 9/5/15), CNA #2 (hired on 2/20/2020), CNA #3 (hired on 8/25/2020), CNA #4 (hired on 5/24/2020) and CNA #5 (hired on 9/20/22) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 5/7/24 at 4:00 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure the best care was being delivered to the residents.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for two (#63 and #6) of five residents reviewed for care planning out of 36 sample residents. Specifically, the facility failed to: -Develop a dementia care plan focus for Resident #63 and Resident #6; and, -Update care plan interventions for falls for Resident #63. Findings include: I. Facility policy The Incident and Reportable Event Management policy, revised 8/15/23, was provided by the nursing home administrator (NHA) on 5/8/24 at 8:12 a.m. It read in pertinent part, The licensed nurse should update the resident's care plan and communicate the intervention to the staff caring for the resident. The Care of the Cognitively Impaired (Dementia Care) policy, revised 8/22/23, was provided by the NHA on 5/8/24 at 8:12 a.m. It read in pertinent part, Develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment. Develop individualized interventions related to the resident's symptomology and rate of progression. Review and revise care plans that have not been effective and/or when the resident has a change in condition. II. Resident #63 A. Resident status Resident #63, age greater than 65, was admitted [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia and insomnia. The 2/15/24 minimum data assessment (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required moderate to maximal assistance with transfers. B. Record review The care plan, initiated 12/7/23 and revised 4/26/24, revealed Resident #63 was at risk for elopement. Pertinent interventions included providing one on one supervision while the resident was out of bed and assessing for fall risk. The fall care plan, initiated 11/10/23 and revised 11/21/23, revealed Resident #63 was at risk for falls due to decreased mobility, weakness, cognitive impairment and poor safety awareness. Pertinent interventions included ensuring the resident wore appropriate footwear, having the call light within reach and completing a fall risk assessment. -The care plan did not include any focus areas for dementia or cognitive decline. -The care plan focus area for falls had not been updated after any of Resident #63's falls in 2024. A progress note on 12/16/23 at 11:30 p.m. revealed Resident #63 was found sitting on the floor on his floor mat. A progress note on 2/28/24 at 8:30 p.m. revealed Resident #63 was found sitting on the floor next to his bed. The note revealed Resident #63 had a floor mat in place but that the resident often moved the mat away from his bedside. A progress note on 4/29/24 at 1:39 p.m. revealed Resident #63 was found sitting on the floor mat next to his bed. The 12/16/23 fall investigation report revealed Resident #63 had an unwitnessed fall and was found on the floor next to his bed. Frequent checks every fifteen minutes were put in place as a new intervention per the report. The 2/26/24 fall investigation report revealed Resident #63 had an unwitnessed fall and was found on the floor next to his bed. No new interventions were written in the report. The 4/3/24 fall investigation report revealed Resident #63 had an unwitnessed fall and was found on the floor next to his bed. No new interventions were written in the report. The 4/29/24 fall investigation report revealed Resident #63 had an unwitnessed fall and was found on the floor next to his bed. Bed in lowest position was documented as a new intervention but was scratched out. -However, the intervention had not been updated on the resident's care plan (see care plan above). The 2/20/24 care plan conference notes revealed Resident #63's care plan was reviewed but no changes were noted at that time. C. Staff interviews Certified nursing assistant (CNA) #6 was interviewed on 5/9/24 at 9:01 a.m. CNA #6 said Resident #63 needed to be in a bed at the lowest position and she was not sure whether the resident needed a fall mat. CNA #6 said the interventions should have been in Resident #63's care plan, along with dementia care and its pertinent interventions. Licensed practical nurse (LPN) #2 was interviewed on 5/9/24 at 9:11 a.m. LPN #2 said Resident #63 needed to have his bed in the lowest position, have his wheelchair and walker away from the bed to avoid self-transfers and have a fall mat in place. LPN #2 said the interventions were in Resident #63's care plan. LPN #2 said Resident #63 had not fallen for some time, so the new interventions were effective. LPN #2 said dementia care was a separate area with its own interventions, and the DON and nursing managers updated the care plans. -However, the interventions mentioned by LPN #2 were not on the care plan (see care plan above). The director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 5/9/24 at 9:34 a.m. The DON said Resident #63 had interventions to prevent falls, including having his bed in the lowest position, fall mat in place and having non-skid footwear. The DON said Resident #63's care plan was updated as needed and reviewed quarterly and the nursing staff could update it if needed. The DON said care plans specifically for cognitive impairment due to dementia were created and managed by the social services department. The ADON said the facility staff met after fall incidents to talk about new interventions, and discussed these interventions during rounds. -The ADON reviewed the care planned interventions for Resident #63's falls and said the interventions of the bed in lowest position and fall mat in place were not on the care plan. The social services assistant (SSA) and social services director (SSD) were interviewed on 5/9/24 at 9:58 a.m. The SSA said for residents with dementia diagnoses, their care plans usually had a specific focus indicating they had impaired cognition due to dementia and pertinent and person-centered interventions. The SSA said care plans were reviewed quarterly, yearly and as needed. The SSA could not identify any specific focus on Resident #63's care plan related to cognitive impairment. The SSD said Resident #63's care plan was different, and that she did not see anything specifically related to his dementia diagnosis. III. Resident #6 A. Resident status Resident #6, age 77, was admitted [DATE]. According to the May 2024 CPO, diagnoses included dementia and neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function). The 2/13/24 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. B. Record review The 5/4/23 care plan revealed Resident #6 had a behavior problem and was taking a psychotropic medication for behaviors with dementia. Pertinent interventions included administering medications as ordered and anticipating and meeting the resident's needs. The 5/18/23 care plan revealed Resident #6 was using a psychotropic medication to treat dementia with behaviors. Pertinent interventions included administering medications and observing for side effects and effectiveness and consulting with the pharmacists to consider a dosage reduction when clinically appropriate. -The care plan did not include any focus areas for dementia or cognitive decline. C. Staff interviews The SSD was interviewed on 5/9/24 at 9:58 a.m. The SSD said she could not find any focus in Resident #6's care plan specifically for dementia. The SSD read aloud the care plan focus for Resident #6 that was related to the resident being on psychotropic medications and pointed out that it said the resident was on the medication related to dementia with behaviors. -However, the care plan did not include a specific focus for dementia and pertinent behaviors to address the resident's dementia and behaviors related to dementia.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards for two of three medication carts. Specifically, the facility failed to ensure inhalers were dated when opened. Findings include: I. Professional reference According to the Incruse inhaler manufacturer's guidelines, retrieved on [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Incruse_Ellipta/pdf/INCRUSE-ELLIPTA-PI-PIL-IFU.PDF, Discard Incruse six weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. According to the Wixela inhaler manufacturer's guidelines, retrieved on [DATE] from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=3beef,d+[DATE]a,d+[DATE]a,d+[DATE]ba,d+[DATE]e4b7e2, Discard Wixela Inhub one month after opening the foil pouch or when the counter reads 0 (after all doses have been used), whichever comes first. According to the Trelegy inhaler manufacturer's guidelines, retrieved on [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Trelegy_Ellipta/pdf/TRELEGY-ELLIPTA-PI-PIL-IFU.PDF, Discard Trelegy six weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. II. Observations and interviews On [DATE] at 8:45 a.m. the H hall medication cart was observed with registered nurse (RN) #1. The medication cart contained a Trelegy inhaler. -The inhaler was not dated with the date it was opened. RN #2 said she did not know the Trelegy inhaler was expired. She said the inhaler should have been dated to ensure safety of the medication and to know when to discard the inhaler. On [DATE] at 8:55 a.m. the G hall medication cart was observed with licensed practical nurse (LPN) #1. The medication cart contained an open Incruse inhaler and Wixela inhaler. -Both inhalers were not dated when opened. LPN #1 said she was not aware the inhalers did not have an open date. She said it was important to date the inhalers when they were opened to make sure it was safe to administer the medication to the resident. III. Additional interview The director of nursing (DON) was interviewed on [DATE] at 11:00 a.m. The DON said it was important for all medications to be dated when opened and discarded when expired to ensure the medication was safe for the residents who received them.

Based on record review and interviews, the facility failed to ensure residents have the right to receive visitors of their choosing at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Specifically, the facility the failed to allow visitation except in cases of Hospice care and compassion care visits for all residents. I. Facility policy The facility policy, Resident visitation during a respiratory pandemic revised 11/11/21, was provided by the nursing home administrator (NHA) on 11/24/21 at 12:58 p.m. The guidance included, Exceptions to Visitation : Facilities may NOT offer or allow general visitation (as opposed to other types of required visitation) on the premises if: -The resident participating in the visit has symptoms of COVID-19 or an active COVID-19 infection and requires transmission-based precautions. -The resident participating in the visit is in isolation or quarantine for COVID-19. -Statewide restrictions are implemented due to increased cases of COVID-19 -Facilities should allow for indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times). Indoor visitation for unvaccinated residents should be limited to compassionate care visits only IF any of the following are true: -The facility has an outbreak of COVID-19 among the residential population. II. Interviews Certified nurse aide (CNA) #1 was interviewed on 11/24/21 at 11:40 a.m. She said the facility was not allowing visitors. She said the facility had one COVID-19 positive resident and one positive staff member. She said visitors were not allowed in the facility in order to prevent the spread of infection. Licensed practical nurse (LPN) #1 was interviewed on 11/24/21 at 11:43 a.m. She said there was no visitation allowed. She said she was only aware of one positive resident in the facility. She said the facility did allow Hospice visitors and compassionate care visits. The receptionist (RECP) was interviewed on 11/24/21 at 11:44 a.m. She said the facility did not allow visitors. She said the facility allowed Hospice and end of life visits, but those visits were only allowed two visitors at a time. She said it was the second week not allowing visitors. The activity director (AD) was interviewed at 11:46 a.m. She said the facility was not allowing visitors. She said there was a resident on isolation precautions. She said the facility did allow Hospice to visit residents. She said the receptionist scheduled the visits. She said the activity department was responsible for the face time visits and the window visits. She said there were no restrictions on those visits. Resident #1 was interviewed on 11/24/21 at 12:14 p.m. She said she was not able to have visitors because the facility was on quarantine. She said there was a resident who was positive for COVID-19 and that caused the facility to stop visits. She said she would like to have visitors. Resident #2 was interviewed on 11/24/21 at 12:18 p.m. She said no one in the facility could have a visitor because there was a resident who was positive for COVID-19 in the facility. She said she would like a visit but knew she could not have one. The director of nursing (DON) was interviewed on 11/24/21 at 12:25 p.m. She said the facility was not allowing visitation because the facility was considered to be on outbreak status. She said the facility was only allowing Hospice and comfort care visits. She said the facility was scheduled to have another round of testing on Friday (11/26/21). She said the facility had one positive resident and one positive staff member. She said she was not aware of the new guidance allowing visitation again. The NHA was interviewed on 11/24/21 at 12:25 p.m. He said he was not aware all visitation was allowed. He said with the outbreak he went with old guidelines for the safety of the residents. -At 1:10 p.m. the NHA said all the staff had been educated on the new guidance, the facility had sent out emails and phone calls to the families, and would allow all residents to receive visitors. III. Observations On 11/24/21 from 11:30 a.m. to 2:30 p.m. no visitors were observed in the building.

Based on observations, record review and interviews, the facility failed to ensure effective infection control practices were maintained to provide a safe, sanitary and comfortable environment to help prevent the transmission of Coronavirus (COVID-19) and other communicable diseases and infections on three out of three units. Specifically, the facility failed to: -Follow proper cleaning processes and doffing sequence of personal protective equipment (PPE) during housekeeping services; -Follow accepted doffing sequence of PPE and hand washing practices following resident care; -Ensure residents used source control during cares and when outside of rooms and followed quarantine protocols; -Restrict non-essential staff from entering COVID-19 unit/red zone; and, -Offer hand hygiene to residents before meals. Findings include: I. Professional references A. Centers for Disease Control (CDC), CDC PPE Donning and Doffing Sequence Graphic, last updated on 5/11/2020. Accessed on 12/4/2020 via website: https://www.cdc.gov/hai/pdfs/ppe/ppeposter148.pdf. It read in pertinent part, that the sequence for doffing PPE was gloves first next the gown then hand hygiene. B. The Centers for Disease Control and Prevention (CDC) (7/15/2020) Infection Control Guidance, retrieved on 11/23/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html. It read in pertinent part, Patients should wear cloth face covering (if tolerated), may remove their cloth face covering when in their rooms but should put it back on when around others (when others enter their room) or leaving their room. C. The Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes, Core Practices last updated 11/20/2020, retrieved on 12/4/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. It read in pertinent part, Remind residents to wear a cloth face covering (if tolerated) and perform hand hygiene. II. Observations of housekeeping cleaning processes and improper doffing sequence of PPE A. Cascade Crossing unit/yellow zone On 11/23/2020, housekeeper (HSK) #1was observed cleaning rooms #201at 10:35 a.m., room [ROOM NUMBER] at 10:44 a.m. room [ROOM NUMBER]; room [ROOM NUMBER] at 10:53a.m. on Cascade Crossing unit/yellow zone. The HSK placed the bleach wipes container that she collected from the mop bucket on the dirty trash and linen cart inside each room. The mop bucket contained clean mop water with a cleaning solution and clean mop pads. The mop bucket had an area to ring out the mop head, however that area was used to hold the wipes container and spray bottles of solution. After doing hand hygiene using alcohol based hand sanitizer (ABHS), she then donned a gown and gloves to enter a room under droplet precautions. The resident was not encouraged to wear source control. She emptied the trash and replaced trash bags in the cans. She did not change gloves and perform hand hygiene before she removed several wipes from the bleach wipes container and wadded them into her left hand. She used her right hand to access a wipe from her left hand then wiped the bedside tables in the double occupancy room. She used the same wipe for each bedside table then placed the used wipe in between her fingers on the left hand where the clean wipes were stored. She did not wipe other high touch areas of the room like the call light, door knobs, television remotes, and etcetera (etc.) She removed a couple of wipes from her hand and wiped off the sink counter, faucets then inside the sink and on the counter again. She placed the used wipes in her left hand between her fingers and got another clean wipe from her left hand and wiped off the broom and mop handles. She disposed of the used wipes in the trash container that the bleach wipes were setting on. She got more wipes from the container and wiped off the toilet seat, then the guard rails, toilet bowl top, then down the base and on the top of the toilet seat again. She disposed of those wipes in the trash. She did not clean the inside of the toilet bowls in each of the rooms. She doffed the gown then the gloves, which was not in the correct sequence for doffing as per reference mentioned above. B. COVID-19 unit/red zone At 2:03 p.m., HSK #3 was observed cleaning room [ROOM NUMBER]. The resident was not encouraged to wear source control. C. Staff interviews HSK #1 was interviewed on 11/23/2020 at 10:53 a.m. She said that she worked at the facility for the past nine years. She said she understood the process for doffing PPE was to remove the gown first then the gloves. She said this was what she was trained on. She said she used the bleach wipes for all the surfaces in the room. She said she usually wiped other high touch surfaces but the resident in room [ROOM NUMBER] did not like the odor of the wipes so she did not wipe the surfaces in his room. She said she usually wiped other surfaces including call lights, overhead and side light switches, walkers, chairs, wheelchair handles, televisions surfaces and remotes, the bed controls and other surfaces she saw that were easily touched by the residents. She did not realize she had not cleaned those surfaces in the other rooms. HSK #3 was interviewed on 11/23/2020 at 2:03 p.m. She said that she was not instructed that residents should be encouraged to wear source control when she was cleaning the rooms. The director of nursing (DON), clinical consultant (CC) and infection preventionist (IP) were interviewed on 11/23/2020 at 4:30 p.m. The IP said that she worked with the housekeeping department and provided training to the staff. She said that included how to use the cleaning equipment and products, the process for cleaning, the proper donning and doffing of PPE for the transmission based precaution resident rooms. She said that HSK #1 should have used the bleach wipes to clean frequently touched surfaces. She said that the wipes required the surface to be damp from the wiping. She said some surfaces included bedside tables, resident personal items, call lights, television remotes, dresser surfaces and handles. She said the housekeeper should clean the room from clean to dirty, which meant that the bathroom would be cleaned last. She said and the final cleaning would be of the products and equipment used before going to the next room. She said after the sink was cleaned the toilet would be cleaned lastly including the inside of the toilet bowl. She said the housekeepers were trained to use one wipe per item being cleaned and to not keep the clean wipes in the same hand as the dirty ones. She said she would provide training to HSK #1 about the correct process with using the cleaning equipment and products. She said the housekeepers were trained to clean the equipment between resident uses and to only bring in the resident ' s room what is necessary to clean the room. Any equipment that was brought in the room was cleaned before being removed from the room. She said the housekeepers were provided caddies to store the products used in each room then clean the caddy before leaving the room. She said the donning and doffing training that was provided to the housekeeper included the same information that was posted on the outside of every residents ' room door in the building which was to doff the gloves first then the gown before doing hand hygiene. She said staff were instructed to have residents follow source control and that was also a sign on the outside of every residents ' room door. She said the housekeepers were instructed to not wash their hands at the sink and to use the ABHS dispensers on the outside of each room or the ABHS that they carried on the housekeeping carts or in their pockets. She said the housekeepers were dedicated to their assigned units and did not clean rooms on other units. III. Observations of improper sequence for doffing PPE and washing hands inside the resident rooms after doffing PPE A. Cascade Crossing On 11/23/2020 at 10:29 a.m., a staff member was observed in room [ROOM NUMBER] doffing PPE at the doorway then went to the middle of the room to wash their hands at the sink. The resident was sitting in a wheelchair near the sink where the staff washed their hands. The resident and staff spoke to each other during hand washing. The resident did not have source control like a tissue to cover the nose and mouth or a mask. At 10:38 a.m., AA #1 enter a room under droplet precautions to provide nail care after performing hand hygiene with ABHS, donning a gown and gloves. Prior to exiting the room she doffed the gown then gloves, which was not doffed in the correct order, see reference above. After doffing the gown and gloves at the doorway she went to the middle of the room to wash her hands at the sink. Both residents were sitting in a wheelchair near the sink where she washed her hands. The residents and staff spoke to each other during hand washing. The resident did not have source control like a tissue to cover the nose and mouth or a mask. At 10:58 a.m., a staff member was observed doffing the gown then gloves in room [ROOM NUMBER], which was the incorrect sequence of doffing PPE. Once the staff member doffed the PPE she returned to the middle of the resident ' s room to wash her hands at the sink where the resident was sitting next to and not wearing source control such as a mask or tissue. The staff member and resident spoke during hand washing. At 11:05 a.m., certified nurse aide (CNA) #1 doffed PPE then washed hands in the middle of the resident ' s room [ROOM NUMBER] at the sink. The resident sitting in the wheelchair next to the sink drinking from a cup without source control. B. COVID-19 unit/red zone At 2:01 p.m., observed CNA #7 doffing PPE in room [ROOM NUMBER] after providing care to the resident. The resident was not wearing source control. The CNA doffed the PPE then washed her hands in the sink located near the resident. The resident yelled out several times and the CNA offered verbal comfort. The resident reached out and grabbed the CNA ' s shirt. The CNA grabbed the resident ' s hands and gave her reassurance then washed her hands again and left the room. At 2:16 p.m., CNA #4 was observed doffing PPE then washing hands in the middle of the resident ' s room [ROOM NUMBER] at the sink. The resident was calling out in bed and no source control was encouraged by the CNA. At 2:17 p.m., CNA #3 was observed doffing the gown first then gloves, which was the wrong sequence for doffing PPE, see reference above. Once the PPE was doffed CNA #3 washed hands in the middle of the resident ' s room [ROOM NUMBER] at the sink. The resident was sitting in a wheelchair without source control encouragement. At 2:21 p.m., CNA #5 was observed doffing the gown first then gloves, which was the wrong sequence for doffing PPE, see reference above. Once the PPE was doffed CNA #5 washed hands in the middle of the resident ' s room [ROOM NUMBER] at the sink. The resident was yelling out in bed without source control encouragement. At 3:47 p.m., CNA #5 was observed doffing the gown first then gloves, which was the wrong sequence for doffing PPE, see reference above. Once the PPE was doffed CNA #5 washed hands in the middle of the resident ' s room [ROOM NUMBER] at the sink. The resident was sitting in a wheelchair near the sink and without source control encouragement. C. Staff interviews The activity assistant (AA #1) was interviewed on 11/23/2020 at 10:38 a.m. She said she was trained to encourage residents to wear masks before leaving their rooms. She said she was not trained to encourage residents to wear masks while she provided care. She said when doing nail care she had to touch the residents hands but she was wearing gloves. She said that she did not think about the residents wearing masks in their rooms. She said many of the residents struggle to wear the masks because they feel like they cannot breathe. CNA #4 was interviewed on 11/23/2020 at 2:16 p.m. She said that she was trained to encourage residents to wear masks when they leave the room. She said they were wearing universal N95 masks and face shields/goggles with every resident in the COVID-19 unit/red zone. She said she received hand hygiene training to include washing hands after doffing PPE and then using ABHS after leaving the room. She said the PPE had to be doffed at the doorway near the dirty linen and trash carts of every resident room. The DON, CC and IP were interviewed on 11/23/2020 at 4:30 p.m. The DON, IP and CC said that staff were trained continuously on the sequence of donning and doffing PPE. They said that the IP did the training. The IP said the sequence for donning and doffing PPE was on a sign posted on every resident ' s door. She said the sequence for doffing PPE was to remove the gloves first then the gown then do hand hygiene by using ABHS located in dispensers on the outside of every resident room. She said they recognized that washing hands in the residents ' rooms presented contamination exposure since the PPE was doffed at the doorway. She said the staff were trained to use ABHS and not wash hands in the resident ' s sink. She said the facility implemented the universal wearing of N95 masks and eye protection. IV. Observations of residents not wearing masks during cares and outside of rooms and following quarantine protocols A. Cascade Crossing Signs on the outside of resident doors on the Cascade Crossing unit read to knock and announce then ask the resident to wear a mask. Other signage included the process for doffing PPE and droplet precautions and the type of PPE to don prior to entering the room. On 11/23/2020 at 10:25 a.m., a male resident was observed ambulating in the hallway on Cascade Crossing talking to staff without a mask. The staff were talking with a female resident, who was propelling herself in the wheelchair without a mask. The staff did not offer masks to the residents. At 10:57 a.m., Resident #13 came out of her room with a sign on the door that read droplet precautions without a mask. She was asking the staff in the hallway questions about her upcoming shower. The staff did not encourage the resident to wear a mask or another form of source control like a tissue, see reference above. At 11:05 a.m., Resident #14 came out of her room with a sign on the door that read droplet precautions without a mask. She was asking the staff in the hallway questions about her upcoming shower. The staff did not encourage the resident to wear a mask or another form of source control like a tissue, see reference above. B. Staff interviews CNA #2 was interviewed on 11/23/2020 at 11:36 a.m. She said she was trained to encourage residents to wear source control if they were coughing when in the resident rooms. She said the residents wore masks when they left their rooms. She said she was not trained to encourage source control for residents during cares. Registered nurse (RN) #4 was interviewed on 11/23/2020 at 11:26 a.m. She said she was the charge nurse for the Cascade Crossing unit/yellow zone. She said the residents were on quarantine/observation for exposure so the residents did not need to remain in their rooms. She said the residents were encouraged to wear masks when leaving the rooms but many of the residents were reluctant due to not understanding. She said the residents on the yellow unit were not newly admitted or tested positive or had symptoms of COVID-19. The DON, CC and IP were interviewed on 11/23/2020 at 4:30 p.m. The DON and IP said that the staff had been trained and signs on the resident doors that read encouraging residents to wear a mask or face covering during cares and when leaving the room. The facility identified certain residents that could not tolerate face coverings and it was care planned. They said they encouraged tissues when the masks were not tolerated. The staff were trained to encourage residents to wear masks especially when out of their rooms. V. Observations of non-essential staff entering COVID-19 unit/red zone On 11/23/2020 at 10:37 a.m., the maintenance director entered the isolation COVID-19 unit/red zone from Cascade Crossing unit/yellow zone. At 10:43 a.m., he left the COVID-19 unit/red zone and entered the Cascade Crossing unit/yellow zone. At 11:30 a.m., the maintenance director and assistant were observed in the COVID-19 unit/red zone taking liquid oxygen tanks out of the oxygen storage room and putting them outside to be refilled. At 11:53 a.m., they exited the COVID-19 unit/red zone to the Cascade Crossing unit/yellow zone. A. Staff interview The DON, CC and IP were interviewed on 11/23/2020 at 4:30 p.m. The DON said that there were dedicated staff for the COVID-19 unit/red zone, the Cascade Crossing unit/yellow zone, and the Memory Lane unit/green zone. They said they were instructed by the County Health Department and Colorado Department of Public Health and Environment (CDPHE) to have dedicated staff for the units. They were instructed to not allow staff that go on the COVID-19 unit to return to the other parts of the building for 24 hours after leaving the unit. The unit had a separate exit at the end of the hallway. The DON said they had not recognized the maintenance staff were entering the rest of the building after being on the COVID-19 unit. She said they would provide education to the maintenance staff and identify how the work can be done and continue to follow the Health Department recommendations. VI. Observations of meals delivered without resident being offered hand hygiene On 11/23/2020 at 11:22 a.m., on the COVID-19 unit/red zone the staff were observed delivering meal trays to residents. The staff did not offer hand hygiene to the residents prior to setting up the meals. The staff were observed doffing PPE at the doorways of the residents rooms then washing hands at the resident room sinks. The residents were not wearing source control since they were eating meals. The majority of the residents were sitting in the room within close proximity to the sinks. On the outside of each room were ABHS dispensers. At 11:28 a.m., on the Cascade Crossing unit/yellow zone the staff were observed delivering meal trays to residents. The staff did not offer hand hygiene to the residents. The staff were observed doffing PPE at the doorways of the residents rooms then washing hands at the resident room sinks. The residents were not wearing source control since they were eating meals. The majority of the residents were sitting in the room within close proximity to the sinks. On the outside of each room were ABHS dispensers. At 12:00 p.m., on the Memory Lane unit/green zone staff were observed delivering meal trays to residents. The staff did not offer hand hygiene to the residents. A. Staff interviews CNA #1, #2, and #3 were interviewed on 11/23/2020 at 1:16 p.m. They said they had wipes to offer residents for hand hygiene before meals. CNA #4, #5, #6, and #7 were interviewed on 11/23/2020 at 4:16 p.m. They said they had wipes to offer residents for hand hygiene before meals. The DON, CC and IP were interviewed on 11/23/2020 at 4:30 p.m. They said they had wipes to offer the residents before meals and each room had a sink for hand washing. They said the staff should offer hand hygiene to the residents prior to setting up the meals for each resident. VII. Facility COVID-19 status The DON provided the COVID-19 status of the facility via email on 11/23/2020. The report included a resident census of 91. Seventy residents and 58 staff were tested positive for COVID-19. The first laboratory tested positive result for staff was on 10/5/2020 and residents were on 10/13/2020.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for two of three stations. Specifically, the facility: -Failed to ensure hand hygiene was performed between care of residents; and, -Failed to sanitize non-dedicated, non-disposable resident care equipment after each use prior to use on additional residents. Findings include: I. The Centers for Disease Control (CDC) recommended guidelines The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (9/14/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (updated July 15, 2020). It read in pertinent part, Environmental Infection Control: All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies. Hand Hygiene: HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. II. Observations and interviews On 9/8//2020 at 11:38 a.m., certified nurse aide (CNA) #3 was observed going room to room on 200 halls taking resident blood pressures. She would exit each room and enter the next room without sanitizing or cleaning the mobile monitoring blood pressure machine. She then placed the mobile monitoring blood pressure machine at the end of the 200 halls. -At 1:04 p.m., CNA #5 was observed exiting room [ROOM NUMBER]. The CNA had a bag of soiled linens in one hand and pushed the Hoyer lift with the other hand. She placed the Hoyer lift at the end of 200 hall and proceeded to enter the dirty linen room. CNA #5 did not wipe or sanitize the Hoyer lift after use. -At 3:50 p.m. licensed practical nurse (LPN) #5 was observed entering room [ROOM NUMBER] with the mobile blood pressure machine. LPN #5 checked the resident's vital signs and exited the resident's room. She returned to the resident's room with a sandwich and then exited the resident's room with the mobile blood pressure machine. She plugged the mobile blood pressure machine next to room [ROOM NUMBER]. She did not sanitize or clean the mobile monitoring blood pressure machine. On 9/9/2020 at 10:17 a.m. certified nurse aide (CNA) #3 was observed taking vital signs (VS) with the vital sign equipment on Resident #6. When she completed, she took the same VS equipment into a resident room with Resident #5 and Resident #7 and tooked their VS. She did not sanitize the VS equipment or sanitize her hands between residents. CNA #3 was immediately interviewed after the observation and said she was pretty sure she was to sanitize equipment and hands between residents when taking VS. She said thank you for reminding me. She said the equipment and her hands should have been sanitized to help prevent the spread of germs. On 9/9/2020 at 10:19 a.m. A CNA was observed exiting room [ROOM NUMBER]. The CNA pushed the Hoyer lift to the end of 200 halls. She plugged the Hoyer lift into the outlet and moved it next to the wall. The CNA did not wipe or sanitize the Hoyer lift after use. -At 10:28 CNA #7 was observed to enter room [ROOM NUMBER]. CNA #7 proceeded to take the resident's vitals. She exited the resident room and proceeded to leave the mobile blood pressure outside of room [ROOM NUMBER]. CNA #7 did not sanitize or wipe the mobile blood pressure monitoring machine. CNA #5 was interviewed on 9/9/2020 at 2:11 p.m. She said we are supposed to sanitize the blood pressure machine before we go into a resident's room and when we exit the room. She said, I should have wiped and sanitized the Hoyer lift after I used it yesterday. Licensed practical nurse (LPN) # 7 was interviewed on 9/10/2020 at 11:18 a.m. She said all staff are required to wipe and sanitize the blood pressure machine before entering the resident's room and after exiting the resident's room. She said this would include the sit to stand and Hoyer lifts. The staff development coordinator/infection control preventionist (SDC/ICP) was interviewed on 9/10/2020 at 2:30 p.m She said staff should wash or sanitize their hands between resident contact and sanitize equipment after use. She said the facility had recently held training on handwashing. She said the CNA should have sanitized her hands and the equipment after each resident contact. She said a negative outcome would be spreading germs between residents. The SDC/ICP was informed of the observations from the previous day. She said all of the resident equipment should be sanitized before and after for each use with the residents. She said the sit-to-stand and Hoyer lifts should be sanitized in the same manner. She said a negative outcome would be the spread of infections and disease. III. Facility COVID-19 status The director of nurses (DON) was interviewed on 9/10/2020 at 2:30 p.m. She said they had no COVID-19 positive residents or staff. She said there were no presumptive positive COVID-19 residents and staff.

Based on observations, record review and interviews, the facility failed to ensure one (#2) out of five sample residents were provided services that met professional standards of quality. Specifically, the facility failed to notify providers of blood sugars outside of ordered parameters. I. Facility policy and procedure The Physician policy and procedure, revised January 2018, was provided by the nursing home administrator (NHA) director of nursing (DON) on 9/10/2020 at 3:18 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 assistant or nurse practitioner must provide orders for the resident's immediate care. II. Resident #2 A. Resident status Resident #2, age 69, was admitted on [DATE]. According to the September 2020 CPO, [DIAGNOSES REDACTED]. According to the 8/28/2020 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had mild depression with the resident scoring five of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. She was occasionally incontinent of bowel and bladder. The MDS revealed the resident had no falls since admission. 2. Record review The care plan, initiated 6/7/19 and revised 8/26/2020, identified the resident had a [DIAGNOSES REDACTED]. Observe and report as needed (PRN) any signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps. Observe and report PRN any signs and symptoms of [DIAGNOSES REDACTED]: sweating, tremor, increased heart rate ([MEDICAL CONDITION], pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait. The September 2020 CPO included: -Accucheck twice daily. Notify the provider if above 200 one time daily for diabetes. -Accucheck twice daily. Notify the provider if above 200 at bedtime for diabetes. The July 2020 electronic medication administration record (eMAR) included: -Resident's blood glucose on 7/1 was 225, 7/3-258, 7/5-267, 7/6-243, 7/7-306, 7/8-203, 7/9-304, 7/11-295, 7/12-285, 7/14-223, 7/15-301, 7/16-209, 7/17-261, 7/19-311, 7/21-208, 7/25-233, 7/26-259, 7/29-293, 7/30/2020. The August 2020 electronic medication administration record (eMAR) included: Resident's blood glucose on 8/3-289, 8/8-265, 8/9-313, 8/14-242, 8/15-216, 8/16-210, 8/18-225, 8/20-235, 8/21-267, 8/22-303, 8/23-236, 8/24-219, 8/25-226, 8/26-223, 8/27-258, 8/29-213, 8/30-256, and 8/31/2020-273. The September 2020 electronic medication administration record (eMAR) included: -Residents blood glucose on 9/1-214, 9/3-276, 9/4-282, 9/5-299, and 9/9/2020-202. The MAR revealed no documentation the facility failed to contact the physician when the blood glucose monitor was above prescribed parameters. Further review of the residents records (identified above) on 7/1/2020-9/9/2020 revealed no notification to the provider of the blood glucose above 200. III. Interview The licensed practical nurse (LPM) # 7 was interviewed on 9/10/2020 at 11:18 a.m. She said when a residents ' blood glucose level was above or below the physician ordered parameters we are required to contact the physician and inform him/her of the levels. The provider will give us the guidance on what they want done or if the resident may require a new order. LPN #7 was asked to observe Resident #2's eMAR. She opened the eMAR and checked parameters for Resident #2 on the months listed above. She said she could not locate any physician notification in nursing log notes or on the eMAR. The director of nursing (DON) was interviewed on 9/10/2020 at 2:40 p.m. The DON was told of the record review above. She said nursing should have notified the provider of the parameters above 200 and they should have documented it in nursing notes or on the eMAR. She said the nurse should have contacted the physician for clarification of the order. She said the negative outcome would be [MEDICAL CONDITION], which could cause health issues such as added confusion, increased heart rate, slurred speech and falls.

Based on record review, and interviews the facility failed to timely and thoroughly investigate an allegation of abuse and injuries of unknown origin for four (#4, #5, #7 and #8) of five residents reviewed out of eight sample residents. Specifically, the facility failed to provide and maintain evidence the allegation of abuse for Resident #4, Resident #5, Resident #7 and Resident #8 were investigated timely and thoroughly. Findings include: I. Facility policy and procedure The Protection of Residents: Reducing the Threat of Abuse and Neglect policy and procedure, reviewed 5/15/2020, was provided by the director of nursing (DON) on 9/9/2020 at 2:15 p.m. It documented in pertinent part: Have evidence that all alleged violations are thoroughly investigated. Procedure: When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/ designee will investigate the occurrence. A written summary of the investigation should include, but is not limited to: -A review of the incident report. -An interview with the person(s) reporting the incident. -Interviews with any witnesses to the incident. -An interview with the resident, if appropriate. -A review of the resident's medical record. -An interview with the employee(s), as needed. -Interviews with staff members on all shifts having contact with the resident at the time of the incident. -Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident. -A review of all circumstances surrounding the incident. II. Incidents between Resident #5 and Resident #7 A. Resident #5 Resident #5, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 8/3/2020 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. The resident displayed no behavioral symptoms during the seven day look back period. She did not refuse cares provided by staff. B. Record review The care plan, initiated on 8/16/19, included the resident had inpaired cognition related to (r/t) changes in ability to recall events since hospitalization . Interventions included: -Allow extra time for resident to respond to questions and instructions; -Ask yes/no questions in order to determine the resident's needs; and, -Cue, reorient, and supervise as needed. The behavior monitoring form for July 2020, was provided by medical records (MR) #1 on 9/9/2020 at 12:45 p.m., identified the resident was taking the psychoactive medication [MEDICATION NAME]. The targeted behavior identified was smoking. On 7/16/2020 the behavior monitoring form identified, 3:43 (a.m. or p.m. was not noted) the behavior code identified verbal aggression and disruptive behavior and documented, yelling at roommate says she doesn't want her in there anymore. Location (was in the) resident's room. Interventions: active listening and positive distraction. Resident response: does not want a roommate. On 7/24/2020 the behavior monitoring form identified, at 9:00 p.m. the behavior code identified physical aggression, verbal aggression in the resident's room. Interventions: active listening and positive distraction. Resident response on the form was illegible. The behavior monitoring form for August 2020, identified the psychoactive medication [MEDICATION NAME]. The targeted behavior identified was smoking. On 8/28/2020 the behavior monitoring form identified, at 8:25 p.m. the behavior code identified physical aggression and verbal aggression. The location was the residents room. Interventions: positive distraction, reassurance of safety, and help resident become more comfortable. The resident response is illegible. The behavior huddle tool, provided by MR #1 at 12:45 p.m. on 9/9/2020, identified incident date of 7/16/2020 at 3:43 p.m. noted: -Brief description of behavior: verbal aggression, disruptive behavior, yelling at her roommate said she doesn't want her to interfere anymore. -New interventions decided in the huddle to be implemented based on the resident's unmet needs: Called daughter 7/16/2020 daughter was going to call the resident and talk with her mother. Daughter suggested that when the resident had these behaviors to have her sit by the nurses station and shut off her television. The behavior huddle tool, identified the incident date of 7/22/2020 and no time identified. -Brief description of behavior: verbal aggression, BA (unknown acronym) yelling and cussing at roommate telling her to get the hell out. -New interventions decided in the huddle to be implemented based on the resident's unmet needs: Redirected. Remind resident that she needs to be kind to others. Spoke with family about resident's behaviors toward others. Family will speak to resident. C. Resident #7 Resident #7, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 8/3/2020 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident displayed no behavioral symptoms during the seven day look back period. She did not refuse cares. D. Resident #7 interview Resident #7 was interviewed on 9/9/2020 at 1:55 p.m. She said her roommate talks rough to her and makes her feel small. She said some girls (certified nurse aides) know about it and it made her feel out of place when Resident #5 yelled at her. E. Record review The behavior monitoring form for August 2020 and September 2020 did not have any behaviors documented. F. Information provided by social services An investigation provided by the social serviced director (SSD) on 9/10/2020 at 10:45 a.m. included an investigation into the 7/16/2020. -However, the facility did not have a follow up investigation with Resident #5 and Resident #7 for the 7/24/2020 incident at the time of the incident (see above). An investigation provided by the social serviced director (SSD) on 9/10/2020 (during survey) at 10:45 a.m. included, 9/9/2020 interview with Resident #5: SS spoke with Resident #5 on 9/9/2020 asked her how she and her roommate are getting along. She stated we get along good. At one time we used to argue, SS asked her when did these arguments occur. Resident could not recall certain dates but stated now we get along fairly well. (no signature) An investigation provided by the social serviced director (SSD) on 9/10/2020 (during survey) at 10:45 a.m. included, On 9/9/2020 social worker interviewed Resident #7 regarding her situation with roommate and she stated that her and her roommate have had their ups and downs but they are getting along so much better now, she understands that her roommate has problems with her memory and forgets things sometimes but feels that she means well. She mentioned that her roommate will often ask her if she would like a treat that the family has brought for her. SW (social worker) asked if she would like to move to another room and she said she likes the room where she is and likes the staff on this hall. She was encouraged to talk to SS office if any problems should arise and she agreed. Follow up questions: Do you feel fearful of your roommate? No just don ' t know how to handle her sometimes. Do you feel abused by your roommate in any way, (verbally, physically, or emotionally)? No Signed by Resident #7. The facility failed to investigate timely to rule out verbal abuse from Resident #5 toward Resident #7 and failed to follow facility policy on investigation timely until identified during the survey. III. Incidents between Resident #4 and Resident #8 A. Resident #4 Resident #4, over the age of [AGE] years old, was admitted to the facility on [DATE] and readmitted [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 7/20/2020 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident displayed no behavioral symptoms during the seven day look back period. She did not refuse cares provided by staff. B. Record review The care plan, initiated 7/15/2020 and revised on 9/4/2020, identified the resident had developed relationships with male residents. Interventions included: -Notify family of any changes; and, -Provide privacy as needed and that both parties are in agreement for safety. The care plan, initiated 1/25/19, identified the resident had some short term memory loss and to have the family assist in complex decisions. Interventions included: -Allow Resident #4 ample time to absorb the information and ample time to respond; -Involve family in complex decisions such as what to wear, what to eat, what activities to attend, etc; and, -Provide cues and reminders as needed. The care plan, initiated 1/19/19 and revised on 1/22/19, identified the resident had impaired cognitive ability/impaired thought process related to dementia with behaviors of impulsiveness and inability to comprehend complex ideas. Interventions included: -The resident had difficulty understanding consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. The behavior monitoring form for August 2020, was provided by medical records (MR) #1 on 9/9/2020 at 12:45 p.m., identified the resident was taking psychoactive medication [MEDICATION NAME]. The targeted behaviors identified were restlessness and illusions. On 9/1/2020 the behavior monitoring form identified, (no time identified) the behavior code documented, Resident #8 was seen 8/31/2020 kissing Resident #4 as I was walking down the hall and when I turned around Resident #4 was moved so I thought it was witnessed and he's (Resident #8) following her around today. The behavior monitoring form did not identify a location, an intervention, or a resident response. The entry was signed by certified nurse aide (CNA) #2. The facility did not investigate the incident to rule out sexual abuse, or unwanted touching of Resident #8 to Resident #4 at the time of the episode. C. Resident #8 Resident #8, [AGE] years old, was admitted to the facility on [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 8/25/2020 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident displayed no behavioral symptoms during the seven day look back period. He did not refuse cares provided by staff. D. Record review The care plan, initiated 9/8/2020 (during survey), identified the resident tries to develop relationships with female residents. Interventions include: -Be observant of encounters with female residents; and, -Notify family of any changes. The behavior monitoring form for August 2020, provided by the social services director (SSD) on 9/10/2020 at 3:30 p.m., identified the resident taking psychoactive medication [MEDICATION NAME]. The targeted behaviors identified were tearfulness and negative statements. -The August 2020 behavior monitoring form had no entries. The behavior mointoring form for September 2020, identified the resident taking psychoactive medication [MEDICATION NAME]. The targeted behaviors identified were tearfulness and negative statements. On 9/2/2020 at 8:10 p.m. the behavior code documented, patient attempting to touch other patients. Location: nursing station. Interventions: active listening and telling him no to touch other residents. Resident response: no change. On 9/3/2020 at 6:45 p.m. the behavior code documented, yelling rude remarks, verbal aggression, disruptive behavior. Location: nurses station. Interventions: active listening, help resident become more comfortable, and validation. Resident response: no change. The behavior huddle tool, provided by the social services director (SSD) on 9/10/2020 at 3:30 p.m., identified incident dates of 9/2/2020 at 8:10 p.m. and 9/3/2020 at 6:45 p.m. noted: -Brief description of behavior: 9/2/2020 Resident attempting to touch other residents (told him to stop touching other residents), 9/3/2020 Yelling rude remarks, verbal aggression, disruptive behavior. Verified with nurse attempting to hold hands with female resident. -New interventions:SS spoke with resident regarding allowing resident's privacy and not get in personal space. Being respectful to his caregivers. E. Information provided by social services An investigation provided by the SSD on 9/10/2020 (during survey) at 10:45 a.m. included, Interview with Resident #8 Interviewed by SSD 9/9/2020 Last week I was in the hallway with another resident (cannot remember the date) just spending time together sitting there and talking and holding hands. After about an hour I decided to go back to my room and as I was getting ready to leave I leaned over and kissed her on the crown of her head to say goodbye. I felt this was a friendly gesture. (signed by Resident #8) Interview with Resident #4 9/9/2020 Social worker interviewed Resident #4 on 9/9/2020 regarding another resident (Resident #8) who was observed holding her hand and attempting to kiss her. Resident #4 stated that nothing like that ever happened and she doesn ' t know who is spreading those lies. (no signature). Staff interviews: On 9/9/2020 with CNA #2, Have you seen inappropriate action or gesture between residents? Yes If so what were the actions? Resident #8 kissing Resident #4 How did you handle the situation? Resident #8 left area went to his room, talked to SS and wrote this in behavior book. On 9/9/2020 with CNA #8, Have you seen inappropriate action or gesture between residents? Yes If so what were the actions? Resident #8 with his hand on Resident #4's leg How did you handle the situation? Moved Resident #4 away from Resident #8 and told nurse (unknown). The facility failed to investigate timely, until identified during survey, to rule out sexual abuse timely between Resident #8 toward Resident #4, failed to follow up with new information revealed during staff interviews, and failed to follow facility policy on investigations. IV. Staff interviews The SSD and social service assistants (SSA) #1 and #2 were interviewed on 9/9/2020 at 1:23 p.m. The SSD said all behaviors exhibited by residents needed to be written down on a behavior monitoring form in a book for each resident. He said social services staff would review each book daily to see if a huddle with the interdisciplinary team needed to be done to address a new documented behavior. He said all staff knew to document behaviors on the behavior monitoring forms. The SSD said he was not aware Resident #7 had the feelings she had discussed during her interview. He said his staff would talk to Resident #5 and #7. He said all of the behaviors exhibited by residents needed to be documented. He said he would look to see if investigations had been completed for the identified episodes, and if there was not an investigation he would start them. On 9/10/2020 at 12:35 p.m. SSA #1 said she had been notified of the kissing, after talking to staff, the kiss happened on the crown of Resident #4's head. She said the entry of the incident was documented on 9/1/2020, which was a day after the certified nurse aide witnessed the episode. She said the certified nurse aide had reported to her she thought a nurse saw it and documented the kiss. SSA #1 said the behavior should have been documented on Resident #8's behavior monitoring form, not in Resident #4's behavior monitoring form. She said she was not aware of Resident #8 placing his hand on Resident #4's leg. She said the investigations should have been completed timely to rule out potential sexual abuse. The director of nursing (DON) was interviewed on 9/10/2020 at 2:40 p.m. She said she was not aware of the incidents between Resident #3 and Resident #7 nor the incidents between Resident #4 and Resident #8. She said she would have expected an investigation to be initiated and if she was aware she would have started investigations to ensure the safety of the residents. The SSD was interviewed on 9/10/2020 at 3:30 p.m. He said he was not aware of Resident #8's attempting to grab other residents. He said he will adjust his care plan and provide education to the resident and to the staff.

Based on observations, record review and interviews, the facility failed to provide one (#2) of three dependent residents reviewed for activities of daily living (ADLs), the necessary care and services to ensure the resident's abilities in activities of daily living (ADLs) did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable out of five sample residents. Specifically, the facility failed to provide Resident #2, who was dependent on staff assistance with ADLs, the showers necessary to maintain her hygiene. Findings include: I. Facility policy and procedure The Activities of daily living (ADL) policy and procedure, no revised date, was provided by the nursing home administrator (NHA) on 9/10/2020 at 3:18 p.m. It revealed, in pertinent part, the resident would receive assistance as needed to complete ADLs. Any change in ability to perform ADLs would be documented and reported to the licensed nurse. To ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that would meet each resident's physical, mental, and psychosocial needs. A. Resident status Resident #2, age 69, was admitted on [DATE]. According to the September 2020 CPO, [DIAGNOSES REDACTED]. According to the 8/28/2020 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had mild depression with the resident scoring five of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. She was occasionally incontinent of the bowel and bladder. B. Resident interview Resident #2 was interviewed on 9/8/2020 at 2:03 p.m. She said, I do not receive frequent showers. She said, I am scheduled to have showers on Tuesday and Saturday evenings but I have not had a shower for a while. She said, I go to [MEDICAL TREATMENT] on Mondays, Wednesday and Fridays. She said, I would even like to have three showers a week but when I ask the staff they tell me they cannot give me more showers because they do not have enough help. C. Observations The resident was observed on 9/8/2020 at 9:13 a.m. She was lying in her bed on her telephone. She was wearing a red blouse. There was a strong body odor, not urine or feces. Her hair was disheveled. The resident was observed on 9/9/2020 at 10:48 a.m. She was reclined in her bed. She was wearing a red blouse. Her hair was disheveled. A certified nurse aide (CNA) was in the room picking up items and placing them in their proper place. D. Record review The care plan, initiated 6/7/19 and revised 8/26/2020, identified the resident had an activity of daily living (ADL) self-care performance deficit related to (r/t) activity intolerance. Interventions include the resident required extensive assistance by one staff with bathing and showering as needed (PRN). The resident required limited assistance by one staff with personal hygiene and oral care. The resident required assistance by one staff member using gait belt for stand pivot transfers. The Monthly Flow Report for showers was reviewed from August 1, 2020 to September 9, 2020. -The flow sheet for August 2020 documented the resident received a shower on 8/1, 8/4, 8/18, 8/23, and 8/29/2020. Five out of nine opportunities in a 31 day period. -The flow sheet for September documented the resident received a shower no showers. Zero out of three opportunities in a nine day period. The facility was asked to provide documented evidence of any refusals of bathing along with the months of bathing records (see above). The facility was not able to provide evidence the resident refused showers on the days she did not receive one. The nurses' progress notes were reviewed from 8/1/2020 to 9/9/2020 (this was all notes that were available) and did not reveal evidence the resident refused showers. E. Staff interviews CNA #7 was interviewed on 9/10/2020 at 1:48 p.m. She said all residents were offered showers twice a week. She said if they did not shower a sponge bath or bed bath was offered. CNA #7 said she reported refusals to the nurse after re-approaching the resident at least two more times. She said the nurse also offered showers, bed baths and sponge baths to the residents when they were alerted. She said sometimes it worked and sometimes it did not. She said she documented it as a refusal in the monthly flow sheet and she thought the nurse also documented refusals in the chart. She said Resident #2 took her showers in the evening and had not heard of any refusal to take a shower regarding this resident. The licensed practical nurse (LPN) #5 was interviewed on 9/10/2020 at 2:03 p.m. She said the residents were bathed or showered at least twice a week. She said some residents were showered three times a week depending on preferences or information the resident's family provided. She said the CNAs notified the nurses when a resident refused and the nurse would approach the resident and offer again. If the resident continued to refuse the CNA and the nurse documented the refusal. She said she had not heard of any refusals of showers by Resident #2. The director of nursing (DON) was interviewed on 9/10/2020 at 2:43 p.m. The DON said residents bathed two times a week or based on their individual preference. The DON said the resident's scheduled days were determined upon admission. The DON said residents were offered a bed bath or sponge bath after multiple refusals and days they did not have a scheduled shower. The DON said the CNAs reported to the nurse on duty when a resident refused and the nurse was to go ask the resident if they wanted to shower. The DON said the nurse was to document the refusal in the progress notes. The DON said she would check to see if Resident #2 had refused her scheduled showers and would provide the dates of refusal. The DON said it was important for residents to receive scheduled showers for personal health and hygiene and to prevent infections and skin breakdown. F. Follow-up No further documentation was provided as evidence the resident refused her showers and any follow up attempts to provide showers were made by the staff.

Based on observation, record review and interviews, the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one (#3) of three residents reviewed for accidents out of five sample residents. Specifically, the facility failed to ensure interventions were consistently implemented after being care planned for Resident #3 to prevent future falls. Findings include: I. Facility policy and procedure The fall management policy and procedure, no revised date, was provided by the nursing home administrator (NHA) on 9/10/2020 at 3:18 p.m. It revealed, in pertinent part, to promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients ' fall indicators -The facility would assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and would identify appropriate interventions to minimize the risk of injury related to falls. A. Resident status Resident #3, age 95, was admitted on [DATE]. According to the September 2020 CPO, [DIAGNOSES REDACTED]. According to the 6/20/2020 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident had mild depression with the resident scoring six of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. She was occasionally incontinent of the bladder and always continent of the bowel. The MDS revealed no falls since admission. B. Observation and interview On 9/8/2020 at 10:19 a.m., the resident was lying in bed sleeping. The resident ' s wheelchair was next to the resident ' s bed and her call light was next to the resident. The bed was not in the low position. The bed was approximately 20 inches above the ground. Certified nurse aide (CNA) #5 was interviewed on 9/8/2020 at 10:19 a.mshe said she was familiar with Resident #3. She said the resident was not on any fall interventions as she had not had any recent falls. CNA #5 was informed of the fall interventions of while Resident #3, which was in a low position. CNA #5 said the bed was not in the low position and exited the resident ' s room. Licensed practical nurse (LPN) #6 was informed of the concern above. She was interviewed on 9/8/2020 at 10:26 a.m. She observed Resident #3 while she was sleeping in bed. LPN #3 said the bed was not in the low position and then left the room. LPN #3 was interviewed on and stated she had spoken with CNA #5 who stated the bed was in the lowest position possible. After the last observation with LPN#6 and the following observations no attempts were made to ensure the bed was in the lowest position or notify maintenance. -At 11:16 a.m., Resident #3 was observed trying to get out of bed. The resident was observed trying to reach the floor but was unable to touch the floor with her feet. The resident started to slide out of bed as CNA #3 walked into the room and stopped Resident #3. CNA #3 said the resident could have slid out of her bed. CNA #3 said the bed was not in the low position. She said, That bed had been broken for some time. CNA #3 proceeded to transfer Resident #3 to the restroom. -At 12:56 p.m., the maintenance supervisor (MS) was informed of the concerns and was asked to observe the residents bed. He said he had not had any work orders for the bed malfunctioning. The MS said the bed was not in a low position because the bed should be a lot closer to the floor. The MS said something might be under the bed restricting its movement. He checked and said there was nothing there. He attempted to lower the bed with the remote control with the bed only lifting. The MS said, I am going to replace the bed immediately and exited the resident ' s room. -At 1:12 p.m., the MS stopped this surveyor stating, The piston in the bed was seized so that was why the bed would not go into a low position. C. Record review Nursing log note dated 8/13/2020 at 4:00 a.m. CNA found the resident on the floor on her buttocks on 8/13/2020 at 4:00 a.m. Resident was found on the floor beside her bed on her buttocks. This Registered nurse (RN) completed a head to toe assessment without skin injuries, bruises, lacerations or bleeding. Resident states, I fell to the floor when I was trying to sit in my wheelchair. Resident did not hit her head during her fall. Denies pain or discomfort after her unwitnessed fall. The resident was not able to complete orthostatic vital signs. Resident's LPN will notify the medical doctor, DON and the resident's family regarding this fall. Resident's LPN will complete the Risk Management form and start neurological checks for 72 hours. Nursing staff will monitor the resident for the next 72 hours. Post fall review dated 8/13/2020 identified the resident as being at a high risk for falls. The fall care plan, initiated 11/21/2018 and revised 9/6/2020 (during survey), identified the resident was at risk for falls. Gait/balance problems, unaware of safety needs, vision/hearing problems. The resident also received accountable care organization (ACO) therapy. Interventions include complete fall risk assessment. Low bed, bed against wall. Grab bars present in the bathroom. Assist with ADLs with one staff. Stop sign on main doorway and on bathroom doorway, be sure the yellow strap is across both of her doorways when she is out of her room to remind the resident that she needs to ask for assistance. Pad hi-rise toilet seat bars to reduce chance of injury related to (r/t) as the resident had a history of [REDACTED]. -Even though these interventions were documented in the care plan for this resident, the bed was not in the low position as observed above. D. Interview The director of nursing (DON) was interviewed on 9/10/2020 at 2:43 p.m. She said the resident did get up on her own and would self-propel herself to the restroom. The DON said the resident had other interventions in place as she would bruise easily. She said staff should have reported the bed knowing it was malfunctioning. The DON said a negative outcome for failing to provide care planned interventions could be further falls for this high-risk resident.

Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#2) of three residents reviewed for supplemental oxygen use out of five sample residents. Specifically, the facility failed to administer oxygen in accordance to the physician's orders [REDACTED]. Findings include: I. Facility policies and procedures The Oxygen Administration/Safety/Storage/Maintenance Policies and Procedures policy, revised 5/15/2020, was provided on 9/10/2020 at 3:18 p.m., by the nursing home administration (NHA). It read, To assure that oxygen was administered and stored safely within the healthcare centers. II. Resident #2 A. Resident status Resident #2, age 69, was admitted on [DATE]. According to the September 2020 CPO, [DIAGNOSES REDACTED]. According to the 8/28/2020 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had mild depression with the resident scoring five of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. She required extensive assistance for some ADL ' s. The MDS revealed the resident received oxygen therapy. B. Record review The care plan, initiated 6/7/19 and revised 8/26/2020, identified the resident received oxygen therapy related to (R/T) ineffective gas exchange. Interventions include giving medications as ordered by a physician. Oxygen at 2 liters/minute continuously via nasal cannula along with bi-level positive airway pressure ([MEDICAL CONDITION]) on while sleeping or napping and off while awake. The September 2020 CPO included an oxygen order dated 4/20/2020 for O2 at two liters per minute (LPM) continuous via nasal cannula. Document two times a day. C. Observation The resident was lying in bed on 9/8/2020 at 9:13 a.m. She was lying in bed scrolling through her phone. The resident was wearing her oxygen cannula while in bed. The resident ' s oxygen concentrator was set at 4 LPM. The resident was observed on 9/9/2020 at 2:20 p.m. She was lying in her bed playing a game on her phone. The resident ' s oxygen concentrator was set at 4 LPM. The licensed practical nurse (LPN) #5 said she was familiar with Resident #2. She said the resident oxygen should be set at 2 LPM. LPN #5 was asked to check Resident #2 ' s oxygen concentrator. LPN #5 observed Resident #2 ' s oxygen concentrator. LPN #5 said, Oh it was on 4 LPM, it was not supposed to be there. She immediately placed the concentrator on 2LPM. D. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 9/9/2020 at 2:20 p.m. She said oxygen was a medication. She said nursing staff are responsible to monitor the resident ' s oxygen LPM. She said, I did not check the resident ' s LPM today during my shift. She said the physician's orders [REDACTED]. The director of nursing was interviewed on 9/10/2020 at 2:40 p.m. She said oxygen was a medication. When informed of the physician's orders [REDACTED]. She said it was her expectation the oxygen should be administered as the provider ordered it and clarified if needed. The DON said a negative outcome could be altered mental status, dizziness, falls, hypoxic events and could have put the resident in respiratory distress.

Based on record review and interviews, the facility failed to ensure a resident was diagnosed with [REDACTED].#4 and #5) of four out of the eight sampled residents. Specifically, the facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Residents #4 and #5. I. Facility policy and procedures The Behavioral Health Management policy and procedure, reviewed on 5/18/2020, was provided by the director of nursing (DON) on 9/9/2020 at 2:15 p.m. It documented in pertinent part, Purpose: To promote resident safety, attain highest practical mental/psychosocial well-being and reduce behavior related events. Policy: The facility will provide services to a resident to correct an assessed problem related to mental disorder or psychosocial adjustment difficulty and, if an asse3ssment did not reveal a mental or psychosocial adjustment difficulty, prevent an occurrence of such in a resident if clinically avoidable. Procedure: Facility staff must: -Assess and plan care for concerns identified in the resident assessment. -Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record. -Share concerns with the interdisciplinary team ()IDT)to determine underlying causes, including differential diagnosis. -Ensure appropriate follow-up assessment. -Discuss potential modifications to the care plan. Initiate Behavior Flowsheet, Behavior Management Care Plan, and kardex as indicated by assessment findings, resident/responsible party conversations, and observations. The social worker is primarily responsible for initiation of the Behavior Management Care Plan. The facility must provide necessary behavioral health care and services which include; -Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. -Ensuring direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. -Providing an environment and atmosphere that is conducive to mental and psychosocial well-being. Communicate the Behavior Management Care Plan and kardex to the resident and/or responsible party and to relevant members of the IDT team. Review and revise the Behavior Management Care Plan as indicated. II. Resident #4 A. Resident status Resident #4, over the age of [AGE] years old, was admitted to the facility on [DATE] and readmitted [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 7/20/2020 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident displayed no behavioral symptoms during the seven day look back period. She did not refuse cares provided by staff. B. Record review The care plan, initiated 12/6/19, identified the resident was dependent on staff for her emotional, intellectual, physical, and social needs related to cognitive deficits, immobility, and physical limitations. Interventions included: -Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, and meals; and, -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. The care plan, initiated 1/23/19 and revised on 3/24/19, identified the resident is resistive to care related to dementia as evidenced by exhibiting impulsiveness and inability to comprehend teaching related to her care. Interventions included: -Give clear explanation of all care activities prior to and as they occur during each contact; -If the resident resists with activities of daily living (ADLs), reassure the resident, leave and return 5-10 minutes later and try again; and,. -The resident's triggers for resisting care are related to dementia. The resident's behavior is de-escalated by quiet time and diversion with a group activity. The care plan, initiated 1/19/19 and revised on 1/22/19, identified the resident had impaired cognitive ability/impaired thought process related to dementia with behaviors of impulsiveness and inability to comprehend complex ideas. Interventions included: -The resident had difficulty understanding consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. The resident's comprehensive care plan did not address physical aggression and verbal aggression behaviors (see below). The behavior monitoring form for July 2020 was provided by medical records (MR) #1 on 9/9/2020 at 12:45 p.m., identified the resident was taking psychoactive medication [MEDICATION NAME]. The targeted behaviors identified were restlessness and illusions. -On 7/19/2020, (no time identified) the behavior coded physical aggression and verbal aggression. The location was the hallway. The interventions were to help the resident become more comfortable and remind the resident she is safe. The resident response was no change. The behavior monitoring form for August 2020 identified the resident was taking psychoactive medication [MEDICATION NAME]. The targeted behaviors identified were restlessness and illusions. -On 8/15/2020, (no time identified) the behavior code documented, kicking, hitting, physical aggression, disruptive behavior, verbal aggression, and hallucinations. The identified location was not identified. No interventions were documented. The resident response noted improvement and no change. The behavior monitoring form for September 2020 identified the resident was taking psychoactive medication [MEDICATION NAME]. The targeted behaviors identified were restlessness and illusions. -On 9/5/2020, (no time identified), the behavior code identified, kicking in the hallway cussing me out saying I owe her money. The location identified was the nurses station. The intervention used was reassurance. The resident response was,kicked me a couple more times. Signed by certified nurse aide (CNA) #2. -On 9/6/2020, (no time identified), the behavior code identified, She was kicking, spitting, and cussing. Location was the resident's bedroom. The interventions used were reassurance and reminded the resident she was safe. The resident response was, hitting and cursing. Signed by CNA #2. The behavior huddle tool, dated 7/19/2020, no time identified, documented: -Brief description of behavior: physical aggression, verbal aggression. Remind resident she is safe. -New interventions decided in the huddle to be implemented based on the resident's unmet needs: Redirect. Nurse assessed for physical needs. Stop task/ reapproach later. The behavior huddle tool, dated 8/15/2020, no time identified, documented: -Brief description of behavior: physical aggression, disruptive behavior, verbal aggression, kicking, and hitting. -New interventions decided in the huddle to be implemented based on the resident's unmet needs: Redirect. Assess for physical needs. Stop task/ reapproach later. The facility did not complete a behavior huddle for the September 2020 behaviors. The facility did not update,develop, and assess the resident's care plans for physical aggression or verbal aggression she displayed based on the behavior monitoring (see above). The facility failed to determine the root cause of her behaviors and try to individualize care to help prevent the behaviors from becoming worse. C. Observation On 9/9/2020 at 1:12 p.m. Resident #4 was observed in the hallway sitting up to a bedside table with her lunch dishes on the table. Social services assistant (SSA) #1 approached the resident and asked her to put her oxygen on. She began cursing at SSA #1 and refused to put the oxygen on. SSA #1 said her son wanted her to wear the oxygen. She still refused. SSA #1 left the area. The resident began cursing at the staff as they walked by her. A certified nurse aide (CNA) moved the bedside table and the resident yelled at the CNA for moving the table. The facility failed to document the observed behavior, interventions,and resident response to the observation above. D. Staff interviews CNA #4 was interviewed on 9/10/2020 at 10:30 a.m. She said Resident #4 had behaviors of hitting and smacking the staff during cares provided by staff, all the time. She said there had to be two people to assist Resident #4 to the bathroom in case she became aggressive. She said when she had the behaviors, for the staff to leave if she was not currently being provided care and come back later. She said she wrote down the resident's behaviors in the behavior book on the behavior monitoring form. She said she informed the nurse of behaviors. Licensed practical nurse (LPN) #3 was interviewed on 9/10/2020 at 10:35 a.m. She said Resident #4 was verbally aggressive and hit staff. She said she redirected Resident #4 when she became physically aggressive with staff. She said she preferred to be called grandma, or just leave her alone for a little while. She said her behaviors were documented in a behavior book. She said CNAs would report to her or to the charge nurse. She said the resident had injured a staff member. The social services director (SSD), social services assistant (SSA) #1, and SSA #2 were interviewed on 9/10/2020 at 12:40 a.m. SSA #1 said Resident #4 had behaviors of yelling out during cares and she could become physically and verbally aggressive. She said staff should try to talk to her, try a different staff member, and encourage her with family if she was having behaviors. The SSD said she preferred to have male staff to care for her. He said she sometimes calmed down when he would go talk to her. SSA #1 said staff should document when she had behaviors in the behavior book on a behavior monitoring form. SSA #1 said she and SSA #2 went through the behavior monitoring forms daily and when behaviors were documented the staff will hold a behavior huddle with the interdisciplinary team led by the social services director. SSA #1 did not know why Resident #4's behaviors were not documented and for the behaviors that were documented there was not a corresponding behavior huddle. The SSD said he did not know why the resident did not have individualized resident care plans with person-centered interventions addressing her physical aggression and verbal aggressions. The director of nursing (DON) was interviewed on 9/10/2020 at 2:30 p.m. She said Resident #4 displayed the behaviors of cursing, yelling a, kicking and grabbing at staff. She said she expected her staff to make sure the resident was safe and let her de-escalate. She said she loved chocolate and soda. She said she wanted the staff to document loud outbursts on the behavior monitoring form. She said the resident's regular behavior was screaming and the behavior was normal for her and did not expect staff to document or report all her outbursts (however, this was contradictory to her saying that loud outburst should be documented). She said she was surprised the resident did not have an individualized care plan for her physical aggression and verbal aggression to include person-centered interventions to help the resident attain the highest practicable mental and psychosocial well-being. III. Resident #5 A. Resident status Resident #5, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the September 2020 CPO [DIAGNOSES REDACTED]. The 8/3/2020 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of seven out of 15. The resident displayed no behavioral symptoms during the seven day look back period. She did not refuse cares provided by staff. B. Record review The resident did not have comprehensive individualized care plans with person-centered interventions for her physical and verbal aggression (see behavior monitoring forms below). The behavior monitoring form for July 2020 was provided by medical records (MR) #1 on 9/9/2020 at 12:45 p.m., identified the resident was taking psychoactive medication [MEDICATION NAME]. The targeted behavior identified was smoking. On 7/16/2020 the behavior monitoring form identified, 3:43 (a.m. or p.m. was not noted) the behavior code identified verbal aggression and disruptive behavior and documented, yelling at roommate says she doesn't want her in there anymore. Location: residents room. Interventions: active listening and positive distraction. Resident response: does not want a roommate. On 7/24/2020 the behavior monitoring form identified, at 9:00 p.m. the behavior code identified physical aggression, verbal aggression in the residents room. Interventions: active listening and positive distraction. The resident response on the form was illegible. The behavior monitoring form for August 2020, identified the resident was taking psychoactive medication [MEDICATION NAME]. The targeted behavior identified was smoking. On 8/28/2020 the behavior monitoring form identified, at 8:25 p.m. the behavior code identified physical aggression and verbal aggression. The location was the residents room. Interventions: positive distraction, reassurance of safety, and help resident become more comfortable. The resident response on the form was illegible. The behavior huddle tool, provided by MR #1 at 12:45 p.m. on 9/9/2020, identified incident date of 7/16/2020 at 3:43 p.m. noted: -Brief description of behavior: verbal aggression, disruptive behavior, yelling at her roommate said she doesn't want her to interfere anymore. -New interventions decided in the huddle to be implemented based on the resident's unmet needs: Called daughter 7/16/2020 daughter was going to call Resident and talk with her mother. Daughter suggested that when the resident has these behaviors to have her sit by the nurses station and shut off her television. The behavior huddle tool, identified the incident date of no date and 7/22/20 and no time identified. -Brief description of behavior: verbal aggression, BA (unknown acronym) yelling and cussing at roommate telling her to get the hell out. -New interventions decided in the huddle to be implemented based on the resident's unmet needs: Redirected. Remind resident that she needs to be kind to others. Spoke with family about resident's behaviors toward others. Family will speak to resident. The facility failed to have a behavior huddle on the behavior on 8/28/2020 with her having physical and verbal aggression (see above). C. Staff interviews CNA #4 was interviewed on 9/10/2020 at 10:30 a.m. She said Resident #5 refused to get up, refused putting on ted hose, hit the staff and kicked the staff. She said she explained to her what she was doing and explained why the staff member was performing the task. She said resident behaviors were documented on the behavior monitoring form. She said she then let the nurse know of the behaviors. LPN #3 was interviewed on 9/10/2020 at 10:35 a.m. She said Resident #5 was usually pleasant, but was known to get aggressive with cares being provided by staff. She said Resident #5 had scratched and injured staff while cares were being provided. She said the behaviors were documented on the behavior monitoring form. She said she notified social services by voicemail and asked for their input. The SSD, SSA #1, and SSA #2 were interviewed on 9/10/2020 at 12:40 a.m. SSA #1 said Resident #5 had behaviors of yelling out, but she was not aware Resident #5 had struck out at staff. She said approaches that worked were to sweet talk to her or ask her if she wanted to talk to her daughter. She said when Resident #5 talked to her daughter and it calmed her down. She said she wanted the staff to document resident behaviors in the behavior monitoring form. The SSD said Resident #5 should have an individualized care plan with person-centered interventions addressing her physical and verbal aggression. He said he would ensure the care plan would be updated to help the resident attain the highest practicable mental and psychosocial well-being. The DON was interviewed on 9/10/2020 at 2:40 p.m. She said Resident #5 had behaviors of yelling, screaming, pinching, swinging at staff, and kicking. She said staff were to leave her alone to allow her to de-escalate when she was having behaviors. She said she wanted the staff to document loud outbursts on the behavior monitoring form. She said that the resident's regular behavior was screaming and the behavior was normal for her and did not expect staff to document or report all her outbursts (however, this was contradictory to her saying that loud outburst should be documented). She said she was surprised the resident did not have an individualized care plan for physical aggression and verbal aggression that she displayed to include person-centered interventions to help the resident attain the highest practicable mental and psychosocial well-being.

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 in two out of three units. Specifically, the facility failed to: -Ensure staff wore personal protective equipment (PPE) appropriately and completed hand hygiene when appropriate; -Ensure staff disinfected shared equipment between resident use; -Prevent staff from entering a resident's room with another resident's bag of trash; and, -Ensure staff ate in designated employee areas. Findings include: I Status of COVID-19 in the facility The director of nursing (DON) and infection prevention and control nurse/assistant director of nursing (IPCN/ADON) were interviewed on 7/13/2020 at 4:25 p.m. The DON said the nursing home administrator (NHA) was not present due to a personal obligation. The DON stated she was managing COVID-19 surveillance and the rest of the duties was the responsibility of the assistant director of nursing (ADON) who was the interim infection prevention and control nurse (IPCN). The unit manager was taking courses to take over the position of IPCN. The DON stated since March they used a green, yellow and red zone system. Residents without COVID-19 symptoms were in the long-term care hall and considered a green zone. Residents with symptoms, new admissions or re-admissions were in the B Hall and considered a yellow zone. Staff called the yellow zone the precautionary hall/unit and droplet precautions with eye protection were used. They designated C Hall as the Red zone for any residents who tested positive for COVID-19. No residents have tested positive with COVID-19. Residents who received [MEDICAL TREATMENT] were currently in the red zone. The DON stated satellite dining rooms are closed to residents. Residents ate in their rooms and those who required assistance with meals were distanced six feet apart in the main dining room. The DON stated staff were to use surgical masks provided by the facility and were to change them twice a week. When not in use, their cloth masks or surgical masks were placed in a paper bag with their name on it. The paper bags were placed in a storage system on the wall. Upon exit, the provided surgical masks were swapped out for the cloth masks to be worn out of the facility. The DON stated that upon entry into the precautionary unit, surgical masks were doffed and placed in a paper bag with their name on it. The N95 or KN95 masks, stored in another paper bag with their name on it, were donned. When resident rooms were entered, goggles/face shields, gloves and isolation gowns were required. The DON stated the housekeeping director provided staff education on using Environmental Protection Agency (EPA) approved products, using correct surface contact times and appropriate cleaning schedules for equipment such as lifts. The nursing home administrator (NHA) provided, via email on 7/14/2020, the COVID-19 status at the facility. The total number of residents in the facility was 112. The date the first laboratory test results were positive for staff was on 4/28/2020. Currently, no residents or staff tested positive or were presumptive for COVID-19. II Personal protective equipment (PPE) and hand hygiene A. Facility policy and procedure The Standard and Transmission Based Precautions Coronavirus (COVID-19 ([DIAGNOSES REDACTED]-CoV-2)) policy, last revised on 7/6/2020, was provided by the DON via email on 7/14/2020. It read in pertinent part, Infection Control Recommendations for Prevention of Infection include the following: Selection of and use of PPE. Per CMS (Centers for Medicare and Medicaid Services) directive issued 4/2/2020, all facility associates should wear a face mask/face covering while they are in the facility for the duration of the state of emergency in their state. Residents should wear a cloth face covering when they need to be outside of their room and should wear a cloth face covering or cover nose and mouth with a tissue when others (visitors or healthcare personnel) enter their rooms. The Isolation Plan for COVID-19, dated April 27, 2020, was provided by the DON via email on 7/14/2020. It read in pertinent part, N95, isolation gown, eye protection and gloves are required for the care of residents with one or more signs and/or symptoms related to COVID-19. The Standard and Transmission Based Precautions Coronavirus (COVID-19 ([DIAGNOSES REDACTED]-CoV-2) policy, last revised on 7/6/2020, was provided by the DON via email on 7/14/2020. It read in pertinent part, Perform proper hand hygiene with soap and water or alcohol-based hand rub (ABHR); before and after all resident contact, contact with potentially infectious material, before applying gloves, after removal of gloves, prior to removal of face shields/eye protection and/or respirator during the doffing of PPE process, after touching or adjusting facemask or face covering. B. Professional reference The Centers for Disease Control and Prevention (CDC) (7/15/2020) Infection Control Guidance, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html (7/22/2020). It read in pertinent part, Recommended routine infection prevention and control practices during the COVID-19 pandemic to implement universal use of personal protective equipment (PPE). Healthcare providers (HCP) should adhere to standard precautions and transmission-based precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnosis. Universal use of a facemask for source control is recommended for HCP. Patients should wear cloth face covering (if tolerated), may remove their cloth face covering when in their rooms but should put it back on when around others (when others enter their room) or leaving their room. HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The Centers for Disease Control and Prevention (CDC), (1/31/2020) Hand Hygiene in Healthcare Settings, retrieved from: https://www.cdc.gov/handhygiene/providers/index.html (7/9/2020). It read in pertinent part, Multiple opportunities for hand hygiene may occur during a single care episode: immediately before touching a patient, after touching a patient or the patient's immediate environment, immediately after glove removal. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). The Centers for Disease Control and Prevention (CDC), (6/25/2020) Preparing for COVID-19 in Nursing Homes, Core Practices, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (7/9/2020). It read in pertinent part, Care must be taken to avoid touching the respirator, facemask, or eye protection. If this must occur (e.g., to adjust or reposition PPE), healthcare providers should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others. C. Observations On 7/13/2020 -At 6:25 p.m., registered nurse (RN) #1 leaned down within inches of a resident's face and spoke to him. The resident was not wearing a face mask and RN #1's mask was under his chin exposing his mouth and nose. -At 6:30 p.m. and 7:00 p.m., housekeeper (HK) #1 walked between the Memory Lane and Cascade Crossing nurses stations. HK #1 wore a surgical mask covering his mouth, exposing his nose. -At 4:15 p.m. and on 7/15/2020 at 8:28 a.m., during the interview with the infection prevention and control nurse (IPCN)/assistant director of nursing (ADON) and the DON, the IPCN/ADON sat in close proximity to the DON and other persons in the conference room with her mask pulled below her nose. Layout of the precautionary unit. Double doors separated the precautionary unit from the residential population. Inside the double doors, to the left, were paper sacks containing individual staff surgical and/or N95/KN95 respirator masks. A large plastic tote that contained isolation gowns for staff to retrieve each day for each resident room. Resident rooms had signs posted at each resident door. The signs read, Droplet precautions. Everyone must wash their hands, including before entering and before leaving the room. Make sure eyes, nose and mouth are fully covered before entry. Remove face protection before leaving the room. On 7/14/2020 -At 6:03 a.m., certified nurse aide (CNA) #4 wore a surgical mask and entered room [ROOM NUMBER], failing to don a N95/KN95 respirator mask. The CNA donned gloves and a gown but failed to don eye protection and assisted the resident to the bathroom. The CNA did not encourage or provide the resident with face covering during the care. The CNA stood in the hallway waiting for the resident to indicate she was ready for assistance. At 6:07 a.m., the resident indicated she was ready for assistance, so the CNA entered the room again wearing the same surgical mask. -She failed to change into the N95/KN95 respirator mask and to don eye protection. -At 7:27 a.m., after the staff development coordinator (SDC) assisted to pass food items to CNA #3, she looked for a room tray but could not find it. The SDC then exited the precautionary unit to locate a room tray without performing hand hygiene or changing from KN95 respirator mask to surgical mask. The SDC returned to the precautionary unit and returned to the food cart. -The SDC failed to perform hand hygiene prior to leaving the unit and when she returned to the unit. -At 8:03 a.m. and 12:03 p.m., the speech language therapist (SLT) entered the precautionary unit and doffed the surgical mask and stored it in the designated bag. She failed to perform hand hygiene prior to donning the KN95 respirator mask. Once the KN95 mask was donned she entered resident rooms. -At 8:31 a.m., the SLT doffed the KN95 respirator mask and stored it in the designated bag but failed to perform hand hygiene prior to donning the surgical mask and exiting the precautionary unit. -At 8:32 a.m., CNA #3 doffed her KN95 respirator mask and stored it in the designated bag, without performing hand hygiene as she donned the surgical mask. -At 12:10 p.m. and 1:15 p.m., physical therapy assisting (PTA) #1 entered the precautionary unit, doffed the surgical mask and stored it in the designated bag, without performing hand hygiene as he donned the KN95 respirator mask. -At 1:00 p.m., IPCN/ADON spoke to a resident not wearing a mask in the hallway. The resident said she was not able to hear her and the IPCN/ADON leaned in close to speak to the resident with her mask over her mouth and under her nose, exposing her nose. D. Staff interviews CNA #4 was interviewed on 7/14/2020 at 6:09 a.m. She stated that residents wore cloth masks when out of their rooms but not when staff were in their rooms. She stated staff were required to wear a surgical mask at all times and wore gloves and an isolation gown upon entry into resident rooms on droplet precautions. -She failed to recognize the necessity of wearing eye protection when entering the resident rooms and changing into the N95/KN95 mask upon entering the precautionary unit/hall. The SDC was interviewed on 7/14/2020 at 6:22 a.m. She stated upon entry to the precautionary unit, staff doffed surgical masks and donned N95/KN95 respirator masks. Each resident room contained a cart supplied with goggles and face shields. Staff were educated to don eyewear upon entry of a resident room and doff the eyewear upon exit. Staff were directed to place the goggles/face shields on top of the cart and wipe them with disinfecting wipes prior to storing them in the cart drawer. The IPCN/ADON was interviewed on 7/15/2020 at 8:21 a.m. The IPCN/ADON said, Staff should wear masks to cover their mouth and nose. Staff should pinch the top of the mask over the bridge of the nose. Residents were provided cloth masks and were hung on hooks inside the doorway of each room. Residents were encouraged to wear them when out of their rooms, or when staff provided care. The IPCN/ADON stated hand hygiene and coronavirus training, with return demonstration, was completed in March 2020 and was ongoing. The IPCN/ADON stated the education/training included PPE, how infection spreads, using one gown per staff per day and using N95/KN95 respirator masks on the precautionary unit. She stated staff received education about how to don a face mask and why it was important to use it. She demonstrated how the face mask secured over the bridge of the nose, over the mouth and under the chin without gaps. She explained that the mask should cover the nose and mouth to capture the secretions from the respiratory system. However, during the demonstration she failed to identify that her mask was over her mouth exposing the nose. She said staff demonstrated the process for donning a mask to her after the education. The DON was interviewed on 7/15/2020 at 11:36 a.m. She said staff were provided education to encourage residents to wear a cloth face mask while staff provided care for them in their rooms. The DON was interviewed again on 7/15/2020 at 12:00 p.m. She said that the facility followed CDC's guidelines on how face masks were used. She said that the face masks were worn over the nose and mouth and tucked under the chin. III. Disinfecting equipment A. Facility policy and procedure The Standard and Transmission Based Precautions Coronavirus (COVID-19 ([DIAGNOSES REDACTED]-CoV-2) policy, last revised on 7/6/2020, was provided by the DON via email on 7/14/2020. It read in pertinent part, Current data suggest person-to-person transmission most commonly happens during close exposure to a person infected with [MEDICAL CONDITION] that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Transmission also might occur through contact with contaminated surfaces followed by self-delivery to the eyes, nose, or mouth. Facilities should follow local and state health department guidelines and state regulations as well as current CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control) Guidelines. Infection Control Recommendations for Prevention of Infection include the following: Education and job-specific training will be provided to associates upon hire and ongoing regarding current guidance related to infection prevention and control measures related to COVID-19 to include how to keep residents, visitors and associates safe by using correct infection control practices. The Isolation Plan for COVID-19, dated April 27, 2020, read in pertinent part, Staff educated, verbally and in writing, of the importance of enhanced cleaning and disinfection of environmental surfaces and shared equipment. B. Professional reference The CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), reviewed 9/18/2016. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/disinfection/rational-approach.html (7/23/2020). It read in pertinent part, Surfaces frequently touched by hand potentially could contribute to secondary transmission by contaminating hands of health-care workers or by contacting medical equipment that subsequently contacts patients. C. Observations and interviews On 7/13/2020 -At 6:29 p.m., CNA #1 and #2 entered room [ROOM NUMBER] with a sit-to-stand type of mechanical lift. At 6:36 p.m. CNA #1 and #2 exited the room, left the lift in the hallway near the room entrance and walked down the hallway. They failed to disinfect the lift prior to storing it in the hallway. CNA #2 was interviewed at 6:37 p.m. She said she received training to disinfect equipment between each resident. She said the disinfectant wipes for cleaning the lift were kept on the vital sign cart. -Immediately after the interview CNA #1 and #2 retrieved disinfecting wipes from the vital sign cart and cleaned the lift. On 7/14/2020 -At 12:03 p.m., SLT while on the precautionary unit picked up a pen from the housekeeping cart, wrote on a clipboard, returned the pen to housekeeping the cart then entered room [ROOM NUMBER]. -The SLT failed to perform hand hygiene and disinfect the pen after using it and returning the pen to the cart. -At 12:10 p.m., PTA #1 entered the unit. He placed his clipboard on the floor, doffed his surgical mask and without performing hand hygiene, donned a KN95 respirator mask. PTA #1 performed hand hygiene then picked up the clipboard from the floor and entered room [ROOM NUMBER]. -PTA #1 failed to disinfect the clipboard after being placed on the floor. D. Staff interviews The IPCN/ADON was interviewed on 7/15/2020 at 8:21 a.m. The IPCN/ADON said lifts should be cleaned with disinfecting wipes at the doorway before taking the lift out of the resident's room. Staff were re-educated in April 2020 and new staff were trained during orientation per the training checklist. The training included verbal instructions and return demonstration on cleaning lifts. She said that they would develop a system to keep the clipboard off of the floor. She said the pen should be disinfected between use and storage. IV. Staff entering a resident's room with another resident's bag of trash A. Observation On 7/13/2020 at 6:36 p.m., CNA #5 left resident room [ROOM NUMBER] with a trash bag in her hand and walked into room [ROOM NUMBER] while holding the trash bag. She walked out of room [ROOM NUMBER] carrying two trash bags. She carried the bags to the dirty utility room for disposal. B. Staff interview The DON was interviewed on 7/15/2020 at 11:20 a.m. She said the trash in resident rooms should be brought to the dirty utility room for disposal and not brought into other resident rooms. V. Staff eating in resident areas A. Standards The Occupational Safety and Health Administration (7/17/2020) Standard Interpretations, Requirements for covered beverages at nurses' stations. Retrieved from: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030 on (7/21/2020). It read in pertinent part, The employer must evaluate the workplace to determine in which locations food or beverages may potentially become contaminated and must prohibit employees from eating or drinking in those areas. B. Observation On 7/13/2020 at 6:25 p.m., through the double doors licensed practical nurse (LPN) #3 was observed sitting at a desk in the precautionary hallway. She took food from under the desk and ate it using her fingers. She did not perform hand hygiene and replaced her mask to her face as a resident wheeled next to and spoke to her. LPN #3 touched the resident's arm with her hand. The LPN continued to eat after the resident left down the hallway. C. Staff interviews The DON was interviewed on 7/15/2020 at 12:10 p.m. She stated the staff had designated break and eating areas that were setup so the staff could follow social distancing guidelines. She said the staff were educated on using the newly designated areas for staff to eat and take breaks in. She said that the tables were spaced six feet apart to ensure social distancing.

Based on observations, interviews, and record review the facility failed to provide adequate supervision to prevent accidents for four #119, #83, #77 and #99) out of six of 48 total sampled residents. Specifically, the facility failed to: The facilities failure to provide adequate supervisor for Resident #119 who was a repeat resident and had a known history of falls from her past admission and was at risk for continued falls for falling and sustaining a fractured left femur within one week of admission. Furthermore, interventions were not added to the care plan (cross-reference F656) and those that were put into place were not always appropriate for a resident who did not remember to call for assistance and had poor safety awareness. A root cause and analysis was not done for each fall to find out the cause of each fall and to keep the resident from future falls. Resident #119 had three more unwitnessed falls within 12 days after her last readmission date of [DATE] following her femur fracture. Additionally, the faciilty failed to: -Ensure Resident #83 had interventions in place to prevent falls. -Ensure mechanical lifts were functioning properly to ensure safety of residents during transfers for Resident #77 and Resident #99. Findings include: I. Facility policy and procedure The policy Fall Management was received from the medical records director (MRD) on 1/29/2020 at 7:35 a.m. It read in pertinent part, To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. The facility must ensure that the resident's environment remains free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. II. Failure to prevent/protect residents from major injury. A. Resident #119 status Resident #119, age 83, was admitted on [DATE] and readmitted [DATE] for [MEDICAL CONDITION] (A-fib), generalized weakness, and muscular reconditioning with physical and occupational therapies and last admitted on [DATE]. According to the 1/2020 computerized physician orders [REDACTED]. The 1/10/19 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident required extensive assistance from two persons with bed mobility; extensive assistance from one person for toilet use, transfers, dressing and personal hygiene; supervision and meal setup for eating. Behavior not exhibited and she did not reject care. B. Observations On 1/27/2020 at 11:53 p.m. Resident #119 was seated in her wheelchair outside of the dining room [ROOM NUMBER], she had a bruise on the right side of her face. The bruise was dark purple and went from her eye down to her cheek. She had no foot pedals and had anti tippers on her wheelchair. On 1/29/20 at 9:30 a.m. the resident was in her room seated bent forward in her wheelchair. Her wheelchair had anti tippers. CNA #16 was in the room sitting in a chair. On 1/29/2020 at 10:35 a.m. CNA #16 was in the resident's room seated in a chair. The Resident was sleeping in her bed. The bed was in the lowest position and a mat was on the floor in front of the bed. The Resident was with a one to one staff member throughout the day. C. Record review Resident #119's clinical record revealed she originally admitted to the facility on [DATE] with a left pelvic fracture due to a fall on ice. She was discharged home and readmitted on [DATE]. She fell four times in 30 days after the 12/18/19 admitted . Documentation of the falls showed the facility failed to develop and implement effective interventions to prevent the resident from falls with injury. 1. Fall #1- 12/24/19 unwitnessed A nursing progress note dated 12/18/19 documented the resident was resting in bed with eyes closed. She had been 'up wandering in other resident rooms at the beginning of the shift and was redirected to her room and encouraged to use call light and not to get up by herself. Call light in reach. Will monitor. -This notation documented the first day of admission the resident will wander and get up by herself without using the call light. The fall risk assessment completed 12/18/19 upon admission, revealed the resident scored a 14 out of 30, a high fall risk. The assessment documented interventions should be initiated for a score of 10 or above. The care plan initiated 12/18/19 upon readmission revealed the resident was at risk for falls related to impaired cognition which resulted in poor safety awareness. The resident got up without assistance and ambulated without devices despite being weak and unsteady. The resident was receiving antianxiety, anticoagulant, antidepressant and diuretic medications. The care plan interventions dated 12/18/19 included: -Assist with ADLs as needed; -Call light within reach; and, -Complete fall risk assessment. -The call light within reach would be an inadequate intervention as the resident was not capable of using the call light (per interviews below) and required more/frequent oversight of her needs. A nursing progress note dated 12/24/19 documented the resident had an unwitnessed fall. Resident complaining of left knee pain Left knee is slightly swollen when compared to the right. Np wrote orders for a 2 view x ray of left hip and knee with a dx of pain related to fall. RN assessed, resident able to move all extremities. Resident stated she slipped out of her bed a few days ago during the early morning when I was going to the bathroom. She couldn't remember if staff assisted her off the floor or if she got up independently. The resident reported the same to her daughter and family. Nueros started notified doc and daughter. Implemented low bed and fall mat. Nueros completed. Went to hospital on [DATE] A progress note dated 12/24/19 revealed the resident had an unwitnessed fall. She complained of left knee pain. Her left knee was slightly swollen when compared to the right. The nurse practitioner (NP) wrote orders for a 2 view x ray of left hip and knee with a dx of pain related to fall. The RN assessed, the resident was able to move all extremities. The resident stated she slipped out of her bed a few days ago during the early morning when I was going to the bathroom. She couldn't remember if staff assisted her off the floor or if she got up independently. The resident reported the same to her daughter and family. Implemented low bed and fall mat. The 12/24/19 investigation of the resident's injury reported post fall was a fracture of left trochanter (hip). Staff documented there were many factors regarding incident are unknown as the resident is reporting it occurred a few days ago during the early morning when she was going to the bathroom. The resident went to hospital on [DATE]. Incident follow-up and recommendation form dated 12/24/19 showed no documentation of the nursing home administrator's (NHAs) review. The summary of investigative facts documented C/O (complaint of) L(left) knee pain, reported on floor and got herself up. Actions taken: Low bed with floor mat bed against wall. Follow up - Hospital, bolsters to bed. A physician note dated 12/25/19 revealed she was seen at the emergency department (ED) for concern for left femoral neck fracture. The resident fell out of bed three to four days prior and landed on her left knee and hip. She had some pain but was able to ambulate after her fall. Her daughter visited on 12/24/19 and noticed resident was walking awkwardly An X-ray was performed which was concerning for a left femoral neck fracture. Surgery was planned for 12/26/19. The resident was readmitted to the facility from the hospital on [DATE] following surgery to repair her left femoral neck fracture. A post fall risk assessment was completed on 12/24/2019. The resident scored a 21 out of 30, which indicated a high fall risk. The care plan was updated 12/24/19. The interventions included: -Anticipate and meet (resident name) needs due to poor safety awareness. (Resident name) won't always call for assistance; -Low bed with fall mat when the resident was in bed. Keep bed against the wall for safety.; -Orient (resident name) to room; and, -Reinforce safety education due to poor memory and recall. 2. Fall #2 -1/7/2020 unwitnessed The fall risk assessment completed 1/3/2020, following surgery for [REDACTED]. The assessment revealed the resident scored a 18. The assessment documented interventions should be initiated for a score of 10 above. A nursing progress note dated 1/4/2020 documented the resident was readmitted to the facility. The note read in pertinent part, She is very familiar with the facility and indicated she was glad to be back. She has a left femoral neck fracture. She has eleven staples that are intact. There is no s/s (signs and symptoms) of infection. She has extensive bruising of her hip area, legs, buttocks and coccyx area. She transfers well from bed to wheelchair and was assisted up to the bathroom. Denies pain. Her call light is within reach. Resident #119 fell on [DATE]. The incident description revealed the resident was found down in her bathroom on her right hip with leg extended. O2 tubing in nose but not attached to tank. No wetness on the floor. Her wheelchair was adjacent to her recliner, approximately 10 feet from the bathroom area. A nursing progress note dated 1/7/2020 documented the resident was found on floor on right side with left leg extended. Resident stated she was trying to use the restroom. MD (physician) in facility to assess resident and ordered three view X ray of right hip and psych referral. Family notified of fall and of new orders. Resident denies all pain and discomfort. Neurological assessment completed and is within normal limits. Resident has fall precautions in place. The Incident Follow up and Recommendation form dated 1/7/20 revealed no documentation of the NHA review and the DON signed as reviewed on 1/10/20. There was no follow-up documented. The summary of investigative facts documented Found in bathroom. The Recommendations/Actions taken were to obtain a three (3) view x-ray, increased supervision and group activities in satellite dining room and common areas. A post fall risk assessment was completed on 1/7/2020. The assessment revealed the resident scored a 22 out of 30. The assessment documented interventions should be initiated for a score of 10 above. Two Interventions were added to the care plan on 1/10/2020, three days after the fall. The interventions included: -Encourage (resident name) to participate in activities and group activities; -Encourage (resident name) to stay in common areas when not in bed; 3. Fall #3 - 1/12/2020 unwitnessed A nursing progress note dated 1/9/2020 documented the resident was assisted by two staff to go to the bathroom. The resident was unable to lift self out of w/c (wheelchair) or bear weight on either leg. She is very weak and exhausted tonight. Will monitor. A nursing progress note dated 1/11/2020 documented the resident was post fall. She continues to not follow her plan of care and is a significant fall risk requiring frequent checks. She does not appear to have any injuries. Her call light is within reach. She is on a low bed next to the wall with a mat on the floor. Her call light is within reach. The summary of investigative facts documented, Found on ground at CNA station. The Recommendations/Actions taken were: antitippers to her wheelchair, remove foot pedals, as allows, and a comfort weighted blanket when available. The Incident Follow up and Recommendation form dated 1/12/2020 revealed no documentation of the NHA review. The DONs signed as reviewed, however her review was undated. The follow up was documented as, working with therapy services for gait training, balance and safety. A nursing progress note dated 1/13/2020 documented the resident was being monitored s/p fall last night. The resident is awake at this time. Is oriented to herself and is confused per baseline. Was found sitting on the edge of her bed this morning getting ready to transfer herself. CNA intervened and got the resident up for the day. The resident sustained [REDACTED]. The resident denied any new pain complaints. Neuro checks remain in place and are without any significant changes. Transferred without any difficulties this morning. Denies any headache, dizziness, and/or nausea. A post fall risk assessment was completed on 1/13/2020. The assessment revealed the resident scored a 28 out of 30, which indicated a high fall risk. The assessment documented interventions should be initiated for a score of 10 above. No interventions were added to the care plan following the resident's fall on 1/12/2020, five days after the last fall on 1/7/2020. 4. Fall #4 - 1/15/20 unwitnessed Resident #119 fell on [DATE] three days after her last fall. The incident description revealed the Resident was noted sitting on the floor. An undated witness statement revealed the resident was sitting on the floor hallway to BR (bathroom) and between her bed. The resident was assessed and no new injuries were found. The Incident Follow up and Recommendation form dated 1/15/2020 revealed no documentation of the NHA review. The DON signed as reviewed, however her review was undated. The follow up was documented as, green tennis ball to call light, continue in satellite dining area during waking hours, keep until 9 p.m. as resident allows and in wheelchair at nurses station as resident allows. The Recommendations/Actions taken revealed one-to-one supervision was requested. The care plan was not updated with the recommended interventions. A nursing progress note dated 1/17/2020 read in pertinent part, Continuing to monitor the resident post fall. Neuro checks remain in place and are without any significant changes. The resident has been propelling herself in her w/c independently t/o this shift. Has been attending group activities off and on in the station #1 dining room to offer distraction. Close supervision is being provided by staff d/t (due to)the resident's poor safety awareness and impulsiveness. Bruising remains to right orbital region from a fall prior to this one. The resident denies any new onset of pain and no new latent injuries noted. The post fall risk assessment completed 1/15/2020 revealed the resident scored a 28 out of 30, which indicated a high fall risk. The assessment documented interventions should be initiated for a score of 10 above. Staff interviews LPN #6 was interviewed on 1/28/2020 at 10:49 a.m. The LPN stated the resident fell at least twice. She was hurt. The bruise on the side of her face was really dark and started above her eye and started fading down. RN #2 was interviewed on 1/29/2020 at 10:43 a.m. The RN stated the shortage of staff affects patient care and contributed to why the facility had so many falls. She said she felt that she cannot give the level of care the residents deserve. LPN #7 was interviewed on 1/30/20 at 5:01 p.m. The LPN stated when the resident admitted she had a low bed with fall mat right away because we were well aware she was a fall risk. The LPN stated she was not sure if the intervention of a low bed and fall mat were in the care plan when she was admitted . We knew she was a high fall risk. She was also a lot more demented than the last time. Staff knew her from her previous admission. Not sure if it was care planned. She needed redirection and one-to-one staff supervision when she got 'riled up'. The last few weeks she had been angry. Two to four family members came to visit after dinner. She gets upset when they leave. She will pull on things or people to stand up. She is not able to use the call light button we have to anticipate her needs. Her family knew she was a high fall risk. They always let us know when they are leaving and asks where they should put her so she would be watched. The LPN stated Resident #119 will follow her around. When the family leaves with no aid then we have a problem. So as long as there are two aids we're ok. We know where she is at all times. It's frustrating she falls so much. Staff was with her and she fell when a nurse was standing right there next to her. The nurse said she couldn't do anything to prevent it. CNA #17 was interviewed on 1/30/2020 at 5:39 p.m. The CNA stated, When a resident is admitted we are told by the nurse if they are a fall risk. The nurse will automatically have us put the bed in low position and use a fall mat. She said Resident #119 did not use her call light. When she was in her room she liked to get up and walk around. She liked to fidget with things. The director of nurses (DON) was interviewed on 1/30/2020 at 6:54 p.m. The DON stated when a resident was admitted they completed a fall risk assessment and have conversations with family to determine if there was a history of falls in the previous 90 days. Falls at home or hospital were definitely high fall risks. Interventions are put in place such as a low bed, a fall mat, call light in reach and the bed against the wall. She said she did not want nurses updating the care plans. She said too many hands in the care plans adding and deleting information and having too many care plans. She said it was Chaos, pure chaos. She said, Now the MDS is a registered nurses (RN's), assistant director of nurses (ADON), and nurse managers were the only staff to update care plans. She said risk management meetings were held on Friday's. The DON, ADON and nurse managers looked at falls every Friday. She said they discussed what the recommendations and interventions were and if the care plan was updated. III. Resident #83 A. Resident status Resident #83, age 91, was admitted on [DATE] and re-admitted on [DATE]. The January 2020 computerized physician order [REDACTED]. The 1/9/2020 minimum data set (MDS) revealed the resident had short-term memory problems and moderately impaired cognitive skills for daily decision making. The resident required extensive assistance for transfers, bed mobility, and toileting. B. Record review The director of nursing (DON) provided the fall investigations for falls occurring on 7/5/19, 7/16/19, 7/18/19, 9/1/19, 9/5/19, 9/9/19, 9/10/19, 9/15/19, 9/16/19, 9/17/19, 9/18/19, and 12/24/19 on 1/30/2020 at 2:00 p.m. -On 7/5/19 revealed the resident was found lying on the floor in her room. A contusion was found on her left forehead. The physician assessed the resident. Interventions included the resident would be enrolled in therapy services. -On 7/16/19 the resident was found sitting on the floor in the common room. The resident reported losing her balance and strength, falling to the floor landing on her buttocks. She reported not hitting her head. The physician was called and she was sent to the emergency department. Initiated interventions included a fall mat at the bedside, a bed to be in a low position when resident was in bed, bed against the wall to allow for more space for ambulation, neurological (neuro) checks upon return from the hospital, pharmacy consult to evaluate medications, assistance with activities of daily living (ADLs) as needed, and non-skid strips to floor in front of sink and bed. -The physical therapy discharge summary was provided by the medical records director (MRD) on 1/30/2020 at 11:15 a.m. It revealed the resident graduated her therapy program successfully while ambulating with her walker on 7/16/19. -The non-skid (grip tape) at the bedside and in front of the sink and in residents bathroom was not initiated on the care plan until 9/11/19 - On 7/18/19 the resident was found laying on the floor at the top of her hallway, next to her wheelchair on her left side. She was assessed by the licensed nurse who found no injuries and the resident had no complaints of pain. Neuro checks were initiated. Additional interventions put in place included call light education, a new anti-rollback wheelchair and placing the wheelchair next to the resident's bed. -The physical therapy discharge summary was provided by the MRD on 1/30/2020 at 11:15 a.m. It revealed the resident graduated her therapy program successfully while ambulating with her walker on 8/16/19. -On 9/1/19 the resident was found by a certified nurse aide (CNA) who went to answer her call light. As the CNA entered, the resident was walking out of her room. The resident reported falling outside her bathroom and got herself back to her feet. She said she yelled for help and no one responded. The nurse assessed the resident, found no injury and no complaints of pain from the resident. Additional interventions included keeping belongings and crafts within the resident's reach and off the floor. -On 9/5/19 the resident was found in the hallway laying on her side. She said she had pain in the back of her head and thought she was in the hospital. Attempts to reorient the resident were unsuccessful. Staff assisted the resident to her bed and waited for the ambulance to transport her to the emergency department. No new interventions noted. A care plan intervention dated 9/5/19 included her falls frequently coincide with her son being out of town or preparing to be out of town. -On 9/9/19 the resident reported falling on her bottom and getting herself back up. No injuries found or complaints of pain. Interventions added after this fall included frequent (every 15 minutes) checks. The resident was on 15-minute checks until 9/13/19. An interdisciplinary team (IDT) meeting note dated 9/10/19 revealed one-on-one staffing was initiated for the resident related to an increase in falls. During this meeting, the removal of the resident's walker was discussed and keeping her primarily in the wheelchair. -On 9/15/19 the resident was found lying in the hallway outside of her room with her walker up against the wall. She reported the right side of her head hurt. No injuries were found and no redness or swelling was noted to the resident's head. -On 9/16/19 the resident was found laying on her back next to her sink in her room. Upon assessment, the nurse found a large bump on the back of the resident's head and the resident complained of severe head pain. The physician was called and the resident was sent to the emergency department. Interventions included storing craft items in the activity room and continued therapy services. -On 9/17/19 staff were alerted by another resident that Resident #83 was laying on the floor. She was found lying on her right side. Upon nurse assessment, a laceration was noted to the resident's right forehead measured approximately four (4) centimeters (cm) and was accompanied by significant bleeding. The resident complained of head pain. Nursing staff applied pressure to the wound and an ice pack was applied. No stitches were documented. The physician was called and the resident was sent to the emergency department. No additional interventions noted. -On 9/18/19 the resident was found crawling on her hands and knees in the hallway outside her room. the nurse assessed the resident and interventions included continued with a one-on-one staff. Additional interventions included medication review, continued one-on-one staff, labs, room change, and decaffeinated coffee at all times. -The physical therapy discharge summary was provided by the MRD on 1/30/2020 at 11:15 a.m. It revealed the resident graduated her therapy program with occasional supervision while ambulating with her walker on 10/29/19. -On 12/24/19 the resident was found sitting on the floor and reported reaching for her craft supplies on the floor and falling out of her wheelchair. The nurse assessed the resident and found no injury and the resident reported no pain. Neuro checks were initiated. Additional intervention put in place included giving the resident a reaching tool to grab things out of reach, reminded to use her call light and encouraged the resident to use the activities room for her craft projects. Interventions included in the revised care plan dated 12/15/19. C. Staff interviews CNA #2 was interviewed 1/30/2020 at 12:50 p.m. She said when she finds a resident on the floor after a fall, she would yell for help and stay with the resident until the nurse comes. She said she reports all falls to the nurse. She said if she were to find Resident #83 after a fall she would leave her where she found her, yell help, and stay with her until the nurse came to assess her. Registered nurse (RN) #1 was interviewed 1/30/2020 at 12:20 p.m. RN #1 said the facility followed the standard precautions and interventions for falls. She said fall mats, grippy floor strips, remind residents to use their call lights, low beds, and frequent checks were used as interventions. She said if the fall was witnessed the nurses completed a packet and assessed for injuries. She said if the fall was unwitnessed, neurological (neuro) checks were initiated, vitals taken and the resident was monitored closely. She said Resident #83 had the standard interventions put into place. She said specialized precautions for the resident included making sure the floor was clear of craft supplies, one-on-one staffing, and anticipating needs. She said the resident can be impulsive and if her call light was not answered immediately, the resident would seek out staff or try to do it herself. The assistant director of nursing (ADON) was interviewed on 1/30/2020 at 2:55 p.m. She said when the facility called Resident #83's son after a fall, he told them he was heading out of town. This was how the behavioral connection to some of her falls was made. She said some of the interventions we tried around her crafts involved table trays for her beads and a shoe [MEDICATION NAME] for her yarn and knitting needles. She said the beads still ended up on the floor and became a fall risk. She said the resident's beads were put into the activity room by the nurse's station and she could craft with them in there whenever she asked. She said the resident had a hard time adjusting to being in a wheelchair and would try to walk or stand-up and fall. The DON was interviewed on 1/30/2020 at 2:35 p.m. She said all falls were discussed during their weekly risk management meeting. She said to determine the root cause of a fall they went over the five whys, asking why something happened until you can not ask why anymore, thus reaching the root cause. She said they look at what the resident was doing, where they were, what time staff last checked in on them, before or after meals, were they incontinent and what the resident was doing before the fall. She said the RNs go over risk management on the floor after the fall. She said when a resident had multiple falls the facility tried to prevent injuries and look into any behavioral and psychosocial components that could have contributed to the falls. She said Resident #83 started falling more frequently when she knew her son was going out of town. She said the resident became anxious and would fall. She said they no longer inform the resident when her son goes out of town and her falls had decreased. She said the fall on 12/24/19 was the most recent fall and her son was out of town. She said the resident figured out her son was away because he did not come to the facility when she called and told him she was sick. She said some of the resident's falls were related to her craft supplies. She said they wanted her to craft and be safe at the same time. She said the resident's beads and supplies would be on the floor posing a fall risk as she leaned over to pick them up. She said the family and Resident #83 were involved in the interventions on the care plan. She said the resident had a one-on-one staff for a time but became agitated with the staff always there so they stopped the one-on-one. IV. The facility failed to ensure mechanical Hoyer lifts were functioning properly to ensure the safety of residents during transfers. A. Record review During record review of Resident #77 and Resident #99 the log notes revealed both residents' had experienced a malfunction of the Hoyer (mechanical lift). Nursing log note dated 10/17/19 at 2:56 p.m. Two certified nurse aides (CNA) were transferring the resident to shower chair. When they turned the Hoyer to put the resident on shower chair, the resident was leaning to the right. Suddenly they noticed the hook came off the Hoyer lift. One CNA put her leg up to hold the resident up and they pulled him back up to keep him from falling and to place the sling back on the hook as she used her left arm and hand to put the sling back onto the hook. We continued to place Resident #77 in his shower chair. Resident was alert and able to make needs known. Resident denied pain at this time. Skin intact, treatment in place no injury noted. Maintenance notified of Hoyer malfunction. Maintenance did educate staff regarding Hoyer to inspect it before doing a transfer which was the intervention. Nurse practitioner and power of attorney notified. Nursing log note dated 1/24/2020 at 12:04 p.m., revealed during transfer with Hoyer lift the clip came off on the right side as a resident was going into her wheelchair. Resident #99's leg dropped approximately ½ inch into the wheelchair chair seat of the wheelchair. Resident denied any pain, discomfort. No redness or swelling or bruising noted. The intra-facility request for repairs or alteration for incident on 10/17/19 was not provided. Intra-facility request for repairs or alteration dated 1/24/2020 revealed a clip came off Hoyer lift a second time. Mashed hook slightly and reinstalled. Intra-facility request for repairs or alteration dated 1/29/2020 revealed clip on Hoyer lift replaced. 1. Hoyer lift UNO 100 LIKO. No serial number. 2. Hoyer lift UNO 100 EE. Product number 11 and serial number 52. -At time of exit, no in-service documentation on Hoyer lift was provided. B. Resident interviews Resident #99 was interviewed 1/29/2020 at 9:35 a.m. She said, I noticed the clip was not on the Hoyer lift correctly this morning. She said the CNA's called maintenance supervisor (MS) and he just replaced the pin right back on the lift. She said she almost fell out of the lift when the the strap fell off last week. She said, I was lucky that my wheelchair was under me or I may have fallen on the ground. She said, I get scared and it worries me. Resident # 77's mother was interviewed on 1/29/2020 at 10:13 a.m. She said she was told of the problems with the Hoyer lift and the incident which happened on 10/17/19. She said she had just walked in her son's room after the incident but did not witness it. She said, I was told there were no injuries to my son but I am sure it scared him. She said the facility was short staffed and the CNA's rushed resident transfers which may have been part of the problem. C. Staff interview The nursing home administrator (NHA) and facility consultant (FC) #1 were interviewed on 1/29/2020 at 6:30 p.m. The NHA and FC #1 were informed of the interviews with the Hoyer lift. The NHA said the manufacturer does annual certifications. She said staff were provided in-service on proper use of the Hoyer lifts. FC #1 said the two Hoyer lifts in question will be taken off the floor until certification were verified. -At 6:46 p.m. the MS said both Hoyer lifts were taken off the floor. -At 7:00 p.m., FC #1 said, We are borrowing a lift from our sister facilit(TRUNCATED)

Based on observations, interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents, through continuous attention to qualify of care, quality of life, and resident safety. Specifically, the facility failed to demonstrate that their quality assurance performance improvement (QAPI) program committee effectively identified quality care issues to address concerns related to abuse prevention, accident hazards, resident rights, respiratory care and highest practicable quality of life. Findings include: I. Cross-referenced citation with harm Cross-reference F689: The facility failed to ensure residents were free from accident hazards related to falls for residents identified at high risk for falls and that all possible interventions were put into place and reevaluated to prevent further falls. In addition, the facility failed to ensure mechanical lifts were in safe and proper working condition. Resident #83 sustained an injury (laceration) to her head requiring hospitalization and treatment. Resident #119 sustained a displaced apophyseal fracture of her left femur identified on 12/24/19 and subsequently admitted to the hospital for surgical intervention. II. Cross-referenced citations Cross-reference F600: The facility failed to ensure residents were protected from abuse. Cross-reference F550: The failed to ensure residents were treated in a dignified manner. Cross-reference F583: The facility failed to ensure residents' private medical information was protected. Cross-reference F684: The facility failed to provide care and services necessary to maintain the highest practicable physical well-being. Cross-reference F880: The facility failed to ensure proper infection control processes were followed to prevent cross-contamination related to housekeeping, handwashing and wound care. III. Repeat deficiencies Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies. F550 During the 1/10/19 standard survey, F550 was cited at a D level for failure to ensure residents who expressed concerns did not perceive they were treated differently; residents who had high care needs did not perceive they were treated differently; and, follow-up with resident emotional needs after addressing resident reported concerns. During the 1/30/2020 standard survey, F550 was cited at an E level for potential for more than minimal harm at a pattern. F689 During the 7/25/19 abbreviated survey, F689 was cited at a D level for failure to transfer a resident with two people in accordance with their plan of care. During the 10/17/19 abbreviated survey, F689 was cited at an E level for potential for minimal harm at a pattern for failure to implement and care plan effective interventions timely after two resident falls, ensure complete and accurate neurological assessments for one of the resident's and ensure a treatment cart was kept lock. During the 1/30/2020 standard survey, F689 was cited at a G level for actual harm. F600 During the10/17/19 abbreviated survey, F600 was cited at a G level for actual harm for neglect and failure of staff to follow resident's plan of care for transfers and attempted unsafe transfer resulting in a major injury. During the 1/30/2020 standard survey, F600 was cited at a D'' level. F695 During the 7/25/19 abbreviated survey, F695 was cited at a D level for failure to ensure oxygen was administered according to physician's orders [REDACTED]. F 880 During the 1/10/19 standard survey, F880 was cited at an F level, no actual harm with potential for more than minimal harm; widespread. During the 7/25/19 abbreviated survey F880 was cited at a D level for failure to follow proper sanitary practices and proper hand hygiene/glove use during incontinence care. During the 1/30/2020 standard survey, F 880 was cited at an E level. III. Staff interview The nursing home administrator (NHA) was interviewed on 1/30/19 at 6:45 p.m. She said the QA meeting was held monthly and attended by the DON, medical director, pharmacist consultant and entire interdisciplinary (IDT) team. She said an agenda format was followed at each meeting whereby each IDT member reported on any concerns that could be QA'd and what the goals would be. She said progress was discussed for any ongoing PIPs (process improvement plans). She said they had subcommittees to include: safety, to include falls, infection control, psyche/pharm, nutrition-at-risk, nursing-skin issues, catheters, rehabilitation and risk management (for falls and reportable events). She said they look at their quality measures and quality indicators as a guide as well in creating the subcommittees. She said items brought forth for QA were identified through resident and family concerns/grievances, through public health surveys and through resident council meetings. She said once a concern was identified the team would decide if a PIP should be put into place and decide who would be responsible for each part of the PIP. They would include measurable goals and would track the progress on a monthly basis and report at QA until 100% compliance was achieved. She said if a concern was resolved 100%, they like to hold that for three consecutive months and then call it resolved. She said if progress was not being achieved, the QA committee would discuss why they did not make progress and then modify the action plan or PIP as needed. She said they utilized audit tools, tracking and trending and would do a root-cause analysis. She said their medical director was very involved, listened to each department's reports and offers suggestions and will provide helpful information and education. She said that no concerns had been brought to QA regarding abuse concerns. She said they follow the guidelines for reporting and do not hesitate to report. She said the neglect concern (F600) during a previous complaint survey was reported to the State Agency as appropriate. She said the most recent abuse allegation would be discussed at the next QA. She said no concerns had been brought to QA regarding privacy and confidentiality of records (F583). She said no concerns had been brought to QA regarding dignity and respect (F550). She said they are always mindful of how they treat their residents and she felt that they addressed things appropriately through investigation or education. She said no concerns had been brought to QA recently regarding quality of care and not following physician's orders [REDACTED]. She said she thought that concerns regarding range of motion and use of splints (F688) had been brought up at a past QA but she could not remember when that was. She said the therapy manager was a part of the QA meetings. She said that falls are a big focus in QA. She said they are continuously monitoring if their interventions are effective. She said they look at falls by neighborhood and by shift. She said they look at root-cause of falls and how they can prevent them. She said they look at any PIPs they have in place and if an intervention was not effective, they would look for an alternate. She said no new concerns had been brought to the last QA regarding problems with falls (F689). She said that maintenance had been monitoring lifts appropriately and replacing rings. She said that no concerns had been brought to QA recently regarding infection control practices (F880) for housekeeping or wound care. She said no concerns had been brought to QA regarding hand washing issues in the kitchen. She said that they had spoken about respiratory issues in the past and had addressed concerns and corrected them. She said there had been no concerns brought to QA recently regarding respiratory (F695). She said there have been no concerns brought to QA by dietary recently regarding any problems in the kitchen with sanitation or handwashing (F812). She said there have been no specific concerns brought to QA regarding Hospice collaboration (F849). She said Hospice was considered a partner in the provision of resident care and services. She said that QA was their opportunity to share plans for improvement and to identify the areas where they are weak and to strengthen their systems. She said they have addressed past citations regarding falls by creating a PIP to see if their interventions have been effective and reduced. She said the PIP was implemented in September 2019 and was currently ongoing. She said they conduct daily post-falls huddles daily during grand rounds and that has seemed to be an effective intervention.

Based on interviews and record review, the facility failed to ensure one (#5) of six sample residents was free from neglect. Specifically, the facility failed to ensure staff followed Resident #5's plan of care for transfers and attempted an unsafe transfer, resulting in a spiral [MEDICAL CONDITION]'s right leg, requiring hospitalization and undue pain. Cross-reference F689 falls/accidents and F697 pain management. Findings include: I. Resident #5 status Resident #5, age 96, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/2/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. She required extensive assistance of two staff members for transfers. II. Family Interview Resident #5's son was interviewed on 10/21/19 at 9:16 a.m. He said the facility told him his mother's leg was broken during a transfer but did not give him any further details. He said his mother was now completely bed bound with a full leg cast on. She would have to remain this way for several weeks. He said the doctor at the hospital said it was a spiral fracture which usually occurred when the leg has been twisted. III. Record review According to the (MONTH) 2019 CPO, orders included for the resident to be transferred using a sit to stand mechanical lift with the assistance of two people. The resident's care plan, last revised 8/26/19, revealed the resident had an activities of daily living (ADL) self-care performance deficit. Interventions included: the resident required assistance by two staff to transfer with a sit to stand lift. The Kardex (a summary for the CNAs of how to care for the resident) revealed the resident required assist by two staff to transfer with the sit to stand lift. According to the 10/13/19 event note, at approximately 1:00 p.m. certified nurse aide (CNA) #1 approached the nurse and told her Resident #5 had a broken leg. The CNA said he was transferring the resident to her bed and her foot got stuck and somehow broke her leg. When the nurse assessed the resident, her left leg was on the bed and approximately three to six inches from the ankle, the leg was bent at an outward angle that clearly showed a break in the leg. The resident was crying and saying, My leg hurts so bad. The physician's office was notified and orders were received to send the resident to the hospital. According to the 10/13/19 risk management report, the resident had a [MEDICAL CONDITION] lower leg. Her pain was rated 10 out of 10. Her blood pressure was elevated at 147/110. Emergency medical services (EMS) were notified and obtained intravenous (IV) access immediately and administered pain medication prior to transferring the resident to the gurney for transport. According to the CNA witness statement on 10/13/19, the CNA was transferring the resident from her wheelchair to the bed and during the transfer the resident's leg got stuck. The CNA continued the transfer, got the resident on the bed and went and got the nurse. The CNA stated he was transferring the resident by himself without the use of the lift. According to the 10/13/19 emergency room report, the resident had a distal tibia/fibula spiral fracture. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 10/17/19 at 3:25 p.m. She said the resident's transfer status could be found on the kardex and in the care plan, and she said they kept a chart at the nurses' station with all the resident's transfer needs. She said if a resident required the use of a lift, the lift was to be used for every transfer and should always be done with two staff members. The director of nursing was interviewed on 10/17/19 at 3:38 p.m. She said the resident should never have been transferred without the lift and the assistance of another staff member. She said the nursing staff had been educated on proper lift use recently, and she was not sure why CNA #1 decided to do it by himself. She said CNA #1 no longer worked at the facility.

Based on record review and family and staff interview, the facility failed to ensure one of three sample residents (#3) received adequate supervision and assistance to prevent accidents and injuries. Specifically: Resident #3, per assessment, was totally dependent on two-plus persons for bed mobility and transfers. On 8/14/14, a right knee injury was documented. The facility failed to provide resident care in a safe manner; and to investigate the root cause of the resident's swollen, painful knee, which was not treated for [REDACTED]. The facility's failures contributed to a knee injury including fracture and muscle tear, delayed treatment, and pain. The findings included: I. Resident Status Resident #3, less than [AGE] years old, was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], revealed the resident was usually understood and usually understood others. The resident had no speech, and his cognitive skills for daily decision-making were coded as severely impaired. The MDS indicated the resident also had long and short-term memory problems. No behavioral symptoms were noted. The resident was totally dependent on two-plus persons for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. Walking and standing did not occur. The resident used a wheelchair pushed by another person for ambulation. He received occupational therapy services on 6/12/14 and physical therapy from 7/10 through 8/22/14. [DIAGNOSES REDACTED]." The resident was not on a scheduled or as-needed pain medication regimen. (Prior MDS review revealed the resident was also noted as totally dependent on two-plus persons for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing, per MDS assessments on 9/16/14 and 3/11/14.) On 4/3/14, physical therapy completed an assessment on resident #3 that read, "Patient requires total assistance including use of Hoyer for mechanical lift transfers in and out of bed and his specialty wheelchair (tilt-in-space with saddle cushion that is being address by an outside company on a regular basis). . . " II. Knee Injury of Unknown Origin A. Failure to thoroughly investigate cause of injury The facility's investigation was provided and reviewed on 11/22/14 and again on 1/3/15. The report indicated the injury date was on 8/14/14 at 9 a.m. and the investigation started on 8/14/14. The summary documented CNA #1 reported the incident and had been providing care to the resident (on the 10 p.m. to 6 a.m. shift) when she noticed swelling to the right knee and reported this to the nurse. The report noted that staff, resident, and family interviews were conducted and the resident was assessed by the LPN. The form had a place to describe the assessment findings including measurements, color, and pertinent medications the resident might be taking. The injury was described as: "Slight swelling along kneecap. No swelling above or below the knee. No redness or warmth noted. Resident complains of slight pain when knee is touched." The form indicated the resident was not transferred to the hospital. The incident form revealed, "When interviewing resident, he was asked if he was afraid of any staff and he shook his head 'no.' He did not show signs of fear." The form indicated treatment was provided. "Resident was assessed by nurse and an x-ray ordered by physician." The form indicated the assessment was completed by an LPN on 8/14/14 (no time). The form also indicated 10 residents were interviewed, listing their resident numbers. The form revealed the resident was nonverbal but could shake his head "yes" or "no" when asked questions. The resident nodded his head "yes" to the question did his knee hurt; and when asked if he bumped his knee, he shook his head "no." When asked if he remembered his knee getting twisted, he shook his head "no." When asked if staff treated him roughly, yelled at him, or was he was afraid of staff, he shook his head "no." The form indicated all of the residents interviewed stated staff had not treated them roughly or yelled at them, and they were not afraid of staff. Under the segment entitled "Summary," the form read 10 staff members were interviewed. CNA #1, who worked the 10 p.m. to 6 a.m. shift, stated she reported the resident's knee injury to a nurse on the nights of 8/12/14 and 8/13/14. When she asked the resident if his knee hurt him, he nodded his head "yes." She attempted to help the resident straighten out his knee, and he began hitting his hand on the bed, so she stopped. CNA #2 (who had also worked the night shifts on 8/12 and 8/13) reported she had not worked with the resident on the 10 p.m. to 6 a.m. shift. She reported she overheard CNA #1 report to the nurse about the resident's knee. The form indicated all other staff members stated they had not seen anyone mistreat or yell at any residents, and they did not know of any residents who were afraid or felt threatened by staff. All staff stated they were comfortable reporting concerns related to resident safety. The form also revealed two family members were interviewed and they had no concern of mistreatment or staff yelling at residents, and were comfortable reporting concerns. The form read the IDT (interdisciplinary team) team had come to the conclusion that most likely the cause of the swelling of the knee was the resident's recent participation with therapy. The form indicated an order was written on 7/11/14 for physical therapy, to treat and evaluate the resident for postural alignment (stretching, positioning and strengthening, etc.) as appropriate. "The abuse had been unsubstantiated, no assailant was identified, and the resident indicated he was not afraid of staff. No cowering, grimacing, or flinching observed. No change in socialization pattern, demeanor noted. No finger marks, skin tears, bruising or abrasions were noted. X-rays (on 8/14/14) showed no cortical fracture, no abnormal periosteal reaction and/or no effusion. Final ultrasound showed no right leg deep vein thrombosis." Tylenol was scheduled for pain. It was documented this incident was not reported to the police, because it did not meet the reportable requirements. The care plan was updated on 8/14/14 regarding the knee injury. The goal was the pain and swelling to the right knee would resolve within 14 day of origination, with a target date of 8/28/14. Physical Therapy Notes Review of the physical therapy (PT) notes on 1/3/15, revealed on 8/14/14, the physical therapist documented there was a concern about the resident's right knee being swollen today as reported by nursing the last night. The physical therapist documented he had treated the resident on Tuesday 8/12 without any adverse events at that time. The physical therapist documented he examined the right knee and noted increased redness, swelling with effusion evident by palpation with tenderness and/or pain as expressed by the resident (on 8/14/14). PT documented passive range of motion remained within normal limits into flexion and extension with minimal pain only. PT documented his recommendations that the physician be called for further work up, and nursing was aware and would follow up. PT was put on hold at this time. On 8/19/14, PT documented he had checked on the resident in the p.m., and the right knee was still with some swelling present, but without redness or warmth to the touch. Passive range of motion exercises to the right hip and knee, PT documented, were within normal limits with some pain expressed by the resident. However, the facility had closed the investigation related to the injury of unknown origin, four days prior. Review of restorative nursing notes revealed a new order was written for passive to active assist range of motion to both the lower extremities on 6/30/14. The restorative note dated 7/31/14 documented active assist to right upper and lower extremities was completed, and the resident reported no complaints of pain or discomfort. In the copies of the restorative notes requested, no note for 8/14 was received. However, on 10/10/14 restorative nursing documented a new order was written to discontinue passive range of motion to the right lower extremity. There was no documented evidence that any restorative nursing personnel were interviewed during the investigation of the injury of unknown origin to the right knee. In addition, review of the staff list on duty from 8/12 through 8/14/14, was reviewed and revealed the following information: - None of the evening staff on duty 8/12, the evening before the first reported time of the knee injury, were interviewed. -The night shift registered nurse (RN), on duty 8/12 and 8/13, was not interviewed. -The day shift RNs on duty on 8/13 and 8/14/14 were not interviewed. -Restorative personnel were not interviewed. -The facility failed to identify and interview the CNAs who had provided transfer assistance, or range of motion exercises, prior to the discovery of the resident's injury. The resident continued to experience pain and swelling, per documentation in nurses' notes on 8/28, 8/29, 9/22, and 9/23/14 when the physician ordered an MRI (see below). B. Delayed Assessment and Treatment According to nurses' notes dated 8/14/14 at 1:29 p.m., day shift licensed practical nurse (LPN) #1 documented a right knee injury, reported by night shift CNA #1, who had observed the resident's right knee to be slightly swollen along the knee cap. LPN #1 charted, upon initial assessment, the resident complained of slight pain when his knee was touched. The physician's office was notified. LPN #1 charted upon the second assessment, requested by the resident's mother, who was present, that the resident began hitting the arm of the wheelchair with his right hand when his knee was touched lightly. The resident also stiffened his body and threw his body back in the wheelchair (w/c), and made a screeching noise. The mother voiced the knee was hot to the touch and very swollen, but this was not noted during the assessment. The resident nodded his head "yes" when asked if he had pain. The resident's pulse was documented as 109. There was no evidence the physician was notified of the resident's severe pain response, or the findings from the second assessment. There was no evidence in the nurses' notes of a complete assessment by a registered nurse (RN). On 8/14/14 at 5:37 p.m., LPN #1 charted the right knee continued to be swollen and the resident confirmed discomfort. The physician ordered an X-ray. The resident had an order (6/10/14) for 650 mg of Tylenol twice a day that he was receiving. On 8/15/14 at 3:41 a.m., an RN charted the resident was not straightening out the knee, there were no complaints per resident of pain, however there was still swelling of the right knee. On 8/15/14 at 1:19 p.m., the LPN #1 on duty documented the x-ray was negative, and the ultrasound was completed, however; they were awaiting the results. The resident complained of slight pain; however, the pain assessment for the shift was blank (void of any charting). On 8/15/14 at 8:04 p.m., an RN documented the resident had a slightly swollen knee. The X-ray and ultrasound were negative. The MD ordered ice packs to the right knee for 15 minutes three times a day for three days. Despite this order, the TAR revealed no documented evidence that this was done on Sunday 8/17/14. On 8/16/14 at 10:37 a.m., a nurse documented there was no swelling when the right knee was bent. On 8/17/14 at 2:42 a.m., an RN documented the resident kept the right knee bent without an increase in swelling noted. On 8/17/14 at 11:45 a.m., an RN assessed the knee and documented the knee remained swollen with no visible redness. There was no documentation about the right knee on 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, and 8/27 until 8/27/14 at 12:41 p.m. when an LPN documented the right knee had increased swelling and also swelling of the right foot. The MD was notified and labs were ordered and drawn, Aleve two tablets of 220 mg was ordered (on 8/28/14) twice a day for 7 days, and nurses were to notify the MD if the swelling did not improve. Also, Voltaren Gel (ordered 8/25/14) was to be applied to the right knee four times a day for 10 days. According to the TAR, Voltaren was ordered on [DATE] at 3 p.m.; however, was not started until 8/27/14, and there was no evidence it was given four times a day as ordered on 8/29, 8/30, or 8/31/14. The TAR revealed the medication was not given OA (on arising) on the morning shift on these three days. According to the MAR and physician orders, Aleve was started on 8/28/14, and not documented as given on 9/1/14 on the evening shift. On 8/28/14 at 8:03 p.m., an RN documented the right knee and right foot were slightly swollen, and the resident denied pain at this time. On 8/29/14 at 3:03 p.m., an LPN charted the resident continued to have pain to the right knee; however, the swelling was decreased. Despite the documentation of this pain, review of the 8/14 MAR revealed a zero (no pain) for the 2-10 p.m. shift on 8/29/14 per the pain assessment entry. There was no documentation specifically about the right knee pain or swelling until almost a month later, when on 9/22/14, an LPN noted at 9:05 p.m., the resident appeared to have "some pain facial expression when (she) touched his right leg and he nodded 'yes.'" Tylenol was given. On 9/23/14 per nurses' notes, the MD ordered an MRI to the right knee related to increased pain and swelling. The MRI was not completed until 10/1/14, nine days after the physician order, and over six weeks after the resident began complaining of pain and had visible signs of swelling. The results of the MRI indicated the resident had a "nondisplaced lateral tibial plateau intraarticular fracture, small knee joint effusion, and anterior torn lateral meniscal complex tear reaches the superior and inferior joint surfaces without significant meniscal fragment displacement." On 10/3/14 at 7:01 p.m., an RN documented the resident was to be fitted by PT (physical therapy) for a right knee immobilizer brace, and PT was to educate the staff on proper transfer techniques with the immobilizer on. In addition, the physician ordered a Lidoderm patch to the right knee tibial plateau beneath the knee cap, on 12 hours, and off 12 hours. The physician discontinued the knee brace on 10/24/14. Family and Staff Interviews: A family member was interviewed on 11/19/14 at 12:32 p.m. The family member said she felt a thorough investigation had not been completed, and the facility had told her what they thought had happened. She stated the facility staff were to use the Hoyer lift to transfer the resident to the bed and when getting him up; however, she had seen staff grab the resident by the back of his gown and his arms and do a two-person lift. The Nursing Home Administrator (NHA), and the Director of Nursing (DON) were interviewed on 11/22/14 at 1:55 p.m. After reviewing the incident report, the NHA stated they had also interviewed PT. They also explained that an RN had assessed the injury, however, no evidence of this was found in the medical record until 8/15/14, at 3:41 a.m. The Physical Therapist was interviewed by phone on 1/3/15 at 12:40 p.m. He stated he had worked with the resident in August two times a week and was assisting him with mobility, tone and helping him to sit better in a chair. The PT stated most of the time, the resident's mother was there. They were working on getting him a tilt back wheelchair. The PT went on to say they did do a two-person level transfer with the resident, which is where one staff member supports the upper extremities and the other the lower extremities, and transfer the resident level from the bed. However, the PT stated that though this two person level transfer method was uncomfortable for the resident, they never did anything that would have compromised the knee. He added that restorative was working with the resident doing range of motion. The NHA (newly hired as of 12/16/14) and the DON were again interviewed on 1/3/15 at 2 p.m. The DON stated they ruled out abuse and did not think about reopening the case again or even starting a new investigation when the resident again complained of knee pain. The DON had no explanation for the dated squares on the MARs and TARs without initials indicating the treatments were not as ordered and the medications were not given as ordered. The DON stated the physician had no idea of what had happened, and agreed with them that using PT more often possibly had caused the resident more pain.

Based on observations, record review and interview with residents, staff, family members, the medical durable power of attorney (MDPOA) and the facility medical director (MD), the facility failed to ensure the resident environment remained as free of accident hazards as possible and that six (#1, #16, #8, #21, #12 and #22) of 26 sample residents received adequate supervision and assistive devices to prevent accidents. Specifically: The facility failed to implement care planned measures to prevent falls, failed to thoroughly investigate resident injuries/falls for causation, and failed to review existing safety interventions. Resident #16 fell after tripping over a fall mat with her walker and resident #1 fell from bed. Both residents' functional status declined following their falls. Findings include: A. Facility Fall Policy Review of the facility policy provided on 10/3/13 at 8:39 a.m. titled, 'Falls Management,' read in pertinent part: Policy: Each resident will be assessed throughout the course of treatment for [REDACTED]. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. The interdisciplinary team will attempt to balance safety needs, resident rights, and quality of life issues that will positively impact each resident's individual situation and reduce the risk of occurrence. Residents who experience a fall will receive prompt medical attention. Immediate needs will be quickly assessed and responded to. The physician and family will be notified of the incident and a plan will be identified and implemented as necessary to protect the resident and/or others from recurrence. Procedure: All residents will have a falls risk assessment completed on admission, following serious injury, after a significant change, quarterly and as necessary. If a resident receives a score of 10 or greater on the fall risk assessment (refer to standard fall risk assessment form on page 1-15) or has incurred at least one fall within the last 90 days, the resident is assessed for hip protection. An interdisciplinary care plan is developed as necessary to reflect each resident's current safety status, needs and interventions. A care plan is reviewed throughout the course of treatment by the interdisciplinary team to assure the most recent, updated, and resident specific fall reduction interventions have been incorporated as necessary into the plan of care. Management of falls: When a resident has a fall the charge nurse will be notified immediately. -The charge nurse will provide prompt medical attention as needed, protect the resident from recurrence, and authorize contact of EMS as necessary. -The charge nurse will assess for injuries prior to moving the resident. -When the initial assessment denotes possible fracture the affected area is immobilized and the resident is provided comfort until EMS arrives. -Vitals signs are taken including B/P (blood pressure), pulse, temperature, and respirations. -The responsible party and physician are promptly notified of the occurrence and status of the resident. -The charge nurse will notify the immediate supervisor of the fall as necessary. -The Charge nurse will gather and record as much pertinent data as possible related to the fall, take note of the environment in which the fall occurred and record any potential causal factors. -The charge nurse will complete an incident report. -The charge nurse will review and update the care plan as needed to reflect the resident's present mobility, safety needs, and will communicate fall reduction interventions to care givers on the unit and in shift report. -Pertinent information regarding the fall will be recorded in the nurses' notes and on the 24 hour shift report. Follow up for falls: Each shift will receive information concerning the fall. -Each shift nurse is responsible for 72 hour alert charting in addition to recording the resident's mobility and comfort status, vital signs, new orders or interventions, and the resident's response to the fall. -All falls will be reviewed by the interdisciplinary team (IDT) members following the daily stand up meeting. The IDT will review the incident report, fall history, the care plan, and other pertinent data to determine the need for further investigation. -The IDT will determine the need for development of any additional facility-wide or resident specific interventions, staff, resident and or family education and training, or other follow up measures that may be needed to reduce the risk of recurrence. -Each resident's care plan is updated following a fall to reflect current health status and fall reduction interventions. -The fall reduction committee (a sub-committee of performance improvement) will review fall trends, analyze data, and determine the need for action plans designed to minimize the risk of falls. 2. Incident Policy A facility policy provided by the facility titled, 'Incident Management,' included in pertinent part: The facility identifies residents at risk for incidents and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence. If a resident has had an accident or fall, the facility investigates and provides focused review to minimize the potential for recurrence. Define an "accident" as an unexpected, unintended event that can result in bodily injury, but does not include adverse outcomes associated as a direct consequence of treatment or care. Identify residents who are at risk for incidents and implement care planned procedures designed to reduce the risks of incidents. Provide timely investigation of incidents and utilize RAP triggers ... to assess causal factors and or trends and implement reasonable and appropriate action plans reducing the risk of recurrence. Provide timely investigation of accident/falls to determine if the incident is reportable to local agencies per regulation. Procedural Steps: -The unit nurse completes the incident report at the time of the occurrence. Each incident report must include the date and time of the incident, a description of the incident, witnesses, parties involved, vital signs, the date and time the family and physician were notified, who was notified and the signature of the person completing the incident report. -Following an incident 72 hour alert charting is initiated per facility protocol, the care plan is reviewed, updated as necessary to reflect the resident's current safety status, and interventions are designed to reduce the risk of recurrence. -Incidents that result from alleged physical and/or verbal abuse, elopement or incidents that result in physical injury that requires medical treatment outside the facility will be immediately reported to the director of nursing and or designee and the executive director. -All incident reports will be reviewed by the director of nursing and or designee to rule out the possibility of willful abuse or neglect. Reportable incidents will be called to appropriate agencies per state guidelines. -The need for further incident investigation is determined by the executive director, director of nursing, and/or designee. Falls, reportable incidents, incidents with injury, repeated incidents, or injuries of unknown origin are examples of incidents that require additional investigation. Subsequent investigation should include assessment of possible contributing clinical and environmental factors. For example a post-fall investigation should include: review of medications, patterns of the fall, behaviors, pain, constipation, and restraints. (Utilization of the RAP modules to assess causal factors for decline or lack of improvement can be instrumental in creating a plan of action designed to reduce the risk of recurrence.) -If warranted, a thorough investigation will be conducted, documented and will include: --Observations, interviews and record reviews of all residents involved. --Interviews of all witnesses, including residents, staff visitors, and family members. --Notifying the physician and the families or responsible parties of the involved residents. --Recording all relevant physical findings. --Determining and documenting a conclusion if possible. --Developing a plan of action to reduce the risk of recurrence. --All completed incident reports will be forwarded to the executive director for final review. --If the incident is determined to be reportable, the incident must be called to state officials promptly. --All incidents are reviewed as necessary for contributing factors and possible trends. Patterns identified from incident reports and/or subsequent investigations conducted by facility management will be presented to the performance improvement committee. If trends are identified, follow-up interventions by the committee may include - increasing the sample size, creating and implementing an action plan based on the data collected. Action plans developed by the performance improvement committee will be communicated to the staff through ongoing inservices, orientation, care planning, and/or staff meetings and will be based on considerations. B. Resident Failures 1. Resident #1 Resident #1, an [AGE] year old female, was admitted to the facility on [DATE], was discharged to assisted living and then readmitted on [DATE]. She passed away on 9/1/13 at the facility. According to her face sheet, her [DIAGNOSES REDACTED]. a. Resident Status According to her most recent minimum data set (MDS) provided by the facility and dated 5/16/13, the resident scored a 12 on her brief interview for mental status (BIMS) indicating that she had moderate cognitive deficits. She was noted as being a one physical assist for all activities of daily living except eating for which she was identified as only needing supervision. She was identified as not having any recent falls or falls while in the facility. Record review revealed that the resident had a care plan initiated on 2/22/12 and last updated 8/30/13, which read in pertinent part: -Resident is at risk for injuries related to falls secondary to impaired mobility, pain, antipsychotic, antianxety, and antiderpressant use, and frequent episodes of bladder and bowel incontinence. -Interventions included to assist the resident with a Hoyer lift as needed for transfers, assist her with toileting tasks at her request and as needed, observe resident for side effects of medications in her current drug regime, place items frequently used by resident within easy reach, bed alarm and personal alarm to wheelchair, lap tray to wheelchair for proper positioning, bed against wall to allow more space in room, non skid strips next to bed and in front of recliner, high low bed with mats next to bed with wedge cushion to left side at all times while in bed (added 8/30/13), vertical grab bar on right side in bathroom for stability with transfers. b. Pain in left ankle and discovery of fracture to left lower leg - Facility response - Failures in facility response Record Review: (1) A nursing note dated 7/17/13 stated that the resident complained of pain to the left ankle. Swelling was noted to medial and lateral ankle and top of left foot. Resident complained of pain with manipulation. The physician was in to see the resident and ordered an x-ray and the legally responsible party was notified. An x-ray result from the x-ray taken on 7/17/13 of the resident's foot (no x-ray was ordered for the resident's ankle) did not show a fracture. There was no investigation documentation available for the left ankle pain and possible injury on 7/17/13. (2) An incident follow up form dated 7/27/13 at 10:30 a.m. was reviewed -It read the resident complained of discomfort to the left ankle and stated she heard a pop to the ankle. Pain noticed with manipulation. The resident denied falling or bumping ankle. She stated it had been hurting for a couple of days now. -Documentation of recommendations and actions taken read that the resident had a history of [REDACTED]. The resident was sent to the emergency room for her fracture and returned with a brace intact and later had an appointment on 8/8/13 to get a full left leg plaster cast. -The checklist for QA (quality assurance) revealed that care plan update was left blank and falls assessment updated was marked N/A (not applicable). -An x-ray of the resident's ankle was attached dated 7/27/13, which indicated the resident had a nondisplaced distal tibial diaphyseal oblique fracture at the tip of an intramedullary fixation rod, identified as an undiagnosed fracture of a major long bone/pelvis. An x-ray of the resident's foot was also taken on 7/27/13 which did not show any fracture. -A care plan was attached which was initiated on 7/27/13 and stated the resident had a fracture of the left ankle (see x-ray above, the resident did not have a fractured ankle but a fractured distal tibia). Approaches were to immobilize site and ortho(pedics) to follow resident. There was no update to the careplan regarding increased safety needs. See above; the investigation of the resident's 7/27/13 ankle pain and identified fracture did not include interviews or a root cause investigation of the fracture; no cause was identified and no interventions were put in place to prevent subsequent accidents/injuries. Record review revealed the resident was placed in a full leg cast on 8/8/13. While the resident's comprehensive care plan was updated on 8/6/13 and indicated the resident had a recent tibial fracture and was non weight bearing making her only appropriate for Hoyer lift transfers, the care plan failed to note the resident's full leg cast and interventions to ensure the resident's safety in bed. Interviews: Interview with the unit manager on 10/3/13 at 2:43 p.m., revealed she recalled resident #1 had a fracture that occurred in the middle of July. She stated the resident had complained about ankle pain in the middle of the month and they did x-rays which were negative, then towards the end of the month, she stated she heard a pop in her left ankle, and she was sent to the hospital for evaluation and a distal tibial fracture above the ankle was discovered. She said the resident declined, especially after the fracture. She stated that she was not aware of the cause of the injury or when exactly it happened. Interview with the nursing home administrator (NHA) on 10/3/13 at 10:00 a.m., revealed the facility had provided all documents for the investigation on the resident's tibial fracture; she confirmed there were no statements from residents or witnesses besides the nurse who filed the initial incident report. She stated that they thought the incident was not an injury of unknown origin because the resident heard it pop. Interview with the social services director (SSD) on 10/7/13 at 12:24 p.m., revealed that they did not have an investigation for the tibial fracture for resident #1 as they were only referred to social services if the injury was of unknown origin. She stated that if she did not have it, the origin of the injury was known. Interview with the NHA and regional vice president (RVP) on 10/8/13 at 9:19 a.m., revealed that the facility had not investigated the injury on 7/17/13 due to the x-ray coming back negative (although see above; an x-ray was conducted of the resident's foot, not ankle). Then on the 7/27/13, when the resident heard a pop in her ankle and had pain, another x-ray was obtained. The NHA stated that they had not found an investigation for the ankle injury and said there should have been an investigation. Interview with the DON and regional nurse consultant on 10/8/13 at 9:19 a.m., revealed that after looking at the x-rays from 7/17/13 and 7/27/13, if she had made the request for an x-ray to the physician due to a resident complaining of ankle pain and she received an order for [REDACTED]. Interview with the medical director who was also the resident's primary care physician on 10/8/13 at 11:21 a.m., revealed that it was her opinion that what happened to the resident's ankle was that she was catching her foot behind on her wheelchair where she put her feet. Interview with a quality assurance representative from the x-ray company on 10/21/13 at 8:50 a.m., via phone after the quality team had reviewed the x-rays the previous night, per request, revealed the resident's fracture was higher in the bone than what would typically show in a foot or ankle x-ray. The quality assurance representative stated the fracture was only evident due to an unusually wide angle that had been obtained on the film on the ankle x-ray on 7/27/13. She stated that if taken in the typical manner, neither the foot or ankle x-ray would reveal the area of the tibia that was fractured. c. Subsequent fall from bed with injury - Facility response - Failures in facility response Record Review: Record review revealed that resident #1 fell on [DATE]. A request was made of the NHA for the facility incident follow up report on 10/1/13 at approximately 8:30 a.m. The incident follow up report was provided by the facility on 10/1/13 at 10:10 a.m. It revealed the resident was seen by the housekeeper with her legs over the side of the bed. The CNA that was informed immediately went to resident's room and found the resident on the floor next to her bed with a laceration to her left forehead, a laceration to her right knee, bruising to the bridge of her nose, a cut to her right index finger and a cut to her right knee. -Recommendations and actions taken included that the facility notified the MD, assessed resident, applied steri strips to the resident's forehead, ordered x-rays of the skull, face, right hand, fingers and wrist and the right knee. A wedge cushion was placed at the left side of the resident while in bed. A high low bed with mats next to the bed and neuro checks were put into place. -Follow up indicated that on 8/30/13 cervical x-rays were taken and indicated that the resident had a possible dens fracture (spinal fracture) and the MD was notified. The MD contacted the legally responsible party and no further test would be performed. -The incident follow up concluded that the resident's bed alarm and chair alarms were in place at the time of the fall. -The QA checklist identified that the legally responsible party had been notified on 8/29/13. No interviews or investigation were included with the incident follow up form. Interview with the NHA on 10/1/13 at 11:16 a.m., revealed they had not gotten interviews and done an investigation of the incident because it was so 'cut and dry.' Interview with the NHA on 10/3/13 at 1:29 p.m., revealed that she had not heard much about the resident. -The NHA stated she knew the resident had a cast on her left leg but did not know what had happened with the fall. She said she was found by the housekeeper to have somehow gotten her leg off the edge of the bed and when the housekeeper returned with the CNA, the resident had slipped out of bed. -The NHA said they had looked at issues with the environment and were not sure in what committee or session but had done an analysis of what had happened with her case. The clinical team looked at previous falls in pressure relieving mattresses; however, resident #1 had never had a fall so she was not reviewed in the fall committee and interventions were not put into place until after the resident's fall. On 10/2/13 at 1:45 p.m., an interview with the housekeeping assistant who had observed the resident on 8/29/13, revealed she was finishing her work for the day and went to fill the paper towel dispenser in the resident's room. When she entered she saw the resident leaning out of her bed with her head first, not with her legs hanging out of the bed as noted in the incident report (see above). She stated that she was sure that she had seen the resident with her head leaning out of the bed. She stated they had social services talk to her and she had never seen a resident have such a bad fall out of bed. She stated she spoke to the resident frequently as the resident spoke Spanish and she only spoke Spanish (this interview was conducted in Spanish.) On 10/3/13 at 2:15 p.m., in an interview with the nurse who had responded to the resident's 8/29/13 fall revealed when she had responded to the fall, she had observed the resident was in an air mattress with bolsters. The bed was a high low bed; however, it was not in the lowest position. The position the bed was in caused the resident to have her casted leg on the open side of the bed (left) while her uncasted leg was on the side of the bed that was against the wall. She had assumed that therapy had evaluated the resident for new safety measures after she returned from the hospital with a full cast on her left leg because it was a major change in status. However, no post-cast bed safety evaluation was found for resident #1 during the survey. Interview with the DON and regional nurse consultant on 10/8/13 at 9:19 a.m., revealed an air mattress was put into place for the comfort of resident #1. The DON said they did not meet with restorative nursing or look at her ability to get in and out of bed as she was not trying to get out of bed at all. -The DON said that prior to the resident's fall from bed, the resident had a personal alarm in bed and the bed was supposed to be in the low position when she was in bed. -The DON said when a fall occurs, the existing fall interventions would be reviewed, and an investigation of how the resident fell and what they were doing prior to the fall would be conducted to determine what the appropriate interventions would be; however, she did not know what resident #1 was doing prior to her fall 8/29/13. Interview with the county coroner on 9/30/13 at approximately 12:25 p.m., revealed that after performing an autopsy it was determined that a fracture of the vertebral column was a contributing factor to the resident's death which occurred on 9/1/13, shortly after the resident fell . 2. Resident #16 Resident #16, age 93, was admitted to the facility on [DATE]. According to the October 2013 Computerized Physician's Orders (CPOs), resident #16 had [DIAGNOSES REDACTED]. The 5/23/13 quarterly Minimum Data Set (MDS) revealed resident #16 required limited assistance from one staff for toileting. She had no limitations to her lower extremities. Resident #16 reported that she did not have pain or hurting in the five days prior to her MDS pain interview. Resident #16 had no falls since her previous MDS evaluation. On 10/2/13 the clinical record for resident #16 was reviewed. The clinical record revealed the following: a. Fall with Fracture Progress notes from nursing staff revealed the following: -On 7/6/13 at 3:04 p.m., resident #16 found on the floor in front of the bathroom. Family and physician were notified of the fall. -On 7/6/13 at 5:14 p.m., resident #16 was not experiencing any change in range of motion or discomfort. -On 7/6/13 at 8:01 p.m., an order was received from the doctor for x-rays related to pain on movement to the left knee. -On 7/7/13 at 12:51 p.m., resident #16 was voicing a complaint of pain to the left shoulder. -On 7/8/13 at 9:42 a.m., resident had bruising to inside of left knee. The resident was documented to say, "It hurts some. The doctor said use Bengay that helps." The 7/11/13 CT scan of the upper left extremity stated that resident #16 may have had a partially torn subscapularis. No fracture was present. An MRI was recommended for follow-up. The 7/11/13 CT scan of the lower left extremity revealed that resident #16 had a nondisplaced medial tibial plateau fracture. No other acute findings were identified. The 7/6/13 and 7/8/13 X-rays of the knee and tibia/fibula did not show the presence of a fracture. The 7/7/13 Physician's Progress Note stated in pertinent part, "Last evening the patient was found on the floor after she fell from her wheelchair. Apparently, her roommate has a mat on the floor next to the bed which pushes against the bathroom door and (resident #16) has a difficult time pushing her wheelchair in and out of the bathroom. Patient had complaints of pain of her left knee." A review of Physician's Telephone Orders revealed the following orders: -7/12/13 at 1:00 p.m., immobilizer to the left knee. -7/12/13 at 2:00 p.m., left lower extremity 50% weight bearing as tolerated. -8/22/13 at 3:00 p.m., Okay to be weight bearing as tolerated. A specialist physician consultation note dated 8/6/13 stated that resident #16 was being seen for follow-up to a left knee tibial plateau fracture. b. Failure to implement care plan resulting in fall with fracture Review of the resident's care plan, originally printed 6/2012 and last updated 7/21/13, revealed the facility had identified that resident #16 was at risk for injuries related to falls due to incontinence of bladder. The goal was for resident #16 to remain free from injuries due to falling for the next 90 days. Approaches for the care plan included, in pertinent part, an intervention to "keep environment free from clutter and safety hazards." (1) Record review and resident/family and staff interviews revealed the facility failed to keep the resident's environment free from clutter and safety hazards on 7/6/13, contributing to her fall. A 7/9/13 note on the back of a fall risk evaluation dated 7/6/13 read, "Fall measure in place is roommate night stand moved too foot of bed to allow floor mat to be placed up to head of bed which allows more space for resident to get into the bathroom with wheelchair." A family member, interviewed on 10/2/13 at 2:00 p.m., while visiting resident #16 in her room stated, in pertinent part, that resident #16 had a fall in the late summer that resulted in a hairline fracture to resident #16's left knee. The family member stated that resident #16 fell trying to move her roommate's fall mat which had obstructed resident #16's access to the bathroom. The fall mat had prevented the bathroom door from being opened. The family member stated resident #16 now had pain in her knee that she had not had before the fall. On 10/3/13 at 1:50 p.m., the Unit Manager (UM) for the Happy Trails unit where resident #16 resided was interviewed. The UM confirmed resident #16's fall on 7/6/13 was a result of resident #16 trying to move her roommate's fall mat so she could access the bathroom. She said since the resident's fall, the facility had rearranged some of the furniture on the roommate's side of the room to ensure that the roommate's fall mat did not prevent resident #16's access to the bathroom when the mat was placed at the roommate's bed side. On 10/8/13 at 10:21 a.m., the Director of Nursing (DON) was interviewed. -The DON stated that resident #16 experienced a fall on 7/6/13 on the roommate's side of the room. The DON stated resident #16's fall was a result of resident #16 trying to move her roommate's fall mat to obtain access to the bathroom. After reviewing the resident's chart, the DON stated the resident's fall on 7/6/13 resulted in a non-displaced fracture of the tibia and a partially torn subscapularis (shoulder tendon). -The DON stated that resident #16 needed to have no obstacles in her path on the way to the bathroom. The DON consulted the care plan for resident #16 and confirmed the care plan included an approach implemented on 2/24/09 that directed staff to ensure resident #16's environment was free from clutter. The DON stated she expected that staff would follow the approaches listed on a resident's care plan. The DON stated the fall mat should not have been in the way of the bathroom because it prevented the resident from accessing the bathroom. (2) Continued failure to keep the resident's environment free from clutter and safety hazards On 10/2/13 at 7:48 a.m., resident #16 was observed in her room seated in her wheelchair maneuvering about. Resident #16 was running the water at the sink and getting items from her dresser. The floor on resident #16's side of the room contained several items of debris including food and food wrappers. Resident #16 resided on the window side of the room. The in-suite bathroom was observed to be on the door side of the room with entry near to foot of her roommate's bed. The roommate was in bed with a fall mat in place at the bedside. On 10/2/13 at 11:28 a.m., resident #16's room was observed again. Resident #16 was not present. Debris and personal effects were strewn across the floor on resident #16's side of the room. The debris and personal effects included a floor mat, a dustpan and broom set, a peppermint candy, a candy wrapper and a box of Kleenex. On 10/3/13 at 9:32 a.m., resident #16 was observed in her room. Resident #16 was engaged in getting personal items in and out of her drawers. Resident #16 was seated in her wheelchair with anti-roll back device and pressure alarm on her wheelchair. Resident #16 had soft rubberized foam clogs on her feet. Resident #16 stated she was getting ready for a shower. A piece of bread, various food wrappers, and two towels were observed on the floor. On 10/3/13 at 1:48 p.m., resident #16 was observed in her room. There were bits of refuse on the floor. Clothes were also present on the floor. Resident #16 stated she needed to have some items of clothes laundered. On 10/7/13 at 4:14 p.m., resident #16 was observed in her room. There was clear plastic wrapper, clothes, and other bits of debris on the floor. On 10/3/13 at 1:50 p.m., the resident's UM acknowledged the plastic wrapper, debris and clothes present on the floor in resident #16's room. The UM explained resident #16 had a habit of creating clutter on her floor. c. Facility failure contributed to resident pain and decline in function Record Review: A 7/21/13 change of condition MDS revealed, in comparison to the 5/13/13 quarterly MDS (see above), revealed resident #16 required extensive assistance from one staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. The resident used a walker and wheelchair for mobility. She had impairment to the one lower extremity. -Resident #16 had pain in the five days prior to the MDS pain interview; she reported pain of 8/10 and reported she had pain frequently that limited her day-to-day activities and made it hard to sleep at night. Resident Interviews: On 10/2/13 at 7:48 a.m., resident #16 (moderately cognitively impaired per 7/23/13 MDS) was interviewed as she moved about her room seated in her wheelchair. Resident #16 confirmed that she had fallen and experienced a fracture to her left leg. Resident #16 indicated her left leg still hurt her when she tried to walk on it. On 10/7/13 at 4:14 p.m., resident #16 stated her knee was hurting her. Resident #16 stated she had been practicing walking earlier which she believed caused the pain. Resident #16 expressed hope her knee would not hurt as much when she had to walk again tomorrow. Staff Interviews: On 10/8/13 at 10:21 a.m., the DON stated resident #16 had toileted herself prior to the 7/6/13 fall by getting up and walking to the bathroom with her walker. 3. Resident #8 Resident #8, age [AGE] years, was admitted to the facility on [DATE]. According to the October 2013 Computerized Physician's Orders (CPOs), resident #8 had [DIAGNOSES REDACTED]. The 9/11/13 quarterly Minimum Data Set (MDS), resident #8 had moderate cognitive impairment as evidenced by a brief interview mental status score of 11/15. Resident #8 did not reject cares or have beha

Based on observation, record review and staff interview, the facility failed to provide two of 38 sample residents (#28, #99) the care and services necessary to attain and maintain their highest practicable level of well-being. Specifically: -The facility failed to monitor, communicate and address resident #28's skin tear in a timely manner, contributing to the development of a stasis ulcer and resident pain. -Provide appropriate and consistent follow-up with blood sugar results according to physician orders [REDACTED]. The findings include: A. Resident #28 Resident #28, age 86, was admitted to the facility on [DATE] with a readmitted [DATE]. His diagnoses, according to the facility face sheet and the computerized physician orders, included diabetes, muscle weakness, [MEDICAL CONDITION], [MEDICAL CONDITION], generalized pain, dementia, [MEDICAL CONDITION]. The annual Minimum Data Set (MDS), dated [DATE], coded the resident with a short-term memory problem with modified independence for cognitive skills for daily decision-making, no loss or limitation related to functional range of motion, no pain symptoms, and history of resolved ulcers. According to physician orders [REDACTED]. 1. Wound and pain management a. Record review and observations Review of nurses' notes revealed that on 8/2/10, the nurse practitioner (NP) was notified that the resident had sustained a skin tear. Review of nurses' notes after 8/2/10 revealed no further documentation regarding the skin tear until 9/17/10, when nursing documented that the wound to the right shin now presented as a stasis ulcer. Review of skin assessments, dated 8/2/10 through 9/10/10, revealed that all the assessments noted a skin tear on the resident's right leg. Review of the non-pressure skin condition record, from 8/16/10 to 8/30/10, documented that the skin tear site was the right shin. Observations of the resident's lower extremities on 9/16/10 at 6:30 p.m., revealed a band-aid on the resident's right shin. b. Failure to monitor, communicate and address skin tear in a timely manner (1) See above; review of nurses' notes after 8/2/10 and until 9/17/10, revealed no documentation on the status of the resident's right lower leg skin tear and no communication with the physician or NP regarding the tear. (2) Although at risk for complications due to his [DIAGNOSES REDACTED]. (3) Review of physician orders [REDACTED]. (4) Skin assessment sheets indicated that the resident went ten days or more without a skin assessment from 8/30/10 to 9/10/10, and from 9/10/10 to at least 9/20/10 (a skin assessment had not been completed on this last date of record review). In an interview with the wound nurse on 9/20/10 at 10:15 a.m., the nurse stated skin assessments are done once in a seven day period, not once a week. When asked if a skin assessment was done on Monday in one 7 day period and then on Sunday in the next seven day period the resident could potentially go 13 days without a skin assessment, she agreed, but said she did not see that happening. (5) Staff failed to manage resident #28's wound pain On 9/17/10 at 11:00 a.m., the charge nurse and unit manager were observed as they changed the dressing on the resident's right shin. -The right shin had two open areas (approximately 5 cm x 10 cm and 5 cm x 7 cm in size) located on the right lower shin and one open area (approximately 3 cm x 3 cm in size) above outside ankle. The ulcers located on the lower right shin were moist, with a pinkish-red wound bed and had moderate serous drainage. The skin surrounding the wounds was dark red. -Resident #28 complained of pain during the dressing change and he exhibited several non-verbal signs of pain - pulling his leg away, grimacing, and groaning. The charge nurse asked the resident if the dressing change was hurting him. The resident replied that it was. However, the nurses did not stop the dressing change, offer pain medication or assess the resident's pain. -The treatment order was to cleanse the stasis ulcer to right shin with wound cleanser, then apply [MEDICATION NAME], cover with 4 x 4 gauze and Kerlix. During the dressing change, the nurse cleansed the wound with normal saline, instead of wound cleanser as ordered. Review of the MAR indicated [REDACTED]. The resident had last had something for pain on 9/1/10. c. Interviews On 9/16/10 at 10:00 a.m., the charge nurse for stations 1 and 2 was interviewed about the schedule for skin assessments. She stated that the wound care nurse had her own system and she was unsure how it worked. She stated the wound care nurse was unavailable (she was away from 9/13/10 - 9/20/10) and they were just trying to get the assessments done. She said the wound care nurse had not left them a schedule or any directions. On 9/17/10 at 9:40 a.m., the Unit Manager for station 1 and 2 was interviewed regarding treatment of [REDACTED]. She said if the treatment was just steri-stripes or something like that, they didn't need an order because such treatment was a nursing measure and did not go on treatment administration records (TAR). She said this was a standard of practice, not facility policy. When asked how other nurses would know how to treat the resident's skin tear, she stated the wound care nurse would be back for questioning 9/20/10. The Unit Manager said she was not sure how the wound nurse did things. On 9/17/10 at 10:15 a.m., the charge nurse for station 1 and 2 was interviewed again and asked about the treatment for [REDACTED]. She stated she had called the NP and now had new orders. On 9/17/10 at 10:30 a.m., the Corporate Clinical Consultant was interviewed. She stated that all dressings needed orders and the orders should be on the TAR. On 9/20/10 at approximately 10:15 a.m., the wound care nurse was interviewed about resident #28's skin tear. She stated that she had been treating the skin tear with a dry dressing. Asked why there was no order for a dressing, she stated that she did not write one because it was a nursing measure and standard of practice and therefore, the resident did not need an order. When asked if that was the facility policy, she stated, "That's what they told me today." When asked her how other nurses would know how to care for the resident's wound in her absence, she stated, "I understand what you are saying." When asked the question again, she said, "It's just a dry dressing; they should know." d. System failure On 9/17/10 at 11:30 a.m., the charge nurse for station 1 and 2 was asked about her wound care knowledge. She stated it was poor. On 9/17/10 approximately at 3:00 p.m. the Staff Development Coordinator (SDC) was interviewed. She stated that all dressings needed an order and that you could not treat a wound without orders. She stated that sometimes wounds needed treatment when the wound care nurse was not here; the wound nurse was not at the facility in the evening or at night, and the other nurses needed to know what to do. 2. Hand contracture and pain management a. Record review See above; resident [DIAGNOSES REDACTED]. Cross-reference F279; the resident had no care plan to address pain management. b. Observations On 9/17/10 at 9:10 a.m., resident #28 was observed sitting in the hallway with his fingers on both hands bent and curled in. The resident complained to the surveyor that his hands hurt "all the time, mostly at night." When asked if he told the nurses he said, yes, but had been told there was nothing they could do. c. Interview On 9/17/10 at 10:00 a.m., the rehabilitation (rehab) director assessed the resident's hands at the surveyor's request. He asked the resident if his hands hurt and the resident replied that they did, all the time but mostly at night. Rehab director was asked if the resident would benefit from treatment to his hands; he stated that he "definitely" would benefit. On 9/17/10 at 11:45 a.m., the medication nurse in charge of resident #28's care was interviewed. The nurse was informed of the resident's statements about hand pain. The nurse stated the resident had PRN (as needed) Tylenol and could ask for it if he wanted too. (See above; the resident had received Tylenol once in 9/10 and four times in 8/10.) 3. Diabetic management a. Diabetic management plan Review of physician orders [REDACTED]. -[MEDICATION NAME] 100 units/ml vial, Give 5 units subcutaneous three times a day with meals. -[MEDICATION NAME] 100 units/ml vial, Give 10 units subcutaneous daily at bed time. Check blood glucose before meals and at bedtime. Notify MD - if below 70 - treat for [DIAGNOSES REDACTED] - and notify MD or above 400. Start date 3/09/10. -Sliding scale: --[MEDICATION NAME] 100 units/ml vial, if blood glucose is 150-200, give 4 units subcutaneous. --[MEDICATION NAME] 100 units/ml vial, if blood glucose is 201-250, give 6 units subcutaneous. --[MEDICATION NAME] 100 units/ml vial, if blood glucose is 251-300, give 8 units subcutaneous. --[MEDICATION NAME] 100 units/ml vial, if blood glucose is 301-350, give 10 units subcutaneous. --[MEDICATION NAME] 100 units/ml vial, if blood glucose is 351-400, give 12 units subcutaneous. b. Failures in implementation of diabetic management plan Review of the blood glucose reading sheets and the MARs revealed that on 8/10/10 (8 pm), 8/19/10 (4 pm), 8/20/10 (8 pm), 8/25/10 (8 pm) and 9/8/10 (4 pm), the resident's blood glucose results were below 70. There was no documentation in the medical record related to physician notification or treatment for [REDACTED]. Review of the blood glucose reading sheets and the MARs revealed that on 8/3/10 (6 am & 4 pm), 8/7/10 (4 pm & 8 pm), 8/9/10 (4 pm & 8 pm), 8/10/10 (4 pm), 8/11/10 (8 pm), 8/14/10 (11 am & 4 pm), 8/15/10 (8 pm), 8/16/10 (4 pm), 8/17/10 (4 pm), 8/18/10 (4 pm), 8/19/10 (8 pm), 8/21/10 (11 am), 8/23/10 (8 pm), 8/24/10 (4 pm), 8/26/10 (6 am) and the 8/28/10 (4 pm), the resident's blood glucose results required sliding scale insulin, according to physician orders. There is no documentation on the MAR indicated [REDACTED] (On 9/3/10, the sliding scale insulin order was discontinued and the parameters for notification were changed. The less than order remained the same at 70, and the greater than order was lowered to 250.) There was no evidence to show the resident experienced harm based on the failures identified above. B. Resident #99 Resident #99, age 90, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Diabetic management plan Review of physician orders [REDACTED]. -[MEDICATION NAME] 100 units/ml vial, give 10 units subcutaneous daily at breakfast. -[MEDICATION NAME] 100 units/ml vial, give 8 units subcutaneous daily at lunch. -[MEDICATION NAME] 100 units/ml vial, give 10 units subcutaneous daily at dinner. -Check blood glucose before meals and at bed time. Notify MD if blood glucose below 70, give orange juice if normal mental status, then recheck in 20 minutes. If less than 70 or if mental status changes, notify M.D. -[MEDICATION NAME] 100 units/ml vial, sliding scale: Blood glucose minus 100 divided by 30. Give additional units subcutaneous as needed. 2. Failures in diabetic management a. Review of the Blood Glucose reading sheets and MARS revealed the following: -On 8/13/10, the resident's blood glucose was 54. There was no documentation that orange juice was given per physician order. -On 9/3/10, the resident's blood glucose was 53. There was no documentation that orange juice was given or that blood glucose was rechecked in 20 minutes, per physician orders. There was no documentation the physician was notified. b. Review of the Blood Glucose reading sheets and MARs revealed that on 8/1/10 (6 am) and 8/9/10 (6 am), the resident's blood glucose results required sliding scale insulin, according to physician orders. There was no documentation on the MAR indicated [REDACTED] c. Review of MAR indicated [REDACTED] -On 8/3/10 - 11:00 a.m., the resident's blood glucose results were 152, 1 unit of sliding scale insulin was administered, 2 units of sliding scale insulin should have been administered. -On 8/9/10 - 11:00 a.m., the resident's blood glucose results were 154, 1 unit of sliding scale insulin was administered, 2 units of sliding scale insulin should have been administered. -On 8/9/10 - 4:00 p.m., the residents blood glucose results were 146, 1 unit of sliding scale insulin was administered, 2 units of sliding scale insulin should have been administered. -On 8/12/10 - 11:00 a.m., the resident's blood glucose results were 211, 3 units of sliding scale insulin were administered, 4 units of sliding scale insulin should have been administered. -On 8/13/10 - 11:00 a.m., the resident's blood glucose results were 177, 2 units of sliding scale insulin were administered, 3 units of sliding scale insulin should have been administered. -On 8/20/10 - 11:00 a.m., the resident's blood glucose results were 176, 2 units of sliding scale insulin were administered, 3 units of sliding scale insulin should have been administered. -On 8/24/10 - 11:00 a.m., the resident's blood glucose results were 208, 3 units of sliding scale insulin were administered, 4 units of sliding scale insulin should have been administered. -On 8/26/10 - 11:00 a.m., the resident's blood glucose results were 205, 3 units of sliding scale insulin were administered, 4 units of sliding scale insulin should have been administered. -On 8/27/10 - 11:00 a.m., the resident's blood glucose results were 147, 1 unit of sliding scale insulin was administered, 2 units of sliding scale insulin should have been administered. -On 8/31/10 - 11:00 a.m., the resident's blood glucose results were 157, 1 unit of sliding scale insulin was administered, 2 units of sliding scale insulin should have been administered. -On 9/4/10 (11 a.m.) and 9/7/10 (11 a.m. & HS) the resident's blood glucose results required sliding scale insulin, according to physician orders. There is no documentation on the MAR indicated [REDACTED] -On 9/9/10, 9/10/10, 9/14/10 and 9/15/10, the resident had two blood glucose results that required sliding scale insulin. According to the MAR, sliding scale insulin was administered once. There was no evidence to show the resident experienced harm based on the failures identified above.

Based on observation, record review, and staff interview, the facility failed to provide five of 36 sample residents (#13, #14, #21, #22, and #31) the care and services necessary to attain and maintain their highest practicable level of well-being. Specifically: the facility failed to administer and/or document the sliding scale insulin as the physician ordered. This deficiency was originally cited during the recertification survey, ending on 9/21/10, with alleged compliance on 10/25/10. The deficiency was re-cited during the revisit on 11/23/10. The findings include: 1. Resident #14 a. Record Review Medical record review revealed [AGE] year-old resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident had short-term memory impairments and was moderately impaired in the cognitive skills for daily decision-making. The MDS revealed the resident needed extensive assistance of two or more staff members with bed mobility, dressing and transferring and needed the extensive assistance of a staff member with eating, toilet use, and personal hygiene. Review of the comprehensive care plan last updated on 8/12/10 revealed the resident required monitoring of her blood glucose levels due to diabetes. Several of the approaches listed included: - Provide the resident with her diet and medications as ordered by her doctor, - Monitor the resident's blood glucose levels as ordered by her doctor. Notify the doctor if the blood glucose is less than 60 or greater than 401. Give sliding scale insulin as ordered. - Monitor the resident for any signs or symptoms of hyper/[DIAGNOSES REDACTED], and - Monitor the residents weight, intake, skin integrity, and lab values. b. Diabetic Management Plan Review of the 11/10 Computerized Physician's Orders (CPO) revealed a 6/23/10 physician's order to check the blood sugar level four times a day (before each meal and at bedtime) and to call the physician if the blood sugar was below 70 or above 400. Another 6/23/10 physician's order indicated the use of [MEDICATION NAME] 100 units/1 ml insulin per sliding scale for Diabetes Mellitus Type II as followed: "Blood sugar 150 or below = 0 units 151-200 = 3 units 201-250 = 5 units 251-300 = 7 units 301-350 = 11 units Above 400 = 15 units." Further review of this physician's order indicated there was no amount of sliding scale insulin ordered for the blood sugar amounts of 351- 400 (cross-reference F281: Professional Standards). c. Failures in Implementation of Diabetic Management Plan Review of the documented blood glucose readings for 10/10 and 11/10 revealed there had been no documented blood glucose readings of 351 or above. Review of the 11/10 blood glucose reading sheets and the MARs revealed: - On 11/12/10 at 11:00 a.m., the documented blood sugar was 157. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 3 units should have been given.) - On 11/13/10 at 11:00 a.m., the documented blood sugar was 179. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 3 units should have been given.) - On 11/13/10 at 8:00 p.m., the documented blood sugar was 163. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 3 units should have been given.) d. Interview The Director of Nursing (DON) was informed of the sliding scale insulin errors on 11/18/10 at approximately 5:45 p.m. No comments were made. 2. Resident #13 a. Record Review Medical chart review revealed [AGE] year-old resident #13 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had no memory impairments and had modified independence in the cognitive skills for good decision-making. The MDS revealed the resident had an indwelling catheter usually incontinent of bowel. According to the MDS the resident needed extensive assistance of a staff member with bed mobility, transferring and with all activities of daily living. The MDS indicated the resident was 68 inches tall and weighed 200 pounds. According to the MDS the resident had two stage II pressure ulcers. b. Diabetic Management Plan Review of the 10/10 and 11/10 CPOs revealed the resident's blood glucose was to be tested four times a day. In addition, there was a 10/1/10 physician's order for [MEDICATION NAME] 100 units/1 ml insulin per sliding scale; however there was no sliding scale documented on the 11/10 CPO. Despite no physician's order listed on the CPO for a sliding scale of insulin to be given according to the blood glucose readings, there were on the 10/10 and 11/10 MARs hand written sliding scale insulin levels for the blood glucose readings as follows: "Blood glucose level of: Under 70 treat and call the physician 71-150 =0 units 151-200 = 2 units 201-250 = 3 units 251-300 = 4 units 301-355 = 5 units 351-400 = 6 units Over 400 = 8 units and call the physician." c. Failures in Implementation of Diabetic Management Plan On 10/31/10, the documented blood glucose was 173 at 4:00 p.m. There was no evidence that any sliding scale insulin was given. (Two units of [MEDICATION NAME]should have been given.) d. Interview See above DON interview. 3. Resident #21 a. Record Review Medical record review revealed [AGE] year-old resident #21 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The 9/23/10 MDS revealed the resident had short-term memory impairments and had modified independence in the cognitive skills needed for daily decision-making. According to the MDS the resident was incontinent of bowel and bladder, was 61 inches tall and weighed 139 pounds. The MDS revealed the resident needed limited assistance of a staff member in all activities of daily living except needed extensive assistance of a staff member with personal hygiene, toilet use, and with dressing. b. Diabetic Management Plan According to the 10/10 and 11/10 CPOs, a 5/8/09 physician's order indicated the blood glucose was to be checked before meals and the physician was to be notified of blood sugars below 50 and above 400. A 9/1/09 physician's order was to administer [MEDICATION NAME] 100 units/1 ml insulin per sliding scale as follows: "150-200 = 3 units sq (subcutaneously) 201-250 = 6 units 251-300 = 9 units 301-350 = 12 units 351-400 = 15 units Over 400 = 18 units and call physician." A 9/25/10 order indicated 16 units of [MEDICATION NAME] 100 units /ml insulin was to be given sq at bedtime. c. Failures in Implementation of Diabetic Management Plan Review of the 10/10 blood glucose reading sheets and the MARs revealed: - On 10/29/10 at 4:30 p.m., the documented blood sugar was 244. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 6 units should have been given.) - On 10/30/10 at 6:00 a.m., the documented blood sugar was 211. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 6 units should have been given.) Review of the 11/10 blood glucose reading sheets and the MARs revealed: - On 11/5/10 at 4:30 p.m., the documented blood sugar was 161. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 3 units should have been given.) - On 11/9/10 at 4:30 p.m., the documented blood sugar was 188. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 3 units should have been given.) - On 11/12/10 at 4:30 p.m., the documented blood sugar was 181. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 3 units should have been given.) - On 11/17/10 at 6:00 a.m., the documented blood sugar was 179. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 3 units should have been given.) d. Interview See above interview 4. Resident #22 a. Record Review Medical record review revealed [AGE] year-old resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/7/10 MDS revealed resident #22 had no memory impairments and was independent in the cognitive skills needed for daily decision-making. The resident was coded as being frequently incontinent of bowel and incontinent of bladder. The MDS indicated the resident was 62 inches tall and weigh 130 pounds. According to the MDS the resident needed extensive assistance of two more staff members with bed mobility and transferring and needed the extensive assistance of a staff member with all activities of daily living except eating with which she needed limited assistance of a staff member. b. Diabetic Management Plan According to the 10/10 and 11/10 CPOs, a 4/28/09 physician's order indicated the blood glucose was to be taken twice daily and notify the physician if below 60 and above 400. A 4/28/09 physician's order was to administer 10 units of [MEDICATION NAME] mix 70/30 70-30 units/1 ml insulin twice daily before meals scheduled at 6:30 a.m. and 4:30 p.m. A 4/28/09 physician's order was to administer [MEDICATION NAME] 100 units/1 ml insulin per sliding scale as follows: "Below 60= call physician 201-250 = 6 units 251-300= 8 units 301-350 = 10 units 351-400 = 12 units Over 400 = call physician." c. Failures in Implementation of Diabetic Management Plan Review of the 10/10 blood glucose reading sheets and the MARs revealed: - On 10/27/10 at 4:30 p.m., the documented blood sugar was 204. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 6 units should have been given.) Review of the 11/10 blood glucose reading sheets and the MARs revealed: - On 11/7/10 at 4:30 p.m., the documented blood sugar was 225. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 6 units should have been given.) - On 11/13/10 at 4:30 p.m., the documented blood sugar was 246. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 6 units should have been given.) d. Interview See above interview 5. Resident #31 a. Record Review Medical record review revealed resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 9/16/10 MDS indicated the resident had no memory impairments and had modified independence with the cognitive skills needed in daily decision-making. The resident was coded as being continent of bowel and frequently incontinent of bladder. The MDS coded the resident as being 60 inches tall and weighing 139 pounds. According to the MDS the resident needed limited assistance of a staff member in all activities of daily living except eating which required the setup of a staff member. Review of the comprehensive care plan last updated on 10/10/10 revealed the resident required monitoring of her blood glucose levels due to diabetes. Several of the approaches listed included: - Provide the resident with her diet and medications as ordered by her doctor, - Monitor the resident's blood glucose levels as ordered by her doctor. Notify the doctor if the blood glucose is less than 60 or greater than 400. - Give sliding scale insulin as ordered. - Monitor the resident for any signs or symptoms of hyper/[DIAGNOSES REDACTED], and - Monitor the residents weight, intake, skin integrity and lab values. b. Diabetic Management Plan According to the 11/10 CPO an 11/21/09 physician's order indicated the blood glucose was to be taken before meals and at bedtime daily and notify the physician if below 60 and above 400. A 9/06/10 physician's order was to administer 15 units of [MEDICATION NAME] 100 units/1 ml insulin at bedtime daily. An 11/23/09 physician's order was to administer [MEDICATION NAME] 100 units/1 ml insulin per sliding scale as follows: "Below 60= call physician 140-200 = 1 unit 201-250 = 2 units 251-300= 3 units 301-350 = 4 units 351-400 = 5 units Over 400 or if above 250 twice = call physician." c. Failures in Implementation of Diabetic Management Plan Review of the 11/10 blood glucose reading sheets and the MARs revealed: - On 11/7/10 at 4:00 p.m., the documented blood sugar was 202. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 2 units should have been given.) - On 11/13/10 at 11:00 a.m., the documented blood sugar was 179. There was no documented evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 1 unit should have been given.) - On 11/13/10 at 4:00 p.m., the documented blood sugar was 163. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 1 unit should have been given.) - On 11/14/10 at 8:00 p.m., the documented blood sugar was 210. There was documented evidence that 3 units sliding scale insulin had been incorrectly given. ([MEDICATION NAME] 2 units should have been given.) - On 11/18/10 at 11:00 a.m., the documented blood sugar was 184. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 1 unit should have been given.) - On 11/19/10 at 11:00 a.m., the documented blood sugar was 216. There was no evidence that any sliding scale insulin had been given. ([MEDICATION NAME] 2 unit should have been given.) d. Interview See above interview